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