Hurricane-Hit Practice Offers Lessons in Disaster Planning

In a recent conversation with the ONCOLOGY Nurse Edition, Ms. Donohue discussed the short- and long-term effects of these disasters on patient care, and offered recommendations for emergency preparation in any setting.

ONC: What were the immediate effects of Hurricane Katrina in your area?

Donohue: We're 2 hours outside New Orleans, but most people here have friends or family there. Most people had evacuees staying at their homes, but we had to go to work and go on with our lives. Almost immediately we started getting calls from patients who had left New Orleans and didn't know where to get treatment. All the oncologists in the area began to see new patients and try to help—not just seeing them at their offices but going to the evacuation centers and trying to get prescriptions written and filled.

The biggest issue with the patients from Katrina is that they arrived with no records: no record of their medication, their treatment regimen, or even necessarily their diagnosis. In some cases they could tell us they had lung cancer, but they didn't know if it was primary or a metastasis. Most patients had been given that information but had left it behind.

The good news was that the American Society of Clinical Oncology stepped in and set up a website to help people reach doctors who had also evacuated, but that took time. Cell phones didn't work. We did the best we could. We tried to keep to protocols for clinical trials, but the priority was to keep patients safe.

By the time Hurricane Rita hit we had another influx of patients from Lake Charles, which has several oncologists; fortunately, almost all of the evacuees had records. The physicians learned from the first hurricane and patients came prepared.

ONC: What did oncology teams have to do to take in patients with no records?

Donohue: You need to take a good history and try to figure out the diagnosis and kind of treatment they have had. Some patients had to be retested to determine the correct diagnosis and/or stage. One patient could only tell us that she had colon cancer and that it had been several months since her diagnosis. We couldn't figure out what kind of chemotherapy she had had until she mentioned that her previous nurse had told her not to put her hands in cold water. We figured out that she was on oxaliplatin. Any cues we could find would help, but even then we couldn't always determine how many courses of treatment the patient had completed.

Eventually we did get records for most patients or created new ones, but many hospitals and cancer centers had records on paper files only, and those were destroyed, or had them computerized but not stored off-site.

ONC: What were the logistic challenges of providing treatment?

Donohue: Because we're not a major cancer center, we usually order our medications weekly. Ground transport wasn't an option for getting new medication, so when necessary we borrowed from the local hospital with the agreement that we would replace the dose when we were able to restock.

We also acted as primary care providers for patients, dealing with their health issues in the short term. Eventually we connected them with area internists for their noncancer care, but at first we dealt with diabetes, heart disease, and anything else that came up in their history.

ONC: Did the hurricanes present problems in terms of reimbursement for care?

Donohue: All the payers were very cooperative, although it took a while to locate the ones whose offices were in New Orleans and had been evacuated. In general, people were accommodating and made exceptions. For next time, we will keep closer track of payers' leniency periods and make sure before starting treatment that it has not expired. Fortunately, none of our patients lost insurance coverage during the aftermath of the hurricane.

ONC: What were the effects of the hurricanes and displacement for this patient group?

Donohue: The majority of people have stayed here because the New Orleans infrastructure just wasn't a good place to be for people who weren't healthy. No one knew what was in the air, water, or ground after the hurricane. We were vaccinating healthy people who wanted to go check on their homes after the hurricane, but it just wasn't safe for the immune-compromised cancer patients because no one knew what contamination there might be.

Patients were simply shell-shocked over what had happened, and they had to deal with this on top of cancer. With Hurricane Rita, several patients lost their homes completely, so they were getting cancer treatment and living in a FEMA [Federal Emergency Management Agency] trailer. Some still are. It's almost overwhelming to try to stay focused on one's health when there is so much else going on.

We saw most patients within 2 weeks of the hurricane, because they knew they needed to find an oncologist and were referred by their doctor or hospital or a local relative. If they had finished treatment but needed follow-up care, it took sometimes 6 months before it would become a priority compared with everything else they needed to do. We'll never know how many patients dropped out of follow-up care as a result of the hurricanes. It takes a lot of discipline to stay focused on cancer care when you're worried about what you're going to eat and where you're going to stay.

ONC: How has that translated into supportive care for the oncology team?

Donohue: Depression is a big issue, but patients coming to the clinic had someone to talk with. They could talk to the nurses; the treatment room almost turned into a big group therapy session with everyone talking about what was going on. It helped them feel less isolated.

We found that just talking to patients was a huge help. My advice for nurses in similar situations would be to allow patients to talk about their fears, their anger, or depression. Focus on them and make them feel important. Offer as much personal counseling as you can give. Be compassionate, but take the lead in getting them back into a care plan.

ONC: What about self-care for the nursing staff?

Donohue: It was very traumatic for the nurses. They had to stay focused on taking care of the patients, even while they were dealing with tragedies in their own families. Nearly everyone was dealing with their own relatives who had lost a home in New Orleans or a rural area. In the clinic, we always felt rushed to deal with the surge in patients, but we could never allow the patient to feel rushed.

It's important in these situations that when you leave the office, you leave the office. Put it behind you until the next work day. Focus on the rest of your life. Network with your peers; other oncology nurses understand the challenges. We changed from monthly staff meetings to impromptu meetings as needed just to talk about what was going on.

ONC: What changes did your practice make as a result of the hurricane experience?

Donohue: The biggest change is that we make sure all of our patients have a document that summarizes their diagnosis and their plan of care (see example in Figure 1), and they are instructed to take that with them if they go on vacation or if they have to leave town. It doesn't detail every last dose of treatment, but it does list what medications they are taking.

We've always had hurricane awareness in this area, but we approach recordkeeping very differently now. We keep our files in the center of the building and up off the floor. We don't have electronic charting, but our care plans and financial records are kept on a web-based server for protection. We're a small practice, but if we're doing it, other practices can do it as well.