August 2007

Preparing for Disaster — Helping Those With Diabetes and Other Chronic Illnesses
By Juliann Payonk
Today’s Dietitian
Vol. 9 No. 8 P. 29

If a natural disaster of Hurricane Katrina’s magnitude occurred tomorrow, would you know how to act? Learn what nutrition professionals can do today to be ready for tomorrow’s disasters.

When Hurricane Katrina reached Gulf Coast shores on the night of August 29, 2005, no one was prepared for its wrath, and those with chronic diseases such as diabetes may have fared worse than most. Although no one envisioned the levees breaking, which turned a culture-rich city into an unsanitary wasteland, the question must be asked as to what more could have been done to prepare citizens, pharmacists, physicians, and—not to be forgotten—nutrition professionals, whose specific skill sets and specialties can aid many in a disaster, especially those with chronic illnesses.

After Hurricane Katrina ceased her fury, “[People were] trapped in their homes—in the attic or on the roof. There was little or no food to eat, and diabetes supplies were under water or left in what was their homes. Just getting out with the clothes on their backs was considered lucky. This was the greatest disaster to hit the United States—ever. We pray it won’t happen again, but it could,” says Peggy B. Bourgeois, APRN, MN, CNS, CDE, CEO of PBB Associates, LLC, an organization designed to assist with various approaches to diabetes management and education.

Summertime is now upon New Orleans and the rest of the United States. But before sun-kissed swimmers and vacation fantasies begin to mask the oh-so-summertime opportunity for hurricanes and other natural disasters, ask yourself one question: What will you do when the next disaster hits?

Drenching Disorder
Hurricane Katrina’s death toll reached more than 1,500, and it displaced more than 1 million people. Its survivors, including an estimated 100,000 with diabetes, were left to pick up the waterlogged pieces. Bourgeois explains, “Usually [in hurricanes], you have terrible wind and rain. But this time, when the levees were breached, the water came and stayed. This was the horror of it all. Today, the water is gone, but the damage is still there. It will take years to get it cleaned up and rebuilt.”

Bourgeois presented the breakout session “Disaster Preparedness: Are You Ready?” with Kathleen Marie Kissane, MSN, RN, CRNP, CDE, at last year’s American Association of Diabetes Educators conference in Los Angeles, where she discussed how diabetes educators and other nutrition professionals can play an active role in disaster preparation. The first step in preparing for future catastrophes is to understand the challenges those with diabetes faced following Hurricane Katrina.

Medical Challenges
Bourgeois went to New Orleans with the Department of Health and Hospitals’ Office of Public Health Center for Community Preparedness one year after the hurricane to complete health assessments. She details, “Many clinics were opening up again in the New Orleans area. We went to the Vietnamese village in East New Orleans and set up our site on St. Mary’s Catholic Church parking lot. The church had been destroyed in the storm, but the church members rebuilt it. After Mass, they came for blood pressure, blood glucose, and other assessments. We found several who had blood glucose levels greater than 450 milligrams per deciliter. They did not speak English, and when asked why they had not seen a physician, they stated that they didn’t know where to go as their clinic was closed.

“We also did medical assessments at the Bienville Projects near the French Quarter. We had tents under the interstate and trailers on the street next to the projects. Again, we found people with elevated blood glucose levels and other medical conditions,” she adds.

David Krol, MD, MPH, FAAP, associate professor and chair of the department of pediatrics at the University of Toledo College of Medicine, and a number of teams of physicians, nurses, medical students, and residents were in Gulf Coast Mississippi and Louisiana following Katrina as part of Operation Assist. A project of the Children’s Health Fund and the Columbia University Mailman School of Public Health, Operation Assist’s goal “was and is to respond to the urgent health and public health needs of the Gulf Coast region that resulted from Hurricane Katrina,” using mobile medical units to reach people who needed and continue to need care, Krol says.

While prepared for the trauma and other physical effects of the storm, “what we found was a great need for primary care and care for chronic disease. … The majority of the people who visited us needed help with problems that existed before the hurricane—chronic diseases like diabetes, heart disease, hypertension, and asthma,” Krol notes.

At this time, access to medications such as insulin and a connection or reconnection with a medical home were the main challenges for people with diabetes. “With pharmacies closed, physician offices closed, and medications lost or damaged in the storm, the tenuous control of their chronic diseases was put in peril,” he adds.

Bourgeois also notes the following additional medication challenges for people with diabetes:

• the inability to obtain regular and NPH insulin;

• syringe disposal in regular shelters (special needs shelters were equipped with biohazard containers);

• medication schedules not followed;

• inability to locate/refill prescriptions due to pharmacy and physician office closures; and

• lack of refrigeration.

Nutritional Challenges
Bourgeois says that food supplies were also a concern for people with diabetes. “Emergency food supplies were not according to various meal plans. The military Meals Ready to Eat were high calorie. But when you eat one meal per day, it will work,” she explains.

Additionally, much of the food was donated by fast-food restaurants or home-cooked by volunteers, which was high in fat with many unknown ingredients. Bourgeois says, “If activity is reduced, most healthy people can survive on half of their usual food intake for an extended period—even go without food for a few days if they have to. With diabetes, these same rules do not apply. There must be a balance of food groups and adequate calories, especially when taking insulin.”

An inability to cook due to power failure, a limited food supply, and people skipping or delaying meals due to these circumstances all created additional hurdles for people with diabetes.

A Child’s Plight
Adults weren’t the only ones who suffered complications from chronic diseases following Hurricane Katrina. Barbara Rath, MD, in her affiliation with Tulane University Health Sciences Center, and colleagues designed a comprehensive questionnaire to assess 531 children who had been affected by the hurricane; 209 of those children had preexisting chronic medical conditions. “As a pediatrician, I know that most children like to have their routines and a sense of security, even more so than adults.

“For children living with diabetes, for example, adequate nutrition and keeping track of food intake and blood sugars are important to maintaining healthy levels and preventing complications,” says Rath.

“With 20% of surveyed children running out of medications and 8% having missed immunizations, likely multiple factors were involved. But children with chronic conditions and their families were facing many additional problems and fears when their routines were interrupted,” she adds.

Lending a Hand
How can anyone, including nutrition professionals, plan for such a multifaceted disaster? Rath says, ”The answer is, simply, by planning ahead of time. Individuals, families, neighborhoods, civic institutions, churches, government, and public health officials all play a role.” Diabetes educators and RDs have the unique skills and knowledge to aid in disaster preparation and relief.

Disaster Kits
Bourgeois recommends talking with clients about disaster preparedness and detailing disaster kits, cartons or boxes packed in advance that should include all the necessary items they would need in a disaster situation. “A disaster kit would contain all you would need for at least three days of being away from home. Make a list of necessary supplies for your disaster kit and another shopping list placed in a prominent area where anyone in the family can obtain it and get the supplies in case you are not there at the time. Tape the list to the lid of a waterproof box or in a ziplock bag,” she explains.

For clients with diabetes, Bourgeois says stockpiling medications is not a good idea as the medications may expire, cost may be prohibitive, and physicians may change the medication taken. “Patients can obtain computer-generated copies of their prescriptions from their pharmacy [ahead of time]. When it looks like [they] may have to evacuate, [they should] be prepared and have prescriptions refilled. Some insurance [plans] will not cover refills if requested too early, but having copies of the prescriptions will help in getting them refilled elsewhere.”

Because most clients do not have a disaster plan and may not speak about it with another physician, nutrition professionals may choose to go over all aspects of disaster preparedness with them. There is no such thing as being too prepared for a hurricane or flood, and clients will surely appreciate the information. “Cover what to prepare for, whom to contact, where to meet, where to stay, making a plan regarding personal information, local contacts, out-of-state contacts, nearest relative, pet needs, etc. [Also cover] making a kit and what supplies to have ready,” Bourgeois suggests.

Rath also recommends discussing a disaster plan with clients, especially for the parents of children with diabetes or other chronic illnesses. She advises, “While all children have needs and dependencies, children with chronic conditions are even more vulnerable to disruption of routines. Children and their families, as well as their healthcare providers, should prepare an evacuation plan and have emergency supplies of medication available with a hard copy of important medical records. This will help to alleviate anxiety in the event of a disaster.”

Get Involved in Government
Lend your thoughts and opinions on disaster preparation to your local or state government because they want your input and expertise. Bourgeois urges nutrition professionals to “get involved with the disaster planning within your state, then volunteer to work in a shelter. Nutrition is one discipline that is missing at shelters. RDs are desperately needed.”

Rath agrees, adding that healthcare professionals need to organize who will help out and where—before the disaster strikes. Remembering Katrina’s effects, she says, “Many registered healthcare providers in the affected areas had evacuated but were uncertain as to where they should go to help and how to get there. A predisaster plan allocating healthcare professionals to areas of need would be extremely helpful.”

Bourgeois advises contacting the Emergency Systems for the Advanced Registration of Volunteer Health Professionals, as they have recently added a form specifically for dietitians and nutritionists, as well as nurses, pharmacists, social workers, and other healthcare professionals. The Emergency Management Assistance Compact in the Office of Homeland Security is also working on obtaining medical volunteers from all disciplines.

Volunteer Your Time
When a disaster is upon your town, state, or country, volunteering is your best bet at helping, and everyone can make a difference. Bourgeois says that CDEs and RDs would be best utilized in special needs shelters, where patients with chronic illnesses abound and need special attention. What are nutrition professionals’ roles in one of these shelters?

Bourgeois answers, “The [nutrition professional] will be able to assist the other medical professionals who don’t have the in-depth knowledge of diabetes [that] they have. You are teaching or collaborating with other professionals and may be [involved in] some patient education,” noting that, in a hurricane’s aftermath, you may be busy with foot and skin care. After Hurricane Katrina, many people were unprepared, having no shoes and only the clothes on their backs. People showed up with wet and cut feet, some having abrasions and blisters. Foot care quickly became an issue for all medical professionals.

Additionally, she says nutrition professionals can aid in “situations that come up where the diabetes educator will be able to resolve an issue quickly. [Regarding nutrition], donuts were delivered to the shelters by well-meaning people; knowing how much [people should eat] when it’s donuts, milk, and juice [would help]. Often, homemade items were brought in, but they could not be used as there was no knowledge of the conditions, sanitation, how the food was prepared, or its ingredients.”

It’s best to fill out volunteer forms before a disaster hits, and Bourgeois says “the state board of examiners for dietetics and nutrition, board of nursing, pharmacy board, and other healthcare boards are working with state boards across the country to obtain speedy verification of license.” She recommends nutrition professionals bring their license and registration to their volunteer site, as you cannot work as a professional without verification of license. You can expect to take care of patients with nutritional needs, such as diabetes, cardiovascular, respiratory, or food allergies.

If you’re eager to get involved and would like to find information on special needs shelters near you, your state Office of Public Health has a list of shelters located in every parish or county. “The state Office of Emergency Preparedness is located in the Department of Health and Hospitals, Office of Public Health,” Bourgeois says. “During a disaster, there are state shelters, special needs shelters, and faith-based shelters. ‘Pop-up’ shelters are well-meaning people who open a shelter but are not on the official shelter list and may have little or no resources.” There are statewide disaster training programs for professionals and volunteers. Find out what is available in your state by visiting www.ready.gov for more information.

Hope Through the Chaos
Rath reminds people that even with planning, allocation of resources and the generation of a clear command structure in shelters and outside hospitals will remain a challenge in disaster planning, which is why volunteers are needed at every stage. “Even if enough infrastructure, personnel, and supplies are available, it will be crucial to plan ahead of time and coordinate how different emergency providers, local healthcare resources, governmental institutions, and human aid agencies are going to interact and work together.”

But through the madness—the flooded streets, ransacked neighborhoods, and beaten down survivors of Hurricane Katrina—specks of brightness came through from both victims and volunteers, such as Steven Smith, MD, of Louisiana State University Pennington BioMedical Research Center, who called countless pharmaceutical supply companies for donations of insulin, oral agents, and blood glucose testing supplies.

Or a man Krol remembers who, following the hurricane, needed help to control his diabetes and was unable to obtain eyedrops for his glaucoma. “He described to me how he could feel his eyesight going because of the lack of medication. Yet, while telling me the story, he was so strong and thankful for what he did have, without a hint of anger. I was floored by his strength in the face of such a challenge.”

And sometimes, the smallest victims can be the most resilient. “What I will always remember are the very serious expressions on the faces of the children arriving at the shelter in the very first days after the storm. But I also remember that it was these same children who first began smiling and laughing again, only a few days later, always looking ahead, curious to explore their new environment,” Rath recollects.

She adds that in her experience following Hurricane Katrina, she was impressed to see how people dealt with each other with such kindness, respect, and patience. “I have seen an incredible amount of help and support arriving in New Orleans after the hurricane. Local initiatives, nationwide efforts, well-organized groups, as well as many, many individuals were able to make a difference,” she says.

September is National Preparedness Month. Whether by making a disaster plan with your clients or signing up at your local volunteer shelter, join the light at the end of the chaos.

— Juliann Payonk is an editorial assistant at Today’s Dietitian.

Disaster Kits
Peggy B. Bourgeois, APRN, MN, CNS, CDE, CEO of PBB Associates, LLC, suggests going over disaster kits with clients, emphasizing items such as extra medication, prescription lists, and other medical papers. Bourgeois suggests the following items be included in each kit:

• 1 gallon of water per person per day for three days;

• nonperishable foods such as those that are canned or packaged;

• one change of clothes and footwear per person;

• three days’ worth of prescription medications;

• a flashlight and extra batteries;

• a manual can opener;

• a battery-powered, solar-powered, or hand-crank radio;

• hygiene items such as soap, toilet paper, and a toothbrush; and

• first aid basics such as antiseptic, bandages, and nonprescription medication.

Specific to clients with diabetes, she notes the following items:

• ziplock bag(s) for copies of prescriptions for every member of a family;

• glucagon/glucose tablets; and

• snacks.

If, for some reason, clients are unable to take more than a small bag and the clothes on their back, Bourgeois says the most important thing to tell clients is to take “their plan with the list of contact phone numbers, medications/meter, and the important list of medications,” reminding people to consider including a portable radio and a cell phone with an extra charged battery. Miscellaneous items that some people choose to add to disaster kits include a small grill and charcoal, coffee and a coffeepot, and a charged laptop to stay current on the situation. Remember, be prepared.

— JP

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Resources
American Red Cross
www.redcross.org

Centers for Disease Control and Prevention
www.cdc.gov

Federal Emergency Management Agency
www.fema.gov

Homeland Security Disaster Help
http://www.dhs.gov/topic/disaster-assistance

U.S. Department of Homeland Security
www.ready.gov