The Medical Record

In the US, a great deal of emphasis is being placed n the use of an electronic medical record to reduce errors and duplications, as well as increase patient safety. Meaningful use initiatives will create incentives (and penalties) to encourage integration of the EMR into practice. Many of my primary care colleagues have had to reduce the number of patients seen as they integrated the record. Those of us that do not have the keyboarding skills of our children feel inadequate as we hunt and peck. Some have gone as far as hired scribes to enter data for them as they spend more time actually with their patients.

In Milot, we are fortunate if we can even register the flood of cholera patients.




After the quake, the population had swelled, and those acutely ill patients died fairly rapidly. Others were in the hospital for a prolonged period for treatment of open wounds or orthopedic injuries. We were able to keep a rudimentary chart on a clip board, and placed a large cardboard sheet above each bed, listing the patient's name, injuries, operations and dates, and PT needs. We didn't worry about HIPAA and with the rapid turnover of medical personel, essential information was rapidly available.

The treatment of cholera is far more acute. Patients present in various stages of shock, and must be rapidly triaged to those that can drink and be rescucitated with oral solution, those that will need a brief IV, and moribund patients, especially children. Obtaining IV access is crucial, and not easily accomplished. Formulas for IV rate is pretty simple - wide open until fluids in begin to exceed diarrheal output and you can again feel a pulse. Over the last few days, the epidemic has spread to the hills toward the Citadel and 40-50 new patients are making their way to Sacre Coeur. We had three doctors and 2 nurses, as well as our Haititan counterparts. Coverage at night was spotty. By morning light, we would find 10-15 new admissions lined up on stetcher or waiting outside the tents. Some of the docs and nurses became concerned that we couldn't register and document them all. At dinner, the consensus was take care of the patient first, worry about registration and documentation later. Once we made that mental shift, the ability to respond to the increasing volumes increased. In many ways, it was a tremendous relief.

At the same time, a physician from UT San Antonio arrived with Project Hope, and several hundred interossous needles that could be rapidly placed in the bones children and adults who were so dehydrated that we couldn't start ivs. He was to have stopped by earlier, but the violence delayed his trip. Circumstance helped us, as he was there when we most needed the help.

I recognize that in a coplex process such as patient care, good documentation aids in passing on vital information. In my roles in the States, I was responsible for ensuring that processes were documented and billed appropriately. I also saw where multiple repetitive layers of documentation and policies created more fatigue and potentially impacted patient care.

In ATLS we deal with the essential ABC of airway, breathing, and circulation. (and D is not documentation) In Haiti, we use what limited resources, including time, we have to save as many lives as we can.

And it's nice to remember why we became healthcare workers, and document that enlightenment in a blog.