Thursday, September 21, 2017

Preventing Flu in Long-Term Care Facilities

Clare Gentry, MD, a Houston infectious disease physician
Member, TMA Committee on Infectious Diseases

We’re just past the dog days of summer, longing for cooler weather and welcoming the start of football season. By now, the flu vaccine is already on its way to local communities, getting ready for the kickoff of seasonal influenza (flu) vaccination efforts. Some specific groups of people — including our elderly family, friends, neighbors, and others living in long-term care facilities (and the people around them) — should plan now to get vaccinated against this disease.

While flu season officially runs from October through May, the flu virus doesn’t always follow calendar rules. The highest rates of infection during the past decade have occurred as early as September/October and as late as January/February. In recent years, Texas’ flu season has peaked in December and January.

Though experts debate the best time people should get a flu shot, the Centers for Disease Control and Prevention (CDC) and the Texas Department of State Health Services (DSHS) continue to recommend all eligible people receive flu vaccine as soon as it becomes available in the community. An annual flu vaccination is recommended for anyone 6 months of age and older. 

While it may be difficult to predict exactly when flu season will strike, two things hold true each year:  
  1. Residents of long-term care facilities (LTCFs), such as nursing homes and assisted living centers, are consistently at higher risk of complications from influenza, such as pneumonia and bronchitis.
  2. Flu vaccine can decrease rates of hospitalization and death in these people. Nearly 70 percent of hospitalizations from flu-related illness are in people who are over age 65. And most (up to 85 percent) flu-related deaths are among the elderly.
Residents of LTCFs can contract influenza from new residents, health care workers (HCWs), and visitors. These people should get vaccinated against flu to provide greater protection to residents. Protecting those we care about and care for in LCTFs truly is a community effort. 

Residents of LTCFs

It should go without saying that residents of LCTFs should be vaccinated to protect against flu each year. Even in years when vaccine has been less effective, vaccinated individuals had lower rates of hospitalization and death than nonvaccinated adults. 

Several flu vaccines are available for people over age 65, including a high-dose vaccination. Ask your doctor about which one is right for you. And be sure you’re up to date on all vaccinations recommended for adults, including a shot to prevent pneumococcal disease

Residents also can contribute to the spread of flu. Residents entering a LTCF for the first time or returning after hospitalization might have been exposed to flu without knowing it. Facilities can help prevent the spread of flu by:
  • Screening new or returning residents for signs and symptoms of flu,
  • Documenting residents’ vaccination status, and
  • Offering (and encouraging) flu vaccination at admission. 
Staff should be aware of atypical symptoms in elderly or chronically ill patients. Older patients may not exhibit typical signs of fever, cough, or nasal congestion with flu. Instead, changes in appetite or energy levels or increased sleepiness can be some of the first signs of infection. Families of LTCF residents can help ensure relatives get their annual flu vaccine and maintain accurate vaccination records.

Health Care Workers in LTCFs

Vaccination of health care workers is a critical part of any effort to prevent flu and its complications in LTCF residents. In fact, many facilities now mandate flu vaccine for all health care workers. Why? Multiple studies have shown that vaccination of health care workers in LTCFs can decrease the number and severity of flu cases in the facilities’ residents. 

Facilities should make every effort to vaccinate workers and document employees’ vaccination status. If a HCW shows signs or symptoms of flu, he or she should be tested for flu and stay home from work until symptoms resolve. Families of LTCF residents should inquire about vaccination rates of workers and be aware CDC has set a goal of 90-percent vaccination coverage for HCWs across the country by the year 2020.

The Society for Healthcare Epidemiology of America (SHEA) has long advocated for mandatory influenza vaccination of all HCWs. In their most recent position paper, SHEA experts classified influenza vaccination as “a core patient and health care provider safety practice” that should be “a condition of both initial and continued employment.” The Texas Medical Association also urges 100 percent flu vaccination for health care workers. 

In addition to flu, HCWs should stay current on all recommended vaccinations to protect themselves and the people they care for. 

Family and Friends of LTCF Residents 

Visitors to LCTFs should take action to prevent unknowingly passing the flu on to their loved one living there. Though CDC recommends flu vaccination for everyone over the age of 6 months, flu vaccination rates in Texas typically are less than 50 percent. Adults with relatives living in LTCFs should get flu shots to protect their loved ones. During peak flu season, facilities may elect to limit the number of visitors and may prohibit residents from gathering in common areas. 

As flu season approaches, it is important to remember that flu prevention, especially with regard to LTCF residents, is a community effort. Why not take the step to protect yourself and your loved ones this flu season? 

Tuesday, September 19, 2017

TMA Establishes Relief Program to Assist Hurricane-Devastated Medical Practices

When staff of a Houston-area children’s urgent care clinic saw security-camera images of brown, murky Hurricane Harvey floodwater submerging the waiting room, they knew it was bad. Quickly, the physicians and other clinic workers jumped into action. They also consulted the Texas Medical Association (TMA) for help, and learned about the TMA Disaster Relief Program.

Pediatrician Anastasia L. Gentles, MD, said help was needed because Harvey flooded their NightLight Pediatric Urgent Care clinic in Humble. “Our x-ray equipment, our nebulizers, all of our inventory except the few things in the upper cabinets – was destroyed,” she said. “Our whole crash cart had water in it… it was awful.”

Floodwaters inundated the typically busy medical practice. Staff helplessly watched the destruction on security cameras. “At first it was just water on the floor,” said Dr. Gentles. “Then a couple of hours later you couldn’t see the chairs. It was a little lake in there.”

After the water receded, photos documented the damage: Unopened packages of supplies to treat patients were crumpled and waterlogged, including child-sized bandages, tongue depressors, boxes of stickers  — Sponge Bob, Paw Patrol, Mickey Mouse — and stethoscopes in water-lined drawers. The cabinets and drawers were all warped and splitting. In the lobby, a nest of furniture — a colorful child-size plastic table and little chairs tangled with adult-size waiting-room chairs, tilted askew — all sat covered in a beige filmy slime. Mold was quickly growing, so all internal walls would have to be removed.

Dr. Gentles outside NightLight Pediatric Urgent
Care Clinic during cleanup after Hurricane Harvey.
They salvaged what they could and raced to schedule a demolition crew and contractor to rebuild the facility. They also started searching for a temporary home in which to care for patients.

“We feel the loss from a community standpoint. Everybody keeps calling us — people were coming up to the door even the day after the storm to get their children seen,” said Dr. Gentles. “So we know they’re missing us from that standpoint.” They also want to reopen quickly to help their staff — many of whom lost their home or cars in the flood – get back to work.

The TMA Disaster Relief Program aims to help the countless medical practices across south and coastal bend Texas facing a similar fate return to caring for patients as quickly as possible — and the need is great. A new TMA survey finds nearly two-thirds (65 percent) of physicians in Texas’ official disaster area counties were forced to close their practice temporarily, and one-third (35 percent) had to reduce their hours or services.

“People need their doctor, but so many of our physicians suffered total, devastating losses to their medical practices as a result of Hurricane Harvey,” said TMA President Carlos J. Cardenas, MD. “We wanted to jump in and help them rebuild or relocate as quickly as possible, because their patients need them.”

Funds the Disaster Relief Program distributes will help physicians pay for storm loss expenses their insurance or other sources will not cover.

The program has raised a substantial amount already. The California, Colorado, Massachusetts, and Rhode Island state medical associations have pledged or sent generous donations. This past Saturday at TMA’s Fall Conference, the American Medical Association and the Physicians Foundation presented checks for $150,000 and $500,000, respectively, pushing the total raised to nearly $1 million. To donate to the program, click here.

“Doctors understand the call to care for their patients, and empathize with colleagues stripped of the ability to help their people, their community,” said Dr. Cardenas. “So we’re thrilled — but not really surprised — that these physicians and their organizations are opening their wallets to help Texas doctors help Texas patients. This storm was a monster, and communities across the south are hurting; they need to get back to normal, and they have basic needs like food, shelter, and health care. We want them to regain that access to their hometown doctor as quickly as possible.”

TMA created similar fund drives after hurricanes Rita and Ike in 2005 and 2008, donating between $5,000 and $8,000 to each medical practice in need. TMA received $700,000 in contributions to the fund in 2008. TMA’s philanthropic arm, TMA Foundation, is overseeing fundraising, and The Physicians Benevolent Fund is administering the TMA Disaster Relief Program. Physicians: To apply for assistance through the TMA Disaster Relief Program, visit or email”

Wednesday, September 13, 2017

Houston Stadium Becomes Makeshift Hospital During Harvey Recovery

Hurricane Harvey has been a disaster for the Houston area by any definition, but the medical response at major shelters has been anything but.

Lisa L. Ehrlich, MD, is codirector of medical operations at Houston’s NRG Stadium shelter and president of the Harris County Medical Society. She volunteered in the wake of previous hurricanes, including Andrew and Katrina.

Dr. Ehrlich, who has earned the nickname “Power Ponytail,” has run the NRG shelter with emergency physicians Beau Briese, MD, and Aaron Schwartz, MD. Numerous volunteers did a great job of screening people as they entered, Dr. Ehrlich told the Texas Medical Association late last week.

Anyone older than 70 or younger than 1 was automatically evaluated by the medical team.

Lisa L. Ehrlich, MD, with Brian Reed, MD,
director of public health at the NRG shelter.
Many of the people in the shelter were homeless, so physicians also screened aggressively for tuberculosis patients and those with behavioral problems, she said.

In both cases, patients tend to underreport their illnesses, so after the shelter staff asked, “Do you have any medical problem?” they would follow up with a second question.

“[The patients would] say, ‘I don’t have any medical problems,’ and we’d [follow up and] say, ‘How long’s it been since you had your medicine?’ ‘It’s been five days,’ ” Dr. Ehrlich said. “We caught a lot of people who needed care that way.”

Physicians also walked among shelter residents to look for signs of drug withdrawal or psychological problems.

“We kind of routed those out early,” she said.

As of late last week, the shelter has seen a variety of predictable illnesses, including type A flu, scabies, bed bug bites, and conjunctivitis, Dr. Ehrlich said. All of those ailments are under much better control than they were in the wake of Hurricane Katrina, Dr. Ehrlich said.

“It’s a totally different place,” she said. “We’re actually isolating people with medical problems.”

During Katrina, people sheltered at the old Astrodome had so many different medical conditions that doctors put the well people — not the sick people — in medical isolation, Dr. Ehrlich said.

“We had a small number of healthy people, and there was just so much pestilence,” she said. “It was the inverse of how it should be if you’re running a shelter.”

The greatest long-term medical problem facing the Houston area after Harvey will be treating behavioral disorders. Like the rest of the country, Houston already has a shortage of psychiatrists.

“Now we have an overwhelming number of people in need, and we’re in a huge stress situation, so things like anxiety disorders, depression, schizophrenia, and other mental needs are going to be higher when we already don’t have enough psychiatrists in the first place,” she said. “And now they have a backlog to just see their own patients because they’ve been displaced and shut down for two weeks. … We already weren’t great to begin with, and [Hurricane Harvey is] going to just put huge stress on the system.”

Thursday, September 7, 2017

Physicians Can Help Stop Teen Drug and Alcohol Abuse

By James Baker, MD
Austin Psychiatrist
Member, TMA Council on Science and Public Health

It takes a community to prevent adolescent substance abuse, and physicians can play an important part in that community effort.

While parents are the most important role models for their children, as physicians, our goal should be to help delay the age when teens first use alcohol or drugs. In addition to all of the problems related to underage drinking — sexual assaults, accidents, poor school performance — research suggests that teens who start drinking early are much more likely to have an alcohol use disorder as adults.

How can physicians help?

Prevention requires a community focus on the many risk factors that often lead to early drinking and drug use. Physicians can be mindful of these factors when they see teens in their practice. Here are some things physicians can look for and, when present, encourage teens and their parents to get help for:

  • Family history of drug or alcohol use,
  • Family problems or disruptions,
  • Low motivation at school,
  • Behavior problems at school, and
  • Friendships with other teens with problem behaviors.

When these issues are present, doctors can encourage interventions to address them. For example, poor school performance warrants an evaluation for undiagnosed learning disorders. Family issues warrant an evaluation to see if family therapy is recommended. Motivation issues and behavior problems might indicate an underlying mood or other emerging psychiatric disorder. The local community mental health center is a good resource for all of these problems.

In addition, physicians can adopt the practice of routinely screening for alcohol and drug abuse in their young patients. Screening for depression, anxiety, stress disorders, and substance use ought to be just as routine as taking vital signs. One possible screening tool is CRAFFT. CRAFFT is just six questions shown to be effective in assessing whether a referral is indicated for a longer evaluation of alcohol or drug use. CRAFFT stands for:

Car (Have you been in a car with a driver — including yourself — on drugs or alcohol?),
Relax (Do you use drugs/alcohol to relax?),
Alone (Do you use drugs/alcohol while alone?),
Forget (Do you forget things while on drugs/alcohol?),
Friends (Are your friends concerned about your drugs/alcohol use?), and
Trouble (Have you gotten into trouble while on drugs/alcohol?).

Finally, because they are community leaders, physicians can encourage the entire community — parents, teachers, coaches, and religious and civic leaders — to give children the same messages discouraging alcohol and drug abuse, starting very early in childhood.

We can help teens — and their families — avoid long-lasting consequences of alcohol and drug use through a collective and consistent message, universal screening, and early and aggressive intervention.

Dr. Baker is associate chair of Clinical Integration and Services in the Department of Psychiatry at Dell Medical School and systems chief medical officer at Austin Travis County Integral Care.

Friday, September 1, 2017

Pharmacies Open In and Around Beaumont

Physicians and patients in areas ravaged by Hurricane Harvey and its aftermath have asked TMA for the names and locations of open pharmacies where they can fill or refill prescriptions. Here is a map of pharmacies known to be operating in the Beaumont area, courtesy of Healthcare Ready’s Rx Open project. (Data last updated at 9:30 PM ET, Aug. 31). Zoom in for more detail. Click on a dot for a pharmacy's name, address, and phone number.

For maps and lists of pharmacies known to be open in other parts of the Texas Gulf Coast, see the TMA website.

Monday, August 28, 2017

Voices of Ike Echo in Harvey

As the nation watches and prays for Houston and the Texas Gulf Coast to find relief from Hurricane Harvey, we are hearing from numerous area physicians who are struggling to provide care to their patients in these very difficult circumstances. We dug up this collection of first-person accounts physicians shared with us in the midst of the chaos of Hurricane Ike in 2008, when winds and flooding last ravaged the Bayou City. We share them with you now as a reminder of the dedication and professionalism of Texas physicians.

As Hurricane Ike bore down on the Texas Gulf Coast in mid-September, physicians across the region had to put aside their fears about the safety of their own families and potential catastrophic damage to their homes and prepare to practice medicine in the most trying of circumstances. Their mission was to care not only for the patients already in the hospital, but also for the patients needing care after the storm passed. Illness and injury doesn't stop just because there's a hurricane. And the storm claims its own medical casualties.

Houston cardiologist A. Tomas Garcia, MD; Houston trauma surgeon Ken Mattox, MD; Beaumont neurosurgeon Mark Kubala, MD; Beaumont orthopedic surgeon David Teuscher, MD; Galveston endocrinologist Kevin McKinney, MD; Crockett surgeon J. Patrick Walker, MD; Texas City pulmonologist Joseph Prince, MD; and San Antonio pediatrician Rebecca L. Huston, MD, MPH, were among the physicians who stayed in touch with the Texas Medical Association via e-mail throughout Ike and its aftermath. Their messages described what they saw, heard, and felt as the storm approached and made landfall, wreaking havoc across the Houston-Galveston-Beaumont area. Finally, Austin internal medicine specialist Lee Frierson-Stroud, MD, recounted her experience caring for patients evacuated from the coast to the Austin Convention Center.

Texas Medicine presents excerpts of their e-mails with limited editing so as not to diminish the powerful emotions they reflect; emotions ranging from worry to amazement to exasperation, and, finally, to immense pride in what they and their colleagues accomplished.

These are the Voices of Ike.

Sept. 11, 2008/ 10:40 pm -Worried  

Ken Mattox, MD  

Just my personal observation, and I make the following observations from my desk INSIDE my office, but here goes.

I am very worried about the SURGE to High Island over to Port Arthur. I am very concerned that there has been too much complacency. I think too many people close to the shore have stayed to ride out the storm. I am concerned that before the evacuations TODAY, we might have had 1,200 fatalities. With what I see, there STILL could be up to 100 deaths, most sudden and by drowning with SURGE. The patients will not be treatable once the SURGE hits.

 Unfortunately, the situation is cast. By 9-11 am in the morning, it will be impossible to move or do anything about it. We focused on the Port O'Connor area for so long we lost sight of the High Island-Port Arthur problem, and most transportation assets were used elsewhere.

I hope my calculations are incorrect.

Sept. 12, 2008/ 6:30 pm - The Calm Before the Storm  

David Teuscher, MD  

Southeast Texas (Jefferson, Orange, and Hardin Counties) is suffering from "Hurricane Fatigue Syndrome." We are in our third mandatory evacuation in a month (Eduardo, Gustav, and Ike).

The previous two "missed us" but found folks returning with orthopedic injuries, lost wages, and gas, food, and lodging bills.

Hopefully this has not let them become complacent should Ike be the real deal.

The mandatory evacuation was called here yesterday at 6 am, throwing every patient and health care provider into another parking lot on our highways north and west. No chance to evacuate east, as Gustav left widespread power outages in Baton Rouge and all of southwest Louisiana. Greatest danger being surge on this bad boy; wind and rain will likely pale in comparison. The surge up Galveston Bay will be catastrophic, in my amateur meteorologist opinion, and may do the same up Sabine Lake.

Right on time, at 5 pm, the major outer bands of wind and rain arrived in Beaumont while I was cooking ribs on the grill and laughing at the dogs playing without any idea of what was about to happen. Now the long wait begins. Rita trimmed the heavy timber of Beaumont in 2005, but there is plenty of coniferous and deciduous forest surrounding our homes and offices. More importantly, the levees of south Jefferson County may be breeched with the predicted 20+ foot surge over the 15-foot levees in Port Arthur.

Connie and I are sheltered in place at home with five dogs, two birds, and two octogenarian guests.

A lawsuit is a lot like a hurricane. If you practice medicine on the Texas Gulf Coast, you can count on both.

More to follow if able. May God grant safety for all who are in harm's way.

Sept. 12, 2008/9:46 pm - Spending the Night  

A. Tomas Garcia, MD

We've had all the transfers from Bayshore (east side of Houston, the hospital was flooding from the surge) to our hospital. The usual, respiratory insuff with CHF, recent left leg amputation with severe diabetes, atrial fibrillation with rapid ventricular response, etc.

We had our first meeting at 7 pm to plan the remainder of the night. We have over 600 people sleeping in the hospital to care for the 160 patients in the hospital, all of them very sick. We anticipate a pretty bad day tomorrow, depending on the amount of damage the city suffers. We have about 15 physicians, including myself, who are sleeping in the hospital. I'll stay online for as long as possible.

My son, Carlos, just came in. He's been helping with security and with all the air mattress inflation for the dependents who are in the professional bldg. There are about 200 to 250 there. The hospital fed everyone at 8 pm. We are to meet at 9 am to access the situation; we are predicting that the physicians here will have to care for the 160 patients who are currently here.

As Saturday goes, it's predicted that the emergency room will get real busy.

Gotta go, I'm being paged.

Sept. 12, 2008/11:23 pm -Waiting for the Worst  

Mark Kubala, MD  

Things are going well so far. We have 180 patients at Christus St. Elizabeth. The ER has been fairly quiet. Usual problems, but nothing major. We expect to find out about the surge around 2 or 3 pm. So far, the levees are holding, but once Ike hits Galveston, the wind will change to southeast and that's when the surge will hit. Right now, the surge is up to 10 feet in Sabine Pass. (The levees are 16 feet.)

The winds are around 60 now but most of Beaumont has electric power. A lot of power outages in Port Arthur and mid-county. We expect a lot more power outages when the wind changes.

Sept. 13, 2008/ 2:51 am -Houston Braces for the Storm  

Ken Mattox, MD

Eye of storm is now passing over Galveston.

Huge oak tree down on McGregor St. -- the access to the Ben Taub Hospital. Any traffic has to come in a back way.

Building in downtown Houston burned to the ground. Three employees were sheltering there. Two with near 100 percent body burns and one with hand burns and inhalation burns. The latter with us and the two former at Memorial Hermann Hospital.

Over 1 million people without electricity and therefore air conditioning. NO FLOODING in Houston. YET. Winds up to 100 mph in gusts, steady at about 65 mph.

We have lots of employees who are here to weather the storm: nurses, doctors, etc.

Will be up to two weeks (or more) to get electricity restored.

Sept. 13, 2008/7:32 am - The Levees Held  

Mark Kubala, MD  

The levees have held! Major power outages, but we do have water. My generator is working, as is my DSL. Only one major trauma last night at Christus St. Elizabeth (not related to Ike).

Sept. 13, 2008/9:03 am - Learn From This

Ken Mattox, MD  

Have just left morning incident command briefing. Hospital still on LOCK DOWN. NO VISITORS. Hospital staff on two or more sleep shifts. Anticipate that staff that came in yesterday at noon-6 pm will be in hospital until noon tomorrow-Sunday. Operating room for stat cases only. Yes, we did some stat cases. Building leaked water on side of major wind assault.

EMS calls to 911 are 65 percent more than for comparable time. EMS does not make runs when the wind is >65 MPH. As soon as the streets are safely passable, we anticipate a huge number of patients who have lost their medicines, scrapes, diabetes out of control. etc. We anticipate that we will have referrals from other hospitals to take complex injuries. Which we will do.

We deeply appreciate the many e-mails and comments of support. Your support, prayers, and e-mails give us added and renewed strength to do what it is that all of us were created for: serve our fellow man during their time of need. And that we will do to the best of our ability.

One word of advice to each and every one of you. At some time in the future, YOU will be looked to by your associates to assume leadership at a time of unexpected challenges. Most of the time there will not have been a blueprint. Take good records and keep your memory sharp in regard to what you learn from watching this natural disaster. These lessons will aid you in your leadership during that future time.

Sept. 13, 2008/10:12 am - Surveying the Damage

Mark Kubala, MD

Steady winds decreasing to 40 mph. Tornadic wind 60 mph over Vidor going north. Still getting rain.

Orange County Judge Thibodeaux says a lot of flooding in Bridge City. People stranded in attics and on roofs. Orange County getting boat out to rescue.

My son's brother-in-law has a big tree through his kitchen.

Sept. 13, 2008/11:01 pm - Caring  

A. Tomas Garcia, MD

Right now, things are pretty bad in the city. No power in vast parts. The hospital (West Houston Medical Center) has maintained power with emergency generators, but no AC, which has been tough on the patients and staff.

Water is now a problem. We are being careful to drink only bottled water for now. We are labeling cups and bottles to conserve water for drinking. Water for the toilets is another problem. We just went through 6,000 gallons to clean out the lines at 7 pm and have another truck on the way.

Last night was tough. The whole hospital building was moving, and we had some leaks, but no windows broke. Many patients were scared, but the staff really came through. We had the usual deliveries and C-sections, and the usual admissions. Unfortunately, many physicians didn't anticipate the tree damage to home, vehicles, and roads, and couldn't make it in.

We had a meeting early this morning and with cooperation of all 14 or so doctors divided the 170 patients among ourselves. Our concern was that there might be a sick patient who needed attention, and with docs unable to round, we might have a critical situation get worse. It happened to me. One of the patients I was rounding on had taken a turn for the worse; he had sickle cell crisis with a hemoglobin of 4.0, with fever, tachypnea, and tachycardia. We were able to transfer him immediately to telemetry and with a full-court pressure turned the corner.

I labeled all my notes as "Hurricane Ike Physician On-Call" for the rounding on other physicians' patients. For the patients who were transferred from the east side, BayShore, (they had raw sewage flood their hospital, as I understand), I wrote a full H&P. Everyone pitched in; there were physicians helping with simple things such as moving patients, passing on communication from administration to the staff, to encouraging everyone to use the stairs whenever possible.

Things went rather smoothly compared to "Rita." With Rita, we had about 1,000 people, family, extended family, and friends in the hospital and professional building. Only added to the confusion and work efforts for our doctors and nurses. This time the requirements were more strict: staff and "immediate" family only. I think the total was about 600 or so. Serving food was a bit of a challenge; with these numbers and limited seating in the cafeteria, the staff, docs, and family members lined up and waited for the folks ahead to decide to sit and eat or move to another area of the hospital to eat. It really worked out well, and the food was hot and good. With so much to do, it was a relief to not have to worry with feeding yourself.

Todd Caliva was excellent as CEO of our hospital; I can't say enough of how important it is to maintain a certain calm with such a challenge. With his leadership, our doctors were able to perform optimally and efficiently.

I checked the house (I live across the street): no physical damage, one tree down; my son and I were able to get it back up and secure it. Still no power or water there, so I'm back at the hospital. There is still a group of us available for any emergencies that will most certainly start coming in.

The last three days have been very challenging, and I'm certain that the rest of the week will offer its future obstacles. But the preparation we did for the week before led to our success here in the hospital. Taking the common sense steps to prepare for such an incredible storm led to our success.

I'm really beat. To bed.

Sept. 13, 2008/11:02 pm - The ER Is Crazy Tonight  

Ken Mattox, MD  

What a difference 24 hours make. Last night the EC was a tomb, and tonight it is crazy with many very sick trauma patients, auto-pedestrian victims, etc. We also have far too many nursing home special needs patients who are just dropped off by an ambulance transporting geriatric nursing home patients to a shelter, whose director thinks the person might benefit from some oxygen and sends them to the hospital. Not a good use of resources.

I drove around the city earlier. Lots of uprooted trees and broken limbs. Nests of lights exist, but there are NO places to eat, NO grocery stores open, and I saw only ONE open pharmacy. Long lines for the gas pumps existed.

We are pretty much FULL. A few beds here and there. Rumors exist that up to 14 hospitals of various sizes are running on total or partial emergency generator. At least two hospitals have asked that the BTGH (Ben Taub General Hospital) receive their patients in transfer with 170 and 87 patients in the hospitals, respectively. The latter is a subsidiary of major hospital chain that has MANY multiples of this number in their system, but they still want BTGH to take the patients for a variety of reasons. We are reviewing their lists, while at the same time, the EC is now OVERCROWDED by political transfers, political acceptances, nursing home dumps, SAR dumps, and private ambulances bringing patients to us totally outside the system because they know that we will take care of them and no other hospital in the region will accept some such patients.

The staff is getting TIRED and will be relieved by noon tomorrow by the E-2 group. Half of the E-1 group is asleep right now.

We have had 10 times more trauma patients in the first 10 hours after landfall than we had the 24 hours previous to the impact.

Sept. 14, 2008/ 9:50 am - Internal Disaster Mode  

A. Tomas Garcia, MD  

I just finished rounds, and the situation at this moment is the following: Some physicians and support staff can't get to the hospital. With the cold front and rains that it brought, flooding is now a real problem. With a saturated ground, the water has to go somewhere and causes its usual problems, i.e., into home and cars and hospitals.

Mainland Hospital is out; it lost its roof and the roof over the OR rooms. All have been transferred. Bayshore Hospital is out -- flooding with sewage. St. Luke's is surrounded with water, as is the TMC, so getting into and out is a real problem. So patients are left with a suburban hospitals like ours.

We are now on strict water conservation. The entire county and surrounding area have this common problem. Basically, all our hospitals are now on Internal Disaster Mode and addressing their unique and individual problems as they see fit. So far, we had no employee injury or patient event.

Our ERs are starting to have the usual injury and "trying to clean up the mess" accidents. We are also starting to have the acute SOB and chest pains that usually occur in the aftermath. Our hospital staff is staying in areas of the professional building to rotate with the hospital staff working their shifts; again trying to have "fresh" folks for our patients.

The docs are hanging in there; I think I'm running on adrenaline now. Had 2-3 hours sleep; got called back to the ER for ACS (acute coronary syndrome). One MD was told there were no generators to be had and if they were available, they are expensive. I've just crossed out my freezer; there go those ducks. Also, the salmon and halibut. Oh well.

Lots of work to do and patients to see.

Sept. 14, 2008/12:31 pm - In Case the Generators Go Out  

Mark Kubala, MD  

We are OK.

Major problem is power outages. Entergy says this is worse than Rita. Water is not drinkable. Still major flooding in areas. Rain this AM, so water draining slowly.

Christus St. Elizabeth is still on generator. All the dialysis patients moved out. Currently moving the critical patients to other Christus hospitals (Texarkana, Lake Charles) in case the generators go out.

Sept. 14, 2008/2:54 pm - The Hospital Is Full  

A. Tomas Garcia, MD  

Our hospital is full, the ER is full. We have requested FEMA to move all patients in the ER to San Antonio; we are waiting for instructions from them.

Water just got going but we are uncertain of the safety so only bottled water for drinking at this time. Dialysis patients are a real concern without the water pressure and sanity; the hospital can't accommodate the number that might need dialysis. Many of the outpatient facilities can't care for them without water, water pressure, and safe water. Another challenge, we'll figure something out.

With the pressure for beds, we are reviewing all patients/charts to see if they are well enough to go home to make room for the high demand we are experiencing currently. Still no power to vast areas of the city. Some physicians are being held up at other hospitals with other patients of theirs and having their patients in other hospitals needing their attention; again the docs are stepping in to cover them.

The flooding is incredible. Fortunately, it has not affected us here on the west side too much, unless it rains again like this morning. If so, build an ark. The administration here at West Houston is doing an outstanding job: good leadership, good planning, and good execution. It also helps to have an M&M peanut dispenser close at hand. (We all have a weakness!)

The physicians have done an outstanding job of caring and treating all the patients here. The problems we have encountered are very similar to (New Orleans physician) Mike Ellis' comments after the Katrina storm: people who stayed on the island now are in trouble and want help. Fortunately, some did learn and left, and the process so far appears to be going as smoothly as could be expected for such a bad storm for the ones that didn't listen or prepare.

Got called back, gotta go.

Sept. 14, 2008/10:10 pm -"Like the Cavalry Coming to Help"  

A. Tomas Garcia, MD  

Well, the ER got busy as predicted. Boy, did it. We went through the hospital and sent the well patients home to create space for the critical coming in. Cardiac arrests, hemo dialysis, CHF patients, and the injured. We culled twice and now have just super-sick folks in the hospital. The ER is packed. I mean packed. The kind that need admission and waiting for an ICU bed for treatment and care.

We called FEMA and next news you know, we had about 11 ambulances with appropriate staff to transfer the sick, ready for admission, to San Antonio. And they will be back to get some more if we have them. I'm sure this is happening in the other hospitals across the city. This really greatly helps and allows us to care for the ones coming in tomorrow.

We have city water now with good pressure so all the toilets are clear, and the hospital is looking clean and sharp. We're still on generator power. The staff is holding up well and the docs are all helping by caring for our patients. We're having the usual Code Blues such as the one I just had when the TE-tube cuff broke and the O2 sat fell. We were able to reintubate the patient immediately. Unfortunately, it's a patient who had a sudden death earlier in the day at home during the heavy thunderstorms and rain and may not make it. The unfortunate person is now with anoxic encephalopathy with a grim outcome, and the family is coming to grips with the loss.

During the intubation, we all saw through the ICU window the 11 ambulances coming down Richmond Ave. with red lights flashing and all in convoy; wow, what a sight. With the city without power and lights, it was very, very impressive. It was like the cavalry coming to help and, boy, did we need them. They came from Riverside, California; drove first to Dallas, then to San Antonio, then here to the command station in Houston, and then to our hospital ER with the assignment to clear out our sick to the San Antonio hospitals. Thank you, San Antonio, and your hospitals, nurses, and of course, you doctors. God love you. By clearing out our ER, we're able to care for more patients bright and early tomorrow.

The city is slowly coming to life, and the people are starting to move around as the power and water are coming on. Business, stores, eating places are beginning to open. Hopefully, by the end of the week, we'll start to have things closer to normal. According to the reports we're receiving, some parts may take longer, unfortunately. Some areas were severely damaged and flooded. Several of our staff have homes partly or fully destroyed or flooded. Yet, they still are committed to our patients and remain here.

Got another call, gotta go.

Sept. 14, 2008/11:37 pm - Still on Generator  

Mark Kubala, MD  

Things are about the same. Christus St. E (and Baptist Hermann Memorial) have moved the dialysis patients. Christus St. E is still on generator. Hopefully, they will be up on power in the next two days. Both hospitals are open for trauma (fortunately, there has been very little). Once power is up they will be fully open, but I doubt much will happen for several days as most patients are out of town.

Since the water is not drinkable, and concern is about the sewage backing up (I spoke with a friend of mine who had some backup), I will probably take Betty to Austin tomorrow and then decide when to come back.

Sept. 15, 2008/ 11:30 am - Back in the Office, for a Bit  

A. Tomas Garcia, MD  

Finished rounds early today. The ER was cleared out by FEMA and the patients transferred to San Antonio last night. Good job, guys. Our ER is now ready for more sick patients. In addition, we are getting the patients on the medical floors discharged if they are well enough to go home so as to have those beds available for any other sick patients who will most assuredly arrive later today.

More physicians are showing up and rounding in the hospital, so I'm now in the office, available for those patients who really feel like they need to be seen, in an attempt to not have them in our ER if at all possible. My staff came in and we saw a few patients. The phones are now quiet so we closed and transferred the phone to the answering service.

Still no power or water at home, but no damage.

Got another call to the ER. Gotta go.

Sept. 15, 2008/1:10 pm - Health Heroes  

Ken Mattox, MD  

Houston is the fourth largest city in the US. The Houston/Galveston greater area has upwards of 4.5 million people, depending on just where you draw the line. It is safe to say that NO ONE in this area is untouched by this storm. NO ONE. Galveston was totally under water from both the gulf and the bay. UTMB and its famous burn center were evacuated. Bolivar Island is still "off limits" to anyone visiting it. West Galveston Island, with its beach houses, was under water and many destroyed. The famous Balinese Room of Galveston is GONE. The Galveston Sea Wall is 17 feet above sea level and the sea ran over it. This was a wind and SEA SURGE storm, not particularly a wet storm.

From Galveston to Houston, one travels Interstate 45, and that is the route that IKE took. The areas of NASA, Kemah, and Seabrook are yet to be fully assessed.

Over 95 percent of the area lost electrical power in the entire greater Houston area, and most are still without electricity. NO HOME or yard is without some sort of damage, be it shingles, an entire roof, glass broken, fences down, or trees fallen and limbs broken. I do not mean just any tree. Many huge oak trees over 100 years old are broken like match sticks or uprooted . The many faithful health workers were at work despite their homes being blown apart.

First, I must give tremendous credit and recognition to thousands of individual health heroes who were here at the Ben Taub General Hospital and many other hospitals for many hours straight. They gave and gave and then gave more of themselves so that others would have a place to receive health-related attention.

Second, I was impressed by the leadership of the state government, both during Gustav and Ike in the days before the storms hit, in creating a 5,000-plus-person conference call 2-3 times a day  to address known course of storm, local needs, evacuation, gas, search and rescue (SAR), and recovery. Both state, county, local governments were on this conference call as well as other assets such as hospitals, EMS agencies, etc. It appeared that most items were covered and addressed. It was obvious that jurisdictional turfs existed.

At the LOCAL area, different jurisdictions set up in different locations: Galveston, Transtar (Harris County), HEC (City of Houston), and assets of the state such as Texas Task Force 1 set up in several locations. Ownership of various assets was under different, but communicating, agencies. What we did not have during Ike, but did have during Katrina, was a region-wide JOINT UNIFIED COMMAND. We really needed that during and for the first two days after Ike hit.

At the hospital and emergency room level, every hospital in the area did their part, but all entered the hours of the storm with full ICUs. We (and everyone else) had patients ready to be dismissed from the hospital, but we would have sent them to an area of high risk of flooding. That would not have been good, but we did need their beds for new ER patients. No local "medical" home health care type shelters were set up in the Greater Houston area. We must address this next time. In my view, this would be an excellent role for DMAT teams - both to be upfront for some few minor problems and to establish an up to 500 bed "medical" observation shelter as opposed to a "clinic" or hospital. We really do not need mobile hospitals; what we need is the intermediate "medical" shelter to unload the existing local hospitals.

By 12 hours after the storm had cleared the area, the mass property destruction was noted and people began to clear their property, including using chainsaws they had never read the instructions on and climbing ladders. We had lots of falls. Also, many hospitals wanted to "evacuate" merely because their rooms were warm and humid as they were only on emergency generators. The water for the entire community was feared to be contaminated due to low water pressure. Therefore, we were requested to receive patients with relatively minor conditions, such as a need for a lower-temperatured room and nasal oxygen in an elderly patient. Some such patients came by outside-the-area-contracted private ambulances who knew nothing about the working of the local EOCs, although those were multiple. We really needed the DMAT-type run medical holding area shelter for these type of patients, who never needed to come to the hospital to use the hospital as a shelter. One or more DMATs were set up in the Greater Houston area, but, initially, coordination with existing trauma center facilities was sparse. If there was coordination, it was with one of the many supervisory silos.

It became interesting to me that within 24 hours after the storm cleared, many of the persons in each of the silos, including representatives and including press people, who by now were very tired, began to point fingers and try to get credit for what was done right and dodge criticism for what went wrong. I could write a book on this subject.

In the five-state area around Texas, there is a fantastic trauma network among the trauma centers and trauma surgeons, headed up by Dr. Ron Stewart in San Antonio. This excellent integrated disaster network is as sophisticated as ANYTHING I have seen from the well-funded federal programs, and it costs NOTHING. The doctors and nurses on this network and the network itself are well known to each of the federal, state, regional, county, and city EOS silos in the five-state region. However, neither for planning, implementation, evacuation, or recovery do these silos utilize this very mature sophisticated trauma network. It is almost as if the hands-on trauma personnel, who in at least five of the cities of the network (Houston, Galveston, San Antonio, New Orleans, Oklahoma City) have a composite experience of active involvement in more disasters than any group that I know about in the country, are purposefully omitted from the government run silos. In my humble opinion, this disconnect between the governmental-mandated EOS silos and the JCAHO-mandated trauma center communications led by the American College of Surgeons and their trauma center and disaster committee MUST somehow get together as has happened in the state of Connecticut.

I have tried to write concurrently with my frank feelings and observations of the real time. Sometimes I was more frustrated than others. On the whole, I have been very proud of my local community, proud of the citizens, and so very proud of the FANTASTIC TEAM OF MEDICAL PROFESSIONALS AT THE BEN TAUB GENERAL HOSPITAL. This team could put a man on Mars in a week. This team seeks to be a resource to take care of the sickest of the sick, that no one else wants, especially during a crisis. This team could reach the illusive peace in the Middle East in five days. Congratulations to the many, many unsung heroes at every unit level of this team.

Sept. 15, 2008/5:39 pm - "I'm Really Proud of the Team"  

A. Tomas Garcia, MD

So far, so good. The ER has been hit pretty hard because so many physicians did not open their offices. It's all been the "I ran out of medicines," dialysis, insulin ran out, and COPD issues. Those are being triaged out ASAP to care for the very injured and very sick.

After hospital rounds by our doctors, we opened more beds to be ready for the injured and sick patients that we expect in the coming week. We were told that the next 5 to 7 days, maybe more, there will be about 2 million people returning to this area, which means the pressure on the ER will go up significantly.

 I'm really proud of the team of doctors, nurses, ancillary staff, and administration that worked as a team to achieve this degree of success to date. We have more challenges in the coming days, but the city is recovering, water and power are coming on, and this is really helping speed the recovery.

I had a consult at the Bellaire hospital and drove over there. Bellaire looks like a war zone: trees, limbs, fences, debris of all descriptions all over the place. You see people helping their neighbors cleaning up and clearing the area, especially streets. The lines at all gas stations are very long.

Gotta go, paged to the ER.

Sept. 16, 2008/ 12:30 am - "Ikeitis"  

A. Tomas Garcia, MD  

The hospital is now feeling the brunt of all the injuries and health issues of people doing the clean-up: cuts, broken bones, back sprain, and other sprains, stuff falling on them, and them falling all over the place. Ibuprofen will be a staple in their diets during this time, along with aspirin and Tylenol. Instead of "boomeritis," we ought to call it "Ikeitis." Every joint is going to be injured or sprained.

Everyone is feeling the relief of having survived the storm and perhaps a little bit of the survivor guilt when comparing what happened to Bolivar, Crystal Beach, High Island, and Chambers County. The images we are now seeing are almost too much. Alma and I had an opportunity to drive through there recently, and it was just beautiful with houses, trees, vegetation, plants of all sizes, colors, and shapes, sand, beach and people walking, biking, having cook-outs, and enjoying the beach.

The patients in the hospital are feeling very fortunate to have been in the hospital during this time -- dry, warm food, doctors tending to them and staff honoring all their requests while they watch the images and reporters' observations of the storm's damage.

Hey, I'm beat and to bed. Big day tomorrow. I'll bet the office will be hopping.

Sept. 16, 2008/1:02 pm - Stay Away From Beaumont  

Mark Kubala, MD

Reporting from Austin today.

Mayor is urging everyone to stay away from Beaumont. Sewage at 95-percent capacity. They're concerned about backup and resultant health problems. Water not drinkable for several days. Hospitals and downtown have power.

I think the power will come back much quicker. Main problem is flooding. Power lines aren't down like they were from Rita. Don't think we'll being doing anything elective until next week, at best. Hospitals are open for emergencies and the sick.

Sept. 16, 2008/1:14 pm - Injuries Coming In  

A. Tomas Garcia, MD  

We continue to have power issues and lack of gas problems. Corporate HCA has secured a tanker that will park in our hospital parking lot with armed guards to help physicians and support staff with 10 gallons of gas per car if it's less than half full -- and this will be checked -- and we will be charged $5.25/gallon. Oh well, it beats being in line for hours and still not get gas. They will bill us later as they don't have the logistics to collect the money, cash or otherwise.

The hospital is still in disaster mode, and there are armed guards to secure the place so we can work without having to be armed, or worry that someone will enter and try something. The ER is now really busy with the injuries coming in, including the chainsaw type.

The city still isn't confident of the water supply, even though it's now coming in and with good pressure. The rule of thumb is bottled water until otherwise instructed. I still don't have power at the house, so my office is my residence for now. Anyway, I need to be close to my patients in case they need me or in case the emergency room needs me for a code stemi/acute myocardial infarction.

Overall, the hospital is responding great and the morale is high. I'm keeping my office open as long as patients continue to call and want to been seen. Better they be seen here in my office, where I have their charts and can care for them quickly and efficiently. Again, to try to keep our emergency room open for the injuries and car accidents. (The traffic lights are still not working.)

Patient just came in; gotta go.

Sept. 16, 2008/1:58 pm - Ready to Go Back to Work  

Kevin McKinney, MD

My house is okay, and I had no flooding. My power came on today. I'm ready to go back to work when able.

Sept. 17, 2008/11:48 am - Pizza by Candlelight  

A. Tomas Garcia, MD

The problem is power. Many of the trees hit power lines, transformers, and poles at many key points. So they say. So the ramp-up has been great in some areas and slow in others, depending on what the storm did. The hospital is now functioning normally. They figured out what the problem was with the generator and why it failed. Subsidence, it had actually drifted 2 inches since its installation, which was enough for the rainwater to shut it down. So when the hospital lost power on Saturday morning, the main backup failed; we then went to emergency power, which is minimal and will not run the AC, only the fan.

Currently, the emergency room is seeing the car accidents, cuts, bruises, broken bones, and chainsaw accidents as predicted. This will probably continue for awhile. Our doctors are opening our offices, but the patients aren't coming in. They're working at home, cleaning up the mess and getting their accidents as predicted. Some businesses are starting to open and the lines at many of the gas stations are smaller now. It seems that the generators that everyone is using are taking a lot more of the gas. Everyone is trying to save their freezer and refrigerator food, as well as run AC units in one room and their television and/or fan. Reports are that this should improve as well.

The key is patience at this time. I lost everything in the freezer and refrig; my sons pitched it all. They found a pizza place open for business and so we enjoyed it with candlelight. The temp dropped with the windows open. I had my first night of rest at home after my first shower since Friday. Needless to say, a 12-hour sleep was just what the doctor needed.

Sept. 17, 2008/1:36 pm - Hospitals Filling Up Quickly

A. Tomas Garcia  

All our suburban hospitals are filling up rather quickly. The medical center is having problems with power, water, and/or telephone systems, so all the patients appear to be coming to local hospitals. As they fill, FEMA with their ambulances are taking the sick to San Antonio.

It appears that there is a paradigm change: where in the past, patients would automatically go to the TMC, now it appears they are going to the local hospitals, which really makes sense. For example, I have a patient just involved in an MVA and has a pulmonary contusion. She's quickly admitted and under my care with a pulmonary specialist to help out -- all done in less than an hour.

This can only help our patients.

Sept. 17, 2008/5:28 pm - We Will Reopen Tomorrow

Joseph Prince, MD  

I am a physician at Mainland Medical Center in Texas City. I believe we were the only short-term acute care hospital along the Gulf Freeway not to close our doors in advance of Hurricane Ike. I stayed on duty in house the night of the hurricane, but once the storm came we were forced to close our doors -- but did take patients up until about 8 pm.

Power went out during the overnight hours, but the backup generators were fully functional, and overall the staff morale was excellent. Unfortunately, due to power loss in Texas City, we lost running water and sewage in the early morning hours, resulting in the need to evacuate our facility. Fortunately, I know of no patient deaths in our facility resulting from the storm.

Although the OR was flooded, the hospital will reopen tomorrow and will have limited ER triage, minor surgical, and medical ICU capabilities. I am informed patients with higher level of illness will require transfer to another facility. It is our hope we will be able to decompress some of the medical needs of Galveston and the coastal areas during the closure of UTMB.

Sept. 18, 2008/ 11:20 am - East Texas Hospitality  

J. Patrick Walker, MD  

Out of power and water for a few days. Now backup. Stayed at the hospital and an evacuation clinic most of the time. Still have a few patients from the coast.

There are a number of second homes in and around Crockett that are open, if you know of any physicians from the Galveston area that need a place for a month or two.

Sept. 18, 2008/12:12 pm - On the Road to Being Normal  

A. Tomas Garcia, MD

Well, things are starting to look normal. Traffic lights are working, no lines at gas stations, ice boxes are full, and Whataburger has an Ike menu: burger, chips, and drink. Keep it simple.

The hospital is full, but back to normal. The ER is busy but handling it well. The ICU has beds available, and the floors are sending patients home.

Power is coming back throughout the city, water is okay; so what about less than a week to recover from a major cat 2 storm?

Bolivar is sand and sea. Perhaps, the state should condemn the place and make a state park? How about Galveston? Thankfully, we don't have to carry the mail on that one.

The house is okay. We're on the road to being normal. What is normal with a hurricane? Oh, well, see you at the next TMA meeting.

Sept. 19, 2008/11:24 AM - Almost Endless Need  

Rebecca L. Huston, MD, MPH

I have had a very small role in the hurricane volunteer effort so far. I volunteered on Wednesday night at the Kelly shelter. It's a pretty overwhelming atmosphere. They are set up in a huge warehouse, with the medical station at one end. There were many wonderful nurses and doctors volunteering under trying circumstances. I wish I had brought many things with me. Two of the most useful were hand sanitizer and books from my clinic's Reach Out and Read program.

Most of the problems I saw were pretty routine: colds, earaches, tummy aches, and headaches. I did what I could, but at least I sent out each child holding a brand new book. The situation felt very similar to Katrina.

For many of the families in the shelter, I sensed almost endless need. Clearly Ike was only one of their many problems. My main hope was to offer a kind word and a listening ear.

Sept. 22, 2008/ 4:29 pm - Back at Work  

Mark Kubala, MD  

Back at work. Lot of elective cases done today. Water is fine. Still about 75,000 without electricity. Lot of stores reopening.

Saint Mary's in Port Arthur is open and running also.

Biggest hit was Bridge City and South Orange, where flooding was up to 10 feet in places.

This was first published in the November 2008 issue of Texas Medicine.

Monday, August 14, 2017

Why Doctors Use Fax Machines

By Bryan Vartabedian, MD
Pediatrician, Baylor College of Medicine/Texas Children's Hospital

This post originally appeared on 33 Charts.

Image via Abhisek Sarda on Flickr
Last Thursday Twitter carried a query from a Vox journalist about doctors and fax machines. Why do we use them? The response by the health infosphere was predictable: Why can’t doctors just get with the program? And why are they so behind the times?

It’s not that complicated. And it’s not because we don’t read Wired magazine.

EHRs don’t talk to one another. We wish they did. When select notes and labs are needed we fax one another.

Paper doesn’t talk to EHRs. The shrinking number of doctors who have not been absorbed by hospital systems write things about patients on paper. I fax other doctors who don’t use Epic.

Email isn’t secure. The legal wonks can slice and dice this but email isn’t entirely reliable within the letter of the law.

DME companies don’t have EHRs. So they fax me forms and I fax them back.

Silicon Valley’s preoccupation with building expensive-but-hopeless health applications for nervous rich people has left physicians and their overworked staff with fax machines.

Meanwhile we passively criticize doctors for using the only technology that keeps them out of the legal line of fire in a health information world that can’t seem to get it together. As grotesque as all this may seem to the Internet’s armchair critics, the fax machine is how communication around patient care gets done in the absence of anything better.

Instead of questioning doctors about the persistence of the fax machine perhaps we should ask those who have failed to shape the technology to replace it.

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