Maurice A. Ramirez, DO, CNS, CMRO

Where Did All The Doctors Go?

In the fall of 2010, the gulf coast of the United States is again struck by a category four hurricane. Five years of planning and preparation swing into action. Hospitals, structurally reinforced to survive such storms, remain open and operational, serving their communities during and after the storm. State and Federal recovery plans assist displaced people return to home and even find jobs. The criticisms of Katrina resulted in palpable change!

As life returns to normal, people begin to shift their healthcare needs from the hospitals back to the community. To the horror of those who have moved back home, they find that many of their doctors have not returned. Not only are the medical professionals missing, but the all important ancillary providers are absent. In many communities, only one dentist or chiropractor is able to return and restart their practices. Healthcare services become the next disaster to spread across the region.

Where Did All the Doctors Go?
While most hospitals in the United States are corporately owned and supported, most healthcare providers are owners or employees of small, local businesses. Even the biggest medical practices in a community are regionally limited in presence, thus when a community is temporarily displaced by disaster, the most secure healthcare providers find themselves displaced as well.

Few small businesses have the financial reserves to meet fixed costs of business during a forced shutdown. The problem for healthcare practices is complicated by the costs associated with malpractice insurance, general liability insurance, employee benefits, healthcare student loans, equipment leases, licensure and more. In most cases, healthcare practices maintain less than two weeks funds for fixed expenses in reserve. Although the delay in payment inherent to insurance billing and other third party payment systems can help bridge the period of shutdown, the shutdown will eventually manifest as a gap in cash flow.

Faced with the probability of financial ruin, many healthcare providers seek new practice opportunities after only a short period of displacement. Once established in a new community, the likelihood of uprooting the family again and moving back to their old home is very small. This was the experience following hurricanes Andrew, Opal, Charlie and Katrina.

What Should Be Done?
The key need for the community is the return of their most trusted and valued professionals. These professionals have a key need as well; they need to reestablish their practice as soon as possible. The most obvious solution is to include these healthcare professionals in the disaster response and recovery plan. One significant lesson observed during hurricane Katrina is that if a healthcare provider is not part of the response plan before the disaster, there will be no role for them during the response and recovery.

How do healthcare providers become part of their local disaster plan?

The opportunities to participate in a disaster response exist in a matrix based on the intersections of four options:

• Paid vs. Volunteer
• Hospital vs. Office/Clinic

The matrix is:

Paid at Hospital	Volunteer at Hospital
Paid at Office/Clinic	Volunteer at Office/Clinic

The healthcare provider seeking to survive as a business may initially serve a volunteer role, but they must eventually transition to a paid, fee for service role and reestablish their profitable business operations.

From Free to Fee
How does a healthcare provider make the transition from a volunteer to a paid provider?

Here are some suggestions:
· The healthcare professional must state how long they can offer their services for free. Healthcare providers in various jurisdictions are constrained as to the type of services that can be offered for free and circumstances in which services can be offered for free, thus it is essential that healthcare providers be explicit regarding the commitments they can make. For example,

“I can afford to volunteer for one week. I can afford to bring X amount of supplies. If we run out of materials before two weeks, you supply the material and I’ll stay the remainder of the time I stated.”

After the two weeks are up, before the healthcare provider pulls out and leaves, the provider should talk with the people they have been helping. At this point, the community can ask the provider to stay and begin providing services for a fee.

· When the community writes the disaster response and recovery plans (before a disaster hits), the healthcare providers should register with the ESF-8 (Emergency Support Function 8) office of their local and state Emergency Operations Center. This office is responsible for ensuring that critical services, including healthcare, are included in disaster planning. Further, during a disaster response and recovery, the ESF-8 office is responsible for ensuring that the critical service provider receives supplies and resources to remain operational.

· Become a community resource as a healthcare service provider and receive referrals for fee based services. This is completely ethical. In fact, it’s a win-win solution. The community keeps its healthcare professionals and the healthcare provider has work. What could be better?

The bottom line is that healthcare businesses need to understand the different ways to participate in a disaster response, and they need to get over the stigma of profiting from disaster. Realize that the people receiving healthcare services don’t mind paying for them. Similarly, communities and emergency management professionals must expand their plans to include all healthcare professionals in the community, not just the medical physicians, nurses and hospital staff. After all, the healthcare providers in a community were important to the community before the disaster, how much more important are these professionals after the disaster?

The Choice to Love

We hear the word love throughout modern society.  We are told to love our customers and that as customers we are loved.  We are told to love our neighbor as ourselves.  We are told that there is no greater gift than love.  We even have a special holiday, Valentine’s Day, dedicated to the notion of love.

Love has been described a basic building block of resilience, the foundation of the family, and in the goal of marriage.  But does love have a place in business?

Father Dan Schulte, a Catholic Priest and Philosopher, has defined love as “Love is the unifying thoughts between two people who have cared for and have said ‘yes’ to each other total being.  It implies mutual respect, freedom and trust, and seeks the happiness of fulfillment of each other as a common goal.”

Father Robert Mitchell has stated that love is an act of choice while “life” is an uncontrollable emotional response to our experience of another individual.  Father Mitchell states that while respect is a pre-requisite of love, life is not.  Father Mitchell does posit that respect is the ideal foundation for a love relationship and that from this respect “life” would ideally spring forth to form the framework of the love choice however, life is not the pre-requisite to the act of choice to love.

In the business world the admonishment to “love our customers” has been criticized as minimizing the meaning and importance of love.  As this admonishment is a pride in most businesses that criticism is quite true.  Father Schulte in his definition points out that love is a unifying response, it binds those in the relationship together trading a new individual, the love relationship itself.  In his definition those in the love relationship choose to “care for and face ‘yes’ to each other’s total being.”  Here Father Schulte and Father Mitchell agree completely, love does not require that you “like” the other individual only that you choose to love.  How many of our customers do we have the immediate emotional response of dislike?  Father Mitchell and Father Schulte prove here that we can embrace that “dislike” and still choose to love that customer.

But how can I love somebody whom I dislike?  Father Schulte’s definition answers this question as well by including that love implies mutual respect.  Just as Father Mitchell stated that respect is the foundation for love, Father Schule states it is an absolute pre-requisite.  Even if we dislike our customers we can still find in ourselves respect for them and perhaps even acceptance of them as they are and through these make the choice to love them. 

Finally Father Schulte points out that a love relationship requires that we seek the “happiness and fulfillment of each other as a common goal.”  Is this not the goal of every business?  Few of us work to be unhappy despite the fact that for many this is the end result.  Instead we speak to gain fulfillment and happiness through the work we do.  Father Schulte points out that it is not the work that creates the fulfillment and happiness but the relationships that we garner from that work.  Interestingly, when the relationships from our work provide fulfillment and happiness we need the last pre-requisite to love our customers.

But what if our customer refuses to enter into this love relationship?  What if our customer does not care for us, is not accepting of us and does not respect us, does not trust us or does not seek our happiness or fulfillment as their goal?  Increasingly in American society we find an almost schizophrenic response to the concept of customers and businesses and business people entering into a love relationship. 

When we fill the role of customer we are often impatient, untrusting, unaccepting, unloving.  Yet when we are in our own business and work environment we strive to respect, accept and even love those whom we serve.  Father Mitchell points out that because love is choice we can choose to offer love even when the requirements of a true love relationship are not there.  For Father Mitchell this is a form of self reliance and self respect.  Father Mitchell states that it is the ultimate form of self love to not allow another person to denigrate decisions and the ideal that we have set for ourselves.  This means that even though we may not like our customers, even though our customer may disrespect us we can choose to offer them love.  This is not to say that we should allow ourselves to be abused.  Nor should we allow ourselves to be exploited.  There is a vast difference between offering love and becoming a victim of our own love choice.  In offering love we are respecting our own choice to enter in to a love relationship however, that relationship becomes exploitive when it is not a unified response, when we are not cared for nor accepted.  We may offer love despite apparent disrespect but if disrespect, distrust and a failure to value our happiness and fulfillment by what we receive in return for our love choice then it is not love but masochist to remain in the relationship.

For many years it was the professional responsibility of physicians to constantly evaluate their relationship with their patient.  The doctor/patient relationship was seen as the ultimate love relationship.  In that relationship the physician along with the patient sought health and happiness, however when evaluating that relationship if the physician found that the relationship itself was not healthy either for the doctor or the patient that physician was both morally and ethically bound to end that doctor/patient relationship and assist the patient in finding a new physician. 

Unfortunately as healthcare became more a business and less a relationship physicians began to abandon this professional responsibility remaining in relationships where they were neither respected nor trusted and where they failed to respect or trust their patient.  Over time the professional decisions to find the patient a more supportive relationship became replaced with the legal decision to “severe the doctor/patient relationship”.  It is interesting to note that about the same time the number of malpractice lawsuits in the United States began an exponential rise.

In any choice to enter into a love relationship there must be the inherent choice to end that relationship if it fails to meet the basic requirements of love.  This is a prospect that is frightening too many businesses however, if a business is to be financially resilient, if it is to be able to extend the same love relationship to its employees as it frequently extends to its customers than it must obey the moral imperative to love its customers enough to seek for them the best business relationship possible even if it is with another business.  How often had a business garnered our undying loyalty by referring us elsewhere for service that they can not truly meet?

The choice to love is the basic building block not only of friendships, marriages and resilience, it is the basic building block of business.

Disaster Medicine: Beyond the ER

In the year since 9/11 disaster medicine has come into its own.  Now a recognized specialty the practice of disaster preparedness, disaster planning, disaster response and disaster recovery as it relates to the practice of medicine and the function of healthcare and healthcare institutions has moved from the realm of the emergency manager and hospital safety officer and into the realm of the healthcare professional.  As with any burgeoning specialty, disaster medicine drew from its strengths and grew from its roots.  Disaster medicine had its beginnings in the disaster field office.  Field response units formulated much of the early information regarding the practice of this newest medical specialty. 

Just as patients flow from the field to the hospital decontamination a triage in decontamination arena the science of disaster medicine grew next in the areas of triage and hospital-based decontamination.  Soon nonemergency room staff were being drawn from their primary duties on the hospital floor to actually step outside the hospital to provide triage and initial treatment in the event of a mass casualty incident.  From the triage and decontamination tents disaster medicine moved quickly into the emergency department bringing with it new concepts in toxicology and mass casualty patient care.  Lessons drawn from military medical experience and from civilian emergency room experience melded in textbooks as well as discussion groups that inside disaster medicine and within the hallowed halls of the emergency medicine professional organizations.

But in this expanding universe of knowledge the hospital floor and the Intensive Care Unit were all but forgotten.  Michael Osterholm and others have discussed the impact of mass casualty events and pandemic influenza on the ability of hospital Intensive Care Units and other high acuity departments to meet the needs of a disaster response.  Unfortunately while models created by Schultz and Ramirez had demonstrated that with a small application of behavioral health savvy surge capacities can be increased not only by the required 20 percent under the US Department of Health and Human Services guidelines but by as much as 400 percent, this vast expansion of surge capacity rely in small part on the ability of the inpatient services to accommodate additional admissions.  A simple review of historically corrected pandemic predictions compared to hospital capability surveys demonstrates the dangers of not expanding hospital inpatient capacity as aptly as intake capacity has expanded.

When the lessons of the disaster field office are applied to businesses these businesses learn first to determine what is the goal of their organization.  In the intensive care unit and other high acuity areas of the hospital the goal is the same as it is in a field disaster hospital, the preservation of life.  In the environment of the intensive unit triage has already taken place for you.  These patients are already determined to be critical and further triage can only serve to determine which individual's care will utilize so many resources as to endanger the care of two or more other individuals.  In this circumstance it is the absolute moral and ethical obligation of those providing the care to make a resource-based decision.  When the continued care of one patient will utilize sufficient resources to endanger the care or life or two or more others then the care of that one patient, then that one patient must be reassigned to the expectant (black tag) treatment area.  This is not a do not resuscitate order (DNR).  This is simply a statement of available resources.  Patients are constantly re-triaged based on available resources and current medical conditions.  A critical patient upon the loss of vital resources may temporarily be moved to an expectant category until resources or conditions are such that the patient may be re-triaged back to a critical or possibly has improved sufficiently to be "downgraded" to triage category yellow (urgent).

On the other hand, if treatment of an ICU or a high acuity patient does not utilize sufficient resources to endanger the care of two or more other individuals then that high acuity care should and in fact must continue as an ethical and moral imperative.

The key to making these decisions is to identify the critical processes that are required for the provision of essential high acuity medical care.  Once these processes are identified specific, measurable parameters must be established to determine if additional resources are needed to bolster that process.  This ensures that valuable limited resources are not squandered on processes that are not in danger of collapse as a result of surge.  More importantly, as the number of patients under treatment expand it ensures that resources are wisely allocated to maximize the surge capacity.

Resources will always be limited in a disaster because of the very nature by which resources are now obtained.  Our "just in time economy" has eliminated most stockpiles from healthcare institutions.  Few hospitals have more than two or three days worth of medication, disposable supplies or food on hand at any given moment.  They rely on regular re-supply from vendors, who themselves maintain only limited warehouse storage.  In the event of a large scale disaster needs quickly exceed resources (the very definition of a disaster) and supply chains break down.  With resources even further limited essential processes fail and a disaster becomes a catastrophe as the ability to respond is lost.

The frugal application of resources to essential processes in the provision of healthcare combined with a continuous re-triage of patients ensures that precious resources are utilized in a fashion which maximizes their impact and benefit.

This lesson has already been implemented in virtually every hospital in the United States, but it has not been implemented in a patient care area.  Information technology departments utilize the constant monitoring of key operational processes with clear and well-defined parameters to determine how best to dynamically shift available resources.  Your information technology professionals speak in terms of "bandwidth" rather than "bed space" and "memory allocation" rather than "ventilator availability."  However, with well over a quarter century experience in process analysis and resource allocation, your information technology professional is an invaluable resource in the method of evaluating your essential processes and resource allocation.

Virtually every supplier of data management equipment and software, from imaging to electronic medical records to registration and accounting software are utilizing this process to ensure continuity of their part of the operation.  Patient care component is the only portion of hospital operation that has not learned to triage itself.

A careful evaluation of the healthcare process utilizing these information technology techniques will quickly show that in addition to those items already on our resource list including medication, food, bandages and other disposable supplies the most valuable and most limited resource is the healthcare professional themselves.  It has been said that it takes at least seven years to grow a doctor, at least two years to grow a nurse or a respiratory therapist and many more years to ensure the experience necessary to operate in these professions and every other patient care profession with any degree of expertise.

The loss of a healthcare professional through injury, illness, or stress has a significant negative impact upon both operational capacity during a disaster as well as the short and long-term recovery following the disaster.  Lose just one of these professionals and you impact the care of thousands or even tens of thousands of patients into the future.

Ensuring the resilience of healthcare professionals within the high acuity arenas of the hospital is the single most effective and most efficient means of expanding surge capacity beyond the emergency department.

There are six areas of human functioning:

• Physical
• Emotional
• Intellectual
• Social
• Behavioral
• Spiritual

Each of these areas of human functioning have a corresponding form of resilience, a canteen which is filled in the time between disasters and drawn from during the response to a disaster.  These six canteens of resilience are:

• Physical
• Emotional
• Intellectual
• Relationship (social)
• Functional (behavioral)
• Spiritual

Physical resilience is exactly as the name would imply.  It is the physical capacity to continue working in light of physical and even emotional stress.  Physical resilience is enhanced through the maintenance of good health and a healthy lifestyle.  Eating a balanced diet both at home and at work, including during the disaster; regular exercise; and adequate rest, even during the disaster, are essential to "filling" your canteen of physical resilience and maintaining that resilience while responding to a disaster.

Emotional resilience deals directly with what we feel and how we respond to it.  The old saying "attitude counts" was never more true than when filling your canteen of emotional resilience.  Loving and being loved, including loving yourself; enjoying the everyday joys of life and ensuring that you have the opportunity for boundless joy and genuine happiness fill your canteen with the sweet emotions that counterbalance the many unpleasant and at times even horrific scenes that we all encounter when responding to disaster.  On the other hand, if you have filled your emotional canteen with despair; selfloathing; angst and animus then you will have nothing but bitter drags from which to drink when in the midst of a disaster response.

Intellectual resilience is bolstered by the very act of learning and practicing the skills which you have learned.  It is as we gain experience and knowledge we slowly imprint new patterns which we may later use to compare and ultimately recognize as familiar situations and events that unfold during an event.  The more of these patterns that we have in our intellectual canteen the more quickly we can recognize and adapt to the ever changing disaster environment.  Just as we learn the patterns of a heartbeat or the patterns of respiration we can learn the many patterns that exist within medicine, patterns which occur more frequently and more rapidly but are no different when they occur during a disaster event.  When we can recognize these patterns quickly we can respond quickly thus bolstering our intellectual resilience.

Relationship resilience bolsters our social functioning.  It is through our relationships with those that we hold dear, spouses and significant others; children and grandchildren; parents; relatives; friends; coworkers that we fill our canteen of relationship resilience with memories and comforting mental images that carry us through our times of separation.  It is also these relationships that safeguard our lives and our emotions.  Disaster response is a high-risk sport not unlike scuba diving and for that reason requires that you have a buddy to check on you and ensure that you are not becoming overwhelmed, ensure that none of your canteens of resilience are running dry.  It is through these relationships that we not only fill our canteens but keep them full and keep watch on each other.

Functional resilience bolsters our behavioral function.  The skills that we have practiced in our day-to-day lives as we have moved through our careers are that with which we fill our canteen of functional resilience.  Like the patterns in our canteen of intellectual resilience the skills of our functional resilience are no different at times of disaster response than they are at times between disasters.  We need only be able to access those skills more quickly and perform them more calmly.

Spiritual resilience is somewhat different because the canteen of spiritual resilience is not filled by what we believe, but rather by the fact that we believe.  Research in the area of resilience has shown that the very act of believing enforces an even intelligence beyond ourselves, a higher purpose for higher power, bolsters our resilience, improves our function and our likelihood to master adversity.

It is through the maintenance and enhancement of resilience both for each individual healthcare professional as well as for the processes by which we provide high acuity healthcare in the intensive care unit and other areas of the hospital that we maximize the surge capacity of these most critical areas as well as ensuring that those that staff them do not become the collateral casualties of our disaster response.

Love: The Basic Building Block of Resilience

Father Robert Mitchell, a noted Catholic priest and philosopher, once wrote of the difference between “like” and “love.”  Father Mitchell believes that “like” is an uncontrollable emotion, a reflexive response to our experience of another individual and the way we interact with them.  According to Father Mitchell “liking” somebody or “disliking” them is as uncontrollable as the color of our eyes or the color of our hair.

“Love” on the other hand in Father Mitchell’s world is a choice, an active decision based on the type of relationship we choose to have with another individual.  Father Mitchell states that while we may respect some individuals very often we will neither like nor love them.  Similarly Father Mitchell believes that there are many people who we like intrinsically.  Our experience of them and our interactions with them lead us to the inevitable response of genuinely liking these people, yet we choice not to love them.  As Father Mitchell states it is nice if we like them as well but we can choose to love somebody, in other words care for them as an individual and more importantly care what happens to them, even without respecting or liking them as a person.

It is this final paradox, loving without liking, that Father Mitchell believes is the reason love is the ultimate “energizing” emotion.  It is energizing because love is an active choice decision that we make to not only extend a relationship to someone else but to take control of ourselves and our lives.  For Father Mitchell to love is the ultimate empowerment.

Another Catholic priest and philosopher, Father Dan Schulte, offered a functional definition of love:

"Love is a unifying response between two people who care for and have said 'Yes' to each others total being.  It implies mutual respect, freedom and trust, and seeks the happiness and fulfillment of each other as a common goal."

For love to be the basic building block of resilience it must not only be a choice as Father Mitchell has stated but it must also fulfill all of the basic tenants of Father Schulte’s definition.

"Love is a unifying response ..."

In this phrase Father Schulte has encapsulates the most basic essence of the choice to love as well as its greatest hurdle.  Love is a unifying response binding the person making the love decision to the person who is the recipient of that gift.  It unites these two individuals creating something that is greater than the sum of its two parts.

"... who care for and have said 'Yes' to each other's total being."

Father Schulte echoes Father Mitchell's sentiment that love here is a choice, a choice to accept ones partner in a relationship exactly as they are.  No conditions, no qualifications, no equivocation. 

It has been said that "no one self can see ones self through the eyes of another."  If this is true then Father Schulte’s definition holds that much more power as a building block of resilience.  When we love another and enter into that "unifying" relationship we not only see ourselves as we are but find acceptance of ourselves as we are, not the way we wish we could be.  It is through this acceptance that we can come first to respect ourselves then to like ourselves and finally we can make the active choice to love ourselves in the same way that we love others.

"It implies mutual respect, freedom and trust ..."

Father Schulte emphasizes that the choice to love grows from the roots of respect.  To love ourselves we must first respect ourselves.  It is from this self-respect that Father Mitchell's emotional response to like ourselves springs.  Similarly, since if we are to love another person we must first respect them. That respect grows from absolute and unconditional acceptance.  Once respect is manifest it demonstrates itself through trust.  Trust like love is an active decision.  Paraphrasing Father Mitchell, "we do not choose to like, that is an uncontrollable emotional response.  But we do choose to trust (love)."

"... and seek the happiness and fulfillment of each other as a common goal."

Finally, Father Schulte reminds us that the choice to love is an active ongoing and demonstrative choice.  We manifest this choice to love through the goals that we have for the relationship.  If our goals for the relationship are completely focused upon ourselves then the relationship may represent respect and even like but it is clearly not love.  It does not contribute to our resilience.

If, on the other hand, our goal of the relationship is strictly to please another person and does not include ourselves actively within the relationship then again it may represent respect and even like but it is not love.  It does not contribute to our resilience. 

For a relationship to actively demonstrate love it must balance our own self-interests with our desire to be selfless.  If love is unifying response and therefore the love relationship becomes a true individual a sum of the two people who choose to share the relationship the contribution of love as a basic building block of resilience is that by choosing to create this love relationship we choose to create a reservoir of resilience for two.

The four forms of resilience are all based on this simple emotion, love.  Whether it is our physical resilience, our emotional resilience, our relationship resilience, or our spiritual resilience each requires that we make the active decision to love in order to build that resilience; to fill that canteen. Similarly, we thus fill our 40,000-gallon bathtub of resilience with this basic element of resilience, love.

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

Making Lemonade

I spent the late hours of this evening with an old friend. My friend and I had gone to medical school together. His wife of 25 years died 3 months ago.

My friend came into town for a convention and looks surprisingly good given the circumstances. The love of his life had been the person that was his perfect compliment. They had met in high school and despite the challenges of being young, despite disapproving families, despite coming from completely different backgrounds and religions, their relationship had thrived.

My friend's wife handled everything that he always claimed he was inept at doing. She matched clothing for him, picked out just  the right gifts for their friends at the holidays, planned social gatherings and drew an ever expanding universe of friends into their life. Similarly he handled everything that she found difficult; planning trips, creating opportunities, keeping the peace among the extended family.

She died a horrific death from widely spread breast cancer at only 41 years of age. She suffered every complication of both her disease and her treatments. Over the final six years of her life she suffered every indignity without ever losing her dignity. She died twice in that six years before finally dying for the last time. My friend had little time to grieve her loss before tragedy became catastrophe as their oldest child suffered a life threatening illness and complications from the ensuing emergency surgery.

As my friend sat at his child's bedside, he found himself writing Thank You notes to those who had attended his wife's funeral, over 500 of them. He said,

"I've become a woman, every note was personalized. I've never known how to do that, she always did it for me and now that she is gone, I've become a woman."

I sat an listened to him describe who he finds that for the first time in his life he can match clothing, cook, writing heartfelt letters, buy "just the right gift" and even wrap it. All things she used to do for him. I marveled at my friend and how resilient he had become because of his relationship with his wife. Even after her death, their relationship had been so full and without regret that it continued to be the source of his resilience even after she had died.

Those of us who knew them, always knew him as the "peace maker" and her as the one who "took lemons and made lemonade." In their life together, he had imprinted patterns of behavior and skills that he never appreciated until she was no longer there. These dormant patterns suddenly became active behaviors when he needed them. These patterns are a tangible manifestation of his Relationship Resilience.

I spent four hours reminiscing with my friend, reliving their last vacation together and their last days. Before I picked him up I contemplated how to tell him that after loving her so completely for so many years that it was OK to move on with his life, to be a father, to be a doctor, to be single and perhaps even to find someone new to love. Much to my joy, I found that through the life and relationship they had shared, she had done this last thing for him. They had loved without regret and become so much a part of one another that he will have her with him always as he move forward in life and drinks deeply of his Relationship Resilience.

Spiritual Resilience for Business

Of all of our sources of resilience, spiritual resilience, it is the only one that is self replenishing.  It is proven that the very act in believing adds to our resilience.  Like emotional resilience spiritual resilience grows when shared.  But unlike all other canteens of resilience it is spiritual resilience that refills itself.  Since we know that it does not matter in what we believe, but that we believe in some form of high order, high wisdom, or higher power a “God” or guiding force in life.  It makes sense that acting on our beliefs would add to our resilience.

It was spiritual resilience that sustained me during the multiple field response deployments of 2005. Hurricane Katrina was an absolute catastrophe in both humanitarian and a physical nature.  What the hurricane had not directly destroyed the levee breaches soon did.  Lawlessness and anarchy brought a few to the basis of human emotion and behavior.  But the tragedy also brought out the best in many people.  Like 9/11 before it Hurricane Katrina’s “ground zero” was dotted with signs that seem to reproduce like mushrooms each one declaring “God bless New Orleans” or we have faith, we will be saved.

These people not only publicized their beliefs (and their spiritual resilience), but they lived it.  These individuals shared not only their stories with us as we treated their physical ailments, they  told us that they would pray for us or that we were the answers to their prayers.  It is not unusual to receive perfunctory thank you’s in healthcare, but to be asked to pray with a group of survivors and then be the object of their prayerful thanks is both humbling and rejuvenating.

And for these wonderful survivors it was the act of expressing their spirituality that renewed them. Remember this is New Orleans, we are not just talking Christianity, Islam, Judaism, but Santorista and Voodoo.  Every form of religious expression both familiar and exotic and yet they all served a common end: they bound a people together and renewed them. The found the way to refill their own 40,000 gallon bathtub by pouring from their canteen of spiritual resilience.

It is this type of resilience that every business must have to handle catastrophic adversity. “Business Katrina’s” fill the news almost every week and those affected are often left bereft of emotional resilience and the financial impact literally bankrupts their physical resilience. It is at these times that an abiding faith is imperative.

But faith in what?

In the 1980’s the study of Sun Tzu and The Art of War introduced American executives to the concepts of balance and flow in battle and business. Sun Tzu wrote not only of strategy, but of the need to understand one’s place in one’s world. More importantly, Sun Tzu emphasized planning with respect and consideration of the environment and the greater forces that determine the fate of our efforts. At the deepest level, The Art of War was about victory through surrender.

In more modern times, masters of Indian philosophy have reintroduced the principles that build spiritual resilience to the American corporate community. Jeff Korhan (www.truenature.com) is the most respected of these new corporate philosophers. A protégé’ of Depak Chopra, Jeff Korhan has successfully made the jump from businessman to business guru in the truest sense of the work through the use of his spiritual resilience both for himself and his clients. How will your spiritual resilience serve you?

(Excerpted from my lecture series and book The Wounded Dog: Avoiding Business Disaster - Lessons Learned from the Disaster Field Office)

For the Record... Thank You for My Resilience

My father died a number of years ago. Our last years were strained and distant because when I became a single parent, he was quite vocal about the fact that my children would be better off if I concentrated on my career rather than changing my goals to raise them. By the time I have learned to understand and forgive, he was gone.

For years after his death, I lamented two things:

• The time I had wasted being angry with him, and
• That he never saw me succeed; he never had a chance to be proud of me.

These laments served for a long time as a drain on my emotional and relationship resilience. At times of adversity, when needs were dangerously close to exceeding resources, these laments would often tip the scales robbing me of the ability to stave off disaster.

As time past, I learned that my father had spent his last years bragging about my accomplishments and how well I had raised my children. I discovered through those who knew my father far better than I that he was most proud of the fact that I had made a new life with a wonderful woman and built a family while rebuilding my career. He had never told me any of this.

Now I have adult children and I look at the resilience they draw from our relationship. Like my father, I brag daily about the accomplishments of each one of them.

My daughter Victoria who has enjoyed success in every professional endeavor she has attempted from boutique sales (first sale totaled over $10,000) to bartender (nightly tips regularly exceed $300) to starting graduating from college 2 semesters early and soon to start her doctorate in education. In addition to work and school, Victoria is a belly dancer who donates her talent at local charity events.

My younger daughter Tiffany has made a success of her part-time garage band, taking it from the amateur stages of local bars to the main stage at music festivals and charity events in only 18 months while maintaining excellent grades and working in the promotions department of a radio station. As if this were not enough, Tiffany makes time to help her cousin find his way back to school and to his family.

My son Nicholas has just received his Black Belt in Tae Kwon Do. While it is no mean feat to accomplish this while still in the 6th grade, he studies at the training school for the 5 time Florida state champion Tae Kwon Do team. Last week he was honored by being promoted to Instructor at this studio. Like his sisters, Nicholas also donates his talents on both his school and church choirs.

My youngest child Christopher is the joy of the family. His contagious smile and never ending fountain of happiness and love brighten even the darkest day and ease the heaviest heart. It is impossible to look at him and not smile, then laugh and feel better. He is a straight “A” student and despite the fact that he is 3 years younger than Nicholas, will test for his Black Belt in just over one year.

My loving wife Laura is my support in my dark hours, my trumpeter in my golden hours and my greatest fan at all hours. It is incredible how Laura can keep up with a household full of children, me and her own career as a prison doctor. For that matter, I don’t know how she does her job at all! She is as amazing as she is beautiful.

My mother Jean is a true force of nature. A nurse for over 30 years, a business woman who has run several businesses and the mother of 6/grandmother of 16, “Mom” is the matriarch who challenged each of her children to be better. She has always believes in me even when I didn’t believe in myself; not because she is blinded by love, but because she sees in me what I could not… greatness.

In this the Year of Resilience; I write this not just to brag about my family, but to say:

“Thank You!”

Thank you for being the source of my strength, even though you think I am the source of yours.

Thank you for being the light that pierces my darkness, even when you look to me to light your path.

Thank you for being the port in my storm and the strong walls of my home so that I can shelter you when you need me.

Thank you for being the greatest source of my emotional resilience and relationship resilience because without you I could not stave off disaster.

I don’t just write this because I need to say it; I wrote it because those I love need to see it. My father bragged to everyone about me except me. I never knew and I spent years wishing I had given him to be proud of me when he already was. I want those I love to know I am proud of them now. I want them to have the emotional resilience and relationship resilience that comes from this knowledge.

I also write this so that everyone who reads this knows the power and importance of saying “Thank You” and “I’m Proud of You” to the ones whom they hold dear. The gift of resilience is the only gift greater than love, because it comes from love.

I write this so that you learn to give the gift of resilience.

New Orleans’ Ninth Ward: Rehabilitation or Recovery

The press has recently focused attention yet again on New Orleans and the process of rebuilding.  But this debate now entering its second year is more monologue than dialogue.  The emphasis has been on rebuilding and rehabilitating and not on true recovery.

A mere question of semantics?  Not really. 

The dictionary defines “rehabilitation” as to restore to original condition.  “Rebuild” is defined as to build again. 

I for one do not wish to see the Ninth Ward put back in the vulnerable condition which led to the catastrophe that was Katrina.  My observation of the political commentaries and emotional pleas that have surrounded the reclaiming of New Orleans convinces me that the residents of New Orleans also expect far more from those charged with its recovery. 

The job of Disaster Recovery more than rebuilding, more than making whole again. The job of Disaster Recovery is to make better and create those situations and systems that prevent the next catastrophe.  Disaster Recovery in the Ninth Wade will require a novel and innovative approach.  Let me suggest one such solution.

Here in Florida we have a unique device, an odd machine called a Dirt Building Plant.  This natural gas fired device is used to literally burn contaminated dirt until it is clean.  The machine is basically a large incinerator which safely burns off hazardous materials, petroleum contaminants, organic contaminants and other items found in the soil.

I propose that several of these devices be moved into the areas of Ninth Ward where the homes can no longer be repaired or reclaimed.  The entire area be cleared and placed through the dirt burning plants.  Additional fill soil would be brought from the various “hazmat” landfills, placed through the dirt burn process and added to the Ninth Ward elevating it until finally the surface of the Ninth Ward is level with the top of the levies.  This will effectively reinforce the earthen levies changing them from levies to new river banks.  The Ninth Ward would become valuble riverfront property. 

The land would then be returned to the people of the Ninth Ward.  They would have the option of rebuilding their homes on new high ground, above the level of future flooding.  They could set strong foundations deep into the earth and in compliance with the newest building codes.  Alternatively residents choosing not to move back to the Ninth Ward could sell their land now far more valuable because it is both high ground and riverfront property.  The development would revitalize the New Orleans economy and the new homes would revitalize the Ninth Ward.

Certainly there would be obstacles, the emotional impact of burning and burying the old Ninth Ward will be hard for many to swallow.  But like a phoenix rising from its own ashes the Ninth Ward would be resurrected not as an example of society failing its most vulnerable members, but as an example of serving those in need.