1. Surviving in the Aftermath Presented by: C. J. Flenniken, RN, CNN DaVita Group Facility Administrator Med-Center Dialysis, Houston, TX Mainland Dialysis, LarMarque, TX Island Dialysis, Galveston, TX When asked to speak here, first of all, I myself was suffering from post-traumatic stress disorder, or I never would have said yes. What was I thinking? My understanding of my portion of this presentation / panel discussion was that I was to discuss dealing with the aftermath of a disaster. I have to say, though, that in a lot of ways Im still having trouble finding the after part. Is there such a word as intramath?

2. Just a Cat 2 Just a Cat 2

3. Just a Cat 2 Just a Cat 2

5. Just a Cat 2 Our patients, docs, and teammates are still struggling also to find their after Ike normalcy 6 months post-Ike. I have spoken with numerous people in the months post Ike that say: Oh, was it that bad? I thought everything was back to normal. I recently interviewed a teammate desiring to transfer to my Houston clinic. We decided we clicked, but she wanted to give her supervisor 4 weeks notice (an admirable trait, by the way). She was concerned I would give away the position. I told her that I continued to be busier than a one-armed man trying to hang wallpaper as we were getting close to hopefully reopening Island post-Ike. She said, oh, I thought everything was back to normal already. I told her that Im unsure if my patients, teammates, docs have a normal anymore. Believe it or not, some of these 3 pics here are not after the storm or during its landfall. Ike made landfall in the wee hours of 9/13. These pictures were taken the day before. While preparing this project, I was surfing the net and came across a blog with comments posted a couple weeks post-Ike. An idiot (thats the nicest word I could think of) basically told the other folks to quit their whining, this was just a cat 2. You basically hunker down and lose power for a couple days, clean up a few limbs, then everythings back to normal. As most of us know even when he posted that, the majority of us in this entire metro area, not even just us on the coast, still were without power. Thanks goodness for that nut, because if we had been able to read his post back then he might have gotten hurt. He actually really said, its no big deal. When I began assembling this presentation, I searched for some photos so that folks could see some of what we dealt with. I think many were unaware because we all had no power for so long. By the time we got power back in our individual homes (if we still had homes), the news had moved on to more important things. After all, it was an election year. A significant election year. And how much damage could a Cat 2 really do anyway. No big deal. And these pics are pre-Ike. Ike was a 900-mile wide storm – a little ol Cat 2. For those who know what theyre talking about, Ike was a Storm of the Century. He had low winds – ha, for those of us whose windows were blown out, both inside and outside – but he was huge – 900 miles wide. Ike has the NOAA considering a new cat system. Ike has been compared to a bull in a china shop – large, lumbering, slow, -- but capable of significant damage.

6. Tell these folks (or their families): No big deal Top left photo was well before Ike made landfall – a warehouse burning in the harbor and a frustrated fireman because they couldnt get to it because of the already rising water. Bottom left is a family in Bridge City – 2 months post Ike... Pics on the right – well, obviously, quite a few things ended up where they should not have been.

7. The day before landfall

8. Tell these folks (or their families): No big deal Photo was well before Ike made landfall – a warehouse burning in the harbor and a frustrated fireman because they couldnt get to it because of the already rising water

9. Just a Cat 2 – No big deal A family in Bridge City – 2 months post Ike

10. Quite a few things ended up where they should not have been.

11. We had 90 patients at Island Dialysis as of 9/11/2008, the day the storm turned. 100% of them had Galveston addresses. The majority of my patients there lived in the areas of the island that were the most damaged.

13. DaVita Island Dialysis A fish in the dialysis unit

14. DaVita Island Dialysis

21. Category 2 Hurricanes Can be Devastating Category 2 hurricanes can be devastating – do not be overconfident Category 2 hurricanes can be devastating – do not be overconfident –Wind damage, flooding and downed trees result in a loss of all services, not to mention fires and people stranded. –In IKE people were stranded by high water before the storm –Fire departments could not access fires

22. Category 2 Hurricanes Can be Devastating We prepared!! But, tired out staff can be callous We prepared!! But, tired out staff can be callous –No matter how hard you prepare, you will ALWAYS be surprised. –Hurricanes come in package – 2008 was Eduardo, Gustav and then IKE –The staff was tired by the time IKE came onboard because they had been dialyzing and preparing for the earlier two

23. Category 2 Hurricanes Can be Devastating Born on the Island Born on the Island Natives always ask the question Do I need to worry about this one? Natives always ask the question Do I need to worry about this one? Here the answer was yes – but, no mandatory evacuation – and on the Thursday before the storm hit, patients were still dialyzing! Here the answer was yes – but, no mandatory evacuation – and on the Thursday before the storm hit, patients were still dialyzing! TAKE HOME – PATIENTS NEED TO LEAVE BEFORE A MANDATORY EVACUATION!!! TAKE HOME – PATIENTS NEED TO LEAVE BEFORE A MANDATORY EVACUATION!!!

24. Lessons Learned: A Tale of 3 Clinics – Island and Mainland and Med Center You can only dodge that bullet so many times till it finally has your name on it – Med-Center has never lost power (for more than a few minutes) – not during Allison, not during Rita. You can only dodge that bullet so many times till it finally has your name on it – Med-Center has never lost power (for more than a few minutes) – not during Allison, not during Rita. History only repeats itself so many times before it pulls a fast one on you. History only repeats itself so many times before it pulls a fast one on you.

25. Island Dialysis Island & Mainland either worked Sundays or pulled patients up for both Eduardo and Gustav within weeks pre- Ike, frustrating patients, docs, and teammates. Island & Mainland either worked Sundays or pulled patients up for both Eduardo and Gustav within weeks pre- Ike, frustrating patients, docs, and teammates. For Ike, no one was very motivated to cooperate with schedule changes – patients, docs, or teammates. For Ike, no one was very motivated to cooperate with schedule changes – patients, docs, or teammates.

26. Lessons Learned: A Tale of 3 Clinics Members of the general public continue to be woefully uninformed about the life-sustaining nature of dialysis. Members of the general public continue to be woefully uninformed about the life-sustaining nature of dialysis. –Utility Companies –Media –Politicians (from City Council members to members of US Congress) A special thanks by the way to Whole Foods Corporation out of Austin who generously supplied us with a generator so we were able to open Tuesday a.m. A special thanks by the way to Whole Foods Corporation out of Austin who generously supplied us with a generator so we were able to open Tuesday a.m.

27. DaVita Med Center We talked to people at Reliant and Centerpoint at 4 a.m. on Monday only to find that despite our efforts every year to ensure we remained on essential services status – well, somehow we had fallen off. There was no convincing these folks that lives were hanging in the balance. We talked to people at Reliant and Centerpoint at 4 a.m. on Monday only to find that despite our efforts every year to ensure we remained on essential services status – well, somehow we had fallen off. There was no convincing these folks that lives were hanging in the balance. We reached out to politicians from city council to U.S. congressmen. We were told to be patient – they were assisting urgent cases first such as nursing homes without power. We reached out to politicians from city council to U.S. congressmen. We were told to be patient – they were assisting urgent cases first such as nursing homes without power. We reached out to sources reported to have access to extremely large generator (Med-Center is 72 stations, one of the largest in the United States, and needs one size of 18-wheeler) – We reached out to sources reported to have access to extremely large generator (Med-Center is 72 stations, one of the largest in the United States, and needs one size of 18-wheeler) – We were told they were being reserved for more important purposes. We were told they were being reserved for more important purposes. RESPONDER UNIT

28. DaVita Med Center –FEMA told us they could not help us; they did not have a generator large enough to accommodate us. –We were told that a generator the size we needed would cost $15,000 per day plus fuel – which was expensive. –A politician was notified and told we were in a life or death situation. He offered to send EMS out evaluate our patients. –When the most beautiful men (from Whole Foods) in the world showed up in our darkened clinic Monday evening and saw some of our patients still anxiously awaiting our reopening, they had no idea what we did here either. After explaining it to them, they decided to bill us only a dollar a day. RESPONDER UNIT

29. THANK YOU WHOLE FOODS A special thanks by the way to Whole Foods Corporation out of Austin who finally supplied us with generator so we were able to open Tuesday a.m.

30. Lessons Learned: A Tale of 3 Clinics Generators required at all facilities will not solve all the problems. Generators required at all facilities will not solve all the problems. –Island Dialysis was my only clinic with a generator, but – well, you saw the pics. –Mainland had no generator, either but it was difficult to get south of exit 12 for a while. –The lack of a generator at other power-less facilities was not the greatest problem – it was the lack of knowledge of city officials and power company employees that our clinics needed priority service. Generators required at all facilities will not solve all the problems, contrary to much of discussion held in past 6 months. Island Dialysis was the only clinic with a generator, but a generator isnt much help for a clinic with 5 foot of water that you cant get back in to even begin cleaning for several weeks. By the time you get there, the whole place is eaten up from bottom to top with mud and mold. The lack of a generator at other power-less facilities was not the greatest problem; it was the lack of knowledge of city officials and power company employees that our clinics needed priority service. Dialysis is not considered life threatening. The Mainland Dialysis clinic (located at exit 10 on the Gulf Freeway) did not have a generator either, but since National Guard would not let folks go past exit 12 to the lower exits, it would not have helped us anyway.

31. Lessons Learned: A Tale of 3 Clinics Network, innovate, think way outside the box. Network, innovate, think way outside the box. –Get past the frustration over what you dont have and focus on what you do have. –Listen / learn – sometimes from unexpected sources.

32. Network, Innovate and think way outside the box –In the Medical Center we could not get a large generator immediately. We needed a huge generator to operate Med-Center for treatment, which we could not get immediately; however, we did have access to little ones. –Kevin Kelleher thought of setting up our stat lab equipment, a lamp and a fan on a small generator - sort of running a little M*A*S*H lab so we could at least determine if our patients potassium values were at a level that necessitated emergency room care –Natti & Virginia, LVNs, took manual blood pressures, and vitals signs of both patients and teammates. –We sent teammates who showed up to help to neighboring facilities who did have power – and insisted they carpool.

33. Lessons Learned: A Tale of 3 Clinics Be here Be here – Our patients need to have confidence that we are committed to being here for them. – As dialysis caregivers we should be the last person out (if we get out at all), the first person back.

34. Be Here Be here as dialysis professionals / caregivers. Be here as dialysis professionals / caregivers. Can you begin to imagine what its like to be a dialysis patient in what we were (are) living post-Ike? Can you begin to imagine what its like to be a dialysis patient in what we were (are) living post-Ike? The vast majority of us are not on dialysis, and our lives sucked for at least weeks post-Ike – for some of us months – for some of us, it still does. The vast majority of us are not on dialysis, and our lives sucked for at least weeks post-Ike – for some of us months – for some of us, it still does. What if we were living this life and dealing with being on dialysis? What if we were living this life and dealing with being on dialysis? Our patients need to know that we are committed to being there for them. They are afraid and justifiably so. Our patients need to know that we are committed to being there for them. They are afraid and justifiably so. As an aside here, too, for any docs in the audience, it meant a tremendous deal to us that 2 of our doctors were consistently there with us in the clinic – even on Monday all day when there was no power. And then on Tuesday, when so many people were arriving that hadnt dialyzed since the prior Thursday (or maybe longer), it was supportive to the teammates to have the MDs there – for arrests, seizures, hypoglycemic crises. So a big thanks to my docs. As an aside here, too, for any docs in the audience, it meant a tremendous deal to us that 2 of our doctors were consistently there with us in the clinic – even on Monday all day when there was no power. And then on Tuesday, when so many people were arriving that hadnt dialyzed since the prior Thursday (or maybe longer), it was supportive to the teammates to have the MDs there – for arrests, seizures, hypoglycemic crises. So a big thanks to my docs.

35. In an emergency, disaster, whatever, dialysis caregivers should be the last person out and should be the first person back.

36. Lessons Learned: A Tale of 3 Clinics Changing horses in midstream is okay (or plans in mid-crisis). Changing horses in midstream is okay (or plans in mid-crisis). –Although DaVita Med Center had been through several instances of drive-by dialysis (Allison, post-Katrina, Rita), the flow did not go so great on day one this time. –We analyzed (tired as we were at days end) what was so different than prior times and Wednesday was smooth as silk. When MC finally opened on TTS, the lobby was chaos. Our teammates were there in full force endeavoring to help. I especially recall our social workers getting bottlenecked in one area trying to assist guest patients. On the second day, we reserved a special dialysis bay for guest patients and moved their in-take into the treatment area.

37. Lessons Learned: A Tale of 3 Clinics Catastrophes do lead to a higher morbidity / mortality rate Catastrophes do lead to a higher morbidity / mortality rate –We have called, checked on our patients, whether they stayed nearby or went to Oklahoma or New York – Patients that we expected to return to us, or at least expected to live for some time, well... –Pre IKE our death rate was as expected per Network reports. Galveston averaged 1.5 deaths per month. One would expect that on September 11, 2008, when we closed, until now, February 27, 2008, less than 6 months, we would have seen maybe 9 deaths.. –We have had less than 50% percent of patients return for care at our sister facility 10 miles north of Galveston. Nonetheless, our social worker and administrative assistant have endeavore3d to track patient status throughout the country. We have lost far more than the expected 9 death maximum when we check with facilities throughout the state. Island has had 15 deaths –Of 90 patients – 40 are in LaMarque, 25 in Houston, 10 have relocated and 15 have died –Mainland had 120 patients in the clinic with 19 stations, 4 shifts of Monday, Wednesday and Friday and 3 on Tuesday, Thursday and Saturday. –31% are displaced and not sure what they are going to do. –6 teammates have lost their homes. Many moved away because UTMB relocated. No one was lost to follow up.

38. Lessons Learned: A Tale of 3 Clinics Dialysis caregivers must stay in touch long-term – with each other, with the docs, with the patients. Dialysis caregivers must stay in touch long-term – with each other, with the docs, with the patients. –Because six months later, life is still not normal for many of our patients (or for our docs and co-workers) – Where are they now? –Island patients – on 9/11 = 90; Today: 40 at nearby sister clinic 40 at nearby sister clinic 25 at farther-flung clinics in Houston metro area (future plans still up in the air) 25 at farther-flung clinics in Houston metro area (future plans still up in the air) 10 permanently relocated – unable to return home 10 permanently relocated – unable to return home 15 deceased 15 deceased 0 lost to follow up 0 lost to follow up –Mainland patients today = 120 (combination of former Island / former, current Mainland): 37 (31%) are still displaced. 37 (31%) are still displaced. –Teammates: 20 teammates with Island pre-Ike 20 teammates with Island pre-Ike 6 lost – will not be returning 6 lost – will not be returning 3 that remain still not living at home. 3 that remain still not living at home. 0 lost to follow up 0 lost to follow up

39. Surviving in the Aftermath These pics were taking this week – February 23

40. Final Lessons Prepare, prepare, prepare – but be prepared for that which you did not prepare, because it will be there. Prepare, prepare, prepare – but be prepared for that which you did not prepare, because it will be there. Never give up hope. Never give up hope. – Hope, as in the biblical definition – belief, faith, that good will happen Improvise, adapt, overcome: Improvise, adapt, overcome: – The Marines aint got nothing on my dialysis teammates.