Fever: When Home Care Ends and the Hospital Begins

If this is happening right now

If the person with fever is confused, unusually drowsy or hard to wake, is breathing fast or with visible effort, has cold, clammy or mottled skin, has passed very little urine since morning, or has had a fit — call 108 now. Do not wait for the fever to break, do not wait for morning, and do not spend the next hour driving from one hospital gate to the next: the ambulance network knows which centre nearest you is equipped for what is needed, and treatment starts in the vehicle rather than at the end of the journey. PPK Hospital, Marthandam runs a 24-hour emergency service with intensive care and ventilator support, and a senior specialist is available round the clock. If breathing stops or the person cannot be roused at all, that is a collapse — start hands-only CPR and call for help. Everything below this line is written for the fever you are still watching at home, not the one in front of you now.

What ICU and ventilator care involve →

What a fever actually is

A fever is not the illness. It is the body deliberately raising its own thermostat, usually because the immune system has met an infection and is mounting a response. This is why a temperature of 103°F in an otherwise alert young adult who is drinking and passing urine normally worries a doctor far less than 100°F in a drowsy, dehydrated elderly man. The height of the reading tells you surprisingly little about the seriousness of what is causing it, and families spend far too much of their worry on the number itself. What tells you a great deal is how the rest of the person looks: whether they are alert, whether they are drinking, whether they are passing urine, how they are breathing, and how their skin feels to the back of your hand. In intensive care we rarely ask what the temperature peaked at. We ask what the patient was doing at the time.

The five signs that end wait-and-watch

These are the ones an intensivist looks for, in the order they usually appear. Confusion or unusual drowsiness — not being able to hold a normal conversation, sleeping through the day, or simply “not himself” in the words the family uses. Fast or laboured breathing — breathing you can count across the room, nostrils flaring, the chest working, or a sentence that cannot be finished in one breath. Very little urine — a whole morning or a whole night with no urine passed, or urine that has become dark and scanty, which is one of the earliest signs that circulation is struggling. Cold, clammy or mottled skin, especially hands and feet that stay cold while the body is hot, or blotchy patches over the knees. And fever in a person with diabetes, an elderly person, or anyone on steroids, chemotherapy or other immune-lowering treatment. A persistent or worsening fever plus any single one of these is a same-day hospital visit — not a wait-and-see, not a teleconsult, not tomorrow morning.

Why there is no three-day rule

Almost everyone here has been told to wait three days before seeing a doctor for fever, and the advice survives because most viral fevers do settle in that time. The trouble is that the rule fails at both ends. A person with any of the red flags above must not spend three days at home proving the point, because deterioration in serious infection is measured in hours. Meanwhile a fever that continues quietly into the fifth or sixth day in someone who looks reasonably well is also not normal, and neither is one that settles and then returns a day or two later — both mean the body has not finished with whatever this is. Replace the calendar with a pattern: persistent or worsening, plus any red flag, equals care today. If neither is true, watching carefully at home for a couple of days is reasonable.

Fever in the rainy season

From the first heavy rains through to the retreating monsoon, fever fills every waiting room from Marthandam down to Kollemcode and up into the rubber estates. Whole households go down one after another, and the natural response is to pattern-match: the neighbours had the same thing, they took such and such, so we will do the same. That is the single most dangerous habit of the season, because several different illnesses look identical in their first two days and only one of them may be the one that turns. Seasonal fever does not get a relaxed set of rules. If anything, the threshold for getting a fever looked at properly should drop during those months — not because panic helps, but because a blood test taken on the right day is worth more than any amount of family diagnosis.

Fever in diabetes, old age and low immunity

This is the group that fills intensive care, and the reason is cruel: the people at highest risk from infection are the ones whose bodies announce it least. In diabetes, in advanced age, and in anyone on steroids or immune-lowering treatment, a serious infection can run with a low-grade temperature or no fever at all. What appears instead is drowsiness, a fall, a sudden loss of appetite, confusion the family puts down to age, or sugar (blood glucose) readings that will not come down however faithfully the medicines are taken. Rising sugars during any illness are themselves a warning worth acting on, and insulin should never be stopped because someone is not eating — the sick-day rules explain what to watch and when to come in. A fever together with a foot wound, spreading redness or a foul-smelling ulcer is a same-day emergency in diabetes, never a weekend problem — see diabetic foot and neuropathy.

What a pulse oximeter can and cannot tell you

Most homes now own an oximeter, which is useful when it is read correctly. For most adults an SpO2 of 94% or above is normal. A reading below about 92 to 93 per cent, or a number that has been drifting downward over a few hours, or breathlessness that is clearly worsening, means hospital now. Three cautions matter more than the device’s accuracy. First, a normal reading does not rule out serious illness — a person can be gravely infected with an oxygen level of 97%, and no oximeter has ever examined anybody. Second, the trend beats the snapshot: one number means little, four readings over an afternoon mean a great deal, so write them down with the time beside them. Third, cold hands, nail polish, movement and a poor grip all produce falsely low readings, so warm the hand and repeat before believing a bad number — and never let a reassuring one delay a hospital visit that the person’s condition has already earned.

Do not self-prescribe antibiotics

Antibiotics are sold too easily in this district, and half-finished strips sit in most kitchen drawers. Starting one at home for fever does three kinds of harm: it does nothing at all if the fever is viral, which most fevers are; it can blur the picture, so that blood tests taken later are harder to interpret and the real diagnosis is delayed; and it adds to the resistance that is making the serious infections we treat in intensive care steadily harder to control. Whether an antibiotic is needed at all, and which one, follows examination and the tests that examination indicates. The same applies to a strip a relative was prescribed for something that sounded similar last month — a prescription belongs to one illness and one person.

Sensible care while you are watching at home

For a fever without red flags, the work at home is observation, not treatment. Keep fluids going in steadily — water, buttermilk, rice kanji water, whatever is actually drunk — and use urine as the honest measure: passing water regularly and pale is reassuring, scanty and dark is not. Rest properly rather than pushing through a day’s work. Do not sponge with ice-cold water; comfortably cool water and a well-aired room are enough. Medicine that brings the temperature down makes a person feel better but does not treat the cause, so a fever that climbs again as it wears off is information rather than failure. Keep one simple record on a piece of paper — temperature with times, how much was drunk, when urine was passed, how the breathing looked — because that page is the most useful thing you can hand a doctor, at PPK or anywhere else.

What happens when you do come in

Knowing what to expect removes some of the reluctance. The assessment is mostly clinical: how the person looks, pulse, blood pressure, breathing rate, oxygen level, temperature and an examination for the source of the infection. Blood tests are ordered as required, and the results decide whether this is something to treat at home with a review, something to observe in hospital for a day, or something that needs intravenous fluids, oxygen and closer monitoring. Bring all current medicines in their strips, recent reports, a note of past illnesses and allergies, the date the fever started, and your piece of paper. PPK Hospital, Marthandam has a 24-hour emergency service and intensive care with ventilator support if the illness turns out to be a serious one — and most of the time, having been checked properly, it does not.

Related

• ICU & ventilator care — what families should know
• Fever, vomiting, high sugar: the sick-day rules
• Someone collapsed — the next ten minutes
• Critical care with Dr. Ruskin