Ltc Herbert Kwon, MC, USA

 

In October 2017, in support of the Federal Emergency Management Agency’s response to assist the Governor and people of Puerto Rico, three Department of Defense (DOD) military hospital platforms were deployed; one each, by the US Army, Navy, and Air Force. They arrived on the island at different times with predominantly wartime surgical capabilities and augmented the Federal Emergency Management Agency (FEMA), US Public Health Service, National Guard, and Puerto Rico Department of Health efforts. My perspective is that of patient care and transport between the Centro Medico hospital complex in San Juan, the larger regional hospitals, the Veterans Administration hospital, the DOD response, FEMA Disaster Medical Assistance Teams (DMAT), and FEMA Federal Medical Shelters about 4 to 6 weeks after Hurricanes Maria and Irma struck. Based upon this experience, I would like to offer the following.

Pre-Disaster: All clinicians have a few patients that teeter “on the edge.” When basic services go away, these patients fall over that edge and become inpatients. Establish a list of patients who require oxygen and devices such as vests, cough-assist, or ventilation. If evacuation before the disaster is possible, those patients need to leave. If they refuse, or are unable to leave, they need to be able to supply their own generated power for a prolonged period of time, as batteries will run out prior to power restoration. They must be able to use oxygen concentrators, as tank re-supply may not be readily available. By law, FEMA cannot give generators to individuals, so individuals must prepare for themselves. In a hurricane-prone area where seasonal risk can be established, planning medication refills at the beginning of the season or giving a larger than normal supply may prove useful. In an area prone to sudden disaster, such as earthquake or tornado, then counseling patients to request refills at least 2 weeks early may be adequate.

Post-Disaster: The most reliable form of communication will be text. You likely already have text contacts for your staff and family members; add other providers, responders, planners, pharmacists, and oxygen suppliers to your text contacts. While you may wish to share a text point of contact with patients, understand that your ability to actually help during the initial disaster will likely be limited. Identify possible language translation needs and possible translators among your staff and/or friends as telephone services will be limited or absent following the disaster. Finally, identify your local emergency response planners on Facebook, Twitter, or other social media feeds. This will allow you to direct others to these sites for accurate information after the disaster.

Responder Recommendations: A single social media post can DESTROY your plans and hamper your efforts. Advertise a single contact point and an information resource (eg, bulletin board, webpage) early and often. Publicly and accurately declare the means by which people will access health care and health-care services, such as medications, dialysis, and oxygen. There will be nongovernment organizations (NGOs), friends, and other well-meaning individuals who will try to assist people in need through unconventional channels. Yet, by requesting assistance through nonroutine channels, those efforts tend to delay assistance, cause confusion, and/or squander resources. Continue to direct those requests through the established response channels, ie, the local 911 equivalent.

 

Plan to use cellular texts to communicate. While satellite telephones are great in concept, in execution, they are difficult to utilize when transmitting complex medical information. If you have an expansive budget, there are now devices available that allow for Iridium satellite-based text communications that require batteries but not intact cellular towers.

Facilities with electricity, water, oxygen, medications, laboratory testing, and CT scanners need to be identified and advertised within the responder community. If FEMA is involved, these resources will be identified and updated on a routine basis. The information will be distributed to their DMAT teams. Those DMAT teams will be distributed throughout the response area. Additionally, if the resources and budgeting are approved, then FEMA will also help re-establish medical transport, as well as Federal Medical Shelters (FMS). The FMS can temporarily house patients who can perform basic activities of daily living but require power, oxygen, or medication administration. For those patients in need of medications without insurance, FEMA may activate medication assistance through the Emergency Prescription Assistance Program. This will allow up to 30 days of medication to be distributed at no cost to the individual through participating pharmacies.

External responders will obviously need to pair with local providers/professionals who can navigate the system and, if necessary, can translate medical terms and care plans. Additionally, external responders will be targets for individuals looking to obtain resources for secondary gain or profit. Establishing a plan or consistently redirecting people to the appropriate resources for those needs may limit the inevitable damage these individuals will cause. Additionally, understand that the efficiencies of the modern society will be gone, and tasks will take much longer than expected. Even if you can communicate by text, the transporting of patients, delivering supplies, meeting with groups, and assessing sites will take far longer than you are used to when none of the stoplights are functional or if gasoline is in limited supply.

Finally, there will be patients for whom no solution, short of an intact, well-resourced medical system, exists—those with severe congenital issues, patients with advanced dementia, patients with advanced cancer, and those with multiple-antibiotic-resistant osteomyelitis are a few of the patients that this response encountered. If transport out of the area is unavailable, NGOs and other charities may be the best, and at times, the only resource for these patients. During this response, I observed NGO and charities helping individual patients and their families with their power, shelter, and medical needs that could not be legally provided by federal government response.

While I hope you may never need to use them, preparations for evacuation, medication, power, and communications before a potential disaster occurs will prove helpful to your patients. After the disaster, consistent and simple communications to the public will be necessary to limit the damage from the social media rumor mill. Working within the organized response framework and leveraging local knowledge and targeted NGO involvement will maximize the effect of your efforts.

 

In October 2017, in support of the Federal Emergency Management Agency’s response to assist the Governor and people of Puerto Rico, three Department of Defense (DOD) military hospital platforms were deployed; one each, by the US Army, Navy, and Air Force. They arrived on the island at different times with predominantly wartime surgical capabilities and augmented the Federal Emergency Management Agency (FEMA), US Public Health Service, National Guard, and Puerto Rico Department of Health efforts. My perspective is that of patient care and transport between the Centro Medico hospital complex in San Juan, the larger regional hospitals, the Veterans Administration hospital, the DOD response, FEMA Disaster Medical Assistance Teams (DMAT), and FEMA Federal Medical Shelters about 4 to 6 weeks after Hurricanes Maria and Irma struck. Based upon this experience, I would like to offer the following.

Pre-Disaster: All clinicians have a few patients that teeter “on the edge.” When basic services go away, these patients fall over that edge and become inpatients. Establish a list of patients who require oxygen and devices such as vests, cough-assist, or ventilation. If evacuation before the disaster is possible, those patients need to leave. If they refuse, or are unable to leave, they need to be able to supply their own generated power for a prolonged period of time, as batteries will run out prior to power restoration. They must be able to use oxygen concentrators, as tank re-supply may not be readily available. By law, FEMA cannot give generators to individuals, so individuals must prepare for themselves. In a hurricane-prone area where seasonal risk can be established, planning medication refills at the beginning of the season or giving a larger than normal supply may prove useful. In an area prone to sudden disaster, such as earthquake or tornado, then counseling patients to request refills at least 2 weeks early may be adequate.

Post-Disaster: The most reliable form of communication will be text. You likely already have text contacts for your staff and family members; add other providers, responders, planners, pharmacists, and oxygen suppliers to your text contacts. While you may wish to share a text point of contact with patients, understand that your ability to actually help during the initial disaster will likely be limited. Identify possible language translation needs and possible translators among your staff and/or friends as telephone services will be limited or absent following the disaster. Finally, identify your local emergency response planners on Facebook, Twitter, or other social media feeds. This will allow you to direct others to these sites for accurate information after the disaster.

Responder Recommendations: A single social media post can DESTROY your plans and hamper your efforts. Advertise a single contact point and an information resource (eg, bulletin board, webpage) early and often. Publicly and accurately declare the means by which people will access health care and health-care services, such as medications, dialysis, and oxygen. There will be nongovernment organizations (NGOs), friends, and other well-meaning individuals who will try to assist people in need through unconventional channels. Yet, by requesting assistance through nonroutine channels, those efforts tend to delay assistance, cause confusion, and/or squander resources. Continue to direct those requests through the established response channels, ie, the local 911 equivalent.

 

Plan to use cellular texts to communicate. While satellite telephones are great in concept, in execution, they are difficult to utilize when transmitting complex medical information. If you have an expansive budget, there are now devices available that allow for Iridium satellite-based text communications that require batteries but not intact cellular towers.

Facilities with electricity, water, oxygen, medications, laboratory testing, and CT scanners need to be identified and advertised within the responder community. If FEMA is involved, these resources will be identified and updated on a routine basis. The information will be distributed to their DMAT teams. Those DMAT teams will be distributed throughout the response area. Additionally, if the resources and budgeting are approved, then FEMA will also help re-establish medical transport, as well as Federal Medical Shelters (FMS). The FMS can temporarily house patients who can perform basic activities of daily living but require power, oxygen, or medication administration. For those patients in need of medications without insurance, FEMA may activate medication assistance through the Emergency Prescription Assistance Program. This will allow up to 30 days of medication to be distributed at no cost to the individual through participating pharmacies.

External responders will obviously need to pair with local providers/professionals who can navigate the system and, if necessary, can translate medical terms and care plans. Additionally, external responders will be targets for individuals looking to obtain resources for secondary gain or profit. Establishing a plan or consistently redirecting people to the appropriate resources for those needs may limit the inevitable damage these individuals will cause. Additionally, understand that the efficiencies of the modern society will be gone, and tasks will take much longer than expected. Even if you can communicate by text, the transporting of patients, delivering supplies, meeting with groups, and assessing sites will take far longer than you are used to when none of the stoplights are functional or if gasoline is in limited supply.

Finally, there will be patients for whom no solution, short of an intact, well-resourced medical system, exists—those with severe congenital issues, patients with advanced dementia, patients with advanced cancer, and those with multiple-antibiotic-resistant osteomyelitis are a few of the patients that this response encountered. If transport out of the area is unavailable, NGOs and other charities may be the best, and at times, the only resource for these patients. During this response, I observed NGO and charities helping individual patients and their families with their power, shelter, and medical needs that could not be legally provided by federal government response.

While I hope you may never need to use them, preparations for evacuation, medication, power, and communications before a potential disaster occurs will prove helpful to your patients. After the disaster, consistent and simple communications to the public will be necessary to limit the damage from the social media rumor mill. Working within the organized response framework and leveraging local knowledge and targeted NGO involvement will maximize the effect of your efforts.

 

In October 2017, in support of the Federal Emergency Management Agency’s response to assist the Governor and people of Puerto Rico, three Department of Defense (DOD) military hospital platforms were deployed; one each, by the US Army, Navy, and Air Force. They arrived on the island at different times with predominantly wartime surgical capabilities and augmented the Federal Emergency Management Agency (FEMA), US Public Health Service, National Guard, and Puerto Rico Department of Health efforts. My perspective is that of patient care and transport between the Centro Medico hospital complex in San Juan, the larger regional hospitals, the Veterans Administration hospital, the DOD response, FEMA Disaster Medical Assistance Teams (DMAT), and FEMA Federal Medical Shelters about 4 to 6 weeks after Hurricanes Maria and Irma struck. Based upon this experience, I would like to offer the following.

Pre-Disaster: All clinicians have a few patients that teeter “on the edge.” When basic services go away, these patients fall over that edge and become inpatients. Establish a list of patients who require oxygen and devices such as vests, cough-assist, or ventilation. If evacuation before the disaster is possible, those patients need to leave. If they refuse, or are unable to leave, they need to be able to supply their own generated power for a prolonged period of time, as batteries will run out prior to power restoration. They must be able to use oxygen concentrators, as tank re-supply may not be readily available. By law, FEMA cannot give generators to individuals, so individuals must prepare for themselves. In a hurricane-prone area where seasonal risk can be established, planning medication refills at the beginning of the season or giving a larger than normal supply may prove useful. In an area prone to sudden disaster, such as earthquake or tornado, then counseling patients to request refills at least 2 weeks early may be adequate.

Post-Disaster: The most reliable form of communication will be text. You likely already have text contacts for your staff and family members; add other providers, responders, planners, pharmacists, and oxygen suppliers to your text contacts. While you may wish to share a text point of contact with patients, understand that your ability to actually help during the initial disaster will likely be limited. Identify possible language translation needs and possible translators among your staff and/or friends as telephone services will be limited or absent following the disaster. Finally, identify your local emergency response planners on Facebook, Twitter, or other social media feeds. This will allow you to direct others to these sites for accurate information after the disaster.

Responder Recommendations: A single social media post can DESTROY your plans and hamper your efforts. Advertise a single contact point and an information resource (eg, bulletin board, webpage) early and often. Publicly and accurately declare the means by which people will access health care and health-care services, such as medications, dialysis, and oxygen. There will be nongovernment organizations (NGOs), friends, and other well-meaning individuals who will try to assist people in need through unconventional channels. Yet, by requesting assistance through nonroutine channels, those efforts tend to delay assistance, cause confusion, and/or squander resources. Continue to direct those requests through the established response channels, ie, the local 911 equivalent.

 

Plan to use cellular texts to communicate. While satellite telephones are great in concept, in execution, they are difficult to utilize when transmitting complex medical information. If you have an expansive budget, there are now devices available that allow for Iridium satellite-based text communications that require batteries but not intact cellular towers.

Facilities with electricity, water, oxygen, medications, laboratory testing, and CT scanners need to be identified and advertised within the responder community. If FEMA is involved, these resources will be identified and updated on a routine basis. The information will be distributed to their DMAT teams. Those DMAT teams will be distributed throughout the response area. Additionally, if the resources and budgeting are approved, then FEMA will also help re-establish medical transport, as well as Federal Medical Shelters (FMS). The FMS can temporarily house patients who can perform basic activities of daily living but require power, oxygen, or medication administration. For those patients in need of medications without insurance, FEMA may activate medication assistance through the Emergency Prescription Assistance Program. This will allow up to 30 days of medication to be distributed at no cost to the individual through participating pharmacies.

External responders will obviously need to pair with local providers/professionals who can navigate the system and, if necessary, can translate medical terms and care plans. Additionally, external responders will be targets for individuals looking to obtain resources for secondary gain or profit. Establishing a plan or consistently redirecting people to the appropriate resources for those needs may limit the inevitable damage these individuals will cause. Additionally, understand that the efficiencies of the modern society will be gone, and tasks will take much longer than expected. Even if you can communicate by text, the transporting of patients, delivering supplies, meeting with groups, and assessing sites will take far longer than you are used to when none of the stoplights are functional or if gasoline is in limited supply.

Finally, there will be patients for whom no solution, short of an intact, well-resourced medical system, exists—those with severe congenital issues, patients with advanced dementia, patients with advanced cancer, and those with multiple-antibiotic-resistant osteomyelitis are a few of the patients that this response encountered. If transport out of the area is unavailable, NGOs and other charities may be the best, and at times, the only resource for these patients. During this response, I observed NGO and charities helping individual patients and their families with their power, shelter, and medical needs that could not be legally provided by federal government response.

While I hope you may never need to use them, preparations for evacuation, medication, power, and communications before a potential disaster occurs will prove helpful to your patients. After the disaster, consistent and simple communications to the public will be necessary to limit the damage from the social media rumor mill. Working within the organized response framework and leveraging local knowledge and targeted NGO involvement will maximize the effect of your efforts.