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Dr. Paul Auerbach’s Update From Haiti

Today was another remarkable day. Here are some of the highlights:

The team continues to be incredibly strong and we are receiving reinforcements from all directions, both from International Medical Corps and from many other NGOs. Before I go any further, I want to express my appreciation for the incredible effort from the U.S. Army, which has provided protection, supplies, transportation, medical assistance and most important, peace of mind. This is not an easy situation, and having a compassionate and responsive military, never shirking a task when we need their help, is incredible.

We continued to triage, operate on and otherwise treat approximately 700 patients, with injuries that will change their lives forever. We have seen countless amputations, disfigurements and open fractures, and face wounds that are in some circumstances infected to the point of gangrene. The medicine is intense, but we are up to the task most of the time. It is quite hot outside and there is little time to eat, drink or go to the bathroom, so by the end of the day we are quite tired and bit dehydrated. But we do not complain, because these people are so strong and now so disadvantaged.

The USS Comfort took more than 50 patients from us today, many of them quite ill. They were transported by vehicle to a landing zone and then helicoptered to the vessel. We await word on the capacity of other hospitals in Haiti.

WOW. We just suffered a serious aftershock. Right now. The building just shook and everyone ran outside. I am sitting here and continuing to write. Is this emotional progress? My heart is racing. I am determined to get this information to you.

Tomorrow I will be spending most of my day working to help structure interactions within the entire medical compound, to identify all the resources and to be certain that everyone can find out how to get help. I am now splitting my time between clinical care and administration.

I will share a typical story of a patient. She is a small 3 year old girl who had the side of her face crushed under rubble. Her ear and cheek were mangled and abraded. When I found her in the crowd a few days ago, I was able to treat her wound, then transfer her to a team of Swiss surgeons who debrided the wound and administered antibiotics. Today the infection has progressed and it is also apparent that she may have a broken femur and be developing a compartment syndrome in her leg. Her face is swelling, but she is a brave little girl. We will do all we can for her. She lies in a tent on with a young boy with a spinal cord injury, children with missing limbs, burn victims, and so forth. This is not easy to watch and not easy to write, but it is real. We are helping each and every patient and have gotten to the point where we have enough staff to examine everyone at least once a day.

The surgeries will continue, and we now have a dialysis setup for kidney failure patients and those with crush injuries, a central storehouse, and a small blood bank, the latter from the Haiti Red Cross. The Norwegian Red Cross is putting up tents as fast as they can get them. We are hoping to transition to a 24 hour operation soon with adequate staff.

Much is improvised – traction, some splints, beds, etc. We are seeing the supply chain begin to get caught up. We have had patients that are not earthquake related, like gunshot victims, but we have not yet seen the “second wave.” We know it is coming.

Out on the streets, it is difficult to conceive how this country will recover with a massive international effort and support. I hope that the world pays attention, because it could happen anywhere.

Tomorrow comes soon. I will try to write at the end of the day.

This post, Dr. Paul Auerbach’s Update From Haiti, was originally published on Healthine.com by Paul Auerbach, M.D..


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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