Kidney Failure And Disaster Preparedness

A paper I wrote a couple of years ago in Kidney Failure and Disasters.

4/4/2011
Disability and Disasters: The Case of Katrina, Kidney Failure and Disaster Preparation
By Gary Crethers

When Hurricane Katrina hit the Gulf coast in 2005 not only were the preparations inadequate but the community of persons with kidney failure had to scramble to find places to go to get their dialysis. Some 148 persons died who had kidney failure and 92 dialysis clinics closed down. In Louisiana alone 26 of 43 dialysis facilities were closed a month after the hurricane had passed (Kenney). “The lack of organization and miscommunication following Katrina prompted providers at all levels to ask just how prepared dialysis facilities are for future catastrophes,” says Dr. Kenney. “Working with the large dialysis organizations and the ESRD Networks, CSC located and tracked some 95 percent of the displaced patients within six weeks” (CSC). This is not a very good track record. End Stage Renal Disease or ESRD patients need to have treatment at least 3 times a week. If they miss more than a couple of treatments there can be serious to deadly health effects.
“Immediately after Hurricane Katrina in August 2005, the survival of more than 5,800 Gulf Coast kidney dialysis patients was threatened as the storm forced closure of 94 dialysis units. Within a month 148 of these patients had died” (Physorg.com). A recent study by the University of North Carolina at Chapel Hill, indicates that only about half of Kidney patients are ready for a disaster with at least a 3 day supply of water, food, medicine and supplies such as a battery powered Am/Fm Radio, flashlight, propane portable stove, medical records ready, and knew where to go for alternative treatment if their normal facility is out of service (Physorg.com).
Hospitals turned away patients after Katrina. “Many arrived at our emergency room doors but due to scarce resources, were turned away if they didn’t meet established screening criteria. Ironically, the summer heat may have reduced admissions, thanks to the excessive sweating it induced. Although diminished in patients with kidney disease, sweat glands will excrete at least a marginally effective amount of excess water, urea, ammonia, and electrolytes” (Ellis qtd.Yosipovitch et at, 1994).
Historically the emergency response to disasters related to kidney disease came after the 1988 Armenian earthquake. At that time there was no international emergency network and many people died due to inadequate dialysis and unprepared emergency personnel. A “Renal Disaster Relief Task Force” was created in 1989 by the “International Society of Nephrology”. This was divided into three sections, one, the Americas, two, Southeast Asia, and three, Europe, Southwest Asia and Africa. They have been active in disasters since and provided consultation for Katrina (Kenney).
The CMS or Center for Medicare & Medicaid Services, held a summit in January 2006 attended by over 100 providers to deal with situations like Katrina. The group formed became known as the KCERC or Kidney Community Emergency Response Coalition. Eight action groups were created and were in place by the 2006 hurricane season. The added a group to deal with pandemics at their 2007 conference (Kenney).
The CDC or Center for Disease Control has a natural disaster recovery fact sheet for patients with peritoneal dialysis. That is the type of dialysis that is performed by placing a sterile solution into the peritoneal cavity in the abdomen via a catheter that has been surgically implanted and flushing it daily either through a machine known as the cycler or manually with a gravity feed tube. The CDC recommends keeping the exit site (the place where the catheter emerges from the body), clean and dry. They recommend vinegar and water solution if it gets red or sore (CDC). They have no suggestions if the peritoneal cavity becomes infected which can happen from exposure to water that has not been sterilized, dust in the air, germs from other persons, dander from cats and dogs, and germs on the hands or dialysis devices. This is a problem as in an earthquake or other disaster there may be no access to sterile water or a means of sterilizing the water. The assumption is that the patient has on hand a supply of dialysis solution, and the equipment to apply it. This may not be the case.
A patient normally gets a supply of peritoneal solution once a month. This should last for a month with a couple of days overlap. The patient takes this liquid in plastic containers, attaches it with supplied sterile tubing to a machine called the cycler and spends 8-10 hours hooked up to this machine at night. The machine requires electricity and would not work in a disaster where the power was lost. The next option is to manually flush the peritoneal cavity with a gravity feed system. Patients normally have a supply on hand that will last several days. This has to be done once every 4-5 hours, approximately 4 times a day. If the patient is out of supplies then he or she has approximately 3 days in which to get access to a facility with supplies or that person will start to suffer toxic effects and could die.
There are clinics in most communities that perform hemodialysis. This is dialysis in which the blood is cleaned by a large machine that looks like the robot from the old TV series Lost In Space. The machine is hooked up to the body through a catheter called a fistula that is attached permanently to the veins normally in the arm. Persons on this type of dialysis go to a facility 3 times a week for 4 hours approximately where their blood is cleaned. This demands sterile water and power. During the Katrina hurricane 92 facilities were closed down and there was serious problem for those that were open, communicating with patients and doctors who could provide information about the particular needs when patients went to emergency clinics (Kenney). Apparently from the U. of North Carolina report, there are serious lapses in preparedness on the part of patients and this patient can state categorically that the facilities that trained him for dialysis had little or no training for emergency preparedness, and he lives in earthquake country. There is a serious need for emergency preparation especially in light of the disaster in Japan.
According to a WHO situation report of March 28, 2011, the Japanese are having trouble providing dialysis in the area affected by the earthquake, tsunami and nuclear reactor failure. This is two weeks after the event. Dialysis patients are dead because of a lack of care. Imagine this scenario in southern California. If there was an 8.0 quake, something the nuclear power plant in San Onofre is not prepared for, and there is a subsequent tsunami, striking North San Diego County, Orange County and South Los Angeles County, the result could be as catastrophic as in Japan.
One suggestion would be locating dialysis supply centers within walking distance, in every community. This could be a larger scale community center with supplies for all types of an emergency. It would be a major commitment but in a region as vulnerable as Southern California, setting up emergency supply locations, similar to fire stations but unmanned except in emergencies, and then with volunteers trained in first aid, and other emergency services assigned to each depot, would go a long way to solving the potential health emergency. The problems are real and if lifesaving is important in our culture then it is important that health services in a disaster be seen as something that needs to be planned for.
Lives are at stake and if people with serious chronic medical conditions, like kidney failure are to survive serious disasters, such as Katrina, where there was advance notice, or an earthquake, tsunami and nuclear disaster as just occurred in Japan, there must be serious planning down to the neighborhood level. It is not enough to simply tell people to stock up on supplies. Often supplies are only available at medical facilities, or at best the nearest fire station. Much more detailed and specific preparations need to be made and for the average citizen to take this seriously, there should be neighborhood disaster preparedness meetings, at least once a year. With a disaster warden, like an air raid warden assigned to each block.
What is required is something like what the Cubans do when preparing for a hurricane. This is from a report in MEDICC REVIEW:
Cuba’s evacuation procedures prioritize vulnerable populations, from pregnant women and the elderly to residents in low-lying villages; and importantly, transportation is provided for all those evacuated. During Wilma for instance, the entire seaside community of Playa Rosario on the southern coast of Havana Province had to be moved to safer ground, so scores of buses were brought in to evacuate the townspeople. Once the storm had blown through, only three of 113 homes were left standing, but no injuries or loss of life were reported (Gorry 7).

Below is a list of preparedness suggestions based on the example of Cuba, again from MEDICC Review quoting from an Oxfam report “Cuba Weathering the Storm Lessons in Risk Reduction from Cuba.”
The Cuban example, “ raises the distinct possibility that life-line structures (concrete, practical measures to save lives) might ultimately depend more on the intangibles of relationship, training, and education than on high cost procedures and resources, a possibility that holds great hope for other poor countries facing high risks of disaster.” Towards this end, the report outlines 12 factors called the “golden dozen” that Cuba manages successfully in it’s risk management program:
• social cohesion and solidarity (self-help and citizen-based social protection at the neighborhood level)
• trust between authorities and civil society
• political commitment to risk reduction
• good coordination, information-sharing, and cooperation among institutions involved in risk reduction
• attention to the most vulnerable population
• attention to lifeline structures (concrete procedures to save lives, evacuation plans, and so on)
• investment in human development
• an effective risk communication system and institutionalized historical memory of disasters, laws, regulations, and directives to support all of the above
• investments in economic development that explicitly take potential consequences for risk reduction or increase into account
• investment in social capital
• investment in institutional capital (e.g. capable, accountable, and transparent government institutions for mitigating disasters) (Qtd.in MEDCC 46).

In conclusion, if we are to save lives the social response has to be complete and serious. Certainly we should learn from Katrina and Japan and create adequate disaster programs. Lives are at stake. It is a question of values. If we value humanity as we claim, then we should establish institutions that support that claim, as the Cubans have done so remarkably with their much more limited resources. It seems strange that the wealthiest nation in the world, the United States, had such a pathetic response to Katrina and has in place such a threadbare emergency infrastructure. But this is symptomatic of a nation that spends more on military resources than almost the rest of the nations of the world combined. No wonder there are few resources available for emergencies and people with chronic illnesses are left to die, or fend for themselves as happened after Katrina. If we truly are in a time of limited resources, and that is a debatable point, then it is even more critical to be spending the resources available on human services and not on wasteful wars.
There is no reason why the United States of America, the richest country in the world cannot have a first class public health and emergency disaster preparedness system. What is lacking is the political will, but when disasters strike and people are dying, then the hands start wringing but even though action has been taken as I have indicated. It is not enough. The social willingness to talk to your neighbor and plan must be reintegrated into the fabric of daily life in America. Disasters often bring out the best in people, we should seek means to bring out the best before a disaster occurs. To co-opt a phrase, yes we can.
Notes
“DISASTER RECOVERY FACT SHEET Infection Control for Peritoneal Dialysis (PD) Patients After a Disaster.” CDC. (September 10, 2005). n. pag. Web. 27 March 2011.
Ellis, Kathy, J. “Article: Disaster readiness: lessons from Katrina (Clinical Consult)” Highbeam Research. Nephrology Nursing Journal. (January 1, 2007). n.pag. Web. 27 March 2011.
“ESRD Program: Continuity of Care for Dialysis Patients in the Aftermath of Katrina” CSC. (March 27, 2011). n. pag. Web. 27 March 2011.
Gorry, Conner. “Hurricane Wilma: Living To Tell The Tale.” MEDICC Review Health and Medical News of Cuba MEDICC Presents… In the Eye of the Storm: Disaster Management Lessons from Cuba (2005). 6-8. Web. 4 April, 2011.
Kenney, Robert, J. “Emergency Preparedness Concepts for Dialysis Facilities: Reawakened after Hurricane Katrina.” CJASN Clinical Journal of the American Society of Nephrology. (2007) 809-813. Web. 27 March 2011.
“Study: Most kidney dialysis patients not prepared for emergency evacuation.” Psyorg.com University of North Carolina at Chapel Hill. (June 3, 2010).n. pag. Web. March 27, 2011.
“Weathering the Storm: Lessons in Risk Reduction from Cuba.” MEDCC Review. (2005). 46.
Web. 4 April, 2011.
World Health Organization Western Pacific Region. “WHO SITREP NO 19 Japan Earthquake &
Tsunami Situation Report No. 19 28 March 2011.” (March 28, 2011). n. pag. Web. 28 March
2011.

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