20 When disaster strikes: managing chaos and instilling lessons for future events
Jeanine Abrons, PharmD, MS
Jennifer G. Smith, PharmD, BCPS
Topic Area
Emergency preparedness
Learning Objectives
At the end of this case, students will be able to:
- Describe methods to accelerate the resumption of normal operations following the occurrence of a natural disaster or emergency.
- Identify the potential hazards and major impacts of extreme weather events.
- Describe critical resources needed by pharmacists and considerations related to these resources to ensure access to medications and services during and following natural disasters.
- Formulate an emergency preparedness or action plan.
Introduction
Natural disasters such as hurricanes, tornadoes and flooding are usually unpredictable. These events typically occur suddenly and with little or no warning and can cause widespread chaos. In recent years, a variety of types of natural disasters have occurred in the United States and around the world. Natural disasters have both short-term and long-term consequences and may result in severe infrastructural damage, personal injury, and public health threats. This can lead to an increased need for pre-emergency planning and post-disaster patient care. Pharmacists are recognized – with increasing responsibility – as important members of disaster preparedness planning and response teams.1-3
Following natural disasters, healthcare providers play a key role in recovery by providing patient care and helping to ensure access. However, during these times, pharmacists and other health providers also may be called upon for more nontraditional roles. In 2003, the American Society of Health-System Pharmacists (ASHP) released a statement outlining roles for pharmacists in emergency preparedness and provided advice tailored to specific groups (e.g., pharmacy directors, pharmacists, administrators).4 The statement included commitments made by ASHP to assist in communication and dissemination of information related to emergency preparedness through their member network.
Potential roles identified for pharmacists in emergency preparedness and disaster management in other literature include medication provision and prevention of communicable diseases.5 For example, pharmacists may be asked to provide medications and/or disease state education for rare infections or complications from exposure to contaminated flood water. Additionally, other literature identified that mass immunization campaigns might need to be initiated and patient needs can quickly overwhelm facilities that are working with limited resources. Pharmacists trained in the provision of immunizations may help to address these challenges.1-6 Finally, management of chronic disease states also was cited as becoming more challenging, with interrupted supplies of common medications and potentially dangerous or difficult living situations that can exacerbate chronic diseases such as diabetes or hypertension.7 Pharmacist awareness of alternative supply chains may help to alleviate these challenges and ensure continuity of management of chronic diseases.
While the roles of pharmacists are expanded during a disaster, it is important to remain aware of and act within the laws, rules, and regulations. Following a severely damaging natural disaster, a state of emergency may be declared, which can lead to changes in rules and regulations that impact pharmacists and pharmacy operations. Specific changes vary among states, so it is important that pharmacists investigate their practice location.8,9 Since natural disasters usually occur with little or no warning, development of comprehensive disaster preparedness plans tailored to individual pharmacies is important.10 Pharmacists at all levels can and should be involved in developing and updating these plans on a regular basis.1 Many resources are available for pharmacies and pharmacists to develop and refine an emergency response and disaster preparedness plan to allow for a more efficient and timely response when needed.
Case
Scenario
CC: “I lost all of my medications when I had to evacuate.”
HPI: DS is a 42-year-old male (71 in, 90.9 kg). His house was flooded in the storm and badly damaged. He is currently staying at a nearby emergency shelter until arrangements for longer term housing can be made with his insurer. He has a minor cut on his leg from an injury sustained while helping a neighbor with cleanup of his flooded home. He states that the cut hurts. Upon examination, you notice the wound is warm to the touch and is red and swollen. He also has experienced some shortness of breath and difficulty breathing during cleanup.
PMH: T2DM (controlled by diet); hypertension; asthma
FH:
- Father: heart attack at age 70
- Mother: history of DM
SH: Limited information about the patient’s social history has been provided. However, the patient states that he currently has limited access to shelter and basic medical resources as a result of his displacement following the hurricane.
Surgical history: Non-remarkable
Vitals:
- BP 149/85 mmHg
- HR 88 bpm
- RR 21/min
- Temperature 99.1 ºF
- Pulse oximetry 92% on RA
Labs: Unable to access. The pharmacy and the local health system computers were impacted and are not accessible. Patient is also unable to recall specific values and states he had a paper with some of his valuables, but this was lost in the storm.
Medications:
- Albuterol – Inhale 2 puffs every 6 hours as needed for SOB/wheezing for asthma
- Lisinopril/HCTZ 20/12.5 mg – Take 1 tablet by mouth daily for hypertension
- Advair HFA 115-21 mcg – Inhale 2 puffs 2 times daily for asthma
- Ibuprofen 200 mg – Take 1 tablet by mouth every 4 hours as needed for pain from leg injury/muscle soreness from clean up following natural disaster
Allergies: NKDA
Vaccinations: Patient is unable to recall
SDH: Patient states that he has medical and prescription insurance but cannot locate or provide his insurance card or identification. He is unable to recall a specific company that provides his health insurance but can tell you that he uses a local smaller chain pharmacy typically for accessing pharmacy services.
Additional context: A temporary clinic has been set up by employees of a local ambulatory care clinic to attempt to care for patients affected by the storm. The clinic location where the employees typically are employed was badly damaged in the storm and is not able to be used for normal operations for quite some time. The attached clinic pharmacy was also affected and is currently inaccessible; however, some supplies have been salvaged for urgent use. The clinic’s medical and pharmacy records are currently inaccessible. Pharmacies located out of state but nearby have offered assistance with obtaining medication stock but need clarification of what supplies are most needed and a plan for transport of the supplies to the affected areas.
Case Questions
1. What documentation needs to be done prior to dispensing medications to patients or providing medications to other healthcare providers involved in disaster management care? How and when should this documentation be completed to provide the patient with medications?
2. How can you determine or verify if a patient has a legitimate prescription when records are not accessible?
3. What pharmacy preparations could be undertaken in advance to ensure your ability to safely and appropriately respond in an extreme weather event?
4. What acute health risks does this patient have?
5. How can you help educate and prepare the community and the patient for response and recovery?
Author Commentary
Although this case focuses on a specific situation of severe flooding, many of the issues and concepts discussed can be applied in emergency situations arising from other natural disasters. As discussed above, the period following a severe natural disaster may be chaotic and contribute to worsening of a patient’s chronic disease states as well as introducing new disease concerns. Pharmacists can offer practical and creative solutions for health-related problems, especially in situations where the usual healthcare resources are limited or unavailable.
Many educational resources are available for pharmacists with an interest in disaster preparedness and management and are included in the references listed below. Participation in education and preparedness activities is key to effectiveness if faced with the challenge of providing care following a natural disaster. It is strongly encouraged that pharmacists seek out their local emergency management organizations to ensure that pharmacy interests are represented when plans are developed. Pharmacists also are reminded to contact state pharmacy boards for specific guidance and considerations pertaining to each state.
Patient Approaches and Opportunities
When counseling patients, it is important to consider the effect of changes in living conditions (emergency shelter, traveling to stay with friends/family, etc.) on the management of chronic disease states. Aside from the added stress of the disaster situation, patients may be unable to adhere to complicated medication schedules; may be unable to eat regularly scheduled, nutritious or well-balanced meals; may have more limited mobility or other functional losses due to loss of medical equipment such as walkers and important personal items like eye glasses, hearing aids, or false teeth; or decreased accessible shower/restrooms. Plans for patients may have to include managing the acute needs (e.g., 72 hours following natural disaster) and guidance on longer planning/response.
Connecting patients with mental health resources following a natural disaster may be important. Education provided to the public and providers can assist with recognition and awareness of mental health needs in times of crisis/recovery. Depending on the type of disaster, patients may experience anxiety and/or depression and feel overwhelmed as they begin the recovery process. Responders and volunteers can also be affected, especially in the acute phase of recovery when the need is greatest and volunteers may be working long hours in high stress situations and austere conditions. It is critical to watch for signs and symptoms related to depression, stress, and post-traumatic stress disorder. Depending on the culture and understanding of mental health, patients may not directly recognize what they are experiencing as stress, depression, or trauma.
Natural disasters happen all over the world. Preparedness is critical wherever you might be.
Important Resources
Related chapters of interest:
- More than just diet and exercise: social determinants of health and well-being
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Anticipating anthrax and other bioterrorism threats
- Immunizing during a pandemic: considerations for COVID-19 vaccinations
- Laying the foundation for public health priorities: Healthy People 2030
External resources:
- https://www.ready.gov/ or https://www.listo.gov/es (Spanish language version)
- These websites are part of a national public service campaign to provide education and resources for all Americans to “prepare for, respond to, and mitigate emergencies, including natural and man-made disasters.”
- Guidance and objectives for a business or workplace preparedness plan are available at https://www.ready.gov/business
- https://www.ccohs.ca/oshanswers/hsprograms/planning.html
- Canadian Center for Occupational Health and Safety (CCOHS) provides easy-to-read fact sheets on a variety of topics, including emergency planning
- https://www.phe.gov/Preparedness/responders/pages/default.aspx
- US Department of Health and Hospitals (DHH) Public Health Emergency Page for Responders, Clinicians and Practitioners
- Includes wide variety of relevant information including links to disaster response organizations, responder mental health and safety, and responder preparedness and planning for specific types of disasters (e.g., bioterrorism, Ebola, etc.)
- https://www.cdc.gov/phpr/index.htm
- CDC Office of Public Health Preparedness and Response is a comprehensive site with a broad range of information on emergency preparedness, potential bioterrorism agents and toxins, the Strategic National Stockpile program, and educational resources for both the public and healthcare providers
- https://www.healthcareready.org/rxopen
- Searchable map resource that provides details of open pharmacies in areas affected by disaster
- https://training.fema.gov/is
- FEMA provides many independent study courses online (free of charge) to learn more about disaster preparedness and response
- Facebook check in: https://www.facebook.com/about/crisisresponse/
- In a time of a natural disaster, communication may be limited and batteries to cell phones or other devices may not be fully charged. Establishing a plan of how to check in or using resources that remove the need to contact a larger number of individuals can help establish peace of mind for loved ones.
- The World Health Organization and the Pan American Health Organization: https://www.paho.org/en
- These organizations provide a variety of natural disaster surveillance and resources
References
- Pincock LL, Montello MJ, Taosky MJ, Pierce WF, Edwards CW. Pharmacist Readiness Roles for Emergency Preparedness. Am J Health Syst Pharm. 2011;68(7):620-623.
- Alkhalili M, Ma J, Grenier S. Defining roles for pharmacy personnel in disaster response and emergency preparedness. Disaster Med Public Health Prep. 2017;11(4):496-504.
- Menighan TE. Pharmacists have major role in emergency response. Pharmacy Today. 2016;22(8):8.
- American Society of Health System Pharmacists. ASHP Statement on the Role of Health-System Pharmacists in Emergency Preparedness. Am J Health-Syst Pharm. 2003;60:1993-5. https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/role-of-health-system-pharmacists-in-emergency-preparedness.ashx. Accessed February 14, 2019.
- Pesenti F, Blanc AL, Mühlebach S, Bonnabry P, Widmer N. Role of hospital pharmacy in response to emergencies or disasters. In the 75th International Pharmaceutical Federation (FIP) Congress of Pharmacy and Pharmaceutical Sciences 2015.
- Moore AF, Kenworthy L. Disaster relief: a look into the pharmacist’s role. N C Med J. 2017;78(3):195-7.
- Arrieta MI, Foreman RD, Crook ED, Icenogle ML. Insuring continuity of care for chronic disease patients after a disaster: key preparedness elements. Am J Med Sci. 2008;336(2):128-33.
- Vaillancourt, R. Legislations to support the pharmacist’s role in natural disasters. Prehosp Disaster Med. 2015;32(S1):S159.
- Hogue MD, Hogue HB, Lander RD, Avent K, Fleenor M. The nontraditional role of pharmacists after hurricane Katrina: process description and lessons learned. Public Health Rep. 2009;124(2):217-23.
- Coppock K. Preparing for Medication Safety in a Natural Disaster. Pharmacy Times. September 12, 2018. Available at: https://www.pharmacytimes.com/news/preparing-for-medication-safety-accessibility-during-a-natural-disaster. Accessed February 14, 2019.
Glossary and Abbreviations