Hurricane Ike :

Surviving in the Aftermath

Presented by:C. J. Flenniken, RN, CNN

DaVita Group Facility AdministratorMed-Center Dialysis, Houston, TXMainland Dialysis, LarMarque, TX

Island Dialysis, Galveston, TX

When asked to speak here, first of all, I myself was suffering from post-traumatic stress disorder, or I never would have said yes. What was I thinking?My understanding of my portion of this presentation / panel discussion was that I was to discuss dealing with the aftermath of a disaster. I have to say, though, that in a lot of ways I’m still having trouble finding the “after” part. Is there such a word as “intramath”?

Just a Cat 2

http://video.google.com/videoplay?docid=743948852354229613

Just a Cat 2Just a Cat 2 Our patients, docs, and teammates are still struggling also to find their “after” Ike normalcy

6 months post-Ike. I have spoken with numerous people in the months post Ike that say: “Oh, was it that bad?” “I thought everything was back to normal.” I recently interviewed a teammate desiring to transfer to my Houston clinic. We decided we clicked, but she wanted to give her supervisor 4 weeks’ notice (an admirable trait, by the way). She was concerned I would give away the position. I told her that I continued to be busier than a one-armed man trying to hang wallpaper as we were getting close to hopefully reopening Island post-Ike. She said, “oh, I thought everything was back to normal already.” I told her that I’m unsure if my patients, teammates, docs have a normal anymore.

Believe it or not, some of these 3 pics here are not after the storm or during its landfall. Ike made landfall in the wee hours of 9/13. These pictures were taken the day before. While preparing this project, I was surfing the net and came across a blog with comments posted a couple weeks post-Ike. An idiot (that’s the nicest word I could think of) basically told the other folks to quit their whining, this was just a cat 2. You basically hunker down and lose power for a couple days, clean up a few limbs, then everything’s back to normal. As most of us know even when he posted that, the majority of us in this entire metro area, not even just us on the coast, still were without power. Thanks goodness for that nut, because if we had been able to read his post back then he might have gotten hurt. He actually really said, “it’s no big deal.”

When I began assembling this presentation, I searched for some photos so that folks could see some of what we dealt with. I think many were unaware because we all had no power for so long. By the time we got power back in our individual homes (if we still had homes), the news had moved on to “more important” things. After all, it was an election year. A significant election year.

And how much damage could a Cat 2 really do anyway. No big deal. And these pics are pre-Ike. Ike was a 900-mile wide storm – a little ol’ Cat 2. For those who

know what they’re talking about, Ike was a Storm of the Century. He had “low winds” – ha, for those of us whose windows were blown out, both inside and outside – but he was huge – 900 miles wide. Ike has the NOAA considering a new cat system. Ike has been compared to a bull in a china shop – large, lumbering, “slow,” -- but capable of significant damage.

Tell these folks (or their families): No big dealTell these folks (or their families): No big deal

Top left photo was well before Ike made landfall – a warehouse burning in the harbor and a frustrated fireman because they couldn’t get to it because of the already rising water. Bottom left is a family in Bridge City – 2 months post Ike . . . Pics on the right – well, obviously, quite a few things ended up where they should not have been.

The day before landfallThe day before landfall

Tell these folks (or their families): Tell these folks (or their families): No big dealNo big deal

Photo was well before Ike made landfall – a warehouse burning in the harbor and a frustrated fireman because they couldn’t get to it because of the already rising water

Just a Cat 2 – No big dealJust a Cat 2 – No big deal

A family in Bridge City – 2 months post Ike

Quite a few things ended up where they should not have been.Quite a few things ended up where they should not have been.

We had 90 patients at Island Dialysis as of 9/11/2008, the day the We had 90 patients at Island Dialysis as of 9/11/2008, the day the storm turned. 100% of them had Galveston addresses. The majority storm turned. 100% of them had Galveston addresses. The majority of my patients there lived in the areas of the island that were the most of my patients there lived in the areas of the island that were the most damaged. damaged.

DaVita Island DialysisDaVita Island Dialysis

A fish in the dialysis unit

DaVita Island DialysisDaVita Island Dialysis

Category 2 Hurricanes Can be DevastatingCategory 2 Hurricanes Can be Devastating

Category 2 hurricanes can be Category 2 hurricanes can be devastating – do not be devastating – do not be overconfidentoverconfident– Wind damage, flooding and Wind damage, flooding and

downed trees result in a loss downed trees result in a loss of all services, not to mention of all services, not to mention fires and people stranded. fires and people stranded.

– In IKE people were stranded In IKE people were stranded by high water before the by high water before the stormstorm

– Fire departments could not Fire departments could not access firesaccess fires


We prepared!! But, tired We prepared!! But, tired out staff can be callousout staff can be callous– No matter how hard you No matter how hard you

prepare, you will ALWAYS prepare, you will ALWAYS be surprised. be surprised.

– Hurricanes come in Hurricanes come in package – 2008 was package – 2008 was Eduardo, Gustav and then Eduardo, Gustav and then IKEIKE

– The staff was tired by the The staff was tired by the time IKE came onboard time IKE came onboard because they had been because they had been dialyzing and preparing for dialyzing and preparing for the earlier twothe earlier two


Born on the Island”Born on the Island” Natives always ask the question Natives always ask the question

“Do I need to worry about this “Do I need to worry about this one?”one?”

Here the answer was yes – but, Here the answer was yes – but, no mandatory evacuation – and no mandatory evacuation – and on the Thursday before the on the Thursday before the storm hit, patients were still storm hit, patients were still dialyzing!dialyzing!

TAKE HOME – PATIENTS NEED TAKE HOME – PATIENTS NEED TO LEAVE BEFORE A TO LEAVE BEFORE A MANDATORY EVACUATION!!!MANDATORY EVACUATION!!!

Lessons Learned: Lessons Learned: A Tale of 3 Clinics – Island and A Tale of 3 Clinics – Island and

Mainland and Med CenterMainland and Med Center

You can only dodge that You can only dodge that bullet so many times till bullet so many times till it finally has your name it finally has your name on it – on it – Med-Center has Med-Center has never never lost power (for lost power (for more than a few minutes) more than a few minutes) – not during Allison, not – not during Allison, not during Rita.during Rita.

History only repeats itself History only repeats itself so many times before it so many times before it pulls a fast one on you.pulls a fast one on you.

Island DialysisIsland Dialysis Island & Mainland Island & Mainland

either worked either worked Sundays or pulled Sundays or pulled patients up for both patients up for both Eduardo and Gustav Eduardo and Gustav within weeks pre-Ike, within weeks pre-Ike, frustrating patients, frustrating patients, docs, and teammates.docs, and teammates.

For Ike, no one was For Ike, no one was very motivated to very motivated to cooperate with cooperate with schedule changes – schedule changes – patients, docs, or patients, docs, or teammates. teammates.

Lessons Learned: Lessons Learned: A Tale of 3 ClinicsA Tale of 3 Clinics

Members of the general public Members of the general public continue to be woefully uninformed continue to be woefully uninformed about the life-sustaining nature of about the life-sustaining nature of dialysis.dialysis.– Utility CompaniesUtility Companies– MediaMedia– Politicians (from City Council Politicians (from City Council

members to members of US members to members of US Congress)Congress)

A special thanks by the way to A special thanks by the way to Whole Foods Corporation out of Whole Foods Corporation out of Austin who generously supplied us Austin who generously supplied us with a generator so we were able to with a generator so we were able to open Tuesday a.m.open Tuesday a.m.

DaVita Med CenterDaVita Med Center We talked to people at Reliant and Centerpoint at 4 a.m. on We talked to people at Reliant and Centerpoint at 4 a.m. on

Monday only to find that despite our efforts every year to ensure Monday only to find that despite our efforts every year to ensure we remained on essential services status – well, somehow we had we remained on essential services status – well, somehow we had fallen off. There was no convincing these folks that lives were fallen off. There was no convincing these folks that lives were hanging in the balance.hanging in the balance.

We reached out to politicians from city council to U.S. We reached out to politicians from city council to U.S. congressmen. We were told to be patient – they were assisting congressmen. We were told to be patient – they were assisting urgent cases first such as nursing homes without power. urgent cases first such as nursing homes without power.

We reached out to sources reported to have access to extremely We reached out to sources reported to have access to extremely large generator (Med-Center is 72 stations, one of the largest in large generator (Med-Center is 72 stations, one of the largest in the United States, and needs one size of 18-wheeler) – the United States, and needs one size of 18-wheeler) –

We were told they were being reserved for more important We were told they were being reserved for more important purposes. purposes.

RESPONDER UNIT

DaVita Med CenterDaVita Med Center

– FEMA told us they could not help us; they did not have a FEMA told us they could not help us; they did not have a generator large enough to accommodate us. generator large enough to accommodate us.

– We were told that a generator the size we needed would We were told that a generator the size we needed would cost $15,000 per day plus fuel – which was expensive. cost $15,000 per day plus fuel – which was expensive.

– A politician was notified and told we were in a life or death A politician was notified and told we were in a life or death situation. He offered to send EMS out evaluate our patients.situation. He offered to send EMS out evaluate our patients.

– When the most beautiful men (from Whole Foods) in the When the most beautiful men (from Whole Foods) in the world showed up in our darkened clinic Monday evening and world showed up in our darkened clinic Monday evening and saw some of our patients still anxiously awaiting our saw some of our patients still anxiously awaiting our reopening, they had no idea what we did here either. After reopening, they had no idea what we did here either. After explaining it to them, they decided to bill us only a dollar a explaining it to them, they decided to bill us only a dollar a day. day.

RESPONDER UNIT

THANK YOU WHOLE FOODSTHANK YOU WHOLE FOODS

A special thanks by the way to Whole A special thanks by the way to Whole Foods Corporation out of Austin who Foods Corporation out of Austin who finally supplied us with generator so finally supplied us with generator so we were able to open Tuesday a.m.we were able to open Tuesday a.m.


Generators required at all facilities will not solve Generators required at all facilities will not solve all the problems.all the problems. – Island Dialysis was my only clinic with a generator, but – Island Dialysis was my only clinic with a generator, but –

well, you saw the pics. well, you saw the pics. – Mainland had no generator, either but it was difficult to Mainland had no generator, either but it was difficult to

get south of exit 12 for a while. get south of exit 12 for a while. – The lack of a generator at other power-less facilities was The lack of a generator at other power-less facilities was

not the greatest problem – it was the lack of knowledge not the greatest problem – it was the lack of knowledge of city officials and power company employees that our of city officials and power company employees that our clinics needed priority service. clinics needed priority service.

Generators required at all facilities will not solve all the problems, contrary to much of discussion held in past 6 months. Island Dialysis was the only clinic with a generator, but a generator isn’t much help for a clinic with 5 foot of water that you can’t get back in to even begin cleaning for several weeks. By the time you get there, the whole place is eaten up from bottom to top with mud and mold. The lack of a generator at other power-less facilities was not the greatest problem; it was the lack of knowledge of city officials and power company employees that our clinics needed priority service. Dialysis is not considered life threatening. The Mainland Dialysis clinic (located at exit 10 on the Gulf Freeway) did not have a generator either, but since National Guard would not let folks go past exit 12 to the lower exits, it would not have helped us anyway.


Network, innovate, think way outside Network, innovate, think way outside the box.the box.– Get past the frustration over what you Get past the frustration over what you

don’t have and focus on what you do don’t have and focus on what you do have. have.

– Listen / learn – sometimes from Listen / learn – sometimes from unexpected sources.unexpected sources.

Network, Innovate and think Network, Innovate and think way outside the boxway outside the box

– In the Medical Center we could not get a large generator In the Medical Center we could not get a large generator immediately. We needed a huge generator to operate immediately. We needed a huge generator to operate Med-Center for treatment, which we could not get Med-Center for treatment, which we could not get immediately; however, we did have access to little ones. immediately; however, we did have access to little ones.

– Kevin Kelleher thought of setting up our stat lab Kevin Kelleher thought of setting up our stat lab equipment, a lamp and a fan on a small generator - sort of equipment, a lamp and a fan on a small generator - sort of running a little M*A*S*H lab so we could at least determine running a little M*A*S*H lab so we could at least determine if our patient’s potassium values were at a level that if our patient’s potassium values were at a level that necessitated emergency room carenecessitated emergency room care

– Natti & Virginia, LVNs, took manual blood pressures, and Natti & Virginia, LVNs, took manual blood pressures, and vitals signs of both patients and teammates. vitals signs of both patients and teammates.

– We sent teammates who showed up to help to neighboring We sent teammates who showed up to help to neighboring facilities who did have power – and insisted they carpool. facilities who did have power – and insisted they carpool.


Be hereBe here– Our patients need to have confidence Our patients need to have confidence

that we are committed to being here for that we are committed to being here for them. them.

– As dialysis caregivers we should be the As dialysis caregivers we should be the last person out (if we get out at all), the last person out (if we get out at all), the first person back. first person back.

Be HereBe Here Be here as dialysis professionals / caregivers. Be here as dialysis professionals / caregivers. Can you begin to imagine what it’s like to be a dialysis patient in what we Can you begin to imagine what it’s like to be a dialysis patient in what we

were (are) living post-Ike? were (are) living post-Ike? The vast majority of us are not on dialysis, and our lives sucked for at least The vast majority of us are not on dialysis, and our lives sucked for at least

weeks post-Ike – for some of us months – for some of us, it still does. weeks post-Ike – for some of us months – for some of us, it still does. What if we were living this life What if we were living this life and and dealing with being on dialysis? dealing with being on dialysis?

Our patients need to know that we are committed to being Our patients need to know that we are committed to being there for them. They are afraid and justifiably so. there for them. They are afraid and justifiably so.

As an aside here, too, for any docs in the audience, it meant a As an aside here, too, for any docs in the audience, it meant a tremendous deal to us that 2 of our doctors were consistently tremendous deal to us that 2 of our doctors were consistently there with us in the clinic – even on Monday all day when there with us in the clinic – even on Monday all day when there was no power. And then on Tuesday, when so many there was no power. And then on Tuesday, when so many people were arriving that hadn’t dialyzed since the prior people were arriving that hadn’t dialyzed since the prior Thursday (or maybe longer), it was supportive to the Thursday (or maybe longer), it was supportive to the teammates to have the MD’s there – for arrests, seizures, teammates to have the MD’s there – for arrests, seizures, hypoglycemic crises. So a big thanks to my docs. hypoglycemic crises. So a big thanks to my docs.

In an emergency, In an emergency, disaster, whatever, disaster, whatever, dialysis caregivers dialysis caregivers should be the last should be the last

person out and should person out and should be the first person back. be the first person back.


““Changing horses in midstream” is okay (or plans in Changing horses in midstream” is okay (or plans in mid-crisis).mid-crisis). – Although DaVita Med Center had been through several Although DaVita Med Center had been through several

instances of “drive-by” dialysis (Allison, post-Katrina, Rita), instances of “drive-by” dialysis (Allison, post-Katrina, Rita), the flow did not go so great on day one this time.the flow did not go so great on day one this time.

– We analyzed (tired as we were at day’s end) what was so We analyzed (tired as we were at day’s end) what was so different than prior times and Wednesday was smooth as different than prior times and Wednesday was smooth as silksilk. .

When MC finally opened on TTS, the lobby was chaos. Our teammates were there in full force endeavoring to help. I especially recall our social workers getting bottlenecked in one area trying to assist “guest” patients. On the second day, we “reserved” a special dialysis “bay” for guest patients and moved their “in-take” into the treatment area.


Catastrophes do lead to a higher morbidity / mortality rateCatastrophes do lead to a higher morbidity / mortality rate– We have called, checked on our patients, whether they stayed nearby or went to We have called, checked on our patients, whether they stayed nearby or went to

Oklahoma or New YorkOklahoma or New York– Patients that we expected to return to us, or at least expected to live for some Patients that we expected to return to us, or at least expected to live for some

time, well . . .time, well . . .– Pre IKE our death rate was “as expected” per Network reports. Galveston averaged Pre IKE our death rate was “as expected” per Network reports. Galveston averaged

1.5 deaths per month. One would expect that on September 11, 2008, when we 1.5 deaths per month. One would expect that on September 11, 2008, when we closed, until now, February 27, 2008, less than 6 months, we would have seen closed, until now, February 27, 2008, less than 6 months, we would have seen maybe 9 deaths.. maybe 9 deaths..

– We have had less than 50% percent of patients return for care at our sister facility We have had less than 50% percent of patients return for care at our sister facility 10 miles north of Galveston. Nonetheless, our social worker and administrative 10 miles north of Galveston. Nonetheless, our social worker and administrative assistant have endeavore3d to track patient status throughout the country. We have assistant have endeavore3d to track patient status throughout the country. We have lost far more than the expected 9 death maximum when we check with facilities lost far more than the expected 9 death maximum when we check with facilities throughout the state. Island has had 15 deathsthroughout the state. Island has had 15 deaths

– Of 90 patients – 40 are in LaMarque, 25 in Houston, 10 have relocated and 15 have Of 90 patients – 40 are in LaMarque, 25 in Houston, 10 have relocated and 15 have dieddied

– Mainland had 120 patients in the clinic with 19 stations, 4 shifts of Monday, Mainland had 120 patients in the clinic with 19 stations, 4 shifts of Monday, Wednesday and Friday and 3 on Tuesday, Thursday and Saturday. Wednesday and Friday and 3 on Tuesday, Thursday and Saturday.

– 31% are displaced and not sure what they are going to do. 31% are displaced and not sure what they are going to do. – 6 teammates have lost their homes. Many moved away because UTMB relocated. No 6 teammates have lost their homes. Many moved away because UTMB relocated. No

one was lost to follow up. one was lost to follow up.


Dialysis caregivers must “stay in touch” long-term – with each Dialysis caregivers must “stay in touch” long-term – with each other, with the docs, with the patients.other, with the docs, with the patients. – Because six months later, life is still not “normal” for many of our Because six months later, life is still not “normal” for many of our

patients (or for our docs and co-workers) – Where are they now? patients (or for our docs and co-workers) – Where are they now? – Island patients – on 9/11 = 90; Today: Island patients – on 9/11 = 90; Today:

40 at nearby sister clinic40 at nearby sister clinic 25 at farther-flung clinics in Houston metro area (future plans still “up 25 at farther-flung clinics in Houston metro area (future plans still “up

in the air”)in the air”) 10 permanently relocated – unable to return home10 permanently relocated – unable to return home 15 deceased15 deceased 0 “lost to follow up” 0 “lost to follow up”

– Mainland patients today = 120 (combination of former Island / Mainland patients today = 120 (combination of former Island / former, current Mainland): former, current Mainland):

37 (31%) are still displaced.37 (31%) are still displaced.– Teammates: Teammates:

20 teammates with Island pre-Ike 20 teammates with Island pre-Ike 6 “lost” – will not be returning6 “lost” – will not be returning 3 that remain still not “living at home.” 3 that remain still not “living at home.” 0 “lost to follow up” 0 “lost to follow up”

Surviving in the AftermathSurviving in the Aftermath

These pics were taking this week – February 23

Final LessonsFinal Lessons

Prepare, prepare, prepare – but be Prepare, prepare, prepare – but be prepared for that which you did not prepared for that which you did not prepare, because it will be there. prepare, because it will be there.

Never give up hope.Never give up hope.– Hope, as in the biblical definition – belief, Hope, as in the biblical definition – belief,

faith, that “good” will happenfaith, that “good” will happen Improvise, adapt, overcome: Improvise, adapt, overcome:

– The Marines ain’t got nothing on my The Marines ain’t got nothing on my dialysis teammates.dialysis teammates.

Hurricane Ike :

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