Dialysis in Disaster Zones: Back-to-Back Disasters Put Response Systems to the Test

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In the aftermath of Hurricane Irma, 130 dialysis patients from the island of St. Thomas found refuge in Puerto Rico. But Puerto Rico provided only a temporary respite on a multiple-stop journey for these patients. Soon, Hurricane Maria would bear down on the island leaving it, too, in ruins.

The plight of those 130 patients demonstrates the incredible challenges that faced dialysis providers, government agencies, and volunteer organizations responding to one of the worst hurricane seasons in memory. Hurricanes Harvey and Irma alone affected 50,000 dialysis patients at 750 dialysis facilities, according to Darlene Rodgers, CNN, RN, a nurse clinical consultant at ASN and Nephrologists Transforming Dialysis Safety who helped with the organizations’ disaster response. An additional 6000 dialysis patients resided in Puerto Rico before Hurricane Maria hit.

Rodgers joined a panel of first responders at Kidney Week 2017 to share lessons learned from the 2017 hurricane season for nephrologists and dialysis providers. Among the key challenges they highlighted were the need for improved communications systems, coordinated disaster response among agencies and nonprofits, and solid disaster plans.

Island hopping

Dialysis patients evacuated from St. Thomas by Department of Health and Human Services staff and National Disaster Medical Assistance Teams from Colorado and Oregon faced repeated displacement.

In Puerto Rico, Jeffrey B. Kopp, MD, captain of the US Public Health Service’s Kidney Disease Section, helped oversee their care. Initially, the patients were housed in hotels in Puerto Rico, along with 30 caregivers who were evacuated with them. However, many of the patients had serious comorbidities and mobility difficulties.

“It soon became apparent they were not thriving in the hotels,” said Kopp. So, a special needs shelter was created at the convention center. The US Army helped set up mobile showers, and food service providers were contracted to provide meals. Patients were transported for dialysis at Fresenius and Atlantis facilities affiliated with their usual provider, Kopp said.

“They can quickly loop patients back into what they are used to,” he said.

Volunteers including nurses, student nurses, and mental health professionals helped provide care for the patients at the shelter. The Federal Emergency Management Agency also hired emergency medical technicians to assist.

“Ideally, you vet [volunteers] very carefully,” said Kopp. “My experience with Hurricane Katrina is that it is important to check their backgrounds.”

Unfortunately, the providers and patients faced numerous challenges. It was a struggle to get patients’ medications. Patients’ prescriptions and medical histories had to be entered anew each time they were moved to a new facility with a new electronic medical system.

“Nothing in a disaster ever goes as planned,” Kopp said. So he and his team just had to do what they could to make things work better each day.

“Then Maria appeared on the radar,” Kopp said. A flight was quickly chartered to take the patients to Florida International University. “That turned out to be an excellent decision,” he said.

It would not be the last stop for many patients. Some moved on to stay with family members throughout the US. Emory University in Atlanta now hosts 30 of the patients, said Janice Lea, MD, MSc, director of Emory Dialysis. Even when they arrived in Atlanta, providers had to relay their care information. Kopp said better systems are needed to ensure seamless transitions of patients’ care information.

Through it all, Kopp said the patients were knowledgeable about their care and understanding about the austere conditions.

“These patients endured a tremendous amount of trauma,” he said. “They showed a tremendous amount of tolerance and grace.”

The eye of the storm

Those patients left behind in the Caribbean faced heart-breaking destruction and life-threatening disruptions in care.

British nephrologist James Tattersall, MBBS, MD, was selected by the International Society of Nephrology (ISN) Renal Disaster Relief Task Force to go to Tortola, one of the British Virgin Islands, in the aftermath of Irma and find out what was needed. On the wings of a small plane flown by a “daredevil” pilot Tattersall touched down on a runway newly cleared of planes and other debris. He was familiar with the island because his parents reside there.

On the ground, he found unfathomable devastation and trauma. A 56-ton catamaran had dropped on a building. Ninety percent of buildings were destroyed. The roofs of most houses had been torn off mid-storm, their contents strewn about the countryside, and their inhabitants left to weather the rest of the storm unprotected. Irma’s wind top wind speeds of 185 miles per hour (mph) were simply too much for residences built to withstand 125 mph winds. Even hospitals, built to withstand 175 mph winds, faced devastation.

“By design, buildings would not survive that wind strength,” he said.

The dialysis unit was flooded and windows were shattered in the hospital’s intensive care unit. The electronic health records system was down. The island’s only nephrologist was unable to return for 2 months. The UK military restored water, but power was unreliable and patients’ dialysis sessions were frequently interrupted.

There were also no accommodations available for patients left homeless by the storm or those who had to ferry from nearby islands, he said. One patient began living in the hospital lobby. Clinically, Tattersall faced numerous challenges treating patients with life-threatening comorbidities and triaging patients who were unlikely to survive.

“I had difficult decisions to make,” he said.

One of the biggest problems Tattersall faced was the complete lack of communications infrastructure left on the island. He relied on a GPS device to relay messages by text back to the UK and struggled to reliably connect with anyone on the island.

“Our communication is dependent on cell phones, but those are quite vulnerable,” he said.

Coordination among the International Society of Nephrology, ASN, and Tattersall helped secure the first shipment of the medications needed for kidney patients on the island. Rodgers said ASN, ISN. and Tattersall held daily calls, and ASN tapped its members and US institutions for help. For example, the University of Miami helped acquire the medications and brought them to the airport. With the help of a pilot, Tattersall’s brother then took the supplies to Tortola. Direct Relief, a US nonprofit, handled the next shipment of medications.

In the immediate aftermath of the storm, Tattersall met 2 patients with kidney transplants who couldn’t get their immunosuppressant medications. Local police officers dug through the rubble of a pharmacy to find the medications, he said. The ASN team also helped connect prospective kidney transplant patients with their transplant centers in the US and UK, so these patients wouldn’t miss out if a transplant became available.

Tattersall emphasized the importance of reliable methods of communication and “the need for focused aid informed by people in the disaster area.”

Harvey headaches

In Houston, Hurricane Harvey dropped a record 51 inches of rain, leaving much of the city underwater. For dialysis providers in the area, like Stephen Fadem, MD, medical director of the Houston Kidney Center Integrated Service Network at DaVita, advance preparations paid off.

In the days prior to the storm, Fadem and his colleagues made disaster plans and started educating patients about how to protect themselves. For example, patients were instructed on what to eat, not to overhydrate, and to have a “go-bag” ready with medications and medical information in case they were displaced. Patients received an extra dialysis session prior to the storm.

His organization’s main dialysis unit was on higher ground and equipped with a backup water system and generator. These features and having 10 staff members stay at a nearby hotel allowed the center to continue providing care for their patients and those who arrived from emergency shelters.

“Our dialysis unit waiting room looked like a bus station,” he said. “I had never seen anything like this in a dialysis center.”

Dialysis sessions were administered on a first-come, first-served basis and truncated to 2 hours to accommodate the increased demand. Ten staff members proved to be too few, and additional staff were brought in within a couple of days.

These efforts and “equal efforts” by other dialysis chains in Houston helped prevent a worse disaster, according to Fadem.

“We have a lot to learn,” he said. “We did well, but [our disaster response] can be improved.”

Advance preparations are critical, Fadem said. For example, his center was stocked with food, medications, and a gasoline truck. Staff and patients need curfew letters. Patients need a list of emergency numbers to call. For future disasters his team will work to have more multilingual patient education available, more staff nearby, and better patient records, including information about hepatitis B status.

“The most important take-home message is that this probably will happen again,” Fadem said. “We need to take disaster management seriously and make it part of our daily routines.”

December 2017 (Vol. 9, Number 12)