RSV, flu, rhinovirus and covid. It’s a long, long season of coughs and snuffles.
Melbourne winter, which roughly lasts March to November, seems particularly bad for respiratory viruses this year. On some days, over the last week, about 80% of my patients presented with rhinorrhoea, cough, sore throat, fevers, myalgia and fatigue.
The myalgia is unusual; while previously this would make me more suspicious of influenza or parainfluenza, this year I can’t clinically distinguish flu from RSV from rhinovirus from covid. I’ve been swabbing everyone for the full respiratory panel to confirm their exact illness. The swabs, of course, which used to take 24 hours, are now taking 3-4 days, because the labs are overflowing and inundated with tests to process.
Before this year, I can’t recall the last time I saw an adult with a meaningful RSV infection; it was nearly always just the little bronchiolitis babies that were a medical concern, in my experience at least.
This year, I’ve been seeing a strange group of symptoms in adults consisting of 1-3 weeks of Ventolin-responsive wheeze, cough, fevers, myalgia and sometimes chest tightness – and they’re rather frequently testing positive for RSV.
Even the patients are very aware of it. Most years, I ask “Have you heard of RSV” to introduce and explain to worried and unfamiliar parents the pathology with which their wheezy babies are inflicted. This year, most patients are either asking me if they have RSV, or explain they are already familiar due to their grandparents/grandbabies/work colleagues/neighbours/hairdressers being recently quite unwell with it for three weeks.
I will be glad to have the widespread RSV vaccine rollout. The number of little bronchiolitis babies that I’ve reviewing daily is, at any given moment, between five to 15. Like all of the other GPs, I’m doing my best to provide family support and very close reviews of these (often happy and chubby) bronch babies because the paediatric wards are just packed to capacity with babies and children even more unwell with the same pathologies. We’re just doing our best to keep the babies out of hospital.
The majority of my patients are very trusting and keen on immunising against preventable illness, like RSV and flu, which is actually a joy and a relief. Mostly my patients have already had a flu vaccine or very quickly agree to do it “while you’re already here” when I ask at the end of every consult. (“Doc, don’t start, you made me do it in April and I brought in the kids to do it a week later, remember.” Or “Yes, yes, I’ve done it at work already because I knew you’d ask”).
The worst bit about their winter viruses is what little we can do to treat them. Despite the pleas and very occasionally quite aggressive demands, there is obviously no role for antibiotics or antivirals in most people (assuming there is no secondary bacterial infection, and assuming the patient isn’t eligible for influenza antivirals etc etc).
Sometimes if there are reactive airways or asthma symptoms, we can try salbutamol or inhaled or oral steroids depending on the patient and pathology. But largely, I’ve got nothing to treat, only perhaps strategies to prevent and then self-manage.
“The good and bad news,” I tell the patients, “is that this is a winter virus and will settle on its own. The bad news is I have absolutely nothing to help.”
“Come on doc, I need antibiotics, my snot is green.”
“Truly I wish,” I reassure them, “Don’t you think that if I could treat this with a quick-fix that I would? Sadly, it’s all home remedies, rest, nasal irrigation, paracetamol and you have to take a breather and few days off work.”
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Usually, the patients understand and accept that, but I also often wonder if the patients who are really insistent on antibiotics perhaps see another GP, because they know me to be an extremely conservative prescriber. “Unfortunately, empathy for you is not a good reason to give you antibiotics when they are definitely not needed – and believe me, I know you feel miserable, and I’d really have given you anything if it would be effective and safe.”
Sometimes I say, “If I actually had a tablet to treat the common cold, I’d open up a Common Cold clinic and charge patients $500 per appointment and maybe see five or 10 people a day then go home. Alas, there is no such treatment so here we both are” and this usually brings a laugh and agreement. (“Doc if you had that, I’d pay $500 for it, too!).
“What I can do, and what I happily willdo,” I say, “is write you a medical certificate for the week. Go home, sleep, read a book, de-snot your head and wait this out”.
Sometimes I get very frustrated when the patients tell me they’ve been at work all week anyway (then they complain about a colleague who was coughing all over the desk and turned out to have influenza A three days ago).
It’s literally been four years into a respiratory pandemic, and we, especially in Melbourne, have clearly proven to ourselves that staying home when sick reduces the spread of these illnesses. Admittedly, I am getting quite impatient reminding patients that a) the reason they got sick is because of the coughing colleague, and if you think that’s annoying and unfair, perhaps consider that you’ve done the same thing to someone else, and b) you have a 39-degree fever, I am unsure how good the quality of your work is currently, and c) there is no other treatment, go home and wait this out.
My accountant once commented to me that my BAS payments unusually are a lot higher in the second and third quarters. Any GP will tell you why – we get seasonal variation in disease – and Melbourne winter doubles my workload.
I hope we all get through the rather grey weeks and months of the Melbourne Marathon of Winter Viruses (MMOWV is fine, you can pronounce it with a silent W and also fine to use in all geographic areas) and stay as safe and well and vaccinated as you can.
