Introduction
Climate change is increasing the intensity of tropical cyclones and hurricanes, with wind damage and flooding likely to worsen in future years.1 Hurricanes pose a particular challenge in graduate medical education (GME), as leaders must ensure adequate health facility staffing while supporting trainees whose homes and loved ones may be at risk due to storms. Residents serve as front-line workers before, during, and after severe weather events, and GME programs play an important role in ensuring the provision of essential care to communities after hurricanes. There is a paucity of research on best practices for how programs should address severe weather; the literature on this topic is largely anecdotal.
The Florida peninsula is particularly vulnerable to hurricanes and floods due to its subtropical location, low elevation, and extensive coastline. As current and former GME leaders in Florida, we have extensive experience preparing for hurricanes and coping with their rapidly changing intensity, trajectory, and consequences. While our individual hospitals’ experiences differ based on program size, geographic location, patient population, and other factors, the lessons we have learned may help others plan for future storms and other climate-related disasters. The Table provides a summary of system, program, and individual considerations, denoting stakeholder responsibilities and providing general guidance.
Table.
Leadership Tasks to Address Before, During, and After Hurricanes and Other Disasters
| Phase | Tasks |
|---|---|
| Pre-disaster | Routine, ongoing preparation |
| |
| Immediate preparation as storm approaches | |
| |
| During |
|
| After |
|
May apply to any disaster.
Abbreviations: SI, sponsoring institution; A, affiliate; P, program; GME, graduate medical education.
Planning for Storms
Anticipatory Guidance
Preparation for climate-related disasters should start early and continue at regular intervals. As a transient group, many residents are new to the region where they train and may be unaware of which residential buildings are in flood or evacuation zones. To this end, our institutions provide information on hurricane planning after the Match, during onboarding, and annually. Anticipatory planning enhances efficiency during all phases of climate-related disaster management. For hurricanes, programs might have a few days’ notice to prepare, given storm trajectory changes. Having information regarding emergency contacts,2 residents’ preferences on team assignments, residents’ resources and needs, clinical needs, and communication frameworks can minimize chaos for all stakeholders and make planning more efficient. Our institutions collect much of this information annually before hurricane season starts. Immediately after each hurricane event, we debrief with the aim of improving future guidance and protocols.
Residency directors should establish relationships with other in-state programs in the rare event that residents and faculty need to temporarily relocate, in accordance with Accreditation Council for Graduate Medical Education guidelines.2,3
Immediate Pre-Storm Planning
It is important for the designated institutional official (DIO) to establish effective communication with local officials and the hospital’s top administrator and maintain frequent and clear communication channels internally, while setting clear protocols for each department; creation of a group chat can facilitate communication between hospital workers.2 Immediately before Hurricane Irma, authors S.B. and J.E.S. experienced a deluge of requests from physicians offering to volunteer during the storm, in exchange for shelter. Due to space, resource, and safety concerns, hospitals are unable to serve as an evacuation refuge for every staff member. During Hurricane Harvey, for example, one Texas hospital ran out of mattresses for staff and had inadequate cafeteria services for employees.4,5 Program directors should consider preferentially scheduling senior residents, who require less oversight than interns and have more experience in managing inpatients, because there are fewer supervising attendings in the hospital during the storm.4
Hospitals should reserve protected, elevated parking for those working in the hospital; during Hurricane Ian, for example, floods inundated and destroyed residents’ cars that were parked in a lot adjacent to a Florida hospital.
During the Storm
Staffing during the storm should be calibrated to provide adequate inpatient care, while not overly taxing hospital resources. The volume of inpatients can be difficult to predict; programs should attempt team continuity while respecting resident preference. In our experience, shelter-in-place mandates usually result in fewer patients visiting emergency departments during the storm; the cancellation of elective procedures may also reduce inpatient numbers. We and others have observed that local long-term care facilities and dialysis centers preemptively sent their patients to hospitals in anticipation of the potential loss of power and staff.6
To maintain morale, we recommend that the DIO, program leaders, or their assigned subordinate(s), stay in the hospital throughout the storm; their presence is necessary to assure patients’ well-being and prevent a sense of abandonment. They will also need to resolve conflicts and system issues.
Battery-powered radios should be purchased and charged in advance to serve as a backup4 in case commercial phone service and satellite-based communication fail as they did during Hurricanes Katrina and Harvey.7 Printed textbooks should be available for medical decision-making in case electronic references are unavailable, as happened in Puerto Rico after Hurricane Irma.8 Programs should consider purchasing air mattresses and stocking up on nonperishable food and water prior to the season to ensure adequate supplies.4
Post-Storm
In our experience, those assigned to cover hospital services immediately after the storm may endure greater anxiety than those covering during the storm. In a survey after Hurricane Irma, University of Miami residents in the “after” coverage group stated they felt extremely stressed about identifying a safe, affordable evacuation site for their family and pets.9 Some single parents evacuated many hours away. Hospitals should consider contracting with hotels outside flood zones to reserve blocks of rooms for staff.
In our, and others’ experience, patient volumes significantly increase immediately post-storm.6,7,10 The acuity of patients’ conditions is often intense, as many people delay seeking care until it is safe to travel. Patients may present with injuries sustained in the post-storm period.11 Chronic illnesses may flare due to patients running out of medications; others may experience mental health crises because of damage to their homes or anxiety-provoking situations they witnessed.12,13 Residents may experience increased anxiety due to damage to their own homes or concerns about their loved ones’ safety. To alleviate this burden, programs should increase the number of residents they schedule post-storm to address heightened patient demands. Programs should create curricula to educate residents on managing common post-storm injuries; while emergency medicine residents receive disaster training, such training is less robust in other specialties.14,15 Programs should collaborate with mental health professionals to help manage conditions such as anxiety and posttraumatic stress disorder among patients and staff.
Outside the hospital, electricity may be out for weeks, affecting transportation and childcare. Residents with damaged homes may need to find other accommodations. Others may have difficulty sleeping in hot, stuffy accommodations until air conditioning is restored. To address these issues, we recommend hospitals consider arranging for on-site childcare and creating start-up funds to help residents find temporary accommodations in the immediate aftermath.
Resources such as the National Institutes of Health Disaster Research Response Program offer promise for improving the evidence base for best practices for programs in the face of future disasters.16
Conclusion and Implications for Other Climate Disasters
Unlike wildfires and tornadoes, hurricanes are usually associated with advance notice; despite these differences, disaster planning remains of utmost importance. In all such emergencies, communication and the active, visible participation of leadership are crucial, as are an emphasis on teamwork, psychological and financial support of staff, and recognition of the importance of each person’s role. More research is needed to establish best practices for graduate training programs in a new epoch of weather-related disasters.
References
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