Q:  I work in a dialysis unit in the Southeastern portion of the United States and although we were spared hurricane damage these past few years, I would like to know about strategies that will help us prepare for a natural disaster in the future.
 
A: Each year, hurricanes threaten the Gulf but with a history of false alarms, many residents refuse, or don’t have the means, to evacuate. Consequently, when a hurricane strikes, heavy demands are placed on hospitals. At Ochsner, we felt well-prepared but Katrina taught us otherwise. We were forced to find creative ways to adapt to adverse conditions and appreciate the broad scope of psychological issues associated with a disaster in order to survive and reconstruct our lives.
Following Katrina, over 4,000 displaced patients with ESRD sought care wherever they could (Dyson, 2005). Many arrived at our emergency room doors but due to scarce resources, were turned away if they didn’t meet established screening criteria. Ironically, the summer heat may have reduced admissions, thanks to the excessive sweating it induced. Although diminished in patients with kidney disease, sweat glands will excrete at least a marginally effective amount of excess water, urea, ammonia, and electrolytes (Yosipovitch et al, 1994). Initially, we had little to offer those we denied care, but later, found information on the ESRD Network 13 website to be very helpful. We have since added that information, as well as other modifications, to our disaster plan as a result of lessons learned from Katrina.

First Response
Our plan includes assignment of two rotating teams who respond whenever a warning is activated. Team A is the first responder group and Team B relieves Team A when it is safe to return.

When a storm threat occurs, all of our patients are dialyzed to increase their survival odds should dialysis later become impossible. Our plan was implemented smoothly, but following landfall of the hurricane, opportunities for improvement or re-emphasis were identified for water, equipment, supplies, personnel needs, evacuation preparation, communications, visitors, and psychological impact.

Water, Equipment, and Supply Lessons
Water conservation is essential if city water is polluted and power is lost. To do that, we:
a.     Reduced treatment times to 2-3 hrs,
b.     Decreased dialysate flows from 800 ml/min to 500 ml/min,
c.     Utilized CRRT in critical care areas on portable R.O. systems,
d.     Placed machines in bypass for any treatment delays, and
e.     Screened patients in the ER and only admitted patients with critical dialysis needs (hyperkalemia, fluid overload, or severe acidosis). 
 
Deionization tanks may not be readily replaceable in a disaster, so portable R.O. systems should be used exclusively and auxiliary power assured to all equipment. Even if all equipment is in working order prior to the storm, there will be inevitable water and hook-up challenges, particularly if evacuation of equipment becomes necessary. Consequently, a bio-medical technician should be part of the first responder team.

Replacement supplies cannot be delivered if warehouses flood or roadways become impassable, so a 30-day stock-up should be kept during storm season. Carts should be readily available for efficient relocation to another area, should it become necessary.

Communications and Support Lessons
Team B’s response proved problematic since we only had their home phone, cell phone, and pager numbers, which were useless after land phone lines and cell towers were lost. Text messaging and satellite phones offered alternatives, but e-mail proved to be the most accessible and reliable for communication. Going forward, e-mail addresses are now required for everyone. Instant messaging screen names can also be useful if individuals need to communicate in real time, but we do not require these.
 
In-house communications can also be compromised for staff members who rely on pagers (which do not work when phone lines go down), so more in-house phones should be allocated when an alert is activated.

Because most Team B members evacuated with families, getting them back was difficult since only caregivers were allowed to return to the disaster area. Employees did not want to drive back alone (some as far as three states away) or leave family behind without a vehicle. In the future, Team B will stay in a regional shelter with back-up transportation. In addition, some of the Team B staff could not get past roadblocks without photo ID badges, so plan directives now include staff members keeping their hosptial ID with them.

Utilizing our visitor resources proved valuable to us and therapeutic for them. If they wanted to help, we gave them non-clinical tasks such as making coffee or running errands. At the end of the day, they thanked us but we were more appreciative!

In case the need for urgent evacuation occurs, copies of the rounding report, medication record, and last flowsheet should be made prior to the storm and given to each patient in a waterproof bag. As seen after Katrina, evacuations can occur in boats so records need to be protected and stay with patients.

Care for the Caregiver Lessons
In extreme heat, caregivers should be as familiar with symptoms of dehydration in themselves as well as in their patients. Because lack of mental clarity, as well as some non-specific symptoms including headache, dizziness, nausea and vomiting, weakness, and tachycardia can occur (Suddaith, 1991), this may be a challenge. Staff members should drink twice as much as they thirst for.
 
If the city water becomes polluted or incoming water pressure is lost, toilets may not flush and it is unsafe to brush teeth or shower. Water from a swimming pool can be used to flush toilets, but large jugs of pure water should be stocked for personal hygiene.

On Day 4 after the hurricane, we realized that 3 pairs of underwear were inadequate since washing clothes was not feasible. We now recommend 7 changes of clothes, including for off-shift hours. Other recommended items to have include: talcum powder, dry shampoo, gum, mouthwash, soap, towels, hand fans, batteries, large flashlight or lantern, high calorie non-perishable food (I lost 11 pounds in 11 days, which I coined “The Katrina Diet”), Gatorade or other drinks, transistor radio/TV, dry ice, wet towelettes, air mattress, pump, pillow, sheets, and lots of deodorant! A small hibachi is good to have since, without power, the menus of cold canned food get old quick.

Diversional activities to reduce stress cannot be underestimated. Individual items are important, but activities others can share, such as a portable DVD player with movies or musical instruments, are very therapeutic. Our Medical Director, Andy Cohen, brought his guitar and our sing-along at the end of the day made for grand memories. 

Pets were also an important consideration. In a disaster, veterinary offices close just as other businesses and many employees simply refuse to leave their family animals at home alone. Being sensitive to that, Ochsner supports a volunteer pet care team who help register and monitor pets in a safe and secure area of the parking garage lobbies. While not ideal, it was consoling for pet owners to know their beloved friends were safe and available for their affection on off shifts. 

If necessity is the mother of invention, then one of our dialysis nurses, Janice Johnson, became a poster child when she devised a means for a warm shower after we switched to icy-cold, brown well water no one wanted to step into. Assured that the initial water crisis had abated, she rigged some suction tubing to a spigot fed by treated water from the holding tank in the (hot) boiler room. Our private “spa” became a carefully guarded secret. Janice also shared the practicality of washing underwear while wearing them to save water.

We also learned that beauty is not even skin deep. Vanity was a wasted effort in the heat and humidity, but losing it was also a great equalizer. Except for the bras, we looked like throwbacks to the hippie generation, without the nostalgia.
 
Psychological Stages of Disaster
By the holidays, things had deteriorated for many. Despite generous outpourings of support to meet our basic needs, no one anticipated the scope of psychological issues, including suicide. Consequently, when a psychologist talked to our group on the stages of disaster (DeWolfe, 2000), we found it enlightening and reassuring. It also affirmed how important psychological support is in every phase of a disaster, in order to be ready for the next phase, and ultimately, to survive. The stages of disaster are:

• Threat, warning, impact (preparation physically and psychologically; bracing),
• Heroic (rescue and recovery),
• Inventory (assessing losses; counting blessings),
• Honeymoon (relief efforts, common experience, media blitz, optimism, goodwill),
• Disillusionment (effect of delays, hassles, red tape, and other frustrations), and
• Reconstruction (new normal emerges; survivor pride)