In Katrina’s wake, extraordinary health care challenges emerge

Cardiologist in Houston reports that evacuees are sicker than expected, with multiple cases of diabetes, hypertension, heart failure.

Hurricane Katrina left a toll of devastation in America’s Gulf Coast region that is unprecedented in U.S. history. In addition to the injuries and deaths resulting from the hurricane and its aftermath, thousands of people with pre-existing chronic medical conditions such as diabetes and heart disease survived the hurricane only to face compromised care in the days and weeks afterward.

While many of the Gulf Coast evacuees sustained injuries directly related to Katrina’s destruction, many more have suffered major disruptions in the treatment and management of their chronic illnesses. As the majority of these patients have been evacuated to other parts of the country, their treatment and long-term care now pose a massive challenge for health care providers throughout the country.

Patients without medication

Cardiology Today recently spoke with Keith Ferdinand, MD, medical director of Heartbeats Life Center, a cardiology clinic located in the ninth ward neighborhood of New Orleans. The ninth ward sustained some of the most extensive damage from Hurricane Katrina, and many of its residents were among those trapped at the Superdome and the New Orleans Convention Center in the days after the storm.

Keith Ferdinand

Ferdinand and his wife were able to evacuate to Atlanta before Hurricane Katrina hit, but he remains deeply concerned about his patients, particularly those who were not able to leave New Orleans prior to the catastrophe.

Ferdinand said patients with diabetes and heart disease faced extremely difficult conditions during the disaster. “Beyond the devastating effects of the wind and water, patients were separated from their usual source of care, transported for long periods of time without medication and often placed in makeshift living arrangements without appropriate attention to their medical needs,” Ferdinand said.

Although health care providers are working at shelters in areas where evacuees have been taken, Ferdinand said he worries that patients’ medical needs are not being met to the fullest extent. “There are thousands of Gulf Coast residents whose doctor-patient relationships are now unexpectedly dismantled,” he said.

“Those patients who have not been thoroughly educated by their clinicians regarding their conditions, medications and previous medical procedures and tests are at an unfortunate disadvantage in communicating their needs to a new health care provider,” he said.

Medical conditions worsening

Frank Smart, MD, associate professor at Baylor College of Medicine and medical director of advanced heart failure and cardiac transplant at the Texas Heart Institute at St. Luke’s Episcopal Hospital in Houston, helped evacuate patients via helicopter from Tulane University Hospital in New Orleans and is now among the group of health care providers treating evacuees in Houston. Smart is a member of Cardiology Today’s Editorial Board on the Myocardial Disorders, HF and Transplantation section.

Frank Smart

Smart said that more than 400 evacuees were treated at his hospital in the first week following their arrival and that all 148 hospitals in the Houston area were treating evacuees. Smart said that overall, the patients were sicker than expected and had a multitude of chronic diseases. The majority of the patients he treated had diabetes, hypertension and heart failure. Among these were two patients with heart disease who were waiting for heart transplants when they were forced to evacuate New Orleans; they are now being cared for at his facility.

A lack of medicine and poor disease management during the disaster led to worsening medical conditions for many of the evacuees. “Many of the patients had chronic disease and suddenly had no medication,” Smart told Cardiology Today. “During the ordeal of the hurricane and in the days afterward, their disease management was compromised. In many cases, by the time they came to our hospital, these patients were significantly disadvantaged with regard to their care.”

Smart said that even though doctors in Houston and other cities are striving to provide first-rate care for evacuees, challenges remain. “It is a very difficult situation because for many of these patients, we cannot locate their families, we cannot find their regular doctors and we do not know their medical history,” he said.

“Patients are often ignorant of their health problems and their treatment regimens. We sort through as much of it as we can and work to provide optimal care.”

A potential epidemic

Some medical professionals are growing concerned that there could be an epidemic of uncontrolled diabetes and hypertension among hurricane evacuees in the near future. Many of the patients with diabetes and heart disease who have been displaced may be ignorant of their medical condition or unable to get proper medication and care. Furthermore, for many of these patients, lapses in medicine and proper nutrition during the disaster could have long-term health consequences.

Special attention at shelters needs to be focused on any evacuees with diabetes or hypertension to prevent future problems. “Patients with diabetes are two to four times more likely to suffer from heart disease and are at increased risk for stroke,” Ferdinand said. “Therefore, much attention must be given to these people, even if they do not request immediate attention.

“Patients with diabetes should be adequately screened and assessed for blood pressure levels and blood glucose status. Those who have excessive blood pressure elevations and uncontrolled diabetic status should be afforded prompt, efficient and expert care vs. waiting until a crisis develops if signs and symptoms are ignored.”

Since many patients may be somewhat ignorant of their medical conditions, doctors at shelters should not rely on patients to know when or if they need treatment. “Simply inquiring at a shelter if anyone needs medical assistance may not be adequate,” Ferdinand said.

“Patients often underestimate the negative effects of insufficient nutrition on their pre-existing condition that may have been aggravated during the days spent without food and/or water following the hurricane.”

Ferdinand also said he is concerned about the quality of nutrition that evacuees are now receiving at the shelters, noting that for some patients, a poor diet could exacerbate their medical conditions. “Some of the meals in shelters may be excessively high in sodium and carbohydrates, causing unsuspected elevations in blood pressure and glucose,” he said.

Preparing for disasters

The relief effort for Hurricane Katrina has brought new focus to the issues of disaster preparedness. In particular, this tragedy has demonstrated that educating patients can be an important way to prepare for a disaster. Education for patients regarding their medical conditions and treatment should be a priority for all health care providers, Ferdinand said.

Although it may be difficult to educate patients who have low literacy skills, low health literacy or complicated disease management regimens, a patient’s knowledge about their own condition is essential in the event that their medical records are destroyed or unavailable or if they are unable to get to a health care provider when necessary.

The events surrounding Hurricane Katrina also reiterate that every hospital and health care facility should have a disaster readiness plan in place. Smart said the Houston disaster management plan, developed after Tropical Storm Allison caused havoc in the Houston area in 2002, helped avoid confusion when the evacuees began arriving at local hospitals.

“Houston disaster planning went extremely well,” Smart said. “We were not short-staffed because the Houston disaster management team kept track of patients for all the hospitals in the area so that none were overloaded.

The disaster management team conducted hourly updates for each hospital regarding the number of patients being treated and the number of new patients that had been brought in since the last update.”

Smart said this citywide approach helped balance the resources of all area hospitals.

Smart also said that the time he spent in New Orleans helping to evacuate patients underscored for him the challenges of treating patients under the worst possible conditions and the importance of preparing for a disaster of this magnitude.

“All hospitals should understand how difficult the planning is when necessities such as power, communications, water and security are not available,” he said. “Hospitals should have a plan and practice it under the worst possible conditions.

“Do not anticipate your back-up generators will work and remember that when the power goes out, so do all phone and pager communications. Also, do not count on cellular service since this, too, can be fleeting,” he said.

Medical records

The disaster also reiterates the importance of electronic medical records. “The displacement of hundreds of thousands of people and the loss of medical records due to flooding increases the recognition of a need for portable, digital, personal medical information that cannot be destroyed, especially for patients with diabetes,” Ferdinand said.

He suggested that electronic medical records could include patient history, results of most recent tests and pharmacotherapy regimens. The records could be accessed by the patient or by a provider with the patient’s permission.

Ferdinand also said this information could be stored in a wallet-sized card patients could carry.

“Even a simple wallet-sized plastic card with treatment and medicinal information can be indispensable in ensuring necessary appropriate care follows displacement after natural disasters and other crises,” he said. – by Jay Lewis