The Trusted Source for Clinical Insights

JULY/AUGUST 2008

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Tornadoes lash a city, quakes collapse a bridge, floods burst a levee, explosionsderail a commuter train. Is there a doctor in the house?

Preparedness for the Ophthalmologist

hurricane lays waste to New Orleans, a bombblows up a London subway, a tsunami roils theIndian Ocean, a cyclone smashes Myanmar andearthquakes rumble through China.

Whether attributable to climate change, politi-cal terror or the increasing habitation of vulnera-

ble geography, disasters around the world are on the rise inboth frequency and severity.

On an almost daily basis a disaster, either natural or not,strikes somewhere in the world.1 In 2007, the Federal Emer-gency Management Agency declared more than 60 major dis-asters in the United States alone, ranging from hurricanes,tornadoes and earthquakes to floods, fires and winter storms.2

Although the statistics fluctuate from year to year, this figureis more than double the yearly average calculated since 1953.3

Complacency about making adequate preparations couldleave you and your patients vulnerable to serious disruptions,if not dangerous situations.

YOU NEED A PLAN “You have to anticipate almost everyeventuality. And you have to anticipate that what you expectmay not actually occur; something entirely different maydevelop and you have to be ready,” said William J. Rand, MD,medical director at the Rand Eye Institute in Deerfield Beach,Fla. “You also have to make the assumption that local or fed-

eral help is not going to be on the way for some time, and youcould be isolated for an extended period.”

REMEMBER YOUR MEDICAL EDUCATION? “The ophthalmol-ogist also has to be prepared in some circumstances tobecome a general surgeon again,” said Henry L. Trattler, MD,in private practice at the Center for Excellence in Eye Care inMiami. “After Hurricane Andrew, I repaired many lacerationson the arms, legs and faces of patients, in addition to treatingeye injuries. In disastersituations things maynot go according toplan, and you just dowhat you have to do.”

Amy G. Coburn,MD, clinical associateprofessor of ophthal-mology at Baylor College of Medicine in Houston, recalled anunexpected situation during which she helped care for morethan 3,000 Katrina evacuees in Houston shelters: “We treatedinfections, lacerations and fractures, yet we also found thatapproximately 80 percent of the patients had refractive prob-lems and important nonemergent issues, such as untreatedglaucoma, cataracts and retinopathy. Many people were func-tionally impaired because they had lost their glasses andcould not resume work or driving. We faced the problems ofhelping a displaced population more than a population withacute trauma.”By Leslie Burling-Phillips, Contributing Writer

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DISASTERFacing the Next

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1. COMMUNICATIONLand-based communications that require powerlines are not dependable in a large-scale disaster.So wireless technologies like cell phones andhandheld radios become critical. “Although it’sdifficult to plan for all the potential contingencies,good communication during a disaster is essential.In an emergency, the directives and needs canchange hundreds of times within an hour. Youmust be able to communicate with your suppliers,workers, physicians and others contributing to theresponse effort,” explained Dr. Coburn.

TAKE CARE OF MRS. JONES. Patients need to becommunicated with, too. “All of our patientsreceive their doctor’s home telephone number incase of an emergency. We do this year-round, notjust during hurricane season. When a storm watchis announced, we try to reach all of our patients tomake sure they have their medications. If someone

is elderly or infirm, we will send our vans on emer-gency distribution runs,” said Dr. Rand.

2. RESOURCES AND ASSETSMany of those who will be assessing and treatingpatients after a disaster will be working within ahospital setting where medical supplies are typi-cally stocked well in advance. “We stockpile a littlebit of everything—dilating drops, antibiotics, sur-gical trays, instruments needed for minor proce-dures—essentially everything that we use on anongoing basis. When a hurricane warning isannounced, supplies are moved to a protected areaso if we sustain substantial damage, we still haveaccess to enough supplies to last for several weeks.We also store our diagnostic equipment and com-puters in rooms that do not have windows,” saidErik van Kuijk, MD, PhD, professor of ophthal-mology, vice chairman of clinical services andmedical director of ophthalmology at the Univer-sity of Texas in Galveston.

DECIDE IF YOU WILL HELP. Some practices maychoose to be explicitly available in disasters. Desig-nated an emergency critical care facility, the RandEye Institute is located adjacent to Broward Gener-al Hospital at North Broward Medical Center.“This is one of the first places people will comeafter a disaster. Items to provide immediate firstaid are essential if you are going to be operationalimmediately after a disaster, which is our intention.Items such as gauze, Band-Aids, eye shields, eyepads and topical antibiotic ointments are avail-able. Our emergency crash cart includes a defibril-lator, IV tubing and solutions, catheters, first-linelife support medications, cardiovascular medica-tions and airway equipment, including oxygen,ambubags, oral airways, tracheal tubes and laryn-goscopes. And, although it may never be used, a

1. COMMUNICATION—maintainingopen lines both within an organizationand externally to access communityresources.

2. RESOURCES AND ASSETS—acquir-ing supplies, accessing community ser-vices, and understanding state and fed-eral programs that help provide medicalcare in crises.

3. SAFETY AND SECURITY—maintain-ing a safe and secure environment forstaff and patients.

4. STAFF RESPONSIBILITIES—adapt-

ing roles to meet unpredictabledemands for patient care.

5. UTILITIES MANAGEMENT—ensuringthe uninterrupted utilities during anemergency, including power, potablewater and ventilation.

6. PATIENT SUPPORT—defining clear,reasonable plans to address the needs of patients during extreme conditions.

Identifying all the potential localhazards will optimize response efforts.This article details the JCAHO’s pointsof preparation.

From December 1964 to January 2008 FEMArecorded 1,550 disasters in the United States that were serious enough to warrant a presidentialdisaster declaration. FEMA tracks disaster eventsby dividing the country into 10 distinct regions andnoting those counties struck most frequently withprogressively darker shading.

George Mills,senior engineer of the StandardsInterpretationGroup at the Joint Commissionon Accreditationof HealthcareOrganizations,outlined six areas to incorporate into an effectivedisaster plan:

SIX DEGREES OF PREPARATION

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disposable tracheotomy kit is stocked in our inven-tory,” Dr. Rand said.

GATHER YOUR FORCES. Partnering with localorganizations is an important asset that can makeresponse efforts more effective. The success of adisaster plan can hinge on establishing relation-ships and coordinating team members from avariety of specialties. For example, the HoustonEye Care Emergency Disaster Response Plan is acollaboration between Prevent Blindness Texas,the Houston Ophthalmological Society and theUniversity of Houston College of Optometry. Itintegrates the skills and assets from each of theseentities, as well as local partnerships, into a cohe-sive response plan designed to serve the eye careneeds of a population of more than 5,500,000 in10 counties after a disaster. “It’s imperative to planfor various scenarios and have regional partner-ships in case local capacity is overwhelmed. Pre-vent Blindness America is in the process of identi-fying all the fully equipped eye vans in the UnitedStates that could be called upon for regionalresponse. These are valuable resources that areuseful for providing onsite care in disasters thatdisrupt infrastructure,” said Dr. Coburn.

3. SAFETY AND SECURITY“One of our main priorities is the safety of ourstaff and patients,” said Dr. Trattler. “It has to bethe primary goal in the immediate short-termwhen a tropical storm or hurricane is looming off-shore. We generally start canceling patients’appointments about 36 hours before a hurricane ispredicted to make landfall. While it is rare for ourpostoperative patients to experience complica-tions, we advise them to continue their presentmedication and stay safe until the weatherimproves and we can schedule their follow-up

appointment. We also close the office early enoughso that those who will remain on duty in the hos-pital can prepare their homes and safely return.”

ENSURE PHYSICAL SAFETY. In an effort to reducestorm-related damage and keep the Rand EyeInstitute operational during hurricanes, manualshutters were installed to protect the doors andwindows from flying debris during a hurricane.The shutters are closed as soon as a watch is issuedfor the region, offering added protection for bothpatients and staff.

The aftermath of Hurricane Katrina broughtphysician responsibility for his or her patients tothe fore. “The plan that we previously had in placeat the University of Texas was to keep all of ourpatients in the hospital during a hurricane. Itbecame evident after Hurricane Katrina that theplan had to be changed. Keeping 800 patients inthe hospital without access to supplies for anextended period, along with the possibility of aninterruption in utilities, is just not practical.Before we had a chance to practice the plan, Hurri-cane Rita was in the Gulf of Mexico. Thanks tothorough planning, however, everyone was suc-cessfully evacuated from the hospital within a cou-ple of days,” recalled Dr. van Kuijk.

CONTROL INFECTION OUTBREAKS. A secondaryconsequence of a disaster is the rapid spread of

FEMA recordsindicate thatfloods and severestorms areresponsible formost disasters inthe United States.

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infectious disease. According to a 2007 article inthe American Journal of Infection Control, “infec-tion control issues in shelters, such as overcrowd-ing, food-borne illness, lack of restroom facilities,inadequate environmental cleaning proceduresand products, difficulty assessing disease out-breaks in shelters, an inability to isolate potentiallycontagious patients, and too few hand hygienesupplies can contribute to secondary disease trans-mission.”4 Maintaining an adequate supply ofgloves, masks and other protective wear as well assterile hand washes and rubs for staff members isvital for keeping everyone safe.

KEEP THOSE PREMIUMS PAID UP. “You also haveto plan for the safety of your practice,” said Dr.Trattler. “It is mandatory that everyone have busi-ness interruption insurance. Integral to the valueof the insurance is keeping a backup copy of yourpatients’ names and phone numbers and your reg-istration and financial information. It should bestored in a distant location that will be unharmed

by a local disaster. These items will be necessary toverify your assets should you need to file a claim,as well as restoring your practice.”

4. STAFF RESPONSIBILITIESAll staff members should know their preassignedrole in a disaster response, understand a clearlydefined chain of command and have a set ofchecklists to guide their actions. Assigned rolescan prevent redundancy of responsibilities as wellas minimize confusion. Disaster drills and mockscenarios should be rehearsed to test both the planand the staff for various contingencies. “There arethree floors in our building: the clinic, the clinicaloffices and the research center. Each floor has aplan that outlines where supplies and diagnosticequipment should be moved during a disaster andwho is in charge of moving it. The technical staffprepares the clinic. The secretaries prepare theoffices on the second floor and the study monitorsafeguards the study center. The plan designateswho is essential for carrying out the plan and whattheir duties are so there is no confusion during anactual event,” said Dr. van Kuijk.

GET READY TO TRIAGE. “Training and prepara-tion are essential to remain effective during majorcatastrophic events,” said Michael S. Baker, MD. Infact, for an article in Military Medicine, Dr. Bakerwrites, “Disaster triage and crisis managementrepresent a tactical art that incorporates clinicalskills, didactic information, communication abili-ty, leadership and decision making. Planning,rehearsing and exercising various scenariosencourage the flexibility, adaptability and innova-tion required in disaster settings. These skills can

For all of their lethal power, hurricanes and earth-quakes may be trumped by biologic, chemical andradiation disasters. Yersinia pestis, for example,the cause of bubonic plague and pneumonicplague, may have killed as many as 75 million peo-ple in Europe and Asia during what has been calledthe “calamitous” 14th century. That epidemic wasfollowed by decades of monumental social andeconomic unrest. And some observers believeYersinia could visit (or be visited upon us) again.

Yersinia, like Brucella melitensis or Bacillusanthracis, would hardly be described as a commonpresentation to most ophthalmologists. But theCDC is anticipating every possibility, including thatof bioterrorists unleashing infectious agents on a

massive scale. Accordingly, the CDC maintainsexhaustive Web pages designed to give healthworkers guidance for unprecedented situations.

Epidemics constitute just one of five primarydisaster categories addressed by the CDC, all ofwhich could demand the skills of ophthalmologists:

Epidemic infections, including anthrax, botu-lism, brucellosis (or undulant fever), cholera,plague (Yersinia), smallpox, tularemia, typhoidfever and the various hemorrhagic fevers.

Chemical exposures to biotoxins like brevetoxinand ricin, blistering agents such as nitrogen or sul-fur mustard, blood agents like cyanide, causticssuch as hydrofluoric acid, choking agents like chlo-rine and phosphorus, incapacitating agents like

PLAGUE, POISON OR PROTONS? MANAGING THE NEXT DISASTER

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bring order to the chaos of overwhelming disasterevents.”5 Dr. Baker is chairman of surgery at theJohn Muir Medical Center in Walnut Creek, Calif.

5. UTILITIES MANAGEMENTQuite often, electrical power and potable water areunavailable after a disaster. Earthquakes can breakgas and water lines, while hurricanes and torna-does can down power lines and contaminate waterby the introduction of fecal material and chemicals.

DUMP DEAD BATTERIES. “We review our inven-tory of emergency items such as flashlights, lanternsand batteries annually,” said Dr. Rand. “Our surgi-cal pavilion has an emergency propane generator.To ensure that it functioning properly, we operateit on full-load monthly for 30 minutes, semiannu-ally for two hours, and yearly for four hours toensure it will work if we lose electric service. Onecontingency that we did not plan for two yearsago, however, was determining how we were goingto get propane delivered when the diesel truckscould not obtain any fuel. Our generator ran outof propane after five days, and we could only wait.”

6. PATIENT SURVIVAL AND SUPPORTLast but, obviously, not least is the welfare ofpatients. The eye is particularly susceptible toinjury during disasters and can be penetrated byflying debris, damaged by blunt impacts and trau-matized by airborne smoke and toxins. From lac-erations, foreign bodies and burns to orbital frac-tures and perforating injuries, eye injuries arecommon in many disasters. Management strategies,however, are improving. Referring to trauma

expertise gathered by U.S. military experience inIraq, Dr. Coburn said, “It is providing valuablelessons in eye care under difficult circumstances,including triage and management of eye and mul-tiple systemic injuries.”

CARE FOR THE CAREGIVER. It is often the rescueworkers who suffer ocular injuries after a disaster.These may be sustained during the initial rescueefforts or during the cleanup afterward. Injuriescan include irritation from smoke and airborneparticulates, and lacerations and puncture woundsfrom falling or shifting debris.

YOU CAN’T CHOOSE YOUR DISASTERThe type, time and target of a disaster are rarelypossible to predict. “The primary objective of dis-aster planning and training is to ensure an ade-quate, competent and flexible response that willsatisfy the acute needs resulting from any disasterwhile still meeting the baseline demands of the

aerosolized opioids, anticoagulants like warfarin,metallic poisons such as arsenic and thallium,nerve agents such as sarin and tabun, solvents likebenzene, irritants like chloroacetophenone, toxicalcohols such as methanol or ethylene glycol, andnausea inducers like adamsite.

Radiation emergencies, including nuclear deto-nations, acute radiation syndrome, the effects ofdirty bombs and contamination from radioactiveisotopes (americium-241, cesium-137, cobalt-60,iodine-131, iridium-192, plutonium, polonium-210, strontium-90, uranium-235 and uranium-238).

Mass casualties, such as those from burns(chemical, electrical and explosive), blast trauma(tympanic membrane perforation, blast-wave pul-monary and abdominal injuries), projectile and

fragmentation injuries (including penetrating globewounds), crush trauma (including reperfusion syn-drome), and fractures and traumatic amputations.

Natural disasters, including well-known cata-strophic earth, water and wind events.

For full details, visitwww.emergency.cdc.gov.Be sure to click on the“more” option for the mostdetailed lists. The Ameri-can Medical Associationalso maintains thoroughlydetailed protocols forphysicians facing large-scale emergencies (see“Disaster Resources”).

—Denny Smith

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affected community,” said Dr. Coburn. “An experienced oph-thalmology-led eye team with appropriate instruments andsupplies is needed to effectively examine, triage and treat eyeinjuries during disasters.” Forewarned and forearmed, EyeM.D.s can help pull their patients and communities throughthe next big one.

1 Goolsby, C. A et al. Disaster Planning (2006). www.emedicine.com/

emerg/topic718.htm.

2 FEMA Federal Disaster Declarations (2007). www.fema.gov/news/

disasters.fema?year=2007.

3 FEMA Federal Disaster Declarations by year or state. www.fema.gov/

news/disaster_totals_annual.fema.

4 Rebmann, T. et al. Am J Infect Control 2007;35(6):374–381.

5 Baker, M. S. et al. Mil Med 2007;172(3):232–236.

The National Trauma Data Bank is designed to inform themedical community, the public and policy makers aboutissues that characterize the current state of emergency care.www.facs.org/trauma/ntdb.html.

The Wireless Information System for Emergency Respondersprovides a range of information on hazardous substances,including substance identification support, physical charac-teristics, human health information, and containment andsuppression advice. www.wiser.nlm.nih.gov.

The American Medical Association Management of PublicHealth Emergencies (also available on a free CD-ROM) pro-vides diagnostic and treatment protocols for a wide variety ofcrises. www.ama-assn.org/ama/pub/category/18200.html.

The Department of Health and Human Services providesinformation and resources to assist disaster responders.www.hhs.gov/disasters/discussion/responders/index.html.

DISASTER RESOURCES

AMY G. COBURN, MD Associate pro-fessor of ophthalmology at BaylorCollege of Medicine in Houston.

FREDERICUS VAN KUIJK, MD, PHDAssociate professor of ophthalmolo-gy, vice chairman of clinical ser-vices and medical director of vitre-oretinal diseases at the Universityof Texas in Galveston.

GEORGE MILLS Senior engineer of the StandardsInterpretation Group at the Joint Commission onAccreditation of Healthcare Organizations, basedin Oakbrook Terrace, Ill.

WILLIAM J. RAND, MD Medical director and chiefsurgeon of the Rand Eye Institute, a private practice in Deer-field Beach, Fla.

HENRY L. TRATTLER, MD In private practice at the Center forExcellence in Eye Care in Miami.

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