Hurricane Maria: A Nephrology Fellow’s Perspective

The 2017 Atlantic Hurricane Season was among the most active and devastating in history. Hurricane Maria caused an estimated $90 billion in damages in Puerto Rico and the U.S. Virgin Islands, making it the third costliest tropical cyclone in the United States since 1900. Almost one year after the storm, the government of Puerto Rico raised the official death toll to 2,975 after maintaining for months that only 64 people had died as a result of the storm. Preparing for hurricanes is almost second nature for people of the Caribbean, but no one on the island had seen the degree of devastation that Hurricane Maria inflicted on Puerto Rico. As a second-year nephrology fellow, it became the defining moment of my career.

Two weeks before the storm, we had already gotten a preview of what was to come. Although Hurricane Irma skirted Puerto Rico, the destruction was evident. More than one million people, including myself, lost electricity in their homes. The weekend after Hurricane Irma made landfall in the Caribbean, I was the nephrology fellow on-call. We got information that a score of displaced dialysis patients from St Thomas had arrived to my hospital and now needed urgent hemodialysis. My team swung into action arranging dialysis for our neighbors in a timely manner and I was extremely proud of my hardworking team. Later that night, it was difficult to sleep because of the steady buzz of the electric generators in the distance. Although I didn’t have electricity, I considered myself fortunate to still have running water in our house. I had an important presentation on water metabolism due the following week. Despite the circumstances and no electricity, I continued to work on that. In these devastating times, doing routine things gives one a sense of normalcy, at least for a few moments.  

It certainly was ironic to think that while I was working on a water metabolism talk, most of my colleagues were struggling without any water in their homes!

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Even while we were gathering pieces after Hurricane Irma and still without electricity, we got a warning that another storm was churning in the Atlantic. It felt like being trapped in a recurrent nightmare. We spent the days leading up to that fateful Wednesday when Hurricane Maria made landfall preparing for the worst. During rounds in the dialysis unit, my attendings and I discussed the importance of following an emergency renal diet with our end-stage kidney disease patients.

Dialysis treatments were scheduled for all patients the day before the Hurricane made landfall. Our nutritionist handed out custom made booklets which provided not only meal plans but also emergency phone numbers and how to prepare an emergency kit.

Given the projected uncertainty, we were not sure when they would get their next dialysis. That day, Hurricane Maria rapidly intensified to a category 5 hurricane, with whipping winds of more than 157 mph heading directly for Puerto Rico. We discussed how we were going to reach the hospital after the storm passed. We anticipated confusion and ruin. Gallantly, a fellow and two dialysis nurses decided to stay in-hospital during the storm. We would relieve our co-fellow as soon as we managed to reach the hospital after the storm.

On September 20, 2017, at 6:15 A.M., Hurricane Maria struck Puerto Rico as a Category 4 Hurricane. On that day, all 3.4 million Puerto Ricans lost power. With no power and no telecommunication services, we felt plunged into the dark ages with no internet access, social media, television or newspapers. Many hospitals suffered damage to their infrastructure. Dialysis centers lay in ruins. Driving was a hazard without functioning traffic lights and with damaged roads. After making sure my family was safe, I drove the treacherous path to the hospital in order to relieve my co-fellow. Thankfully, my hospital had generators and water storage tanks and the treatment of our hemodialysis patients was not interrupted. We also provided treatment and counseling to the patients who had been days without dialysis because their centers had been destroyed or closed. Some hospitals couldn’t handle the water load that hemodialysis required. Treatment times had to be shortened and patients were transferred to other institutions. I recently spoke to two hemodialysis patients who described their experience to me. With despair closing in, five days passed before they would know where they could receive hemodialysis. Going from ER to ER they heard the same response “We don’t have water.”

Puerto Rican officials warned that reestablishing power could take six to eight months.

Slowly, living without electricity became the new normal. New questions were added to our history and physicals: “Do you have running water at home?” and “What about electricity?”

After work, we waited patiently for hours in order to fill gas tanks to feed our electric generators. The world kept turning and, at the end of the day, I was still a second-year fellow with plenty to learn. I adapted to my new normal, arranged educational activities and I was able to prepare two posters for that year’s ASN Kidney Week in New Orleans. I have never been prouder of a poster before in my life. Unbelievably, it took more than 100 days before power was restored in our home.

 

We faced many hardships and learned many lessons. The importance of communication was emphasized. It is vital to have an established communication plan with our kidney patients. Although many natural disasters come without warning, in case of hurricanes, we can prepare in advance. Up to 5 days before the event, a patient communication plan should be established as well as a “buddy” system for patients. Plans for regional disaster should assume that dialysis units will be non operational and that dialysis patients must be treated away from their usual dialysis facilities. There should be an established contingency plan for each hemodialysis unit. Early and mandatory evacuation from remote communities should be done with the goal of improving the safety of our dialysis patients. Each patient should also be equipped with their medical information and list of current medications. Before a storm hits, patients should have their prescriptions refilled, in case they cannot reach a pharmacy. Dry supplies, including enough bottled water and packaged food, to last 2 weeks should also be kept at hand. The National Kidney Foundation has a guide directed towards people with chronic kidney disease in preparation for a natural disaster.

Ensuring adequate preparation for natural disasters can improve patient outcomes and help save lives. Pinpointing exactly when a natural disaster is going to strike is often impossible. Therefore, it is of utmost importance to have established contingency plans in place in order to protect our patients. Being a fellow caring for dialysis patients during this natural disaster has made me sensitive to these issues and was a life lesson as I progress in my nephrology career.

Check out a fellow’s perspective on another storm, Hurricane Harvey, which hit Houston, Texas in 2017.

Post by: Krystahl Andújar-Rivera, MD
NSMC Intern, 2019