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Treating pneumonia in a post apocalyptic setting
Bargain Not With Live Dragons
miiro wrote in little_details
This isn't for a work of fan fiction and no, there's no risk of zombies ;)

As a background:  Near future (next 1-2 years) and civilization has come to a crashing halt and fallen apart around our ears.  There's literally no way to re-supply unless taking a very, very risky trip into a city and that city is a few days by horseback away.  Technology, if you have power, will indeed work.  The locale is very, very rural -- deep into farm country with a significant forest & river nearby.

Considering this is set during spring melt said river is also flooded heavily leaving them cut off from any help that could have come anyway.

What they have access to:  One Canadian university trained surgeon/medical doctor with at least ten to fifteen years of experience, an ambulance's worth of supplies and a warm and safe location to treat the unfortunate person who has fallen ill.

The person fallen sick is a normally healthy, but older, man of around 65.

Vices include:
Smoking (but he hasn't been able to because cigarette supplies ran out months before so he had to quite 'cold turkey) and was an active smoker since around his thirties and somehow has avoided lung cancer.
Social drinker.
Coffee... for those familiar with NCIS think Gibbs level of coffee drinking.  Cannot, and will not, go without coffee.  Unfortunately, coffee supplies ran out a while before he got ill as well.

Other than that he's healthy and leads an active lifestyle... for a salesman from the city.  He's not a tough farmer or cowboy type and is built rather compactly and slim.

I'd ideally like him to get really, really sick but not sure just how far -- given the circumstances -- is safe to take it without killing the character off and just how the doctor that they have access to would be able to treat it, and what she could do to treat him.

I searched online using Google for:
Causes of pneumonia
Treating pneumonia

WebMD and wikipedia had some okay explanations that for a layperson were easy to follow but fuzzy on exact details.  Everything else (ie: Mayo Clinic, etc) went right over my head even with a dictionary beside me.

I'm looking for steps in treatment, how he would feel, how long he'd be down and what she could do to help him recover... and how 'recovered' he would really get.

My husband went through two bouts of pneumonia last winter. He was in pretty rough shape. There's a characteristic rattle/rasping to someone's breathing - I bet if you googled it you could probably find a video of it. The treatment was a weeks worth of pills, one a day, and the second time was only three or four pills. Even after you start taking the pills though, it can take several days to a week before it starts to make a difference. There's also a lot of chest pain. My husband was on the edge of being hospitalized in the first bout.

Another thing about pneumonia is it has a tendency to come back, like it did with my husband. Apparently getting it again a few weeks or months later is very common.

not the OP, but this is very useful info to me right now. especially your last comment. i did not know that pneumonia could come back so easily. thanks, this is something i can stick in my current story's epilogue!

The the pneumococcus bacteria can also infect the sinuses, nose, ears (very painful and can cause deafness) and cause meningitis, which I wouldn't recommend giving your character if you want him to survive. It can also infect bone which is supposed to be incredibly painful and long-lasting.

Pneumonia can be a survivable condition without antibiotics, which your regular ambulance won't carry. It sounds terrible and the character will look (and be) extremely ill. Basic supportive care (warmth, fluids, breathing steam), keeping him in a sitting position rather than lying down, possibly chest physio to keep moving the mucus out. He will have severe chest pain, fever, probably wasting and even broken ribs if the cough goes long enough. He will be left with a lingering cough, at least for months, possibly forever, and a greatly increased likelihood of getting it again, and worse.

It's surprisingly easy to break a rib from coughing (or to pull the tendons between rib bones, which feels the same as a break and takes the same amount of time/treatment to recover). If it happens to your character, the doctor would know to tell him to put a pillow between his arm and side whenever he has to cough, it helps with the pain. (I know firsthand that that works!)

Before antibiotics, pneumonia was nicknamed the "old man's friend," because it was very common for older people to get it and die, fairly quickly and without extreme suffering, sparing them things like cancer, heart attacks, kidney failure, or senile dementia (now called "Alzheimer syndrome"). "Old" here certainly included people in their sixties. So there's a fairly serious chance of your character dying.

I don't know the actual typical course of pneumonia, I'm afraid.

The loss of coffee will have caused him a couple of weeks of killer headaches that felt like a bolt had been hammered through his forehead. He probably would be sleeping ten or twelve hours a day for a while after that. But it wouldn't actually be harmful.

Oh, come on, there are plenty of kinds of non-Alzheimer's dementia.

Are there? I haven't looked into the matter closely. I don't see many references to "senility" or "senile dementia" any more. I was mainly trying to make the point that I was using an older term deliberately, because it was the term someone in the pre-antibiotic era would have used; if some things that were then called "senile dementia" are not now called "Alzheimer syndrome," I don't think that makes it unnecessary to make that point, though I could have made it more clearly had I known about them.

I think the term senile dementia is less in use, but there are quite a few forms of dementia, many of which are associated with disorders that occur frequently amongst the aged. Lewey body dementia, vascular dementia and the neurocognitive problems associated with Parkinson's (which are more specific than dementia, but were at one time often called dementia) jump to mind. But then, I'm a neurobiologist - this isn't my specific field, but I probably get more exposure to this kind of thing than the average bear.

When my mom was about 40, she came down with pneumonia. She was a smoker at the time. It made her SO SICK my dad -- a scary-stoic Vietnam vet -- actually gave me the "your mother may actually die but I will always love and take care of you" speech. (I was like eight, and yeah, that was scary as hell.) She was allergic to penicillin, so she was left fighting it off with inferior drugs mostly on her own. She was hospitalized for a couple three days. I didn't go see her at all, I was too little.

Mostly what I remember from that time is that she stayed in bed for like two weeks and was so tired I never spent more than a couple of minutes with her. She didn't talk much. She slept almost all the time. She coughed a LOT, this terrible, racking cough, not really gusty, there wasn't the lung capacity, but just . . . crackly and hard and painful-sounding. Sometimes she coughed so hard she threw up. (My mom was a barfer, though. I mean, drop of a hat. Still, coughing until you gag is a thing with really bad coughs. I've done it -- not thrown up but I thought I was gonna -- just from swallowing wrong.) It took her a long time to recover, and she wore out easy for a long time.

I've had pneumonia, too, though it was milder and I was a tween, so I was pretty resilient. It was like a really bad case of the flu, is all. The chest pain felt like . . . like when you run yourself out of breath, and you get that burning in your lungs? It was like that. It hurt to breathe deeply.

A massive infection like that makes you SO GODDAMN TIRED. You get cold easy.

Breath bubbles, you can't breathe in deeply, and even after recovery is underway, you can hear a crackle in the lungs with a stethoscope. You aren't out of the woods until that crackle is gone.

Mom was more vulnerable to lung/chest infections after that. A few years later she had the Shanghai flu and it beat her ass right back down. Bad pneumonia is nasty stuff.

Recovery from pneumonia is a funny thing. You feel all right enough to do something, but just vaccuuming the floor makes you tired enough to need a nap.

True story...I was feeling pretty good several weeks after a bout of pneumonia, and decided to walk two blocks to a mall. By the time I got there, I was so tired. I ended up sitting in a comfy chair for a few hours until I felt well enough to shamble home.

My dad had pneumonia in the early 90s when he was in his late 30s. He initially tried to keep working through it and didn't know it was pneumonia because he didn't go to the doctor. When he finally did go to the doctor they were shocked that he hadn't been off sick with it. He stayed in bed for about a week and had a terrible cough where kept coughing up phlegm. When he was otherwise recovered the cough stayed around for months and to this day he still coughs up phlegm every morning. If he gets a cold it always goes to his chest and gives him a worse cough than anybody else with the same thing as well. He's never smoked, doesn't drink coffee, drinks very little alcohol but is overweight and doesn't get much exercise.

No time right now for a longer reply, but one thing I was thinking of is that low- and high-level antibiotics are regularly used in animal breeding today - be it chickens or cattle. I have NO CLUE whatsoever how these are dispensed, the strength, quantity and form they come in and whether they're even the right kind. But if they are kept on hand in farms, a trained doctor might be able to adjust the dosage for a patient. Someone here who's not a city girl from Germany (like me) might be able to help here?

(You're looking for penicillin or amoxicillin to treat the most common causes of bacterial pneumonia, but many other modern antibiotics will work as well.)

Heck, a trained and *clever* doctor might be able to fake it with bread mold.

Whilst bread mold is the original source of antibiotics... it was a very difficult task to actually turn out significant quantities of actual antibiotics; also bacteria have evolved, and there's no guarantee that the same antibiotics would still be effective.

It's something that a doctor might try, if there was nothing else possible, but it would have a big chance of not working.

Yeah, seriously - looking into the history of penicillin manufacture here might be useful, as purification was a major problem in early days, and they simply couldn't produce very much of it.

(And it'd be a rare doctor - that's far more the kind of seat of the pants attitude you'd get from someone on the research side. Though you do still find the occasional MD who really likes the chemistry/biochem side, they're just rare, particularly these days. I know this because I'm a researcher who regularly deals with medical doctors, and I am frequently told that my ideas, while likely scientifically valid, are totally inappropriate for medical care. At least until they've gone through a couple of decades of testing.)

Yeah. Penicillin was discovered in 1928. It was not until World War II that they managed to mass-produce it, and that was with a massive industrial base behind them.

Yeah, proper antibiotics would be better, but people have been using bread mold to treat illnesses since before we even knew about bacteria...

okay so depending upon the severity you want, and the method by which he picks up the disease, there are two main types of pneumonia: bronchopneumonia and lobar pneumonia. Bronchopneumonia is diffuse, spread across the whole lung(s), while lobar pneumonia affects a whole lobe(s) of one lung, but is pretty much isolated to that one lung. Typical running order for pneumonia, without antibiotics, is as follows:
1-2 days= oedema (swelling, fluid enters the lungs)
2-4 days= red hepatisation (red blood cells, neutrophils/white blood cells, fibrin in the lungs)
4-8 days= grey hapatisation (red cells broken down to leave fibrinosuppurative exudate in the lungs)
>8 days= resolution, clearance of lung fluid

(Hepatisation being the changes in the lung tissue so it feels solid, like the liver, rather than inflatable, like a balloon as it normally does.)

The biggest problem with pneumonia is the inflammatory infiltrate causing the hepatisation. if you search google images with 'histology lung' and compare it to 'histology pneumonia' you can see why- all the empty air sacs in the lung have become clogged up with inflammatory cells, mucus etc. With the lung packed solid with fluid, you can't get any air into those sections of the lung, so it won't get into the blood stream via those alveoli.
On top of just getting in the way, the inflammatory cells can cause damage to the body themselves (imagine your body sends in little soldiers, and they just attack anything they can see. sometimes, your own tissues get caught in the crossfire, and you cause damage to yourself). This can potentially lead to permanent damage of the lung tissue too.
Another issue, associated with the stabbing pains in the lung/inability to breathe properly, is the fibrin in the infiltrate. Fibrin is kind of like scarring, it makes the lung inflexible while it is there. Under normal healing conditions it should be cleared during the resolution days, but a complication of pneumonia could be the incomplete clearance of the fibrin deposition, leaving a scar at the affected part of the lung, making it dysfunctional/unable to function at all.

If your characters don't have proper antibacterial drugs specific for the bacteria involved (which could be hard to determine anyway, if they don't have access to a histology lab or other clinical testing facilities) you could treat him with generalised anti inflammatory drugs. If you could get a hold of them, fibrinolytic (breaks down fibrin) treatment would help prevent permanent scarring on the lung. To a degree anti inflammatory drugs would help break down fibrin, but specifically targeting that would be useful.
As someone else mentioned, physiotherapy to help get the goop out of the lungs would be useful. They may have a general antibacterial drug/pill that he could take, which could either help or do absolutely nothing, depending on what you wanted to happen.

...I hope that wasn't too technical-sounding! If you want any clarification just ask :)

That helped a lot. It was just technical enough to fill in the details (I'm a "retired" PSW) but also just clear/layperson enough to understand.

As for how he ended up with it - hoping this is realistic but if not perhaps we can discuss what needs to be changed in order for it to be realistic, if you're open to that - he was helping his friend save a bunch of horses in a barn that was caught in rising flood waters (dangerous enough right there) but considering the source of the flood (ie: Spring melt in Northern Ontario, Canada) the water is just barely above the freezing mark. It's not cold enough to form solid ice -- melting, actually -- but it's still as cold as the water that would come out a fridge. Chunks of ice are still present, kind of thing.

He was saving the last of the horses as the water slowly rose around him. It started ankle deep, but by the time he was able to get out of the barn, it was knee to hip deep, and he also managed to trip, fall and thoroughly soak himself. He was just hypothermic enough to barely be conscious and was pulled out of the barn, and the flood waters, by friends.

The pneumonia came from that -- but what I wasn't sure was if the pneumonia is caught directly or is the follower of a severe cold & and the hypothermia, or because of the hypothermia his immune system was just compromised enough.

They actually found the ambulance in an abandoned fire hall, which, if worse comes to worse, is only about ten to fifteen minutes by horse up the road and away from the flooded river so there could be other supplies there too.

That kind of scenario is plausible, the hypothermia would demand so much of his body's energy that his immune system would have a lowered capacity for defence. The cold air coming in contact with his lungs may also exacerbate the condition, the cells will become irritated by cold air in extreme conditions- normally the nose/throat humidifies the air and brings it to body temperature, but in really cold conditions that may not be as effective.
Another way to really up his chances of getting pneumonia would be for him to inhale some of the water into his lungs- the irritation could lead to compromised immunity in the affected areas and give the bacteria/virus an opportunity to infect. All up these conditions would lead to lessened immunity, and when he is exposed to the bacteria in his everyday life as he is trying to recover he could easily get sick instead of fighting off the infection immediately.
(There is a disease called ARDS, which is like pneumonia's ugly cousin, which often develops in people who have survived near-drowning experiences and inhaled a lot of water. It is a super wide-spread pneumonia-like disease in the lungs, but the survival rate is so low I don't think you would want to use it unless you want to kill the character)

I had read up about ARDS but killing the main character of the book midway through is not in the cards. I knew pneumonia was surviveable but serious with a good chance of killing him, which would scare everyone around him and worry them sick -- which is the intended outcome -- as well as make his doctor friend hover like a helicopter even after he's recovered.

In that case I think pneumonia is your best bet. You can make it as severe as you want, too- I mean he's not going to recover in 24 hours, but if you want permanent scarring to impair his breathing in the future, or a full recovery, either is totally plausible.

Just a suggestion but if you want something that makes someone really, really sick and *wanting* to die, and alarms everyone around them, plus feeling like shit for a week after, Norovirus works a treat.

I've had it three times (I seem to be susceptible) and the first time was scary as hell. The second times weren't much better. Most people only know they have noro because a newspaper tells them there is an epidemic.

And the odd thing is that while it is *highly* catching some people don't get it at all, I've never given it to my partner even tho he has been the one wiping up.

Edited at 2014-04-28 08:44 am (UTC)

I believe some people have genetic immunity to norovirus - a friend who works in research mentioned it as something they could easily find out from DNA.

There are always people that can't catch any particular disease. Even in virgin field epidemics.

A few years ago (at a reasonably fit age 39) I had bronchitis that morphed into light pneumonia and it took me two weeks to go back to work but definitely another 3 weeks or so for my lungs and my stamina to be back to normal. At the time I lived on the 4th floor, without an elevator, and where I used to be able to walk straight up I now had to take a break halfway through and even then it was less than pleasant - I remember always being sweat-soaked when I got into my apartment. That was the first time in my life that I truly felt weak and frail, and it worried me.

The ambulance probably isn't going to be terribly helpful - most of the standard treatments are pharmaceutical.* Though if they have some kind of gurney that can be cranked up into a halfway sitting position, it'll probably make getting some sleep a lot easier. Something for the pain, which in most cases will both bring down some of the inflammation and help with the fever. (Oh, here's a useful bit for working in primitive conditions - a variant of aspirin, though more likely to upset the stomach, was originally derived from willow bark, and willow bard was in broad use pretty much across the world for relief from pain and fevers. And it's one of the things that's really commonly known, so it's pretty likely your MD has heard of it, though she's less likely to have much clue on how to prepare is or what the dosage should be. But don't scoff, aspirin is a really big deal when working under primitive conditions.)

...and then a lot of supportive care, and waiting around somewhat helplessly. People die of pneumonia is hospitals, not infrequently. People recover at home all the time. It can pretty much be as bad as you want, as the range is really broad. If it is bad, I would expect full recovery to take some weeks once he is past the worst of it. (Though honestly, I don't know nearly as much about recovery in people with normal lungs. I'm asthmatic, and before I found effective treatments for it, I usually ended up in the hospital about once a year with bronchitis, and it turned into pneumonia more than once. In my case, even after the infection is gone, my lungs might stay inflamed for weeks and weeks, and some times I ended up needing to take oral steroids to calm them down. *sigh* In the event of standard apocalypse scenarios, I would be incredibly useful - right up until my allergy meds ran out.)

* Antibiotics if there's a bacterial infection - though it's often viral (and anti-biotics are often prescribed anyway, but aren't going to do much in that case) - expectorants, possibly a mild cough suppressant at night because really, sleep is important, though really, you want the gunk out of the lungs, etc. etc.

I have a couple of chronic lung conditions which have gifted me with permanent lung damage (gee, thanks, you really shouldn't have). A couple of years ago I managed to get pneumonia in the summertime. It was really bizarre because if I hadn't puked, I wouldn't have known. I was tired, but heck, I'm tired most of the time. My husband forced me to go to the dr who sent me for a chest x-ray and informed me I had pneumonia. I was given a course of antibiotics and told to go home.

I asked if I could go to work... Doc said 'you have two choices, you can go home and go to bed, or you can go to the hospital'. I chose to go home. *g*

The really odd thing is, normally I cough - a lot. It's a noisy cough and people think it must hurt, but it doesn't. And it's very productive as well. When I had pneumonia I did not cough at all, even though I had physio to clear the gunk. I wasn't overly tired and felt a bit of a fraud staying home. I spent two weeks at home and then went back to work. I was told to rest and drink plenty of fluids while I was down. What you really want to do is loosen the gunk building up in the lungs so he can get rid of it. Drinking lots of fluids helps thin it out, steam inhalation helps, so does physio (where you get to lie with your head over the edge of a bed and have someone beat on your back). I think you'd probably want something to bring the fever down too.

I've never had pneumonia again, even though you'd think with my crappy lungs I should have it at least once a year. So I can't really help with the pneumonia, but I can tell you if you give him permanent lung damage he's going to be okay for walking on the flat at a moderate pace with short bursts of speed if required. Hills, particularly going up are going to be difficult. Using a pushmower to cut the grass is not something he'll want to do because it'll leave him gasping for breath after every five feet.

Anything that takes a lot of effort will leave him gasping, but if he's otherwise pretty fit, he should recover fairly quickly.

Crackling and wheezing sounds in the lungs are a sign of fluid in the lungs. With severe pneumonia you'll be able to hear wheezing without a stethoscope, and you may be able hear the crackles if you listen closely.
The doctor will probably use a stethoscope to listen to the lungs, and crackles (the doctor might call them rales) is a quick way to diagnose pneumonia (or congestive heart failure) while in the field, but many heavy smokers will already have minor crackles and reduced breathing, so that can add a complication to diagnosing and/or determining whether a patient has recovered. If there are crackles/fluid sounds throughout the lungs the patients odds of survival without antibiotics are pretty low, but if they are only in one lung or only in the bottom half/halves the odds are much better.

Congestive heart failure (CHF) is something the doctor will probably try and rule out since if the left side of the heart fails fluid backs up into the lungs and it can look like pneumonia. If they have an ambulance they'll also have a cardiac monitor and pulse oximeter, although whether or not the batteries are still good is up to you. The doctor is going to want hook the patient up to a cardiac monitor to make sure it's not CHF. The pulse oximeter monitors pulse and how much oxygen is getting to the extremities. A healthy resting O2 saturation is 94-98%, but a heavy smoker is going to have a lower sat even without pneumonia. Since other than smoking he's relatively healthy I would guess that for the patient a normal resting O2 sat would be about 90-95%

An ambulance will also have oxygen tanks. Whether the expiration dates have passed is up to you, and whether the expiration dates are ignored is up to the characters. The doctor will want to hook up oxygen if the patient's O2 sat is less than 90% and the patient is confused or sluggish. An ambulance will probably have 2-3 small oxygen tanks on board with about 600 L capacity (although this might vary depending on the ambulance service). For an O2 sat of 85-90% he'll probably just use a nasal canula to conserve O2 and the airflow will be 5 L/minute. If the O2 sat is lower than that the patient will probably be unconscious and the doctor will use a face mask with the airflow set at 15 L/minute. As you can tell with airflow set that high the oxygen won't last very long.

The real trouble is an ambulance isn't going to have much in the way of antibiotics, which is what you really need to fight pneumonia rather than just treat the symptoms.