KP Volunteers Return to The Big Easy to Continue to Restore and Rebuild

Editor’s Note: Caitlin Cobb is a communications consultant at Kaiser Permanente and is part of a team of Kaiser Permanente employees and physicians rebuilding communities in New Orleans that were destroyed by Hurricanes Katrina and Rita. Kaiser Permanente has sent teams of employees and physicians to the Gulf Coast since 2007. 

“Welcome to the family.”

This seemed to be the general sentiment among longtime volunteers as they introduced themselves to new recruits and re-connected with old friends on the first day of this year’s New Orleans Gulf Coast rebuild.

Taken on as a very grateful first-timer from the communications team, I could photo 2feel the camaraderie among the volunteers instantly. Not a shy face in the room, I entered the bunkhouse to open arms and introductions. I was also told to beware of caterpillars that frequently fall from the trees near the bunkhouse and leave nasty welts if attached to the skin… should keep me sufficiently paranoid for the rest of the week.

The excitement and electricity was palpable and contagious.

Our first day in New Orleans included a city tour for the first half of the day, providing a realistic look at how far the city has come. While several homes and buildings sprinkled throughout the area remain in disrepair, the volunteers continually voiced how pleased they were to see the amount of progress that has been made since they began volunteering (some of the volunteers have been coming for more than five years).

The second half of the day proved productive but challenging. The volunteers photo 3divided into their first project sites and hit the ground running with their rebuild.

The work ethic was remarkable: Holes were dug, fence sites were measured, and concrete was mixed to begin work in new community gardens, museums, and other project sites still in need of rebuild after Hurricane Katrina. Most of the first day’s work was completed before a severe thunderstorm rained (literally) on the parade.

Despite the small setback, the volunteers remained upbeat and even more energized for the days to come. One of the project leaders (and multiple-year participant) even mentioned that this was the most energetic group she had ever seen.

photo 4The positive energy and team spirit continued well into the night at the bunkhouse before volunteers were off to bed to gear up for another ambitious day at the project sites.

Given the amount of work that I’ve already seen completed in a short period of time, I can’t wait to see the accomplishments that come from the first full day of work with (hopefully) no weather constraints.

 

 

Seham El-Diwany, MD, Paints Picture of Refugee Health in South Sudan Refugee Camp

Seham El-Diwany, MD, is a pediatrician with Kaiser Permanente San Jose Medical Center. She has been on numerous missions to support the health of underserved communities, and communities in the throes of conflict. Recently, Dr. El-Diwany’s reflection on her Medecins San Frontieres (Doctors Without Borders) mission, where she cared for refugees in South Sudan’s Yida Refugee Camp, was published on Issuu.com. You can read the full article here

This was my fifth mission to Africa and the second with Medicins San Frontieres. Prior missions were to Kenya, Zambia, the Congo, and Egypt, my native homeland. Each mission lasted four weeks on average. Despite the similarities in the medical problems, each mission brought new experiences and exposure to new cultures.

My MSF mission in South Sudan was at the Yida Refugee Camp, which is

Dr. El-Diwany caring for patients in South Sudan's Yida Refugee Camp.

Dr. El-Diwany caring for patients in South Sudan’s Yida Refugee Camp.

in the northern part of South Sudan. The camp houses approximately 70,000 refugees who came primarily from the Nuba Mountains and South Kordofan, which are part of Sudan.

The MSF facility consisted of an outpatient department, which averages 10,000 consultations per month, a 50-bed inpatient department, and a mobile clinic for outreach in case of outbreaks of epidemics. I was primarily involved in the outpatient clinic with call duties every other night, covering the emergency room tent and the inpatient department.

Arabic (with a heavy local dialect) is the prevailing spoken language in the refugee camp. English is also widely spoken, but mostly as a second language with varying degrees of proficiency. My language skills in Arabic, English and French were highly prized. Many patients were surprised and probably shocked that someone from MSF spoke to them in their native language. Scaling down the language barrier made it much easier to train the clinic staff, who also spoke English and were teaching a two-day neonatal resuscitation course to the midwives of International Rescue Committee and the United Nations High Commissioner for Refugees, who are in charge of 80 percent of the deliveries in Yida.

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Midwives from the International Rescue Committee after completing their resuscitation training.

A typical day starts at 8:15 am with rounds and clinic at 8:30. The outpatient clinic resembled an emergency room with all sorts of infections: pneumonia, bloody diarrhea, and UTI, STI, ear and skin infections in addition to seizures, hypertension, diabetes, asthma and dehydration. Schistomiasis, Kala Azar, Filariasis and Malaria are prevalent in this area of Africa. Friday was the Tuberculosis clinic day for patients in initial intensive or in remission phases.

I was in charge of screening all cases before they could be admitted. Before my

Examining an infant's ear in the outpatient clinic.

Examining an infant’s ear in the outpatient clinic.

arrival to Yida, a Hepatitis-E epidemic outbreak had peaked among the refugees, and I continued to see about 3-5 cases each week. These cases were managed together with the community health workers who would take the newly diagnosed patients from the clinic back to their tents and educate them about all precautions to prevent further transmission of the disease.

It was not uncommon to see toddlers with severe burns from the fire pits used for cooking. I learned to do the initial treatment of these burns under procedural sedation. I also learned to treat abscess, including breast abscess, get sutures done–even on lips–and to cast broken bones using my “x-ray vision” (no x-ray machines were available).

It has been my privilege to work with so many dedicated physicians and support staff at the MSF Yida Refugee Camp. I admire their courage and perseverance in working under such stressful conditions for such prolonged periods of time. My hopes and prayers are for their safe return after completing their mission.

Media Spotlights Kaiser Permanente Caregivers for Relief Efforts in the Philippines

In November, Kaiser Permanente caregivers across the country left home to volunteer aid to families affected by Typhoon Haiyan, which killed more than 5,000 people in the Philippines last year.

These physicians’ selfless acts garnered media attention. Before and after their travels, Kaiser Permanente volunteers were interviewed by reporters hoping to find out what drove these doctors to leave their family and work obligations behind, and how their experiences impacted them.

Here are some of the articles that highlighted their work:

Oakland Doctor to Travel to Philippines with Team to Offer Typhoon Haiyan Relief by the Contra Costa Times 

http://www.contracostatimes.com/news/ci_24613275/oakland-doctor-travel-philippines-team-offer-typhoon-haiyan

Dr. Weil Saw Filipinos Rising Up by the Press Democrat

http://www.petaluma360.com/article/20131218/ARTICLES/131219520/0/BUSINESS?Title=Smith-Dr-Weil-saw-Filipinos-rising-up

Local Medical Responders Head to Philippines to Help by KTVU

http://www.ktvu.com/news/news/local/bay-area-medical-responders-their-way-philippines/nbwFL/

Kaiser Permanente Nurses Return From Medical Mission

http://losgatos.patch.com/groups/karl-sonkin-at-kp/p/kaiser-permanente-nurses-return-from-philippines-medical-mission_5cd4aebb

Local Doctor Returns From Typhoon Relief

http://www.news10.net/video/2962859683001/1/Local-doctor-returns-from-typhoon-relief-trip

S. J. Doctors Join Typhoon Relief Efforts in Philippines

http://www.recordnet.com/apps/pbcs.dll/article?AID=/20131121/A_NEWS/311210325

 

 

Vivian Reyes, MD, Reflects on Lessons Learned from Disaster Relief Efforts

Editor’s note: Vivian Reyes, MD, is an emergency room physician at Kaiser Permanente San Francisco Medical Center. She led a team of Kaiser Permanente caregivers on the ground in the Philippines in the wake of Typhoon Haiyan, which killed at least 4,000 people and left millions homeless. Reyes and her team were in the Philippines at the request of Relief International. She filed this dispatch upon her return to San Francisco.

Jan. 5, 2014

When we enter the New Year we often look at the previous year’s successes and failures.  We ask what we learned, what we will bring forward, and what we will change.  Returning home from a disaster response is similar.  Now that I am back in the United States, having just celebrated the holidays, I can look back at my experience during the Kaiser Permanente/Relief International Philippines typhoon response and see the lessons learned.

At the start of our medical response, I spent most of my time assessing the medical needs in various affected areas.  The damage was unimaginable, both in intensity and expanse of its destruction.  Initially, I thought the extent of damage was due to the poor quality of home construction, as we saw many “shanty” structures. It took only a day or so before I realized that the shanty structures were new and that they were built on top of what once was a well- constructed building.  But still, it was only after seeing hill after hill littered with coconut trees that were literally snapped in half as a result of the 200 mph winds  that I stopped thinking, “This kind of destruction would never happen in the U.S.”  Memories of the destruction sustained in Hurricane Katrina in 2005 brought me back to reality – natural disasters know no boundaries.  And thus, the first lesson is 1) Don’t ever think this can’t happen to you. Who ever would have predicted that Japan would suffer through an earthquake, tsunami, and nuclear event all at once? Yet it happened.

Once we accept the first lesson, we must consider how the public is notified about an impending disaster.  In California, where earthquakes remain our greatest vulnerability, warnings will not be possible like they were for Typhoon Haiyan. In the areas of Tacloban City where we worked, a lot of the severe damage was caused by the “storm surge. Prior to this response, I did not truly understand what storm surge meant.

Patients told us that Typhoon Haiyan not only brought 200 mph winds, but also a series of large ocean waves – 18 to 20 feet high in Tacloban City, The multiple waves fed into each other’s turbulence, creating large whirlpools strong enough to crumble concrete homes, office buildings, and warehouses.  When I first arrived in Tacloban City, I wondered why no one evacuated to higher ground.  Why would sea-level communities stay home once a storm surge was predicted?  A few days later one of the community leaders answered my question: The locals, just like me, didn’t really understand what a “storm surge” was.

After the 9/11 attacks in 2001, the United States adopted the NIMS (National Incident Management System). This is now the basis for emergency management in our country and is practiced in most, if not all, U.S. hospitals.  Under NIMS, code words and ambiguity were retired and replaced by plain English.  Communication is the key to a good warning system, and it must be delivered in a way that its recipients can understand.  Again and again, I thought to myself how many people would still be alive if the warnings described a typhoon with a ‘tsunami-like wave.’  Sure, the terminology is not scientifically correct, but doesn’t the point come across more clearly?  I’m not sure what the right answer to this dilemma is, but the second lesson is 2) Effectively communicate warnings about impending disasters, using simple and plain English that allows recipients to truly understand what the impending disaster may bring.

Warnings and preparedness don’t prevent disaster, they only mitigate damage.  After the inevitable happens, the community still needs to respond to the damage and to those injured by it.  The early hours after a disaster only have local responders.  International medical teams cannot help. The Typhoon Haiyan response was particularly difficult. The typhoon struck multiple islands, making transportation nearly impossible.  At the same time, it knocked out internet and cell towers, in some cases for days to weeks. Together these factors led to prolonged assessment and response times.

In the United States we use the “96-hour rule” for hospitals, meaning a hospital should be self-sufficient for 96 hours following a disaster.  This rule is based on the fact that it generally takes medical teams 96 hours to become fully functional, taking into account “out-the-door” transport, staging, and set up times. After Typhoon Haiyan, the medical response time was closer to a week.  This means that the first responders were locals, medically trained or not.  By the time our KP/Relief International team arrived, most of the typhoon- related injuries had already been addressed by the local community.

So, if you learned the first lesson and believe this can happen to you, then the third lesson is 3) The best way to increase your community’s survival rate is to undergo some basic training in disaster response because you will be your community’s first responder; trained responders will generally arrive too late.

Once the medical response team is underway, they need to be coordinated. While disaster relief often seems chaotic, there is a formal national (NIMS) and international (throughout the United Nations) coordination process. I realized in the Philippines how few people, including disaster responders from the United States, know about this system of coordinating clusters of disaster responders. While I will not describe it here, the fourth lesson is simply that 4) A coordinated disaster response system exists and all responders should strive to work within the system to prevent duplication of effort and response.

The last lesson is the simplest to understand, yet the hardest to follow.  5) Allow communities to recover.

This seems insultingly obvious, yet this is the most difficult lesson for responders, including myself, to grasp. When we respond to disasters that happen outside of our communities, we bring with us our cultural beliefs, tendencies, judgments, and ways of doing things. Recovery may mean different things to us as responders than it does to members of the affected community. The Philippines typhoon response and the Haiti earthquake response in 2010 provided aid to cultures very different from our own. We need to recognize this, and remember that we are not there to change culture, but to help communities return to a new normal that will work within their cultural framework.

Imagine if the tables were turned. If we had European medical teams come to our aid after a severe disaster, they may question the fee-for-service model used in much of the United States. This same dilemma arose in the Philippines.  As Kaiser Permanente employees, we are not accustomed to witnessing how fee-for-service works.  But in the Philippines, few patients receive “charity care”, and EMTALA (Emergency Medical Treatment and Labor Act) does not exist. While fee-for-service practices were postponed for most of our time spent in the Philippines, as recovery furthered, fee-for-service practices resurfaced. With so many people still down on their luck, it seemed unfair to me for them to pay for health care services. However, this, too, is a step to recovery.  How will health workers earn a living if they cannot bring in revenue from working? What will drive them to work month after month if they cannot earn money? I do not have the answers to these questions but it is something to consider early during any disaster, so that it does not come as a surprise later.

And so, as we move forward into the New Year, and as I continue to process my experience during the Typhoon Haiyan medical response, I resolve to make the Kaiser Permanente health care organization, as well as our members and staff, more prepared to confront, survive, and recover from a disaster. As my friends and colleagues have supported me on this response to the Philippines, I hope they will also support me on my mission toward better organizational resiliency.

Thank you again to all who have read my updates.  And, thank you again to all who have supported my endeavors in disaster response, as well as emergency management. I feel lucky to be supported in doing what I love to do.

Manigong Bagong Taon!

Happy New Year!

Vivian

As Relief Efforts Wind Down, Demand for Basic Health Needs Rises

Joshua Weil, MD, is an emergency medicine physician with Kaiser Permanente in Santa Rosa, Calif. He recently flew to the Philippines to support the relief effort in the weeks after Typhoon Haiyan, which devastated the country in November. Dr. Weil joined his colleagues in Tacloban City, the Philippines last month.

Yesterday’s rain and breezes brought a significant drop in temperature.  It was the first day where I didn’t feel drenched in sweat by the time we were finished with our work and I didn’t feel as if I needed a second shower at day’s end.  Maybe I’m just getting used to the heat.

It’s interesting contrasting my observations here versus Haiti following their disaster.  It is striking to me how much rebuilding I see here compared to how little I saw in my time in Haiti.  And I’m not talking about large scale government or institutional led rebuilding (though we see some of that, too).  Drive down a street here and you will see dozens of folks out with their hand saws, chain saws, and hammers, banging away and putting their homes and fences back together.  Granted, I was in Haiti slightly sooner after the earthquake, but my sense is that Haiti is a much poorer country and perhaps as a result there was more of a sense of desperation. Regardless of the reason, I did not witness that kind of large scale individual initiative to recover as I have seen here.

Yesterday’s mobile clinic brought another difficult story from the typhoon.  A patient complained of ear pain and told me how during the storm he clung to an object (I had a little trouble discerning exactly what) as the water rose, but then ants started climbing up his arm as they tried to escape the water, too. Some ran into his ear and bit him, but he was afraid to let go lest he get swept away, so they kept biting.  I’ve been bitten by a few ants while here, so don’t doubt the story, plus he had an ear canal infection to go with it.

Not every story from our mission is horrific, mind you.  For instance, Deb Cohen, MD, the pediatrician amongst us, treated a young boy a few days ago at the outpatient clinic at Carigara.  His mother came back a few days ago to tell her that the child kept saying she was the “most beautiful mother” and couldn’t sleep until he had a picture.  It was very touching and she will try to send a photo.

I’ve also been bemused by a few of the patient complaints.  For instance one patient complained to me that her joints hurt when it was cold.  I suggested with a smile that she should move to a warmer climate.  She laughed, as well.  Hopefully I don’t have to explain the irony, but in case you haven’t picked it up from my writings I doubt very much the thermometer has dipped below 75 since we’ve been here.  Another patient complained of getting headaches in the heat.  My response: “me, too.”

Fear not, though. I did offer some pain relief for these patients, and they are very happy to receive tylenol or ibuprofen (as opposed to some patients back home who might feel slighted with an offer of anything less than norco or percocet).  And then there was the women who insisted that I had given her some medications last week when it was our very first visit to that particular location.  I could only say, “you know us white guys, we all look the same.”  Which here we probably do.

There is something about the Filipino language that struggles with pronouns.  Our interpreters regularly flip-flop “he” and “she”.  What makes it more perplexing is it’s not a 50-50 proposition, but rather 80 plus percent of the time they say “she” when speaking of a male and vice-versa, which makes it very confusing and a little challenging.  For me, though, I couldn’t get by without our interpreters.  Some of our nurses  haven’t been able to find nursing work  while others who have no medical background have been able to quickly pick up the flow of what we’re doing and ask insightful questions of the patients without our prompting. They help navigate many of the cultural differences we have faced and I find it very enjoyable to learn from them.

Today will be the last day of our presence at the Carigara District Hospital and there is clearly a sense of winding down. At the Health Cluster meeting yesterday they announced that clinic and hospital visits are returning to pre-Yolanda numbers.  We have generally seen our volumes drop at the ER, outpatient clinic, and mobile clinics.  While the acuity has always been lower at the clinics (mobile or fixed) than the ER, we’ve definitely moved in to a phase where a large proportion of visits are simply seeking vitamins.

For whatever reason, in Haiti the code for “I would like some vitamins” was “I have vaginal itching.”  Here, it’s, “I have a cough.” The good news is that chief complaint is not limited to half the population, as it was in Haiti.  Still, I find it amusing when I’m working with a patient and the interpreter is telling me about her muscle ache or years of arthritis.  We go over the history, I examine the patient, I grab some ibuprofen and start handing it over, and inevitably the interpreter will then say “and HE has some cough.”  Bring on the vitamins!  Of course the best part of the story is that when I returned from Haiti to my own ER the very first patient I saw complained of…vaginal itching.  I may have to insist that the first case I handle on return this time is cough.

Bangon!

Joshua B. Weil, MD
Kaiser Permanente Santa Rosa Medical Center