Brad Puffer: Welcome, everyone, to this episode of Field Notes. I'm Brad Puffer on the medical office communications team at Fresenius Medical Care North America, and your host for this discussion today. Here, we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

Hurricane Laura recently hit the Gulf Coast as a Category 4 storm, the fifth strongest ever to hit the continental U.S. It's been one of the most active hurricane seasons on record with 7 named storms making landfall since the end of August.It's hard to believe we are working to respond to a pandemic, and now we have hurricane season at the same time. No matter what this season brings, our company will have teams ready so that we can ensure our patients maintain their access to critical life-sustaining care.

So, what does it take to ensure patients can receive dialysis even after a major event when the roads are blocked or flooded and the power and water is out? How can our experiences help teach other health care organizations about preparation and response? And what do caregivers and physicians need to know to be ready this hurricane season, especially during an ongoing pandemic?

Well, here with me today is Bob Loeper, Vice President of Disaster Response for Fresenius Medical Care North America. Bob has led the company through many major disasters, including hurricanes Katrina, Harvey, Maria, and Michael, as well as wildfires, tornadoes, and blizzards. Bob, welcome to Field Notes.

Bob Loeper: Thank you, I'm glad to be here.

Brad Puffer: Well, Bob, it may surprise some people that we even have a disaster response team. So, maybe you can tell us a little bit about what your team does but also why a dedicated team is even needed.

Bob Loeper: Well, it's very important for our patients. They're very vulnerable. And they need dialysis three times a week, four hours each session. And if they start missing treatments-- if you miss even two treatments, your chance of hospitalization gets very high. So, we've got to make sure they don't go to the hospital, that we take care of them, we get our clinics open or we have backup clinics that we can send them to. That's the most critical thing that we do after a disaster is to find the patients and get them in a chair.

Brad Puffer: And how does your team do that? How is it structured in order to be able to respond?

Bob Loeper: Well, we do a lot of training. I have calls every month with the field team. I have calls every other week with my incident command team. So, it's a lot of training and a lot of drills. You've got to get ready for the unexpected.

Brad Puffer: Tell us what it looks like as you prepare for a storm’s arrival? What needs to be done?

Bob Loeper: Well, the first thing we tell people to do is make sure you're prepared at home. Make sure your cars are gassed up. Make sure you've got water. And you're not doing that the day before it's going to hit because you would just be waiting in line.

But then for our facilities, we have to make sure our generators are topped off. Talking to our patients, we have their most recent emergency contact information. And then we print out their medical records and hand it to them right before we close the clinic.

The hardest part is judging, when are you going to get hit? And that's when you want to close. So, you've got to make sure you back up your treatments the day before. You might do an extra shift and bring those patients in, cut the treatment time. And then the storm blows through. And then you, hopefully, can open up that second day after. So, missed treatments is something that we're very keen on to make sure we minimize missed treatments.

Brad Puffer: And I understand that you've kind of created dedicated specialist teams that are trained and ready to go into any area all over the country.

Bob Loeper: That's correct. We follow the incident command system that FEMA and EOCs use. So, I have an incident commander-- there's actually six of them throughout the country. They are incident commanders. And they have, on their team, very specific people-- a financial section chief that tracks all the costs of the event; a patient section chief that makes sure we find all the patients; a staff section chief that works with staffing the clinic, bringing other staff, setting up hotels; and then someone is also with the external entities like Coast Guard, National Guard, and Navy, things like that.

So, these teams are dedicated. They're already in place. We train every other week so we're prepared.

Brad Puffer: And then when after the storm hits or passes, what are some of the biggest issues you need to address to get up and running? I assume its water and power that are at the top of your list?

Bob Loeper: Yes. About a third of our clinics have generators. Another third have the automatic transfer switch. And we have about 52 generators on trailers that can energize a whole building. So, the response can be pretty quick. And then, of course, we have backup facilities.

Most of the time, we don't need to bring in external gas, diesel, and water because it's usually pretty fast. But if it's a major hurricane hit-- 111 miles an hour or greater, what we call category three as a major hurricane-- then we're going to expect some pretty significant infrastructure problems. And then we will deploy the incident command team and bring in the gas, the diesel, the water, the fuel, the campers, security guards, all that stuff that we bring in.

Brad Puffer: So, when you have a major event like how Hurricane Maria impacted Puerto Rico, how does that change your approach? I assume sometimes you just have to improvise even when you have the best plans in place.

Bob Loeper: Yes, we did. And I flew down there very soon afterwards. And communication was very challenging. We didn't even know for a couple days after Maria hit whether or not the folks down in Ponce and Mayagüez were even up and running. We couldn't get to them. We were in San Juan. And we finally heard from them.

And what was amazing was they said, oh, yeah, we've been up since the day after the hurricane. We just got the chainsaws out, cleared the road, got our generator started, and the patients started coming in.

So, the resiliency, the local training, the patience of the staff is so important. They've got to be self-sufficient to the point that they can.

Brad Puffer: And I understand water rescues have also been needed. And you've kind of stepped up our capacity for water rescues. How big an issue is water in getting access to our patients?

Bob Loeper: Well, there's two things there, there's the flooding and the rescuing. So, what happened in Harvey, 2017—when Hurricane Harvey sat off the coast of Houston for 5 days and dumped 20 inches of rain. The place was completely flooded out.

And I'm watching the news and I'm on calls. And I start seeing people getting rescued off of roofs. And we're calling our patients. And they're saying, I'm stuck in my house, I'm in the attic, I'm on the roof. And we'll call 911. Well, they can't get here for two days. So, then I said, we've got to get boats.

So immediately, when I started calling people-- we've got to buy some boats, we've got to get some high-water vehicles and rent some duck boats out of Mobile and bring them down.

When we did the first duck boat rescue, that was really, really exciting to get that patient, getting him out of the house, getting him onto the boat, bringing him down to the clinic. That really, actually, made CNN news, it was so powerful to see that.

So, they were the best thing, high-water vehicles were the best. It was the first time we did patient rescues, to tell you the truth. So now we have a fleet of boats as well as high-water vehicles.

Brad Puffer:  You must have seen just how these storms really impact patients and how the right response can make a huge difference.

Bob Loeper: Well, what we've learned is that when we do a rescue we normally don't want to rescue patients. We leave that up to the first responders. But if they're overwhelmed, then we will go in to get them and then get them back to the clinic.

Brad Puffer: I imagine sometimes it's just as much as getting our clinic back up and running within a few days where everything else has been destroyed around it. That must be pretty overwhelming for patients, when they can get back into their dialysis center and get the care they need.

Bob Loeper: Yeah, absolutely. So, what we do-- we call it staging. So, if the storm's coming in-- like last year, Dorian was going to hit Florida. And thankfully it didn't. It went off the coast. But we are staging Lake City, Florida-- northern Florida-- with 10,000 gallons of diesel, water tankers, campers, security guards, washer/dryers-- I mean, everything that we bring. We are all camped out there, 30 vehicles, a big convoy.

And then after the storm passes, we go right in. And that's what gives us our ability to get these clinics up and running so fast.

Brad Puffer: Of course, it's not just caring for our patients that's important, it's also caring for employees. Talk about that. Because our employees are essential to be supported so that they're available to care for our patients.

Bob Loeper: Yeah, that's exactly right. And we have a model that we have to take care of employees so we can take care of our patients. We'll give them a rental car. We'll put them in hotels. We'll bring in extra food.

Actually, when we bring in food, we cook for the entire facility. So, all the patients get a hot meal when they come in. We'll give them scrubs. So, we do a lot for the employees and they really do appreciate that.

Brad Puffer: What have you learned most from some of these storms? Do you feel like you and the response team get better every time?

Bob Loeper: We hold calls every other Friday throughout the year. And we're constantly training and thinking about things that are different, and how can we respond? What worked well? What didn't work well? We used to go in and get hotel rooms around the command post and have the command post at a conference room in a clinic.

We stopped doing that a couple of years ago. We don't want to take over a clinic. So, we now bring RVs in. We sleep in the RV in the parking lot. And then we conduct our command post out of the RV. So, we're at a facility location, but we're not taking over the clinic.

Brad Puffer: It's not just these hurricanes that we've been talking about that can cause a lot of problems, right? We've been dealing with the wildfires. You've dealt with tornadoes before. It's the whole gamut.

Bob Loeper: When a hurricane is coming, you top off the generator, and then you turn it off. When you evacuate the clinic, you turn the generator off because we've learned if you don't and this storm blows through, and knocks the power out, your generator kicks on. It runs for a day so you can get there. By the time you get there, the tank's half empty. So, we turn them off for hurricane season.

Now, if you're getting a blizzard up north, when we do a disaster preparedness and response, we keep that generator on so if the power goes out, the clinic stays warm and the pipes don't freeze. If you have a fire and you have a generator, and a fire is approaching the clinic, we have to get that gas or that diesel out of that generator. We have to offload it. Otherwise, it's like a bomb sitting there ready to blow up the whole building. So different disasters require different types of responses.

Brad Puffer: We've talked a lot about our dialysis centers and clinics. But there's more and more people who are doing dialysis in their own homes and need steady supply. How does our disaster preparedness help those patients be ready?

Bob Loeper: Now, every home program is under the same conditions for coverage as a clinic. So, they have to have their own emergency plans, and the patients have to have their own emergency plans. And the home team has done a great job standardizing that.

We also will contact utility companies and let them know that there's a patient at this house address that has life-supporting equipment that needs priority for commercial utility restoration. We tell the patients if they're on a PD cycler or they're on an automatic cycler to go to manual. That's the APD supplies.

And then if your supplies are running low, then you can bring your cycler into the clinic and plug it in there, bring in your NxStage into the clinic and plug it in there. So, we've done that as well.

Brad Puffer: As we look to the rest of the season, it's been so active already. What are your biggest concerns? I imagine managing the pandemic is at the top of your list?

Bob Loeper: I'm on a lot of calls with FEMA, and EOCs, and my team. And we're talking about how we're going to respond now, how we're going to be different because of the pandemic. Because our response team cannot be 30 vehicles and a big command team coming up. Our response team is going to be much smaller and more specific that they're determining immediately what they need and get it there as soon as we can.

All responders, our incident command teams all have their own PPE now. I made sure that they all got shipped. So, it's going to be a big challenge this year and going forward, responding to a disaster during a pandemic.

Brad Puffer: Bob, it sounds like the response plan and the incident command teams that you had in place were also helpful for the pandemic. Did you have to make some adjustments, though?

Bob Loeper: We were hearing that different states were requiring us to count our PPE. And in some cases, we had to report weekly how many gloves and masks we had. And these were coming in as executive orders from different states.

So that was a different situation, a different use of incident commander. Then when we ran into transportation issues trying to get the patients to their COVID place, we needed a transportation team.

Brad Puffer: Having all of these teams prepared, whether they were prepared for hurricanes, or a tornado, or a blizzard, now applies just as importantly to our pandemic response, which is really great. Well, turning back to hurricane season-- which is already very active-- if you are a physician or a patient right now, what are the most important things you can do to be prepared for this season?

Bob Loeper: Well, it's really about training and doing drills, knowing what to expect, being prepared, and doing drills. So, when the coronavirus first hit, the first thing I did was create a pandemic tabletop drill. And this is when we didn't even have one case yet.

So, I put this together. I also got on a few calls with some VO's and we went through this drill. And that prepared people for what to expect. And when I look back at that tabletop, it's almost eerie on what we did is almost what we predicted, that we'd have to send patients away to different clinics that were positive, and some that had symptoms. And, where are we going to send your patient? How are they going to get there?

We also would ask the physician sometimes, if we can't find a patient, we call the physician up and say, do you know how to get a hold of them? Sometimes they might know something as well.

Brad Puffer: Finally, if someone else is listening to this from another health care organization or is thinking about ways that they can improve their own preparedness, what would be the top pieces of advice? I mean, obviously, be prepared. But are there two or three takeaways that you've learned that are most important?

Bob Loeper: Yeah. You've got to have trained staff. Now, our staff are not dedicated solely to disaster response. Neither am I. But when something happens, we have a team that will jump into place. So, you've got have people defined on their role and the support teams, like I mentioned, incident command teams.

And you've got to have redundancy. You have got to have several. And like I told you, I have six incident command teams. And they all are structured exactly the same way. They all know their roles and responsibilities so you can respond.

And the other thing is when you send a team in, it's very clear they're there for a seven-day tour. At the end of seven days, they're packing up. They're pretty exhausted. Their team's coming in right behind them. They have a one-day overlap.

I make my teams keep a journal. So, every day, you're writing down what you did, what you rescued, what do you need. You can look back at your journal and see what you did.

Brad Puffer: Well, Bob, it's been a pleasure speaking with you. Thank you so much for taking the time.

Bob Loeper: Thank you for inviting me. This has been a lot of fun. And we hope we don't have to respond to too many more. But I'm sure we're going to be ready. I'll tell you that part. We are ready.

Brad Puffer: And to our audience, you can find Field Notes on the Apple Store, or Google Play, or right here at FMCNA.com where you can also find our annual medical report and other feature articles.

We hope you'll come back and join us as we discuss more important issues in the weeks ahead. Until next time, I'm Brad Puffer, and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.