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.

More from Milot

My internet access is a bit better and I'm posting some observations from several days ago. More to follow.

The flight to Cap via Turks was uneventful and I was happy that we could squeeze all the necessary supplies into Ed Constanine’s Baron. Although We didnt what the sunrise, the light playing off the clouds and casting shadows on the Carribean was amazing. After some unusual ATC instructions in French,we broke out over the harbor at Cap, an interesting experience with no radar coverage. The airport was quiet. Immigration d was empty and we actually had to find someone to stamp my visa. The customs agents, however, had the time to open and inspect every box. Ray, the hospital COO, was there, and after some closed door discussions, it appeared that our charitable donations would be allowed into the country.



Despite warnings from the State Department regarding post election violence, the streets were calm and other than some vandalized political billboards, it would be hard to tell that there were any significant issues. The cholera epidemic did not seem to affect the street vendors, and there was the normal buzz of activity around the hospital and the open air market.




Accessing the compound, however, there was a clear change since my last visit. Security was much tighter and fences had been erected to isolate the cholera ward. You could only enter through a decontamination tent, where you put on boots and gloves. Dilute Clorox solution was spread about in open bins, and hand cleansing was mandatory. The former school had been converted to a cholera ward and special beds (with a hole cut in the middle, to allow the diarrhea to drain,) were arranged in three rows. Some children looked better than I expected, although those early in the rescucitation were still quite lethargic. A nurse, who had heard that I was coming, asked, if I knew where there were some Lactated ringers for IVs, - they had been told by staff that there was no more, and patient census was increasing. I found several liters and a fresh case at other sites less than 100 yards away – I guess that confirms why we need the inventory system.

There was a different intensity since my last visits. The volunteers remain as committed as ever, and it was good to see familiar faces. The patients are more acutely ill and get better or die quickly. The treatment of cholera isn’t as dramatic an earthquake victims with crushed extremities, yet diarrheal illnesses remain one of the leading causes of childhood death worldwide. Over the next month we will potentially save more lives than after the earthquake, quietly and competently.

And if we can get this inventory system up and running, we might even find the Lactated Ringers we need, without me raiding my secret stash…

On the Ground in Milot

We have had continuous rain, which makes it tough on our staff trying to treat the cholera victims. In addition, the internet and cell phones have been very intermittent. I'll write more tomorrow.

As expected, the staff is doing an amazing job with an increasing number of patients. The political unrest has died down and in fact, the atmosphere in Cap was quite easygoing.

I need to get off to allow others a chance to check in with their world.

No me bulee

H

Clarity of Thought in the Dark of the Night

As a surgery resident, our schedule required an early arrival at the hospital to check on the patients prior to starting the day’s schedule. The hours from 4-6 am brought us into a quiet world, with virtually deserted streets, and a peacefulness that I certainly appreciated before the hectic day commenced. Although a bit sleepy, there was clarity of thought. There’s something special about “0 Dark 30”

I was actually looking forward to experiencing that again this morning, as Ed Constantine and I were to meet at the Boca Raton airport at 0500, to begin a trip that would take the computer equipment and me to Milot via Turks and Cap; then Ed flying back the same route bringing CRUDEM volunteers to the States to catch evening flights home. In previous posts, I mentioned looking forward to sunrise from the cockpit. The schedule once I got to Milot was also tight, as I needed to work with the local hospital administration on their perspectives to ensure a successful rollout and begin the pharmacy inventory. I also wanted to give the local physicians treating the cholera victims (we have 600), some help.

I spent last evening with my brother in Boca, and slept fitfully. A front was moving through and the wind was picking up. At 4 am I looked out at the palms in the back swaying against the black sky.

Not surprisingly, the phone rang at 0430. It was Ed. He had just finished a briefing that included gusty winds, the possibility of thunderstorms, and an approach into Cap that was doable, but depended on several issues lining up. The flight could be done legally, the question was should it be. There were volunteers that would miss flights home, and my time in country, which was already reduced due to the impending move to California, would be further cut. We were 2 experienced pilots, and prided ourselves on the ability to manage risk and use our aircraft to their fullest capacities. Ed had seldom, if ever, had to cancel a relief flight for CRUDEM. The conversation lasted about three minutes.

We immediately cancelled until tomorrow.

It’s important to have the confidence to move ahead and accomplish a goal, and risks are inherent to any decision. As surgeons, we must have a level of healthy narcissism to open another human being and correct what nature has turned awry. We also must pause to recognize when risks exceed benefits and develop alternative plans. The older I get, I find myself paradoxically more confident and more aware of risks. Perhaps, it’s knowing that you will accomplish your goals, despite setbacks, even if it takes a brief delay to regroup. I didn’t always see that as a younger man. In the blackness that is 0 Dark 30, is the knowledge that the sunlight will be soon be coloring the Eastern sky.

Catch you tomorrow from Haiti.

A Last Run with the Handsome Men

Saturday dawned cold and windy, but the sky was cloudless, and the sunlight's low angle cast long shadows over the homes and gardens of the East Side, creating Dali - like abstractions. As I turned the car down Intervale, the crew were already gathered, exchanging insults over who wasn't tough enough to wear shorts in the 30 degree weather. It seemed like any other Saturday.

But I realized it was my last run with the Handsome Men, before starting the journey to California, via Haiti.

I've described the group before - attorneys, an accountant, an English Professor, businessmen. All have long term connections to Providence, and as they welcomed me to join them 4 years ago, I didn't realize this would be more than just exercise. I would learn about the city, its politics, friendship, and about myself.

It's easy to generalize about men getting together to play or watch sports - that the posturing, the sense of confidence, and irreverance is a way to maintain the right to belong in a competitive environment. But as I would listen during the runs, I recognized that deeply seated relationships developed, even though we may not be emotive in displaying them.

This morning, I chose the route, and decided on "2 bridges" - down Elmgrove to Angell, across the river on the red bridge to East Providence, down to Broadway, then back along the East Bay Bikepath, with views of the water and the city. We would cross back on the I195 bridge, and head up Gano from India point. I wanted to watch the sunlight reflect of the buildings and the Bay, and take in the images.

We started off at an easy pace, our joints beginning to warm up and the discussions centering around the Celtics and politics. I ran past our old house on Hazard - Christmas lights were out and I was happy that the new family was settling in. The guys asked me about the job and LA. They have been a sounding board over the last year as I redirected my professional efforts. They helped me think through options and kept my perspective aligned. And they occaissionally would kick my ass if I got too introspective.

We crossed the bridge outbound and the wind was kicking up - I'm not sure I'll miss that in SoCal. Although at first we would run 5 across in the street, traffic was increasing and we stretched out into pairs. These would rearrange depending on pace and rest stops. We got our water and gels on Warren and headed up the hill on the path. I may have gone out a bit quickly, and started to lag behind. I motioned the others to go ahead, and they finished the hill, then waited. We worked our way back to the East Side, and I admired the city from the bridge. A floating duck blind with a couple of hunters passed underneath.

The unwritten rule is that once we turn back onto Elmgrove, you can pick up the pace heading for home, even if you break away from the group. I was definately slower today and expected that I would finish up well behind them. But on that day, everyone stuck together. It was only in the last quarter mile, mostly downhill, that we sprinted. I finished in the middle of the pack.

We exchanged high fives, and checked our times. "Another one in the books," Alan always says. The goodbyes weren't awkward - I had come into the group, and it was now time to move on. Handshakes, bear hugs, and good luck. We made plans for them to come to California for the 100th Bay-to-Breakers. I'd love to get back for the Blessing.

So why this story in a Blog about Haiti?

As a surgeon I was taught to be self reliant, and not show weakness. I missed out by doing that. I learned in Haiti about faith and interdependence. I learned from my colleagues at Miriam that a common vision of compassionate patient care can help overcome turf issues, and I learned from my running group, that sticking quietly together, even if you can break away on your own, is the greatest sign of acceptance and support. (And now you can kick me for being introspective.)

One more interesting event later that evening. I was with an acquaintance who said he saw me running up Elmgrove with the group on the way back. I mentioned the Handsome Men - turns out he knows a few of them, and is a runner himself. Maybe the numbers will be maintained...

I'll be checking in with you on my way to Milot later this weekend - it should be intersting. Given the current situation, we felt it prudent to fly the inventory computer equipment privately to CAP. I'll be in the right seat and hope to send you some pictures. I'm told that sunrise over the dark Atlantic is spectacular.

Transitions

The recent elections in Haiti were, as expected, wrought with accusations of fraud, outbreaks of violence, and general disarray. However, despite the cholera epidemic and continued refugee issues, the citizen gathered to vote for a new president to replace Previl. His supported candidate Celestin has been seen as both a continuation of the current corruption as well as a pragmatic leader. There are 18 parties involved, and opinion poll leader Mirlande Manigat, has filed protests with 11 others regarding irregularities. American rapper Wyclef Jean, although declared ineligible to run, is in the country and calling for a rapid response to these allegations, citing the risk of violence. And we won’t see preliminary results for another week. Such is the nature of transition.

At Sacre Coeur, we continue to respond to the cholera outbreak. The uprisings in Cap have settled down and in Milot, our volunteers are beginning to return. We still need supplies, and hopefully the relative calm will allow us to bring them in. Tim Traynor, our overall technical and construction wizard is back on site, and we are ramping up the sprung building inventory project. The political climate remains uncertain, however whoever is declared the new President will have unprecedented amounts of support to try to rebuild his country. The transition will be more vocal and chaotic than in the US, but it will occur.

And my own transition also begins. Those of you who have followed my blog know that I have been on a Sabbatical from my academic surgery practice as I returned to school and looked at new options. The times in Haiti, my children growing and leaving home, as well as other experiences have brought me new perspectives on the next phase. This past year, though difficult in many ways, has been a gift. But as I looked at new job opportunities, I was able to relate the lessons learned from the past and this helped me focus on the future.

Beginning January first, I will be heading west and relocating to Los Angeles to join Cedars Sinai Medical Center. I will be involved in the clinical transformation project, Cedars Medicine, as well as serve as administrative Vice Chairman of a large and talented surgery department. I am excited about the opportunity.


Every day we see a transition from the darkness of night to light of day and I will look forward to sunsets over the Pacific. I remain hopeful that a new day will also dawn for Haiti, although if history is any guide, there may be a few storms along the way.

Appreciate the Present

So, many bloggers will reflect on the upcoming Thanksgiving weekend, where families and friends will gather, eat and drink too much, and enjoy the present, even if some of the actions aren't completely healthy long term. It's important to appreciate the now, even as we plan for the future.

Over the last year, I've had more free time than in the previous 30 years combined. At first, I was antsy, that I needed to find something to do, besides school. My previous days as Chief of Surgery had been filled with a constant stream of information, decisions, triumphs. and challenges. Often times, I would forget to eat and by the end of the week, it seemed all seemed like a blur. There were certainly high points - a great conversation with family, friends, or colleagues; a warm Seven Stars roll; a patient that had turned their life around after bariatric surgery. Yet on balance, it was difficult to appreciate the now.



I recently came across the enclosed picture. It reminded me of the gifts I've been given recently with time. Chester and I have had numerous walks through the woods. When I was working, dog walks were fit in to a schedule and the goal was pretty clear. Now they are part of an experience of the day. I appreciate the changes in the sunlight filtering through the leaves as the seasons progess.

Even in Haiti, amid the chaos, we felt the presence of the moment. It is an awareness of the balance of powers and emotions. Trying to project into the future removes the chance to experience the now.

I will be returning to academic medicine in a more formalized role January first. There are several things I want to achieve long term. As I work to those goals, staying present will help me understand the motivations and needs of those around me, and how to work to reach those goals. And during my trip back to Milot in December, I know I will again be energized by those around me by staying in the present.

For those who are traveling - be safe...