Hurricane season is a fifth season, and medicine has to plan for it [PODCAST]

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In South Louisiana, hurricane season is treated like a fifth season of the year. Angela C. Johnson explains what that means for physicians and patients. She is an internal medicine physician and member of the American College of Physicians Board of Regents. This episode is based on her article “Physicians and natural disasters: the fifth season,” published on KevinMD. You will hear what care looks like inside a medical shelter, where the exam rooms, the records, and the staffing are gone and the work comes back to a doctor and a patient. She describes who ends up in a shelter, why getting people home is its own problem, and why a community without power, water, or open doctor’s offices is not ready to take them back. She also tells you what to bring and what to ask your providers before an evacuation, and why she watches storm intensity as closely as the count. Stay to the end for her case that the differences a storm exposes are the ones to work on between storms.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Angela C. Johnson. She’s an internal medicine physician and member of the American College of Physicians Board of Regents. Today’s KevinMD article is “Physicians and natural disasters: the fifth season.” Angela, welcome to the show.

Angela C. Johnson: Thank you. Thank you for having me.

Kevin Pho: All right, so this is the first time I have you on. Welcome, and why don’t you briefly introduce yourself and share your story, then we’ll jump right into your KevinMD article.

Angela C. Johnson: Sure, sure. Angela C. Johnson. I am an internal medicine physician in an academic practice in South Louisiana. I was pretty much born and raised here. I was born in Bethesda, my dad was finishing up some time in the Army, but my parents moved back to Louisiana to be near family when I was just six months old. So I was essentially raised in, and grew up in, the community that my family had always been a part of.

I ended up doing all of my medical training, including residency, in the South Louisiana area, and stayed on as faculty for our residency training program here in Baton Rouge as part of one of the medical centers in New Orleans. And I have really enjoyed doing all of the actual medical work and the teaching, obviously, but doing that in the community that I am heavily invested in, with our patients and the community as a whole. So I have kind of stayed close to home, but I have done that very intentionally and in a very, very fulfilling way.

Kevin Pho: So for those who may not be familiar with where you practice in South Louisiana, what makes your community unique?

Angela C. Johnson: Oh, wow. I think a lot of people, when they hear about Louisiana, think of New Orleans, and we are just a little bit north of that area. People think about our culture as a food and a fun place to visit, and a place to see a unique perspective on life, and a lot of what is portrayed can be a very easygoing, happy-go-lucky kind of area. I think for the most part that’s very true.

We certainly have some very unique multicultural aspects to South Louisiana as a whole. The food, I think people talk about our food a lot. Our love of sports and particular sports teams. And I think that there are certainly parts of us that aren’t unique. We struggle just like everyone else does with the impacts of health disparities, and overall, as physicians practicing in this area, there are a lot of commonalities to the struggles that we see and the joys that we see. But yeah, I think we’re probably best known for our food and our love of life in general.

Kevin Pho: And one of the other things we’re going to be talking about, of course, in this article would be what you call the fifth season. Your article’s titled “Physicians and natural disasters: the fifth season.” Now, for those who didn’t get a chance to read your article, first off, share why you decided to write this particular piece, and then tell us about the article itself for those of you who get a chance to read it.

Angela C. Johnson: So part of living in South Louisiana, along with a lot of our other coastal communities in the southeastern U.S., is hurricane season. There is a hurricane season, and we name it as such. And it is as much a part of seasonal activity as anything else, if not more so than our traditional seasons. And so every June or so, which is when I wrote the article, every June is the constant reminder in our personal lives to be prepared and to be thinking about how we will address the needs for impacts from weather, potentially evacuations from our homes and things like that. So that rolls around every June or so to prepare us for the start of when those storms can begin to impact our lives.

It also, very much so for me, brings a preparation and planning of how that will impact my work life as well. One of the things I have been, I will say, fortunate to have been involved in, although we don’t like the reason why we’re involved in that care, is that part of my job, when hurricane evacuations happen along our coastlines in Louisiana, has been being part of the Medical Special Needs Shelter Network, because we are slightly inland from those immediate impact areas. When those evacuations occur, patients who are not healthy enough to go into normal general-population type shelters, and who have no other means of getting to safety, come to our organized shelters. And I have been a part of the medical care of the shelters, one of the largest ones for the state that does open when those evacuations occur. And so it takes a lot of planning, a lot of preparation, in trying our best to be ready if we are needed.

And so, as those times were rolling around, I started to think about it not just from my boots-on-the-ground work, but really looking back over the last 25 years of my career at how, from a personal standpoint, from a professional standpoint, and really on a larger health care system standpoint, those things have evolved, and, unfortunately, at some of the things that haven’t changed about it. And I decided to write about it.

Kevin Pho: What’s it like to care for people in a temporary medical shelter that you may not have learned or experienced in a traditional clinic setting?

Angela C. Johnson: Yeah, I think one of the biggest things is, and again, those shelters have evolved some over the years, but in the end, most of our training is going to happen in health care systems, whether it’s clinics or hospitals, that have certain resources, including electronic health records now, and organized exam rooms and personal spaces and privacy issues, a support structure that is kind of there at your fingertips.

And I think when we go into our medical shelters, a lot of that is disrupted. We do the best that we can to create environments that respect patient care and privacy. We want to have the best of comfort for our patients. We want to have the best of resources for our physicians. But the reality is that most of our shelters are in very large single areas. Ours are athletic facilities. And it is almost impossible to try to recreate the physical environment that we practice in, including the manpower resources and some of our typical things that we would have with us that we take for granted.

And so it’s remembering what we can do, and honestly, it really gets us back to the very, very specific doctor-patient relationship, right? Because what we do still have is our ability to directly interact with our patients. And so while we lose a lot of the technology, we gain a lot of the things that brought us into medicine to begin with. So it’s the shift of mindset of what kind of care we can provide, and maximizing that, and knowing when that is not enough and how to make our patients able to access a higher level of care when necessary. It’s a big change in practice environment, though, and it really gets you back to the basics of you and your patient, for good or for bad.

Kevin Pho: Now, do you have any case studies or stories that you could share with us about some of the more common clinical scenarios that one may encounter in one of these temporary shelters?

Angela C. Johnson: Yeah. I think that has certainly evolved over the years since my initial involvement, which was with a very, very large effort with Hurricane Katrina. I think for the most part, patients, or evacuees, that end up in our shelters have, one, obviously, a barrier to an evacuation to a different environment, whether that is family members that are outside of the impact area, or financial means to leave the area and have a hotel accommodation, other things. So clearly we’re dealing with patients that already have some limitation to evacuating to some other more stable environment.

That being said, the patients that end up in there usually have some kind of need that leaves them unable to provide their level of medical care unassisted. Mobility issues, need for access to electricity, as simple as that, right? Patients relying on chronic oxygen support who need a plug for their concentrators, patients that have medications that require refrigeration or assistance with administering. During those evacuation times in the areas, if you have reliance on home health, if you have reliance on some other medical service, those services obviously get interrupted. And so we kind of serve as filling in that gap for patients. So in general, they have something that doesn’t allow them to care for themselves independently, either from a structural or a functional reason, or both.

Kevin Pho: How does a physician prepare themselves for something like this? Is there any special training? And obviously you grew up in this area, so you knew what to expect. But from a clinical standpoint, tell us about your very first evacuation as an attending, and what was going through your mind, and how did you prepare yourself for that?

Angela C. Johnson: Yeah. One, I think it’s difficult to say that you can prepare for every possible scenario of the care that is going to be needed. So I think in general, the things that do help prepare, one is being as broadly, I guess, educated from a medical care standpoint, because we do see a wide variety of clinical conditions.

I think an ability to triage, and so the physicians that I see that work best in the environments that we have worked in are our emergency medicine physicians, right? It’s important to have training in triaging of level of care, acuity of care, who does belong with us in our resource environment and who needs some higher level of care, and coordinating that. So obviously training in those initial assessments of patients, and an ability to, I say internal medicine is well suited for this, general internal medicine, our ability to be comfortable with a wide variety of chronic medical conditions, and both the ability to maintain stability of those conditions and to recognize when there is instability that needs to be acted on quickly. I think it requires a certain amount of training or comfort in the uncertainty of your environment, and being able to adapt.

Kevin Pho: And is there training for that?

Angela C. Johnson: To some degree. I think a lot of it comes with experience of working in environments where you are allowed to be creative, to problem solve. Those are skill sets that are really important.

I think for the shelter structure itself, it is important to know that there is a structure to the design of these shelters. It’s based on the incident command structure from the military. And so for those in leadership positions, it’s incredibly important to actually train in that and have a background in understanding how the pieces of these shelter operations work and where you fit in them. So it’s not just chaos and everyone doing what they can. There is actually a background organized framework that is incredibly important for people, especially in the leadership roles, to understand.

Kevin Pho: Now talk to us about the recovery after a storm, because of course it doesn’t end after the storm ends. There’s a recovery process, and you alluded to Hurricane Katrina. Tell us about any notable recovery stories, about what it’s like after a storm hits.

Angela C. Johnson: Yeah. I think to me it is that initial energy of getting people out of the danger zones, doing that initial triage, bringing people in when the emotions are high, when the acuity of the situation is high, and then realizing after a few days that it is all about trying to make the efforts to get people home. And I think that that is where a lot of times the preexisting differences in health care resources and community resources really, really start to come out more strongly.

And I think that part of the issue for us in the medical shelters is that it depends on whether or not our local community is impacted, not just the areas where our patients, our evacuees, are coming from. We work best when our community is relatively spared. Our local resources can really come in and help. When our community is hit as well, our own manpower has their own personal struggles and their own practice environment, and our medical community has more difficulty doing that.

And I think part of it is trying to get patients home when there’s still uncertainty at times about whether or not there is a safe home, and when normal basic requirements, electricity, water, access to grocery stores and other things, gas stations, those local structural things that we need to survive every day regardless of our health, are those things back and functional in the communities? And then layering on top of that the struggle of, is my medical infrastructure intact again? When communities evacuate, doctor’s offices close. They don’t always reopen in timely ways. They don’t always reopen at all if there’s structural damage or other things to the offices themselves.

And so the ability to get people out of our shelters back into their home environments is not just about whether or not their individual home is intact. Is the community ready for people to come home just for basic needs, much less layering on top of that what their medical needs are? And in particular, our patients in our shelters often had unstable access to those resources even before a storm. And it adds an additional layer of complexity of trying to improve those situations when the situations weren’t good to begin with. How do we even try to work in that environment for the best of our patients? It’s very, very difficult at times.

Kevin Pho: Are you seeing the effects of climate change increase the frequency of evacuations over the years?

Angela C. Johnson: You know, I was just speaking with some of my colleagues about this. We have been, the Gulf Coast, or at least our area in particular, has had the fortune of some quiet years. But when you look at the system as a whole, the United States as a whole, I think we are absolutely concerned, and not just about the frequency. We know there will be storms every year. Where I worry is that it appears the intensity and the frequency of the higher-intensity storms that have the ability to create higher levels of destruction to property, destruction to infrastructure, those things seem to be escalating, and obviously the fear is that that will continue. The intensity of the storms, not just the number, is really what it’s about for us, just as much as the number of storms.

And so yeah, I read the news and see that it’s not just hurricanes, right? We see similar situations unfolding in other areas of our country with different types of natural disasters. And so I think that’s certainly a concern of ours that’s certainly not going away, and that the intensity of it seems to be increasing. Again, not always the number, but the severity of the storms when they are coming our way.

Kevin Pho: And for our patients who may be listening to you now, what are some key pieces of advice that you could share with them so they could be best prepared in the event of any type of potential disaster?

Angela C. Johnson: Right. I think for patients it is always about preparation, and it is anticipating as much as possible that if you are asked to leave your environment, that means that your support structure is likely leaving as well. And so we still struggle to have people heed those warnings at times. The decision to stay home instead of leaving is understanding that there is not just direct harm of what may happen with you in your home environment should you not leave, but recognizing that even if you are able to weather through that, your normal resource environment around you in your community especially, or including your health care environment, is going to be disrupted.

And so thinking about it ahead of time, making sure that you have, if you are on chronic medications, one of the most critical pieces is coming with those medications. Having those medications on hand gives the best chance of your chronic illnesses remaining stable with less effort, less of a struggle to find the things that you need on a day-to-day basis. So a lot of it is about ahead-of-time preparation.

It’s really about also thinking about ahead of time where you will go if you are asked to leave your home community. How will you get the assistance if you rely on assistance? Does the health care facility that is helping you do that already have a plan for you? What we’ve learned over the years, and I’ve been very happy to see in Louisiana, is that every storm brings about new requirements or new changes to prepare for the next one, that now actually put a lot of the responsibility on the health care entities that provide services for our patients to have a plan for their patients.

Our nursing homes, right, are looking at facilities outside of impact zones. Where will they evacuate their residents to so that they don’t need us in our shelters? Oxygen supply companies, home health companies, do they have a plan for their patients to hand off that care to resources outside of the impact zones that can be better coordinated, where patients can go in a more directed fashion to stay near resources?

So it is nice to know that those things exist, and patients should be asking about that. “What happens with my support?” And to not feel like it’s only on them, and really asking their system to let them know where that support might already exist that could make that process easier. It doesn’t always happen like we want it to, but a lot of times I think patients don’t realize that the resources that are used for them, the medical companies that are assisting in that care.

Kevin Pho: Are supposed to have plans.

Angela C. Johnson: Of how their services might be impacted, and how and if they can support their patients through those times. And it’s nice for our patients to know that and ask those questions.

Kevin Pho: We’re talking to Angela C. Johnson. She’s an internal medicine physician and member of the American College of Physicians Board of Regents. Today’s KevinMD article is “Physicians and natural disasters: the fifth season.” Angela, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Angela C. Johnson: Absolutely. I think that any time we’re facing natural disasters, it’s a perfect time for our physicians to be thinking about not just how they will react from a personal standpoint, right? How do I take care of my family and balance the needs in my personal life with my needs as a physician to serve my community still, to serve my patients, to help promote health in the community during those times, and being ready to work through those issues and to be in systems that can help you work through those issues.

But I think it’s also an incredible time to look at a bigger-picture view. A lot of the struggles that we see are magnifications of disparities that already exist in our systems, and working after the storms, or in between the storms, to really see the bigger picture and engage. Part of the reason I love being part of the American College of Physicians, obviously, is the ability to engage at a higher level on systems, our systems of care, our ability to try to address social determinants of health and other health care disparities that give us a better chance to practice medicine in crisis. We need to be able to do it better when we’re not in crisis, and really understanding that it requires local and personal effort, but that there’s a bigger picture that physicians can be a part of, and it’s important for us to do that when we can.

Kevin Pho: Angela, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Angela C. Johnson: Thank you so much for having me. Enjoyed it.

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