Crash Cart: Handling the hurricanes in Houston and Florida—and beyond; a safe space for illegal drug users?

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This week: NPR on a Houston ER during Harvey; Hospitals preparing for Irma; Health records among Harvey losses; Supervised drug injection in Canada. Join in as our editors discuss the week’s headlines.

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Downtown Houston’s only hospital is just blocks from a convention center where thousands of Harvey evacuees are staying.

As NPR reports, 600 patients were seen in the first five days, and many staff who have been working 15-16 hour shifts, haven’t been home since Harvey hit—and some may be underwater. Nurse Araron Pardon says he’s never seen such emotion in staff. “People that you work with you think that wouldn’t crack just put their head in their hands and take a second to cry to themselves, or not to themselves, and wipe away the tears and get back to work,” he says.” Original Article by NPR.

E. Paul DeKoning, MD, MS: Totally get it. Today more than ever. Not wanting to draw attention away from the needs of Harvey or Irma victims, we had our own scare here last week: active shooter + hospital = truly scary situation…and a week like no other. Didn’t actually reply to last week’s series because I was holed up in a helicopter hanger while our hospital was on lockdown. For more info, look here. Regardless, there is no “business as usual” during and for a long time after events like these. As I told my residents in the aftermath of our own crisis, while none of us signed up for this, we actually kinda did. We chose to commit our careers–and by extension a good portion of our lives–to the care of people in what is perhaps the worst moment of their lives. That includes natural disasters like Harvey and Irma, terrorist events, active shooters, all the way down to STEMIs, CVAs, and for some, even the common cold. At times, we’re actually living that pretty crappy day right along with our patients–like those providers in Texas and Florida. We can’t forget to “put our own oxygen masks on first.” The second victim thing is real and we need to take care of each other–and actually let others care for us. Oh, and hug your family perhaps a little tighter or longer than usual. And give thanks.

Nicholas Genes, MD, PhD: Wow, Paul, I’m so sorry you and your colleagues and patients had to go through this.

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Given good planning and decision-making, hospitals can continue to provide medical services
despite disastrous conditions.

Hospitals should start with quality information—not hype—from sources such as National Oceanic and Atmospheric Administration, then focus on communications, running drills, making checklists, testing reliability of resources, and creating a post-storm plan. Original Article by Healthcare IT News.

E. Paul DeKoning, MD, MS: As far as “what our hospital did”, I’ll let you know using my example above. We’ll be rehashing this for months. This sort of thing just doesn’t happen up in my neck of the woods…or does it? As an institution, we are looking at all aspects of what happened, what [thankfully]didn’t happen, and what can be better. I think there can be a tendency to over-look what didn’t go well and, fortunately, that isn’t happening here. I am appreciative of the leadership of our new President and CEO less than 2 months into her tenure here. My hope is that we respond to the event instead of react to it. I know there will be changes in our ED security–most of these events start or end there–but we aren’t alone. We all need to think differently. Every day. Like, I will never be without my phone, my keys, or my wallet/ID.

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For patients and medical professionals, the information void that comes from a natural disaster can be almost as devastating as the disaster itself, Wired explains.

Just over a decade ago when Katrina, only about 25% of docs reported using electronic records. Today, the numbers are reversed, with 75% keeping electronic records, but access is still the issue. But there is hope on the horizon. This summer, Federal health officials finished the first big test of new technology, PULSE (Patient Unified Lookup System for Emergencies) that allows disaster workers to find and view all important documents—prescriptions, recent test results—for anyone that walks into ER, shelter, etc. Original Article by Wired.

E. Paul DeKoning, MD, MS: While I certainly do relish being able to find and utilize medical records of ED patients, at the same time we specialize in the care of patients with a paucity of time and information. Our training is precisely geared to provide acute care even if we don’t know what is going on. The bigger challenge in my mind is the ongoing management of more chronic issues.

Ryan McKennon, DO: I have a hard time getting information on a patients medical history from the hospital across town on a regular weekday, I can’t imagine in gets better during a natural disaster. Luckily, as Paul mentioned, we do much of our job with a deficit of information already. I really feel bad for PCPs and specialists (and patients) who are trying to piece this stuff together after the fact. Maybe someday we will have a universal EMR transmittable between systems without all the unnecessary faxing and forms, but as long as we have different proprietary software and some of the over-restrictive clauses in HIPAA, it will be a long time coming.

Nicholas Genes, MD, PhD: I’ve been following Pulse with interest and hope it works. It’s a little like the “waiving of HIPAA” that was discussed in the aftermath of the Orlando mass shooting. Best case scenario: Pulse works great in an natural disaster, letting EMTs and EPs and primary care doctors exchange records and share data. Then people start asking, why do we need a natural disaster to use this technology – wouldn’t a patient’s personal emergency suffice? And if popular pressure mounts, we back into a robust national Health Information Exchange with reasonable break-the-glass capabilities.

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Every Day, hundreds visit Insite, North America’s first supervised drug injection center, located in Vancouver.

Opened in 2003, more than 75,000 people have injected more than 3.6 million times in total. Can it still be a good thing? Original Article by HUB.

E. Paul DeKoning, MD, MS: I frankly have a hard time stomaching this one. I understand what might be a unique opportunity (article calls it a Touch Point) to perhaps help these individuals transition to recovery, but I would suspect that’s a pretty rare occurrence and doesn’t actually happen near as much as the author or the Insite staff would have us believe. I wouldn’t be surprised if there was some policy actually forbidding staff from initiating such a conversation in order to not violate the “safe space”. I liken it to telling my kids that they can play with a loaded weapon, but they really should do it in my presence so that if something “bad” happens, I’ll be there to help them. That’s probably a gross overstatement, but it illustrates what I think is a conflicted message such facilities give: we provide a safe environment for you to participate in a behavior that is inherently dangerous on all levels. Ostracizing such individuals on the other hand, tends to push them further toward the periphery of society and into the shadows where we may never reach them. We all know it’s a real problem that involves real people who never set out to be addicts. Just not sure “normalizing” the behavior is the right approach.

Ryan McKennon, DO: Why not take this money and spend it on inpatient rehab? It’s all well and good that Insite staff can help individuals transition into recovery, but that assumes that these resources actually exists. There is a substantial lack of both inpatient and outpatient resources for those who are seeking help with recovery, seems like that would be a more effective use of the money.

Nicholas Genes, MD, PhD: As a society, I think we’ve come a long way toward viewing addiction as a disease and not a moral failing… but not nearly far enough to let “supervised injection sites” proliferate in the US. This issue just seems too vulnerable to simplistic but powerful slippery-slope arguments (are we going to hand out drinks in the drunk tank? are we going to let the smokers come back inside?) Also It’s not far-fetched to think the current Attorney General would encircle the first such American safe drug-use cafe with DEA agents, and arrest anyone who walked in or out (patients, surely, but maybe staff too – as accomplices to a crime). As far as analogies go, Paul’s is good, but I keep returning to HIV pre-exposure prophylaxis. The equivalent here would be not just prescribing meds that facilitate risky behavior, but also supplying a venue for the risky behavior to unfold. That may happen in some enlightened future, when so many other issues of US healthcare access and cost are solved, but that’s not today.

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