Maurice A. Ramirez, DO, CNS, CMRO

Healthcare Recovery for the Gulf Coast

A recent article in the USA Today stated that there was a 47% rise in deaths in the Gulf Coast states within the impact area of Hurricane Katrina as a result of the loss of healthcare professionals in those areas.  Healthcare professionals displaced by Hurricane Katrina, many laboring under the burden of student loan repayments and the daily financial needs of life assimilated themselves into their new home community as they landed in cities and towns across the United States.

Now that the cities of the Gulf Coast are rebuilding they are discovering that these healthcare professionals are not rushing home to the Gulf Coast.

Startup cost for a private medical practice vary between $100,000 and $200,000 for rent, business insurance, malpractice insurance, equipment, supplies, information systems, computers and simple office decorations.  Most of the healthcare providers in the Gulf Coast region lost well-established practices and if they were insured at all they used the funds from those insurance payments to begin again in their new communities.  Unfortunately, healthcare practices in 2007 have little resale value; particularly, when only one or two years old.  Even if these professionals were inclined to move back to the Gulf Coast region, they face significant financial hardship in accomplishing that feat.

Add to this the lack of meaningful business recovery and a decline in the number of insured patients in many of these regions.  The sad facts are that employment statistics and new business starts in the areas most affected by Hurricane Katrina are well below national averages.  Healthcare providers, now comfortable in their new homes, find little inducement to assume the responsibilities, liabilities and hardships of returning to their former practices and even when they do often find that their former patients have yet to return as well.

Physicians are not the only individuals affected in this fashion.  Hospitals that have already reopened in the Gulf Coast region are finding it more difficult to recruit nurses in a nation where there are already nursing shortages. Even when temporary staffing agencies provide nurses, known as travelers in the industry, to the Gulf Coast region to fulfill short-term contracts, most of these nurses decline the opportunity to extend their stay, take full-time positions, or return at a future date.

Much of the problem is that as healthcare has moved from the individual private doctor and the small community hospital to large corporate enterprise, it severed its relationships with its healthcare professionals seeing them more as expendable drones and less as a necessary and valued part of the healthcare delivery system.

Healthcare professionals regularly find themselves mandated to choose between maximizing patient flow and maximizing patient safety.  They are often forced to forego important family events under threat of suspension, retaliation or termination.  When the healthcare professional finds a home where they can achieve a level of work/life balance, it is difficult if not impossible to dislodge them again.  It took a hurricane to dislodge these professionals from the Gulf Coast and nothing short of another force of nature, perhaps this one favorable, will move them back.

Another Season, Another Storm

We’ve all heard the predictions. Despite a restful 2006 hurricane season, nobody yet has forgotten the unpresidented 2004/2005 hurricane double whammy that battered Florida and the Gulf Coast. But before we look ahead to this coming season, let’s stop and take stock of the lessons we’ve learned from our most recent experiences and prepare our children for this year.

In 2004 and 2005, we pulled together as a community and did all the things good friends and neighbors do when the chips are down. We shared food, water, tarps, and cell phones, and we took time to connect with the strangers across the street. We reached out to those in need and made some great new friends in the process. We hunkered down, we weathered the storm, and together we cleared the deadwood.

We became accustomed to the blue tarps, and fortunately, “tarp city” is almost gone. So what can we do to prepare for this year? Certainly we cannot change Mother Nature. After all, few “mothers” allow her “children” to change her. However, we have now learned how to live with her. And that is the first step towards a safe season.

The good news is that most of the things hurricanes can damage have already been damaged and replaced. New roofs, stronger windows, and better structures mean less damage. The old trees are gone and the new trees are firmly rooted in their place. Our communities are now ready to come through the storm with minimal or no damage.

Yes, we’re ready. We all know what we have to gather, and for the most part, we all have our storm supplies ready. Sure, there are some things we can still do. For example, we can still have our plan of where to go when the phones are out. We still need to know where the closest shelter is.

Those of us with kids should consider going to visit friends or relatives when the next storm comes. After all, what better time is there to go on vacation than when a hurricane is in town?

We’ve all discovered that cell phones work during the storm, and we’ve all learned that if you can’t call directly to a family member, then we need somebody else to call—a central friend or message board—somebody out of town who can let everyone else know we’re okay. Don’t forget text messaging, email and SMS. Teens and even young kids with cell phones are expert at these technologies. Chaos is the only constant in natural disasters such as hurricanes. The answer to coping with the sense helplessness chaos brings is to take control of some aspect of the disaster. Even if you know how to text message, ask your kids to help you or even teach you to use these technologies.

The key to feeling safe and not worrying about this year’s storms is to be prepared and to have a plan. Make sure your children know the plan, have practiced the plan and can implement the plan without you. That’s right, the key to security is knowledge. After 2004, we have the knowledge and we have the experience. And as a result, we’ll get through this year’s storms far easier than we got through last year’s.

So when the wind blows and the rain falls this season, we’ll be warm, dry, and hunkered down. We’ll play games with our kids, talk with our kids and maybe even learn something about them as people.  We’ll hold your children close until the sun shines in Central Florida again. After all, they don’t call us the Sunshine State for nothing.

Hunker Down Again

It is 2007.  It is summer.  The sky is blue.  The sun is shining again over central Florida and you are enjoying one of Orlando’s beautiful spa and resorts.  The kids have met Mickey and Minnie, Pluto and Donald, Shamus and every character in Universal Studios.  You know because you have had to walk every inch of every park.  As you nestle in for a much deserved evenings rest you turn on the Weather Channel and there before you are the two red flags with those ominous black squares. 

Hurricane!

Your mind races.  What do you do? 

You are miles from home.  All your worldly possessions are safe but your most precious possession, your family, is here. 

Are you prepared?  I have a disaster plan for home.  You followed the D.I.S.A.S.T.E.R. acronym. 
* You know how to Detect. 
* You know how to find out who is In charge. 
* You know how to be Safe. 
* You know how to Assess the situation
* You know how to get Support. 
* You understand the concepts of Triage and Treatment, how to decide what is most important and how to get help if I need it.
But…
* You do not know how to Evacuate.
* And you are not part of any Recovery plan here. 

You are just a tourist. 

At home you are R.E.A.D.Y. 
* You know what you Rely on. 
* You have Educated yourself and your family. 
* You have learned to Appreciate those around you and those who will help you. 
* You have Drilled, Drilled and Drilled again.
* But in the end any disaster plan comes down to You and here you are in a strange place far from everything that you need; everything that you rely on; everything that is familiar. 

The P.L.A.N. acronym is all you have left. You have to start all over again. You need a new plan.
* Take inventory of the People participating, your family. Prepare each person for the disaster. If you have small children, you may need to talk to them about what is happening, and reassure them that everything will be all right.
* If instructed to Leave, when and how will you leave (evacuate)? Where will you go and how will you get there? Will your family or fellow evacuees meet before you leave or when you arrive at your destination? The decision to leave makes communication and your contacts outside the disaster zone critically important. How will you communicate while you evacuate and after you arrive at your destination? What are you going to do if you get separated? Operate on a buddy system; no one should be left alone. When you and your family or business associates become mobile, make sure everyone knows the plan.
* Anticipate plan failures and plan for the “what ifs.” This is a chance to brainstorm. Make a list of all the possible failures. What if the phone lines go down? What if your basement floods? What if you get caught in traffic? No “what if” is too extreme to consider. The only possibility that you can’t plan for is the one you didn’t think of. Once you’ve brainstormed possible failures, you need to Adapt to each one with an alternate plan. If the phone lines go down, can you use your cell phone? If your basement floods, can you seek shelter with a neighbor or in some other nearby location?
* Make sure you account for all your Needs for seventy-two hours. Be prepared to be self-sufficient during this time. Each one of your family members must have personal identification and photos of all others in your plan, one quart (liter) of drinking water, seventy-two hours of food, seventy-two hours of clothes, two weeks of medications, two weeks of toiletries, a supply of cash (credit/debit cards can’t be verified if phone lines go down), a flashlight, a portable radio, batteries, a signal whistle, white/silver duct tape, a first aid kit, prepaid calling card, and a list of emergency phone numbers.

Take heart my traveling friend.  As a professional speaker as well as a disaster responder, I travel every week. I can tell you that you are better prepared on the road than you are at home. 

First, you are already packed.  All those worldly possessions that you could not bring with you are waiting safely at home and all the things that you need to get through a trip whether for pleasure or disaster are already in conveniently packaged in suitcases, backpacks, duffle bags and we hope not a steamer trunk.  What you need is right there. 

Second, everything else you will need is conveniently located in one place, the nearest pharmacy. Flashlights and radios are easily obtained at any of the local drugstores and even at the local attractions.  Stay away from candles.  While they are safe at home where you know the environment and you control the environment, in a hotel you might get wet and not from the hurricane but from a sprinkler system. An inexpensive first aid kit is also a quick and easy item to obtain while on the road.  Again a simply trip to the pharmacy and you have what you need. 

Don’t forget water. You might be on your own for as much as 72 hours.  Most hotels have water in the room at an obscene price but while you are at the pharmacy or drug store picking up your handcranked radio and flashlight, your toiletries and filling any medications that you may need to have transferred in from back home, do not forget to pick up a liter of water per day per person and then you are ready to go. 

Pack it all in your suitcase and give up the items that may not be so important.  Leave them for the hotel to take care of. 

Third, make contact with the hotel.  Find out what their disaster plan in.  I assure you they have one.  They are responsible for you.  They no more want the bad press or the liability of someone getting hurt than you want to be that someone who is hurt. Ask them if their staff is trained in Disaster Life Support, the “CPR” of disaster response. This training is available throughout the United States. It is offered nationally by High Alert, LLC and several major universities. Here in Florida, this training is offered by National Disaster Life Support of Florida and several state universities.

Rely on your hotel.  They will provide for you.  Our central Florida hotels provided their guests extraordinary service and comfort during the last two seasons of hurricanes.  There is no reason to believe it will be any less so now.  In fact every facility is more prepared now than they were two years ago.  There was even a major medical convention last year during Hurricane Wilma and the convention went off without a hitch.  So will your vacation. 

Finally, resist the urge to try to go home.  Do not jam the airport full.  The airport is the last place you want to try to hunker down through a hurricane.  If you can get out and get on, do so.  Check out by phone after you get home.  This way you have a hotel room to come back to.  If your hotel checkout is already preplanned and the storm is some distance away, consider leaving for home early, before the travel rush.  Whatever you do, don’t rent a car and try and drive out of the state of Florida.  Unfortunately there are only a few major highway exits from our state.  We have been credited with the largest traffic jams in world history during the last several years’ hurricane seasons.  Only Hurricane Rita misplaced us from that number one position as Houston evacuated 1.2 million people over 48 hours on the highway.  If the airport is a bad place to weather a storm, a rental car is worse. 

So enjoy your vacation.  Stay.  See the sites.  When the weather turns bad listen to what the officials tell you to do. 

We are good at this.  Trust in the people that have made the pleasurable part of your trip so great and remember in Central Florida the sun always shines again.  The sky is always blue again and we are

Katrina: Have We Really Learned Anything?

On this anniversary of the disaster now known by a single word: “Katrina” all of us in disaster response look around and shake our heads.  One year ago we saw misstep after misstep, failure after failure. As we look back over a landscape that is still scarred by the aftermath of flooding and looting to see both despair and rebirth we ask ourselves:

“Are we any better prepared today?”

Two recent reports by the National Academies of Science clearly stated that America’s hospitals and emergency rooms are no more prepared now than one or even five years ago.  Worse, hospitals have failed to integrate emergency medical services (EMS) into their planning and response operations.  This first link in the chain is not broken it is simply unhitched. 

What happens the next time Mother Nature roars?  We cannot yet mitigate an earthquake or a hurricane, a tornado or a volcano.  We have yet to learn how to immunize our planet against the next great pandemic or the next plague. 

Why is it after we see one of the great cities of America laid low and sunk beneath the waters of its own shores that we have yet to do any meaningful planning? This is not our government’s fault.  Money is available and spent every day for training. Why we must fight to get any hospital to train to avoid the next catastrophic failure in the wake of unavoidable disaster?

On those occasions when healthcare does choose to train, it is discouraging to see a room more than half empty.  In a profession that loudly proclaims a dedication to patient safety and customer care, to see so few people interested in preserving the most necessary of community resources, healthcare, is demoralizing beyond words. Disasters can seldom be avoided. On the other hand, catastrophe can almost always be averted with conscientious planning and practice.  The difference between a disaster and a catastrophe is that while disaster is when needs exceed resources, catastrophe is when needs exceed all ability to respond. 

Equally disturbing is the territorialism among the specialties, each one laying claim to disaster medicine.  Most healthcare delivered after a disaster is a simple the daily practice medicine under the worst conditions.  These groups fail to realize that Disaster Medicine is primarily practiced before the disaster ever strikes.  Disaster Medicine Specialists are part and parcel of planning for the community disaster response and the elimination of profession-specific silos of authority and knowledge.  Rather than embracing the concept of board certification in the new specialty of Disaster Medicine, these territorial and fractious groups seek to stake their claim.  They have learned nothing. 

The good news, Disaster Life Support (DLS) has become the national standard for preparedness of individuals, families, businesses and healthcare professionals, Healthcare First Responder training (HFR) has become the ruler by which hospitals and other healthcare institutions are measured.  While it is frustratingly difficult to get these audiences to come to class, it is immensely rewarding when they finally understand how important it is to be prepared, to be aware and to be able to protect themselves, their families, their communities, and their patients.  Much like the early days of CPR, it will take time for the nation to understand the importance of every man, woman and child knowing what to do when the wind blows, the buildings falls, or the whole planet sneezes at once.  Until then, we who teach these most precious skills will continue to strive to ensure that everyone goes home alive at the end of the day.

Will the Gulf Coast and New Orleans recover?

Certainly… in time.

The bigger question is will we ever learn to be D.I.S.A.S.T.E.R.  R.E.A.D.Y. & P.L.A.N.?