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Plan ahead for weather emergencies, doctors advise peers
Hurricane season starts June 1, for many bringing memories of the severe storms that battered the United States in 2017 and serving as a reminder of the importance of preparedness.
Doctors who have been affected by weather and other disasters told Healio Family Medicine the adage ‘be prepared’ is probably more relevant for weather-related emergencies than any other professional instance.
These survivors and experts said the steps they recommend should be taken now, before 2018 hurricane names like Isaac, Chris and Valerie are heard on news reports warning of their impending arrival. Further, they add that their advice can often mean the difference between a practice staying open during and after a disaster or being forced to close, sometimes forever.
First-hand perspectives
Southeast Texas, particularly Houston, bore the brunt of Hurricane Harvey’s destruction when it struck in August 2017. United Press International reported that in 2017, more than 90% of the total damage estimate of $202 billion in the United States was attributed to that one storm.
At least 30 inches of rain fell in southeastern Texas during a 6-day period, with some places seeing more than 50 inches. The National Weather Service had to develop two new colors to depict the amount of precipitation on their weather maps.
“The only time I lived outside of Texas is when I went to school in North Carolina, and while there, I rode out three hurricanes,” Troy Fiesinger, MD, a family doctor in Sugar Land, Texas said in an interview with Healio Family Medicine in September 2017while the waters from Harvey were still high. “Harvey is the worst storm I’ve ever lived through. I never thought I’d see flooding like we did in 2001 [with Tropical Storm Allison] again but we did, and this time it was worse.”
Another medical professional described the storm’s impact months later.
“We had some significant damage in certain pockets of our health system,” Jennifer A. Small, AuD, MBA, CCC-A, interim executive vice president of ambulatory care services at Harris Health System, one of the largest such organizations in Houston, said in an interview.
“We had damage to our administrative office and education space located at our largest hospital. We also had some leaking with water in the walls and the windows to the point where we had to transition patients for care and management after the flood,” she said.
“We also had some severe damage in some of our clinics, with one of them being closed from the storm until the middle of February because we had to get new furniture, get new equipment, and supplies,” Small continued, adding a financial estimate from the storm’s impact was still being calculated for Harris Health System.
A Texas Medical Association survey of 524 physicians conducted in September 2017 in the 39 Texas counties declared disaster areas by the Federal Emergency Management Agency showed 65% of the physicians had to temporarily close, 35% had to reduce hours or services, and 6% of respondents had to relocate after the storm. Survey respondents also reported having staffing shortages, absorbing other health systems’ patients, not filing claims for several weeks, and loss of vaccines.
“We had to gut our office. Thinking hard about quitting the practice of medicine, but that would leave our area vastly under served for obstetrical services. What to do?” one respondent said.
“Office open but will suffer economic injury due to decreased demand,” another said.
“My office was totally destroyed when the roof went and flooded everything. Ruined five computers, one server, patient charts, all furniture. [I] have to start over after 28 years here ...” according to a third respondent.
More than 8 months after Harvey dissipated over Kentucky, the state of health care in the Houston area is varied.
While places like the VA Medical Center in Houston were “fully operational” at the time of this writing, and Small said much of Harris Health System is back up and running, ABC recently reported that Rockport Family Planning Clinic — about 3 hours south of Houston — finally reopened 8 months after the storm on May 1, albeit in a temporary location. NBC recently reported that two health care facilities in Aransas Pass, a town of about 8,300 residents, also about 3 hours south of Houston, were destroyed and patients have since had to encounter longer waits to get basic medical care.
Lack of preparedness
Experts report that there is lack of preparedness among the family medicine community for weather-related medical emergencies.
“Knowledge of how to respond to disasters and coordinate that response with other agencies and organizations is essential,” Mark K. Huntington, MD, PhD, of the department of family medicine at the University of South Dakota and Thomas F. Gavagan, MD, MPH, of the department of family medicine at the University of Chicago, wrote in Family Practice in 2011. “The literature suggests that physicians as a group are unprepared for this role, due to inadequate training and limited experience.”
In a recent interview with Healio Family Medicine, Huntington said little has changed in the 7 years since he and his colleague authored the paper.
“There are more courses and training going on, but there hasn’t been much outcomes-oriented evaluation of the effectiveness training and most of the publications about this type of training have been written and published overseas.”
Huntington suggested reasons why this might be so.
“We’re an instant gratification kind of society, we don’t always like to plan ahead. We don’t expect the bad things to happen to us, only other people,” he said. “Training is like a fire extinguisher. You buy it because you might need it, but you hope you never do.”
The lack of preparedness extends to infrastructure, supplies and patient accommodations too, Sarah Nafziger, MD, an emergency physician at the University of Alabama at Birmingham said in an interview shortly after a small tornado blew through a nearby town.
“I’ve been working in disaster preparedness for 18 years, and time after time after time I’ve been to talks where people talk about this disaster happened or that disaster happened. And so often you hear people say, ‘I never thought this would happen here’. And I hear the regret in their voice. If you’re one of those people, you probably need to stop and think about how often things really do happen,” she said.
To-do listThere is no group that regulates primary care and family medicine practices’ preparedness for disasters, leaving these locations to prepare on their own.
To fill in this gap, the Emergency Preparedness Toolkit for Primary Care Providers, published by the Morehouse School of Medicine, offers help. The toolkit provides five planning basics: “Knowing Your Local Team,” “Promoting a Culture of Preparedness,” “Creating a Practice Response Team,” “Assessing Facilities Annually,” and “Supporting Staff Needs.” The toolkit’s authors also suggest:
- Forming a planning team;
- Evaluating risks and hazards;
- Ascertaining goals and objectives; and
- Creating and then putting the plan into place
Exercises come in two categories, according to the toolkit: discussions-based, which involve games, tabletop exercises workshops, and seminars; and operations-based, which involve full-scale exercises, drills, and functional exercises.
“Your infrastructure drill should start with a way to notify staff of the emergency,” Nafziger said. “There are smart phone apps that can track your location or use pre-programmed locations to allow them to notify you of an impending weather event. But you should also have a backup system in place, too, because one thing we know about using technology is it will fail at some point.”
The drill should then move on to taking care of patients and handling electronic health records, she said.
“With patients, practice moving people away from windows and doors and into the deepest, most interior room. When it comes to EHRs, make sure you have a place to maintain those servers on generators. Also, have a backup location that’s separate from your primary location, so you can have preservation of those records in the event that you do lose access to your office location temporarily or permanently.”
Input from other experts in nonmedical fields is needed too, Nafziger added.
“Work with engineering experts to make sure that your facilities are up to code and that you’ve done everything you can make facilities as durable as possible for whatever threat is in your area,” she said.
Medical professionals might also want to work with information technology experts to switch over to EHRs if they are among the approximately 25% that have not already done so, researchers said.
“We have seen before, and it was true during [Superstorm] Sandy, that the use of an EHR system can facilitate record recovery if a facility is damaged or destroyed. [Sandy] also shows that, with only a small amount of additional planning, it is possible to maintain access to an EHR system during a significant event even if a facility has been damaged or destroyed,” Kevin Horahan, of HHS’ Office of the Assistant Secretary for Preparedness and Response, wrote in Online Journal of Public Health Informatics.
“Given the dual vital roles for EHRs, in both day-to-day practice and disaster relief and recovery, health care systems, community clinics, and individual providers alike should consider the transition from paper health records to EHRs a higher priority. When a disaster like Hurricane Katrina or the Joplin tornado strikes, many patients — and sometimes providers — are left with few remnants of their pre-disaster lives,” Mahshid Abir, MD, MSc, of the department of emergency medicine at George Washington University, and colleagues wrote in Prehospital and Disaster Medicine.
“By adopting and meaningfully using EHRs, provider practices and hospitals can continue to deliver care with their patients’ medical records and critical health information left intact and accessible when most needed,” they added.
The Emergency Preparedness Toolkit for Primary Care Providers also contains scorecards PCPs can fill out as to assess their preparations in areas such as waste and medical equipment management, infection control, and contact information lists for community liaisons, practice support services, and vendors.
There are other things clinicians can do before disaster strikes, Paul Lyons, MD, chair of the department of family medicine at University of California, Riverside, said in an interview.
The university is near where some of the California wildfires took place last year. The state also lives under a cloud of uncertainty of when a major earthquake might strike.
“In the face of a fire or flood, you should have medications and equipment together, prepared and ready to go.
Huntingdon and Gavagan recommended the following websites and, where appropriate, specific sections to prepare for medical emergencies during hurricanes and other weather-related disasters:
- Advanced Trauma Life Support;
- American Heart Association (advanced cardiac and pediatric advanced life support course);
- American Hospital Association;
- American Medical Association;
- Association of State and Territorial Health Officials;
- Comprehensive Advanced Life Support;
- Federal Emergency Management Agency (National Incident Management System and Incident Command System training);
- International Critical Incident Stress Foundation (management information and training);
- Johns Hopkins Office of Critical Event Preparedness and Response;
- JumpSTART Pediatric Triage Tool;
- National Disaster Life Support Foundation; and
- U.S. Army Medical Research Institute of Infectious Diseases.
Many of the planning components are interchangeable, and can be applied to fires, earthquakes, and blizzards. Nafziger, who is also director of the University of Alabama’s Office of Emergency Medical Services, added that nonweather emergencies should be considered when medical professionals make emergency plans.
“We had a fire on our parking deck at my hospital and that required us activating a lot of emergency procedures. We’ve had water main breaks and those are things that require you to activate your emergency procedures. Emergencies are not always glamorous, headline-generating events. But you do have things that happen on a fairly regular basis that would require [doctors] to activate your emergency procedures,” she said.
After the storm
Even after the storm or other emergency has significantly abated, and even if a PCP’s practice is not structurally damaged, there are still issues that must be addressed, former CDC and HHS employees stated.
Both agencies’ websites provide information on handling emergencies after events like hurricanes, heavy rainfall that causes flooding or standing water, and fires.
“The aftermath of disasters such as Hurricanes Harvey and Irma can be just as dangerous as the storms themselves,” then-CDC Director Brenda Fitzgerald, MD, said in a press release distributed in September 2017. “We encourage affected communities and responders to take advantage of the wealth of practical information CDC offers.”
Karen DeSalvo, MD, MPH, MSc , president-elect of the Society of General Internal Medicine and previous acting assistant secretary for health at HHS, reports that when she was professor of medicine and vice dean for community affairs and health policy at Tulane University, she helped oversee six clinics seeing about 450 patients daily when much of New Orleans was under water after Hurricane Katrina.
She said during a speech at this year’s American College of Physicians Internal Medicine meeting, that the city lost its entire health care continuum and health care infrastructure, even its 911 operations for many days following the 2005 Category 5 storm.
DeSalvo added that medical professionals need to be prepared to answer a variety of questions following disasters.
Patients were asking questions “not so much about physical trauma ... but about emotional trauma, and chronic disease ... and about life, such as when will the schools reopen, when will the electricity be put back on, is there a place to buy food ... how do I keep my insulin cold because I don’t have a house” after Katrina, she said.
“When we step in and intervene and provide transportation and access to healthy food, we can make a difference in people’s health outcomes, improve quality of life and reduce costs,” she told the crowd.
Emotional trauma also exists after Hurricane Harvey, David Bauer, MD, MS, a family physician with Memorial Hermann Medicine Group in Sugar Land Texas, told Healio Family Medicine.
In his first interview the week after the storm hit Houston, he expressed gratitude for his practice not sustaining damage and reopening a few days after the storm. In a more recent interview, the thankfulness was taken over by concern that many of his patients are suffering from PTSD, anxiety and depression.
“I’ve seen quite a few patients coming in for chronic care telling me they are having difficulty sleeping, problems focusing, worrying about what’s going to happen next,” Bauer said in a follow-up interview this month, adding that patient concerns regarding lack of adequate housing and scam artists only make the symptoms worse. “Psychological disorders are much more pervasive in the Houston area than I would have predicted before the storm.”
Bauer’s concerns were underscored by a survey released by the University of Texas School of Public Health earlier this year. The questionnaire, conducted 4 months after Hurricane Harvey, found that 18% of Harris County’s estimated 4.6 million residents showed signs of serious psychological distress since the storm. Comparatively, the national rate for serious psychological distress is 4%, the report said.
“Regardless of what the disaster is — mudslide, fire, earthquake, whatever — primary care physicians need to look for PTSD, anxiety and depression. Patients will experience loss of control, fear of what is going to happen next, how am I going to pay for things like medications regardless of the source of the weather disaster.”
Bauer encouraged PCPs to ask their patients questions on the PHQ-9 or GAD-7 questionnaires during their annual wellness visits, so that when patients come in after a weather-related disaster, it may be easier to ascertain the scope of any psychological disorders.
The American Academy of Family Physicians also provides post-disaster guidance on its website:
- Contact employees and let them know what short-term action they should take and conduct a meeting with those employees deemed most critical.
- Secure all business and medical records
- Conduct a general assessment of the damage to the building your practice is housed in with the landlord, obtain new office space and equipment and reroute mail and phone calls as needed.
- Notify insurance carrier.
- Perform salvage operations.
- Contact billing services, an accountant and bank to rebuild financial records.
- Maintain an account of all damage-related costs.
- Contact patients.
Take-home message
Nafziger said preparation should go further than the “must-dos.”
“Just meeting the minimum regulatory requirements that may exist in your state is only the first step in your preparation,” she said. “One of the biggest mistakes I see is that people are not going to the next level of preparedness. There are more long-term planning things that have to happen on an everyday basis so that when we do have an event we can minimize the impact.”
Fiesinger the doctor and long-time resident of Houston, who endured Harvey, concurred and indicated that though his clinics did not sustain damage, he would not be complacent.
“Make sure your practice, no matter how small or large, has a disaster plan. If our clinic hadn't put one in place in the spring of 2017, we would have not done nearly as well as we did,” he told Healio Family Medicine when we spoke to him last week. “Our disaster plan worked well, but needs to be tested periodically to be certain everyone knows how it works.”
Because almost no part of the U.S. is immune to natural disasters, all medical professionals should be prepared, Lyons added.
“We have seen in the past few years that weather-related emergencies can happen just about anywhere and just about any time and often with less warning and predictability than we might wish for. All physicians would be well-served to be prepared all the time,” he said.
“If you’re prepared for the emergency and nothing happens, there’s no real downside to that; however, if you’re unprepared and something does happen, there are very significant and potential consequences. Prudence suggests preparation would be the better gamble,” he added. – by Janel Miller
References:
Abir M, et al. Prehosp Disaster Med. 2012;doi:10.1017/S1049023X12001409.
American Academy of Family Physicians. Actions to take after a disaster. Accessed May 15, 2018.
CDC.gov. CDC Hurricane Support. https://www.cdc.gov/media/releases/2017/p0913-hurricane-support.html. Accessed May 15, 2018.
Emergency Preparedness Toolkit for Primary Care Providers. Morehouse School of Medicine. Accessed May 15, 2018.
Geology.com. Tropical Storm Names – Hurricane Names – 2012 through 2021. https://geology.com/hurricanes/tropical-storm-names.shtml. Accessed May 17, 2018.
Gordon SH, et al. RI Med J (2013) 2015 Oct 1. 98(10):29-32. Accessed May 17, 2018.
Horahan K. Online J Public Health Inform. 2014;doi:10.5210./ojphi.v5i3.4826.
Houston.va.gov. Current operating status – Michael E. DeBakey VA Medical Center – Houston Texas. https://www.Houston.va.gov/emergency. Accessed May 17, 2018.
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Sph.Uth.edu. UTHealth finds unprecedented psychological distress months after Harvey. https://sph.uth.edu/news/story/uthealth-finds-unprecendented-psychological-distress-months-after-harvey/. Accessed May 15, 2018.
TexasMed.org. TMA Hurricane Harvey survey. https://www.texmed.org/uploadedFiles/Current/2016_Advocacy/TMA_Survey_Report_on_Hurricane_Harvey.pdf. Accessed May 16, 2018.
UPI.com. Record 2017 hurricane season cost $370B, hundreds of lives.
https://www.upi.com/Record-2017-hurricane-season-cost-370B-hundreds-of-lives/7711511317614/. Accessed May 4, 2018.
USAToday.com. Harvey has dropped almost 52 inches of rain in Houston. Here's where it's moving next. https://www.usatoday.com/story/weather/2017/08/29/where-harvey-now-where-go-next/611456001/. Accessed May 25, 2018.
Disclosures : Neither Bauer, Huntington nor Lyons report no relevant financial disclosures. Healio Family Medicine was unable to determine the other contributors’ relevant financial disclosures prior to publication.