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American Diabetes Association DOC News
July 2006 vol. 3 no. 7 16-17
Availability of drugs and information critical
The Gulf Coast region had high rates of diabetes, hypertension, and obesity, particularly in rural areas. Then Hurricane Katrina struck last August, knocking out power and crippling other utilities. Cell phones and the Internet were rendered useless. Health care facilities as far as 200 miles from the coast were shut down.
"When the electricity went out, the only way we had to communicate was by landline phones," says Linda McMullan, general counsel for the Mississippi State Medical Association.
There was almost no way for people who evacuated to reach their physicians to obtain needed medications. People with diabetes who require insulin suffered because there was no electricity to keep their insulin refrigerated, McMullan notes.
"Layer on top of that the fact that we had no fuel," she says. That meant patients with renal disease missed their regular appointments and pharmaceutical suppliers could not make deliveries.
As in other affected areas, Mississippi caregivers went out of their way to tend to high-risk patient populations in the aftermath of Katrina. "Most of those patients we tried to get someplace else," McMullan says.
PREVENTING A MEDICATION SCRAMBLE
Less than a month after Katrina, Hurricane Rita exacerbated the health predicament in the region. For both hurricanes, a little extra preparation would have forestalled the need to scramble for medications, according to McMullan. "Keep drugs in a place where you can get them," she advises patients and health care providers alike. This could mean making advance arrangements with a pharmacy or even throwing a bag of medications into the trunk of a car when evacuating.
Insulin and other perishable medications should be stored not only in locations that are accessible in a crisis, but preferably in a place with backup power. If necessary, patients could purchase a portable generator and a small refrigerator and load them into a vehicle ahead of an evacuation, or at least fill an insulated cooler with plenty of ice.
It is okay to switch insulins and branded medicines to generics, as it is better to have some medicines than none, according to Vivian Fonseca, MD, chief of endocrinology at Tulane University Health Sciences Center in New Orleans and chair of the American Diabetes Association's (ADA's) Disaster Response Task Force. Specific information about how long it is safe to keep insulin outside a refrigerator varies according to the product and is available on the Food and Drug Administration, Eli Lily, Sanofi-Aventis, and Novo Nordisk Web sites, Fonseca says.
Public health officials at all levels of government are gathering supplies of vaccines, drugs, and other medical provisions for use in the event of almost any type of public health emergency (terrorist attack, flu outbreak, earthquake, etc.), notes Robert Pallay, MD, chair of the New Jersey Public Health Council. The Centers for Disease Control and Prevention's (CDC's) program is called the Strategic National Stockpile. "The federal stockpiles are very significant and they are real," Pallay says.
Typically during an emergency, the CDC will distribute stockpiled medications through state and local health departments and via private-sector relief organizations such as the American Red Cross.
KEEPING PATIENTS IN TOUCH
James Holly, MD, is chief executive officer of Southeast Texas Medical Associates (SETMA), which has 33 clinicians and 3 clinics in Beaumont, 80 miles east of Houston. When the next major hurricane approaches the Texas coast, Holly says his practice will set up a toll-free hotline for patients to call in about missed appointments and instructions for obtaining medication refills or emergency supplies and will ask radio stations to broadcast the number as a public service. For Rita, SETMA had a number for practice employees to call to report on their status and learn when they needed to come back to work.
"Next time it will be for patients," Holly promises. "There's no shame in not knowing the first time. The shame is in not learning."
Smaller practices might not have the wherewithal to operate a hotline, but Holly suggests larger providers in a community can offer to host the service, while independent physicians simply can make themselves available on the phone to assist their own patients.
ENSURING PHYSICIANS' ACCESS TO PATIENT RECORDS
Even so, doctors are limited in what they can do over the telephone if they can't get to patient records. For example, Texas law requires physicians to have a written, patient-specific treatment plan before a pharmacy can dispense or refill prescriptions for narcotics or other potentially addictive medications. If a physician cannot access the plan, the patient might not be able to get the proper meds.
SETMA has an advantage over most other medical groups in that it has full-fledged electronic medical records. After Rita, SETMA physicians had complete access to patient records-including treatment plans for those on controlled substances-whenever pharmacists called one of them at home to fill a prescription for an evacuee.
"Not only were we prepared for Rita, we are prepared for any eventuality," Holly says. SETMA backs up its computer systems six times a day. Every night, the practice makes three copies of the backup and sends each tape to a different location. All information is encrypted so it's essentially useless to a burglar.
Holly notes that the practice could be back to full capacity within 7 days of a catastrophe. "If the building burned down, the bank has already approved a line of credit," he says. "We could call Dell and they could drop-ship us a server."
A longtime proponent of electronic medical records, Holly says every widespread health crisis underscores the need for a national health information network, including the Continuity of Care Record (CCR), a standard for the minimum information necessary when a patient moves between care settings. The CCR does not have to be electronic; it can be as simple as a piece of paper so any clinician can refer to it, no matter where the patient ends up.
Whether the format is standardized or not, patients should be encouraged to carry or store online a personal health record or even a basic medical snapshot listing chronic conditions, medication history, and allergies.
COMMUNICATING THE NEED TO PREPARE
Helping patients to become as knowledgeable as possible about their illnesses and health needs also helps them prepare. This includes encouraging them to take responsibility for having enough medication on hand if they can't get to a pharmacy, says Pallay, an American Academy of Family Physicians board member.
"Inventory control is the same whether you're a business or an individual," he says. "The education component is a major part of what the physician needs to be doing."
Many people have emergency provisions stashed at home, but those with diabetes need to take extra precautions whether they're at home or work or find themselves unexpectedly dislocated. The ADA Web site provides detailed information about what emergency supplies for diabetes should include (see sidebar, "Diabetes Emergency Supply Kit").
ADA's Disaster Response Task Force submits recommendations to the ADA board regarding the association's role in emergency preparedness for the diabetes community. The task force plans to develop definitive guidelines that will be published in ADA standards of care and core educational curricula.
In the meantime, other important emergency information available from ADA's Web site and National Call Center instructs patients with diabetes to know that avoiding hyperglycemia, which can lead to dehydration, is of the highest priority. They need to try to obtain fluids such as clean water or low-calorie drinks as soon as possible.
If they have to evacuate, ADA advises people with diabetes to identify themselves to a health care provider or to a member of the Red Cross or other relief organization when arriving at a shelter or other temporary location to make sure they are evaluated appropriately.
Diabetes Emergency Supply Kit
By taking a few minutes today to gather supplies and discuss their diabetes with family, friends, and coworkers, patients can make a difference in maintaining blood glucose control and staying healthy under stressful circumstances. The American Diabetes Association recommends the following tips for emergency preparedness:
- Store at least one week's worth of diabetes supplies in an easy-to-identify container in a location that is convenient to get to in an emergency. The supplies might include oral medication, insulin, insulin delivery supplies, lancets, extra batteries for a meter and/or pump, and a quick-acting source of glucose. Patients also may want to have an extra glucagon emergency kit. Many people with diabetes take medicines for high blood pressure and cholesterol as well.
- Your emergency supply kit should contain a list of emergency contacts, and parents of a child with diabetes should keep copies of physician's orders that may be on file with the child's school or day care provider.
- When away from home, patients should consider discussing their diabetes with those around them and noting where their emergency supply kit is stored.
- As always, patients should consider wearing medical identification that will enable colleagues, school staff members, or emergency medical personnel to identify and address their medical needs.
- Parents of school-age children should ask their child's school to identify staff members who will assist the child in an emergency evacuation.
Source: ADA, www.diabetes.org/type-2-diabetes/travel/emergency-tips.jsp.
- This is part two of a two-part series on how primary care practitioners can prepare to provide for their patients during a natural or manmade disaster. Part one (DOC News, June 2006) looked at protecting a practice in order to continue caring for patients. This month we explore how providers can help patients better plan to take care of themselves when disaster strikes.
- "The Disaster Preparedness Guide for People With Diabetes," published by the American Diabetes Association. Order online at store.diabetes.org.
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