10 Things to do Today

Tomorrow is the first day of a new year. Resolutions will be made, new leaves will be turned over, and fresh starts will be taken. As a big believer in lists, I'd like to offer a list of things to do TODAY........things that will clear the way for a healthier new year.

_____1. Clean out the medicine cabinet.

If possible, relocate the contents to another area of the house. The heat and humidity of the typical bathroom are not good for medications.

_____2. Throw away any prescription medications more than a year old.

Medicines lose their potency and may even be harmful if they are expired.

_____3. Make a list of all medications, including over-the-counter and herbal medicines.

Include the name of the medicine, the strength (mg, units, etc), the prescribing doctor's name, and the way that it is taken (twice daily, at night, with meals, etc.)

_____4. Make a copy of the medication list. Place the list in a clear jar with a lid, and place the jar in the back left corner of the top shelf of the refrigerator.

In the event of an emergency, loved ones and EMS will not have to dig through a pile of paperwork to find the medication list.

_____5. Program an "I.C.E." number in your cell phone.

I.C.E. stands for In Case of Emergency. Program the number of the person that you would like to be notified if you are unconscious or unable to speak. Many EMS, fire, and police departments now look for this number in an emergency.

_____6. Check your thermometer. Does the digital display work?

If you do not have a digital thermometer, get one. They are easy to use, will not shatter, and do not contain mercury.

_____7. Throw away any sunscreen left over from last summer.

Sunscreen ingredients do not have a long shelf life. Using a sunscreen that has been open for a year could result in an unexpected sunburn, and increases the risk of developing a cancer related to sun exposure.

_____8. Replace the batteries in the emergency flashlight in the medicine cabinet.

An emergency flashlight in a known location is important to prevent falls and/or injuries in case of a power outage.

_____9. Replace the batteries in ALL of the smoke detectors in the house.

This should be done twice yearly. Replacing the smoke detector batteries on New Year's Eve and the Fourth of July makes it easy to remember.

____10. Have a happy, healthy, and safe new year!

Snow in Galveston and Cold Weather Tips

I realize that snow in December is not shocking for many of my northern neighbors, but in Galveston, Texas, snow at anytime is a shocker.  I also know that most people know the common sense tips for staying healthy in cold weather:

*Avoid going outdoors in extreme cold unless absolutely necessary.  This is especially important for children and the elderly.

*Dress warmly, and in layers, to avoid overheating during exertion.  

* Most body heat is lost through your head, so wear a warm hat that covers the ears.

*Mittens provide more warmth to your hands than gloves.

*Wear insulated, waterproof boots to prevent frostbite and to keep firm footing on snow and ice.

*Stay hydrated and well fed during outdoor activities.

*Be aware that some cold weather activities, such as snow shoveling, may place a strain on the heart from overexertion.

*Pay attention to the weather forecast and be prepared for a sudden change in the weather.

A few days ago it was 79 degrees here on the balmy Gulf.  Most of the island residents are unprepared, and many don't have heat in their homes.  (Of course, many don't have homes after Hurricane Ike, but that's another story.)  For this reason, I have developed a very special set of 

COLD WEATHER TIPS FOR GULF COAST RESIDENTS

*Don't surf if there is snow on the beach.

*Dress warmly, in layers.  A bikini AND shorts do not constitute layers.  A winter coat is required.

*Most body heat is lost through the head, so wear a warm hat.  A ballcap, regardless of decoration, does not qualify as a warm hat.

*Wear gloves or mittens or socks or anything warm that you can put on your hands.  Do not bother to go to the local WalMart to find snow gloves.  They do not have any.  They do have small plastic packets called "hand warmers" that will warm hands nicely.

*Flip flops are not proper snow footwear.  Wading boots are not proper snow footwear.  Cowboy boots are not proper snow footwear.  Tennis shoes are not proper snow footwear.  Your hunting boots will do.

*Drink plenty of water.  Avoid alcohol during snow-related outdoor recreation.  The alcohol may temporarily make you feel warmer, but it actually causes you to lose heat faster.  Passing out in the snow on the beach will also make you lose heat faster.  

*Don't let your kids stay outside until the snow melts.  They don't control body temperature as well as adults. 

*Call and check on your mama.  Older folks don't control body temperature very well, either.  

*Don't try to shovel the snow, especially with the garden hoe.  It will all be melted in a few hours anyway.

*Enjoy this moment.  Never before has a hurricane destroyed the island and been followed ninety days later by a snowstorm.

Photo courtesy of Catrena Hughes

  

Are You an Aggressive Driver?

Answer these questions:

 

1.)           Do you speed?  If the answer is yes, do you exceed the speed limit by more than 10%?

2.)           Do you ever change lanes without using a signal?

3.)           Do you change lanes whenever you want, even if another driver will have to slow down?

4.)           Do you pass on the shoulder?

5.)           Do you pass in an emergency lane?

6.)           Have you ever raised your voice in anger at another driver?

7.)           Have you ever used obscene gestures toward another driver?

8.)           Have you ever adjusted your speed to prevent another car from passing?

9.)           Have you ever intentionally driven too close to another vehicle to “pay them back” for bad driving?

10.)        Have you ever merged into a lane without a signal or without adequate room for your vehicle?

 

A “yes” answer to any of the first 5 questions constitutes a traffic offense known as aggressive driving.   A “yes” answer to any of the second five questions constitutes “road rage”.  The exact number of motor vehicle crashes caused by aggressive drivers is unknown, but NHTSA has previously estimated about 66 percent of all traffic fatalities annually are caused by aggressive driving behaviors, such as passing on the right, running red lights and tailgating.

A nationwide study by NHTSA of fatal crashes at traffic signals in 1999 and 2000 estimated that 20 percent of the vehicles involved failed to obey the signals. In 2004, more than 900 people were killed and an estimated 168,000 were injured in crashes that involved red light running. About half of the deaths in red light running crashes are pedestrians and occupants in other vehicles who are hit by the red light runners.

 

Some of the factors linked to aggressive driving include:

Crowded roads

Being in a hurry

Road work

Stress from other areas of life

Dangerous driving attitudes

Selfishness

 

There are a number of common tips for avoiding aggressive drivers such as:

 

Leave plenty of room to merge

Avoid eye contact with other drivers

Ignore obscene language and gestures

Always obey traffic laws

Leave the left lane available for passing, regardless of your own speed

Report aggressive driving to the proper authorities

 

It is the season of shopping, stress, and crowds, however, so here are a few tips to avoid BEING an aggressive driver:

 

Leave plenty of time to reach your destination – this may mean doubling the time you think it will take.

 

Avoid multi-tasking – talking on the cell phone, text messaging, reading, completing your shopping list.

 

Don’t drive hungry, inebriated, or exhausted.

 

Know where you are going.  (Prevent the frustration of being lost.)

 

Make this your holiday gift – forgive the transgressions of those drivers less talented than yourself. 

 

HAVE A SAFE AND HAPPY HOLIDAY!

Report Card Recommendations

Yesterday at a press conference in Washington, D.C. the American College of Emergency Physicians released the 2009 Report Card on the State of Emergency Medicine.  The Report Card makes eight national recommendations from a blue-ribbon panel of experts with expertise in areas including hospital emergency care, public health, disaster preparedness, injury prevention and emergency medical services.  Each state Report Card contains recommendations specific to each state.  The national recommendations are:

 

1. Create stronger emergency departments through national health care reform.
2. Alleviate boarding in emergency departments and hospital crowding.
3. Pass the Access to Emergency Medical Services Act.
4. Enact federal and state medical liability reforms.
5. Infuse a greater level of federal funding and support into disaster preparedness targeted for medical preparedness and response.
6. Increase support for the nation’s health care safety net.
7. Develop greater coordination of emergency services.
8. Increase the use of systems, standards and information technologies to track and enhance the quality and patient safety environment.

 

The five Report Card categories (and weightings) are:

 

·       Access to Emergency Care (30 percent) — the District of Columbia ranked first, and California ranked last.  This category contains 26 measures that include the number of emergency physicians and percent of population without health insurance.  New measures since the 2006 Report Card include the number of nurses and on-call specialists (e.g., surgeons, orthopedists), percent of physicians accepting Medicare, hospital closures in 2006 and staffed inpatients beds.  Other new measures assess what percent of the population live within 60 minutes of a trauma center and whether additional primary care or mental health services are needed in the state.   

 

·       Quality and Patient Safety Environment (20 percent) — Washington State ranked first, and South Dakota ranked last.  This category contains 15 measures  New measures include whether the state funds quality improvement of the state’s EMS system, requires reporting for adverse events and hospital-based infections or funds a state EMS medical director. Also included is whether the state has (or is working on) emergency cardiac and stroke systems of care and the percent of hospitals using computerized practitioner order entry and electronic medical records. 

 

·       Medical Liability Environment (20 percent)  — Colorado ranked first, and the District of Columbia ranked last.  This category contains 21 measures that include whether the state has caps on non-economic damages, uses pre-trial screening panels or has abolished joint and several liability.  New measures include average malpractice payments and the average medical liability insurance premiums of primary care physicians and medical specialists.  This category also assesses the number of lawyers (not included in the grading).

 

·       Public Health and Injury Prevention (15 percent) – Massachusetts ranked first, and Louisiana ranked last.  This category contains 23 measures that include the percent of alcohol-related traffic fatalities and seat belt use, as well as motorcycle helmet use.  New measures include whether states have child safety seat legislation and the percent of the population that are obese, smoke and engage in binge drinking.  In addition, new measures include what percent of tobacco settlement funding is spent on health-related services and programs and the number of homicides and suicides. 

 

·       Disaster Preparedness (15 percent) — the District of Columbia ranked first, and Tennessee ranked last.  This new category has 31 measures that include how much federal disaster preparedness funds are spent per capita for medical preparedness and whether an all-hazards medical response plan is being used.  It also includes whether the state planning process involves input from emergency physicians and whether plans are in place for patients with special needs, such as those who need medications or dialysis.  In addition, it assesses whether the state has a real-time notification system (to notify health care providers of a disaster), a statewide patient tracking system, a statewide victim tracking system or a real-time (or near real-time) syndromic surveillance system. This category also assesses whether physicians and nurses are trained to respond to disasters, the state’s bed surge capacity and the number of ICU and burn unit beds.  It also assesses whether there are liability protections in place for health care workers during a disaster. 

 

The National Report Card on the State of Emergency Medicine was made possible, in part, by funding from the Emergency Medicine Foundation, which gratefully acknowledges the support of The WellPoint Foundation and the Robert Wood Johnson Foundation.

ACEP Report Card Released Today

Economic woes and a failing health care system mean more people than ever before are relying on emergency care at a time when the nation is receiving a substandard C- grade for it support of emergency patients, according to the 2009 Report Card on the State of Emergency Medicine.  Dr. Nicholas Jouriles, president of the American College of Emergency Physicians (ACEP), which released the report, said policymakers can no longer remain oblivious to what is happening in emergency departments and called on President-elect Obama and the new Congress to make emergency patients a top priority in health care reform proposals.

 

“Emergency medical care is the most overlooked part of our health care system, and also the one that everyone depends on in their hour of need,” said Dr. Jouriles. “Policymakers must make strengthening emergency departments a national priority. The role of emergency care has never been more critical to this nation.  It is an essential community service that can no longer be taken for granted.  Ninety percent of the states in this Report Card earned substandard or near-failing grades!  That is a national disgrace. The nation’s emergency physicians have diagnosed the condition and prescribed the treatment. It’s time to get serious and take the medicine.”

 

States that showed the best support for emergency patients are Massachusetts, which ranked first with the highest overall grade and the only B, followed by the District of Columbia and Rhode Island (tied for 2nd) and Maryland (ranked 4th), which earned a B-.  States showing the least support for emergency patients are Arkansas, which ranked last (51^st) with the only overall D-, followed by the D states of Oklahoma (ranked 50^th), New Mexico (ranked 49^th), Oregon (ranked 47^th) and Idaho ranked 46^th).

 

The national grades are based on population-weighted averages for each of the categories, calculated using the same methodology used to calculate the overall state grades.  The overall grade for the nation is a weighted average of the nation’s category specific grades.  The Report Card measures state support for emergency patients — not the quality of care provided at specific emergency departments or hospitals.  The national category grades are: 

Access to Emergency Care:  D-

Quality and Patient Safety:  C+

Medical Liability Environment:  C-

Public Health and Injury Prevention:  C 

Disaster Preparedness:  C+.

 

ACEP’s first Report Card was released in 2006, and it contained 50 measures in four category areas.  The new Report Card has more than double the measures (116) and a new category for disaster preparedness, which makes it more comprehensive and useful, but not directly comparable to the previous Report Card.  It was made possible, in part, by funding from the Emergency Medicine Foundation, which gratefully acknowledges the support of The WellPoint Foundation and the Robert Wood Johnson Foundation.

 

The focus of health care reform efforts has been on the distant future at the expense of the right here, right now.  The emergency care system is a "ticking time bomb," accelerated by the financial crisis, plus physician shortages that won’t be solved for at least a decade.  Economic woes and a failing health care system mean more people than ever before will be relying on emergency care.  In an ideal world, everyone will have a medical home, but this won’t happen for many years to come, if ever.  Meanwhile, every minute of every day in this country people need emergency medical care, and that need is growing  our population ages and lives longer.  Emergency departments are already crowded to the point where patients experience life-threatening delays in care.  With crowding forecasts described as ‘catastrophic’ in the near future, the time for action is now.

 

Greetings from Orlando

I am in Orlando, Florida, attending the American Medical Association Interim Meeting. I have been here several days, participating in and observing the workings of this complex process. The Section Council on Emergency Medicine represents the interests of emergency physicians in this venue. The Section Council on Emergency Medicine includes:

John C. Moorhead, MD, FACEP, Chair
Nancy J. Auer, MD, FACEP
Michael D. Bishop, MD, FACEP
Brooks F. Bock, MD, FACEP
Stephen K. Epstein, MD, MPP, FACEP
Jo Linder, MD, FACEP
Richard L. Stennes, MD, FACEP
Jolie Holschen, MD, YPS Delegate
Keith Borg, MD, PhD, YPS Delegate
Camaran Roberts, MSS Delegate
Megan Quintinilla, MSS Delegate


Dr. Nicholas Jouriles, Dr. Linda Lawrence, and I represent the Board of Directors of the American College of Emergency Physicians. There are emergency physicians involved in all levels of leadership in the AMA, as Delegates, as Alternate Delegates, and as members of the Board of Trustees.

The Section Council on Emergency Medicine and all interested emergency physicians met yesterday to discuss position and strategy relevant to AMA resolutions affecting emergency medicine. Approximately 116 resolutions and reports involve some aspect of emergency medicine, requiring careful consideration and response.

The House of Delegates officially opened yesterday with an emotionally charged tribute to AMA Past President Ronald M. Davis, MD, who died four days ago after a courageous fight with pancreatic cancer. Reference Committees meet today, hearing testimony from parties interested in the various resolutions. As of the time of this posting, emergency physicians were in attendance at all the reference committees, offering testimony on behalf of their colleagues. The Reference Committees will consolidate the information and produce recommendations in their reports tomorrow.

Go Vote, America!

I've just finished my first shift, a night shift, after spending 9 days in Chicago for the American College of Emergency Physician's Scientific Assembly. My island and my hospital are slowly returning to something that more closely resembles our pre-Ike condition. UTMB is operating a number of outpatient clinics, but still has no inpatient beds. Our emergency department volume is up to 40 per day, about a quarter of our previous volume. Unfortunately, without on-call physician support and without inpatient beds, most of those patients are transferred to other facilities.

The cruise ships have returned, bringing the curious and the adventurous to see the ravages of the September 12th hurricane. Downtown still looks like a war zone, with rubble and destruction everywhere, but the noises of cleanup and construction promise a brighter future.

On a personal level, I now have hot water and air conditioning, two elements essential to life on the island. There are three pharmacies and two grocery stores open and fully functional. Two well-known national retailers have opened their doors for business. It is estimated that two-thirds of the island population has returned.

I also have the privilege of choosing my future today. No, I can't control the weather, the economy, or the war in Iraq, but I can choose the person who will govern our nation for the next four years. There will be record numbers of Americans turning out to exercise that same privilege today, and whatever the result, the existence of choice makes my life a better one.

Go Vote, America!

Your Child Needs a “Flu Shot”

The Centers for Disease Control and Prevention (CDC) changed the recommendations for pediatric influenza vaccination this year. Previously, the CDC recommended that children under 5 years old receive the flu vaccination. This year, the CDC recommends that all children between the ages of 6 months and 18 years be vaccinated.

Why the change? Although children less than 5 years are more frequently hospitalized for the flu, healthy school age children have higher rates of flu than other age groups. Recent research from Dr. John Brownstein and Dr. Kenneth Mandl, published in the Annals of Emergency Medicine, indicates that adult visits to emergency departments for flu-like symptoms increase by 4 percent for every 1 % increase in the pediatric population. The Harvard-based epidemiologists tracked adult winter emergency department visits for flu-like symptoms for four years. They found that influenza struck first and struck hardest in zip codes that had more children.

The flu vaccine protects 75 to 90 percent of adolescents and young adults from the flu. It is as much as 30 % less effective in people over 65, according to some research. The hope is that preventing the illness in the younger population may lessen the incidence and the severity of the flu in the older population. Dr. Brownstein and Dr. Mandl are currently conducting research to see if this is indeed the case.

This season, which has already begun, the United States has a large supply of vaccine, between 143 million and 146 million doses. Even with the approximately 30 million additional doses needed to vaccinate all of the children, the United States will have an adequate supply. It is also recommended that the following groups receive vaccinations:

**Those over the age of 50

**Health care workers

**Women who will be pregnant over the flu season

**Anyone with a chronic illness, such as asthma or diabetes

**Anyone with a weakened immune system

**Caregivers for the elderly and the ill

And now…..virtually all children between the ages of 6 months and 18 years.
(Children with serious egg allergies should not be vaccinated.)

One interesting place to consider receiving the flu vaccination is at the polling place where the national election will be conducted. Through a government sponsored program called “Vote and Vax”, the influenza vaccine will be offered on Election Day at numerous polling places. A similar program conducted in 2006 almost 14,000 doses were administered, many to people who had never previously received the vaccine. So, take your children with you on election day. You can protect their health and their future at the same time.

After Ike: The Good News and The Bad

Look carefully at this picture. Although residents of Galveston are never more than 1 mile from the water, we usually don't park our boats in the back yard. Local media have called this "unintentional dry docking" of watercraft. The workers laboring to restore electricity had to wait several days for cleanup crews to remove the mast from the power lines before proceeding.

The good and bad news is that residents of the island will be allowed to return on Wednesday, September 24th. There is some restoration of electricity. There is no drinkable water. The largest of the debris in the streets is removed (including the boats) but cleanup crews cannot enter private property.

Here are a few interesting recommendations for people returning to the island that most mainlanders probably have not considered.

*Tetanus booster, Hepatitis A, and Hepatitis B immunizations are required by the Health Dept before returning to the area.

*Among the cleanup supplies that people must bring with them (none available on the island) is a tire repair kit. Small, but sharp, debris remain everywhere, including the streets. There are no retail places to repair a flat. People returning to the island must be capable of fixing their own flats.

*Although running water will be restored very shortly, for several weeks all water must be boiled before drinking.

*Most refrigerators must be replaced. Food has been spoiling inside the refrigerators for 11 days now. No amount of cleaning will remove the contamination from the plastic. The city has issued instructions for preparing all debris, including refrigerators, for removal.

*Everything flooded must be removed.......plaster, drywall, studs (if soaked), upholstery, drapes, carpet, even wood flooring. Any material that adsorbs water will have mold growing by now. Even with ventilation and moisture removal methods, mold damage remains a risk.

*There is a 6PM to 6AM curfew on the island until further notice. (That's going to make it hard for me to get to work!)

*The hospital is still not functional for inpatient or clinic care. DMAT teams (from Connecticut and Ohio, thank you!) are providing basic care at this time. We will transition with them beginning late this week. In spite of that, as of today, we are still weeks from being able to provide anything more than stabilization and transfer.

*Our emergency medicine residents, who cannot afford to lose a month of their training, have been graciously accepted (temporarily) into several other programs for "away" rotations. Thank you very much to the EM programs in Corpus Christi and Houston for helping us out.

I'll keep you posted on the continuing recovery efforts.

Photo courtesy of Joshua Feinstein

Greetings from Los Angeles

Yesterday it was my privilege to give Grand Rounds at the Los Angeles County-Harbor-UCLA Emergency Medicine residency program. I gave a presentation entitled “Risk Management for Residents” to the emergency medicine residents, the emergency medicine faculty, and some very important representatives of the California ACEP Chapter. It was a highly interactive and energetic session, and I appreciate the interest shown by the residents.

I was able to present an update on ACEP activities to the residents , discussing the various initiatives of ACEP. I stayed for their journal club, learning a lot about the evaluation of chest pain and the [lack of ] communication between physicians. Dr. Robert Hockberger, chair of the department gave me a tour of the emergency department. It certainly gives a new perspective to crowding and boarding. He also shared the plans for the new emergency department, slated to break ground soon.

Harbor-UCLA has a host of famous faculty, and a number of them were kind enough to attend my presentation and lend their wisdom to the discussion, including Dr. Diane Birnbaumer,Dr. Marianne Gausche-Hill, and Dr. Roger Lewis. A special thank you goes to Dr. Medell Briggs-Malonson, Chief Resident, for her hospitality and finesse with all the details that make a presentation go smoothly.

I have a great deal of respect for the job that the entire medical community does at the Los Angeles County-Harbor-UCLA Medical Center. It is evident that everyone on the team works hard to provide great care in an environment that is challenging. Thank you to all for the invitation and for your gracious hospitality.

After Ike - Lessons from Rita don't work

Galveston Mayor Lyda Ann Thomas announced in a press conference yesterday that the island would implement the “Look and Leave” policy beginning at noon. Three hours later the policy was rescinded. Why? Three lanes of traffic lined up 15 miles, trying to get onto the island. The backup delayed emergency crews working to restore power to the crippled island. According to Texas’ oldest newspaper, The Galveston County Daily News, police had their hands full dealing with irate drivers trying to return to the island.

More concerning to me is the rumor that most of these people had no intention of honoring the “Look and Leave” provisions. Most intended to stay in their homes – without sanitation, water, or power. Dr. David Lakey, state health commissioner, has declared the island a health hazard, and warns of water-borne illness, food-borne illness, and the lack of health care on the island. UTMB is the state’s oldest medical school, and most residents have no concept of life on the island without nearby medical care.

Evidence of this was borne out today, when the Kroger grocery store opened. The Kroger suffered no flood damage, and only minor roof damage. They imported workers from neighboring workers, and brought in 16 dump trucks to carry out food spoilage. They were given clearance to sell packaged/dry goods and any remaining fruits and vegetables. They also opened the pharmacy, saying they would fill any existing prescriptions with a 72 hour supply. They also promised to honor new prescriptions, unless for narcotics, with a 72 hours supply. They declined to fulfill any narcotic prescriptions.

Guess what happened? Needing new or replacement prescriptions, people lined up to be seen in the emergency department. The emergency department, and indeed the entire medical facility, is closed. The DMAT teams are treating minor injuries and transferring serious injuries to mainland facilities.

My sources are in disagreement about what happened next, but the crowd eventually dispersed, upset and angry.

I am not in the middle of this maelstrom, but I ask these questions:

If the island is unlivable, why are people being allowed to live there?

If the island is a health hazard, why are people being allowed to live there?

If there is no medical care, no sanitation, no water, no electricity, and a grave health

threat to the remaining population, why are people being allowed to stay?

In a policy developed as a result of Hurricane Rita, residents were supposed to be allowed to come to the island between 6 AM and 6 PM to view their property. However, with 3500 people still living on the island 24/7, it is difficult to rationalize the 12-hour-only policy. What seemed so practical in 2005 has proven to be unworkable in 2008. Ah, well, another lesson learned. I feel certain that more are to follow.

For those of you with morbid curiosity, you may view the island by relatively recent satellite image at http://ngs.woc.noaa.gov/ike/IKE0000.HTM. The views were sufficient for me to tell that a corner of my roof collapsed, but the main structure is still standing. And, as I still maintain, it’s only stuff.

Galveston Update

Dear friends,
Thank you so much for the outpouring of concern and sympathy. I feel truly blessed to have such good friends. Here is the latest news from Galveston.

From a general standpoint:
80% of the island is damaged. UTMB is not seeing patients of any type at this point. DMAT teams are providing any necessary care. There is no electricity, no running water, and not enough fuel to start pumping water out of the flooded areas. Many of the emergency generators were damaged by storm. Phone lines and internet connectivity are spotty. Even cell phone coverage is unreliable. Today, UTMB estimates re-opening the doors with a skeleton crew next week. Services will be added as it becomes possible. It is just a guess that we may not be able to have inpatients for 4 to 6 weeks. Full operability of all the hospitals/clinics/outpatient services/area clinics will probably take months. Much of the operability of the hospital depends on the time it takes for the city/county infrastructure to be rebuilt.

This is emergency medicine's surge capacity nightmare. The nearest fully functional hospital is 60 miles away, in Houston, if someone has enough gas and a truck to get there through the water and the debris.

From a personal standpoint:
I am fine. I evacuated the day before the storm, and have been staying with my parents in West Texas. I will return to Dallas today or tomorrow. My home in Galveston is still standing......in 5 feet of water. The roof line is damaged and the front door was torn off, but the basic structure and most of the windows (?!?) are intact.

I am officially E2 personnel. I will be called back to Galveston in the next 3-4 days, and will live and work at the hospital until we go off emergency status. Hopefully they will be able to flush toilets and provide showers by then. My friends who are still there tell me it's a toss up as to what smells worse, the toilets or themselves.

My email is flooded. (Who knew that getting internet access in rural West Texas would be so hard?) The UTMB email is nonfunctional. I will try to post daily updates on the blog, and will answer my emails in as timely a fashion as possible.

I fear that the aftermath may be worse than the storm. The flood waters are a cesspool. There is no sewage or trash service. There is no electricity to run air conditioners and refrigerators. There is no water for washing hands or bathing, and I fear that even FEMA can't provide enough fresh water for everyone. There is not enough ice to keep food suitably cold, and not enough fuel to heat food properly. There is no gas to get off the island, and no stores to purchase goods.
AND....the storm hit Saturday a.m., but many of us have been displaced since the evacuation, seven days. Who knows how much longer the island will be unlivable?

I plan to provide updates through this blog. If you aren't a regular reader shame on you! No, seriously, please pass this on to others interested in the recovery: http://gardnersgate.blogspot.com/

Thank you again for all your care and concern in this trying time.
Angela

From a Hurricane Ike Evacuee

This post is a personal note to my friends, wherever they may be.

I am fine. My family is fine. I evacuated Galveston before the storm, and have been staying with my family in West Texas. My home in Galveston is at least underwater. Details will have to wait until someone can actually get to the neighborhood. (This is probably not a good sign.)

There are some true heroes of emergency medicine who stayed at UTMB so that many of us could evacuate with our families. They include my boss and friend, Dr. Brian Zachariah, Dr. Joshua Feinstein, Dr. Joe Chang, Dr. Paul English, Dr. Robert Goh, Dr. Brent Vasut, and Dr. Jim Hunderup.

I spoke with Brian today briefly, and have been told that they have no air conditioning, no water for showers, no electricity, and virtually no telephone or internet communication ability. Other than that, they are exhausted, but in good spirits.

They have treated about 100 patients in the past 36 hours, most of them relatively minor. The DMAT team arrived today, and now clinical care is being provided by the DMAT teams. (THANK YOU!)

Everything I heard was a mixture of good news and bad news......most of the university and hospital buildings appear to be structurally sound. There has been extensive flooding and some wind damage. Emergency operations have moved back to the Trauma Building. (For those of you unfamiliar with the campus, the Trauma Building, which houses the Emergency Department, is less than 100 yards from the water. The Emergency Department is actually on the second floor, and has a drive-up entrance ramp.)

All clinical activities at UTMB (other than emergency) have been suspended indefinitely. Emergency patients are stabilized and evacuated.

The bleak outlook for the island is the most distressing part of the news I received from the team today. The main water supply to the island is disrupted. Since it travels under the bay to the island, they cannot begin to fix the problem at this time. The Causeway is the only roadway to the island, and it is closed for debris clearance. It will be closed until the structural integrity can be guaranteed. There is no electrical power to the island. City officials currently estimate that water and electricity will be restored in 2 to 4 weeks.

UTMB officials stated in the 3:00 briefing today that they hope to relieve the E1s (the people who stayed through the storm) with E2s in the next 2-3 days, so I will head back to work when that happens. Employees have been instructed to contact their supervisors for details. Of course, this will depend on the restoration of transportation to the island. The conservative estimation for return to baseline functionality is 4 to 6 weeks. For the meantime, we remain on emergency status.

Thank you to everyone who has kept us in your thoughts and prayers this week. Thank you to the many volunteers and sponsors at shelters across the country. Thank you to the Texas Guard, the DMAT teams, the MANY fire/police/military and search and rescue teams...there are no words to thank you for the gift you have given my beloved island. Your generosity will not be forgotten.

I will keep you posted over the next few weeks as the recovery continues.

Obviously this is a "pre" photo.

Hurricane Redux

"UTMB’s Emergency Room is always open and will remain in operation."

My hospital went into evacuation mode at 7:00 this morning in anticipation of Hurricane Ike. I lifted the quotation above from the official memo. That one statement is the summation of the specialty of emergency medicine.

When all other doors are closed.....our doors are open.
When the clinics are closed......our doors are open.
When it's late at night or late on a holiday..........we'll be here, seeing patients.
When noone else will treat a patient without insurance..........we'll be here, taking care of them.
When it's YOUR child, or spouse, or parent with a heart-stopping, dread-inspiring, life-threatening problem..........trust me, we'll be here.
We may not have have hospital beds to put you in after the emergency treatment,
We may not have nurses in the hospital outside of the emergency department,
We may not be able to guarantee that you can be seen in follow-up,
But, stethoscope in hand,
WE WILL BE HERE.

.......and no little hurricane will change that.

Killer Pain Killers

According to a CDC report published in June, medications were either given in the ED or prescribed at discharge at 76.7 percent of all emergency department visits. This represents about 1.8 medications given per person, per visit. The most frequently prescribed drugs at discharge are pain relievers. (In fact, the first antibiotic on the list of top twenty prescribed drugs appears at number eight on the list.) The top medications prescribed/ordered/recommended at discharge, in order of frequency, were:

1. Ibuprofen
2. Acetaminophen with hydrocodone
3. Acetaminophen alone

This makes sense, given the fact that the number one reason people give for coming to the emergency department is to obtain pain relief. Given the number of prescriptions written annually for prescription pain medications, parents and caregivers are reminded that these medications are a threat to teenagers and very small children, principally because they are so readily available at home.

The news on young people and drugs these days is mixed. A government report out this week shows a decline in all types of drug abuse by children ages 12 to 17, from 11.6 percent in 2002 to 9.5 percent in 2007. The same study shows a rise of 12 percent in illicit use of prescription pain relievers among young adults ages 18 to 25. A report out earlier this year from the Centers for Disease Control and Prevention shows that despite an overall drop in illicit drug use, deaths from drug use among people age 15 to 24 more than doubled between 1999 and 2005.

A study published this week in the Annals of Emergency Medicine reports nearly 10,000 accidental ingestions of opiates by children age six and under; study authors speculate that the actual number is likely much higher, since their study only assessed a portion of U.S. poison control centers, not all of them.

Here are some tips for restricting access to prescription medications:

· Hide all medications in a secure location, which may not be the bathroom medicine cabinet.

· Discard any prescription medications that are left over or expired.

· Alert grandparents who visit or host their grandchildren that their prescriptions should always be locked up and hidden away, including individual pills which curious toddlers may put into their mouths.

· Monitor your teenager’s internet use for shopping on pharmaceutical websites.

· Discuss with neighbors and parents of your child’s friends the importance of keeping prescription medications locked away.

Hurricane Ready

It was a gorgeous day in Galveston today. The skies were crystal clear, the water was a sharp blue, the sands were warm and the sunlight was plentiful. Spirits raised by the downgrading of Hurricane Gustav to a Category 3, islanders came outside to play.

The surfers and the fishermen shared the beach today. I treated two of them, one with a fishhook stuck in an awkward place, and one who stepped on a stingray and took a barb through his Achille’s tendon.

A group of young men drank a bit of alcohol, used some cocaine, and decided to have a knife fight. Five men with multiple stab wounds in dangerous places occupied most of my afternoon.

Then we cared for the half dozen people who fell off ladders while putting up their storm windows. One unfortunate man fell while trying to trim his palm trees, and lacerated his ear with his machete. I have to admit that trimming palm trees just before a hurricane with 125-mile-an-hour winds seems a bit superfluous to me, when nature will do the job tomorrow anyway.

Galveston Island has no plans to evacuate. We will stay here, batten the hatches, and take care of those who remain on the island to ride out the storm. At this time, the experts predict that we will have tropical storm force winds and rain, but we are on the “light side” of the system. Our thoughts and prayers are with our neighbors 300 miles east on the coastline, New Orleans, and we are praying for a miracle.

McCain's Misstep

The American College of Emergency Physicians (ACEP) today lambasted McCain health policy advisor John Goodman’s assertion that anyone with access to an emergency department effectively has health insurance, and called his logic flawed and his statement irresponsible toward all patients, insured and uninsured alike.
“The Centers for Disease Control and Prevention’s latest report showed visits to emergency departments climbed 32 percent over a ten-year period, and there is no sign that this trend is slowing,” said Dr. Linda Lawrence, president of ACEP. “Emergency departments are the nation’s health care safety net, but that net is breaking under the load, in part because so much of the care goes uncompensated. To suggest that there are no uninsured patients is to cast a blind eye toward the needs of all emergency patients, insured or not, who are waiting longer and longer for care, sometimes with deadly consequences.”
“We urge the McCain campaign to rethink the reckless suggestion by Mr. Goodman that the tragedy of uninsured patients can be erased by the magic of emergency departments,” said Dr. Lawrence. “Emergency physicians can and do perform miracles every day, but taking on the full-time, medical care for 46 million uninsured Americans is one miracle even we cannot perform. Access to care in the emergency department is no substitute for the comprehensive health care reform policy that should be at the heart of the platform of any presidential campaign.”
ACEP is a national medical specialty society representing emergency medicine with more than 26,000 members. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

MTV - Not your Daddy's music video

One of the great things about being an emergency physician is the ability to see the latest social trends as they are born. As people dream up all new ways of indulging in risky behavior, the consequences are seen in the emergency department. One recent trend that is particularly disturbing is the use of a “party pack” known on the street as MTV. MTV stands for M-ethamphetamine, T-enofovir, and V-iagra. Tenofovir is a powerful antiviral used in the treatment of AIDS. The other two pills are self-explanatory.

In World War II, just after the discovery of penicillin, soldiers would pop a Penicillin pill, then go out to have a good time. There are no scientific studies to prove that this method was effective, but the idea held on with surprising tenacity. Now members of the gay community are using the “party packs” as a substitute for safe sex.

According to author David France in the latest edition of GQ, use of the “party pack” is also known as “taking a T” and has recently enjoyed increasing popularity in the gay and bisexual male community. The problem is, there is no science that proves that PReP (Pre-exposure Prophylaxis) works to prevent HIV transmission. Failure to use a condom in that false belief that PReP works could result in increased transmission of the virus.

It is confusing to me to hear young gay men talk about using a “Party pack” and ignoring the condom. It’s true that with early detection and today’s antivirals, people newly diagnosed can expect to live long lives if they faithfully take the medication. However, AIDS is still a killer. Half a million Americans have died from the disease. About 15,000 people die every year in America, a preventable and tragic event. Globally, there are about 33 million people living with the diagnosis. Another 1.2 million become infected each year. For many years 40 million Americans became HIV+ each year. The CDC is closely guarding the latest figures, but rumors are that there has been a surge, perhaps as large as 52 million, new cases. Since 2001, there has been a 33% increase in transmission of disease in the under-30 gay crowd. According to a recent New York Times article, the largest is boys between the ages of 13 and 19, who show 112% increase in infections.
It would be unethical to perform prospective, double-blinded studies to determine if taking retrovirals before sex can prevent the transmission of HIV. So, until the proof is in, please continue to have safe sex. Use a condom, every time

How Long Until I Get A Bed?

I admitted a patient to the hospital a few days ago. She was a nice (young) lady of 54 who had taken a popular prescription sleeping medication along with her usual Vodka tonic nightcap. She remembers deciding to take shower before bed at approximately 8:30 p.m. Her next memory is meeting me at 11:00 p.m.

Her son dropped by the house on his way home just to check on her. She had been under quite a bit of stress at work, and he was concerned about her. She did not answer the doorbell, so he let himself in with his key. He discovered her lying unconscious in the bathroom, her head surrounded by a pool of blood.

When the ambulance arrived, she was awake and tearful. She had a large, deep laceration across her forehead. She arrived in my emergency department in much the same condition. While this makes a dramatic tale, it is hardly unusual. About 15% of our weekend patients present because of falls, many involving alcohol, drugs, or both.

The reason that I’m writing about this patient today is that I left a note with the unit coordinator, asking that I be paged when the patient received an inpatient bed assignment. I just received that page.

SEVENTY-TWO HOURS AFTER ARRIVAL, THE PATIENT GETS A BED!

All over the country patients and physicians face this same challenge. There are simply not enough resources to take care of the patients that come to the emergency department on a routine basis. How can we hope to be prepared for the coming flu season……or worse?

Do We Need A Medical Home?

The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA) recently issued a statement entitled “Joint Principles of the Patient-Centered Medical Home.” While the concept of a safe “home” in the middle of the storm that is health care these days is attractive, the loosely defined patient-centered medical home (PCMH) could potentially hinder access to high-quality emergency care.

I have several concerns. I would like to see the specifics of this proposal before wide-spread implementation is begun. A “make it up as we go” implementation plan does not work for our already ailing health care system. I would like to make sure that the patient does not become “medically homeless” if they lose their insurance. The plan should truly be patient-centered, with guaranteed access to medical specialists.

The American College of Emergency Physicians has released eight principles about the concept of the patient-centered medical home, paraphrased here. The full statement is available on the ACEP website. (www.acep.org)

Principle 1

ACEP supports high-quality, safe, and effective medical care. ACEP supports the use of evidence based medicine and believes there should be accountability for continuous quality improvement and performance measurement. ACEP supports the use of information technology to optimize patient care, communication, and education.

Principle 2

ACEP supports health care payment reforms that ensure all medical care providers are fairly compensated for the care they provide to patients. ACEP believes that it is critical that physicians who provide EMTALA related services be adequately compensated for those services. ACEP supports additional compensation for primary care physicians for the medical home services they provide to patients outside of face-to-face visits.

Principle 3

Enhanced access must be demonstrated. Home is a place you go where they know you. There is a significant shortage of primary care physicians in America. In 2005, 36% of primary care physicians were working in practices with one or two physicians. It is unlikely that such small practices could meet the criteria for becoming an approved medical home. Most physicians' offices are closed on nights, weekends, and holidays and, in some instances, all or part of certain weekdays. Many patients are unable to get an appointment even during regular working hours because their physician's schedule is booked. The medical home model contemplates an ongoing relationship between a patient and a personal physician who understands the patient's health care needs and has a history with the patient. Much benefit of the model will be lost if a patient must see a host of different physicians and midlevel providers in large group practices in which there may be little or no experience with the patient. There should be a demonstrated ability and commitment to provide the continuous care that is central to the medical home concept before additional payments are made to physicians to offer this service.

Principle 4

Once established, the medical home should continue regardless of insurance status or ability to pay. You are always welcome at home. Many Americans go through transitions when they become unemployed or otherwise lose their health insurance coverage. Essential to the improvement of health care for patients using the medical home model is that there be an ongoing relationship in which a physician provides continuous and comprehensive care. The ongoing relationship must not be interrupted based on the presence or absence of the patient's ability to pay for care. While the medical home does not purport to provide health care for the millions of uninsured Americans, there should be a requirement as part of this model that once a person is enrolled in a medical home, the provider must continue to deliver care to those individuals whether they continue to have insurance or not. In a similar vein, health insurance companies must cooperate and not exclude coverage for patients of medical homes when the insurers are making changes in their networks of providers. To truly be patient-centered and most effectively realize the benefits of the medical home approach, the health care needs of patients must be paramount.

Principle 5

Patients must have freedom to switch medical homes, select specialists of their choosing, and access emergency medical care when they feel they need it. Patients should have the right to choose the home they want without restriction. Patients must be allowed to switch providers and choose whom they wish for their medical home. Proponents of the medical home insist that it is not a gatekeeper model. Yet in order for there to be the cost savings touted by proponents, there will undoubtedly be pressure for medical home providers to limit choices and restrict access of patients to certain providers. ACEP strongly opposes any coercive effort to prevent patients from seeing specialists they may choose. Of utmost importance is the ability of all patients to access emergency medical care according to the "prudent layperson" standard whenever they perceive they are experiencing symptoms of an emergency condition, even if later diagnosis determines there was no serious medical problem.

Principle 6

Research must prove the value of the medical home before it is widely adopted. Society must get the home it is paying for. There should be more research to demonstrate the benefits and continuing costs associated with implementation of the full PCMH model. Demonstration projects being conducted by the Centers for Medicare & Medicaid Services must be carefully evaluated. There should be proven value in health care outcomes for patients and reduced costs to the health care system before there is widespread implementation of this model.

Principle 7

Universal health insurance coverage is necessary for the PCMH model to be most effective. There are an estimated 47 million uninsured in America, and that number continues to grow. In addition, there are many millions more who are under-insured. Those without adequate insurance coverage will remain "homeless" under current PCMH models. Without providing adequate insurance coverage to the growing ranks of uninsured and under-insured, the overall health of many Americans will continue to deteriorate and the PCMH model may have the unintended consequence of increasing health care disparities.

Principle 8

The medical home must include the safety net of emergency care. Resources used to test the PCMH model should not undermine or further compromise the crumbling emergency medical care system. Regardless of the anticipated benefits from having a medical home, there will still be many millions of Americans who experience life-threatening illnesses and injuries for which they need emergency medical care. In addition, there is a serious need for increased surge capacity and medical preparedness for natural and man-made disasters. Ongoing research should be conducted to determine the extent to which implementation of the PCMH actually has the benefit proponents contend of reducing patient visits to emergency departments. Ongoing research must also evaluate whether resources utilized for PCMHs have unintended negative effects on the essential community service of emergency medicine.

The emergency department remains the “home away from home”…….and we’ll leave those big red lights on.