The greatest irony of this year’s influenza epidemic is the gulf between dire messages urging us to protect vulnerable children and the reality of our actual options. One of our best weapons against pediatric influenza is oseltamivir (Tamiflu) suspension, but you might as well be prescribing platypus blood. Nobody has it.

On a recent Friday night, a single mother brought in a 4-year-old girl who developed a fever and cough over the previous 12 hours. The girl had a history of pneumonia and moderately severe asthma requiring two hospitalizations. Her test swab was positive for influenza A, but she did not appear gravely ill and had no findings that warranted hospitalization at that time.

I explained to her mother that she had a good chance of an uncomplicated recovery, but risk factors for severe disease made starting oseltamivir an important safeguard. Her mother was appropriately concerned and promised to fill the child’s weight-based prescription for oseltamivir suspension (45 mg orally twice a day for 5 days). Three hours later, she came back, frustrated and exhausted, having tried five local pharmacies. None of them had any oseltamivir suspension in stock; only the adult-strength 75-mg capsules were available. The child was crying, her pediatrician wasn’t calling back, the mother was exasperated and wanted to leave, and to make matters worse she was working the next 2 days. It was clear that if this child didn’t get the suspension tonight, she probably wasn’t going to get it at all.

Winging it wisely

I rarely recommend compounding medications in the emergency department. It’s time consuming, it makes the nursing staff fretful, and you don’t always have the ingredients you need. And there’s that whole “skill and training” thing.

If you have a pharmacist in-house (or a good relationship with one in your area) a simple phone call usually can remove this burden. Exceptions are necessary when the patient has a great deal to lose, time is a factor, options are limited, and your instincts tell you sending the exhausted parent out to “try harder” is unlikely to succeed. Sometimes the confluence of medical risk, social realities, and weekend inertia means that you have to do your best on your own.

The oseltamivir package insert provides detailed compounding information for pharmacists. It involves adding a small amount of water to adult capsules and then combining a flavored base to create a suspension of 6 mg/mL. Because I didn’t have any flavored base available, I calculated the total dose of oseltamivir the child would take over standard 5-day course (45 mg by mouth twice a day for 5 days, for a total dose of 450 mg). Then I figured out how many of the adult-dose 75-mg oseltamivir capsules would add up to the same total dosage (six of them) and emptied them all into a sterile specimen cup. I added 30 mL of normal saline and gave the whole thing a shake.

I gave the mother a marked syringe and wrote instructions for her to refrigerate the liquid and give 3 mL mixed into a small amount of fruit juice by mouth twice a day for the usual 5-day course.

To be unqualified, you must be honest

The patient’s mother and I had a mega-documented conversation in which I explained I was not a compounding pharmacist, and that there were no guarantees that this medication would be as safe or effective as the official suspension, although I believed the potential benefits greatly outweighed the risks. I still gave her a prescription for the suspension with instructions to switch to the “real thing” if she ever found a pharmacy that carried it.

I also documented that the parent was reliable and attentive, understood my instructions, and that the child had good daytime supervision while the mother was at work in case she appeared to be getting worse.

The universe hates you

Anti-karma is part of our lives as emergency physicians; good deeds that are even a little unconventional attract the attention of a baleful cosmic eye that seeks to punish us with misfortune, humiliation, and policy guideline meetings. The only defense is confessing to people who know more than you do.

Whenever you compound a medication for a late-night emergency, talk to your pharmacy department the next day. In this particular case, our pharmacist confirmed that the oseltamivir suspension I had created was likely to be stable and effective, but because he knew we had a severe supply problem he went further: he compounded an additional supply to keep in the department as “first dose” treatments and found an independent local pharmacist who would compound suspension during regular business hours.

This way we could give a first dose in the department and prescribe the rest of the suspension, and we could actually suggest a pharmacy that was willing to make it.

Influenza is big this year, and death is still not selling well, so remember; it’s one thing to write down what the patient should do, it’s another thing to make sure they can do it.

Oozers

Much like a hideous winter crocus, anterior epistaxis has a season. The convergence of cold winter air, upper respiratory infections, and dry heat blasting into tiny apartments make friable nasal mucosa even more delicate. And spontaneous anterior bleeds are common. The very mild and very severe cases are straightforward to treat: simple pressure and perhaps a little cautery for mild anterior epistaxis, and packing with ENT involvement for the severe bleeds (and admission if necessary).

“But what if I bleed to death one drop at a time?!”

Then there are “the oozers.” These are patients who are profoundly troubled by the janitorial nature of bleeding that has mostly improved with pressure and cautery alone. They are in little danger, but they often return a few hours after discharge furiously jabbing at a rare, languid droplet of blood with wads of toilet paper. Some of these patients are so anxious that they simply will not tolerate an anterior packing balloon without entering a state of enthusiastic agitation.

You can try sending them home with that giant inflatable sausage in their nose, but you can sense the impending panic attack, tingling fingers, and pinching chest pain begin to stir in the depths of their uneasy psyche. You know they’ll just come back again unless you find a third option.

In these cases I like to try a “nose sandwich.”

The ingredients are tissue adhesive (e.g. Dermabond or Indermil), an absorbable hemostatic sponge (such as Surgifoam), and some bacitracin topical ointment. While the patient holds pressure on the nasal septum, trim your absorbable hemostatic sponge as needed. Place a small amount of bacitracin on one side only, and rest this side down on a narrow, firm object such as trimmed piece of a sterile tongue depressor or a culture swab. The bacitracin provides some antibiotic coverage, but also keeps you from gluing your tongue depressor or swab patient’s nose, requiring forceful removal and resultant psychic distress.

Just before the patient stops holding pressure, liberally coat the edges of the other side of your hemostatic sponge with tissue adhesive – this side will be applied to the nasal septum. Lift up the whole ensemble before the adhesive has a chance to dry, gently insert into the nare, and press firmly against the nasal septum. Keep the sustained pressure for at least a minute (tell a few jokes.)

Once you remove the tongue depressor or swab, trim any excess material poking out of the nare and have the patient resume holding pressure for another 20 minutes. If you need a little extra volume, insert additional layers of hemostatic sponge (no tissue adhesive this time) adjacent to the first one. To further prevent blood or hunks of hemostat from falling out of the nose, gently cover the affected nostril with a steri-strip, using a little benzoin to help it stay in place. Don’t cover both nostrils unless your patient does not need to breathe at regular intervals.

Most patients find this form of nasal packing to be much more comfortable than inflatable packs, even if you have to insert more than one layer of absorbable hemostat. Usually it falls out in 3 days, so prepare the patient for this likely outcome. I usually tell the patient to remove the steri-strip in 48 hours if it hasn’t come off already. Because the entire unit is absorbable, I don’t consider the dangers of aspiration or ingestion to be higher than they would be for a regular blood clot from untreated epistaxis, but it’s worth discussing the possibility with the patient.

He made these nose tongs for me. He cares!

Prescribe the same antibiotics and follow-up would ordinarily give with any nasal packing. Everyone loves a freebie, so give your patient their very own nasal clamp to take home in case they ooze through a little. If you make your own out of two tongue depressors, write “30 minutes – NO PEEKING” in huge letters. Having the rules in plain sight seems to encourage honesty and produce maximum benefit from any placebo effect.

Have a nifty idea you’d like to see on Tricks of the Trade? E-mail it to me at fisherwhit@gmail.com, and I promise to give you credit if I use it.

Dr. Fisher practices Emergency Medicine in New England and New York.