After Hurricane Maria, Physicians Team Up to Provide Care

Ricki Lewis, PhD

October 06, 2017

From the military to professional medical organizations, to grassroots efforts, the healthcare community is uniting to help the people of Puerto Rico surmount and survive diverse challenges in the aftermath of back-to-back powerful hurricanes.

Hurricane Maria struck Puerto Rico on September 20 with sustained winds of 155 mph. It wasn't a rescue-from-the-rooftops sort of storm, but instead a profound collapse of communication and transportation systems that left many people medically stranded.

By October 5, 64 of the 69 hospitals on the island had reopened, not all up to full speed, and 17 were on the power grid, with the remainder using generators. The day before, the first patients were helicoptered from overwhelmed hospitals to the intensive care unit of the USNS Comfort, an air-conditioned hospital-ship with 200 beds and more than 500 medical staff. At the same time, the Department of Homeland Security Disaster Medical Assistance Team set up field hospitals to ease the burden on emergency departments. And by October 5, the US Army Corps of Engineers had placed the first "blue roof," on Multy Medical Facilities in San Juan, a private hospital, creating temporary beds.

Because cities are farther along in recovery than other areas, the fatality count is fluid. Governor Ricardo Rossello initially said 16, then raised it to 34 on October 4, attributing 20 deaths directly to drowning or being buried in mud, two to suicide, and the rest to the elderly and the ill, such as people who ran out of oxygen. But many regard those statistics with skepticism. "I've just heard that in the western part of the island, many have died due to lack of medications and power outages," Michelle Carlo, MD, a pediatrician in Guaynabo, Puerto Rico, told Medscape Medical News. Sources report an uptick in suicides, although unconfirmed.

The Most Urgent Medical Needs

The devastating hurricane and its aftermath are affecting all medical specialties. One of the hardest hit patient pools was people with diabetes. Myriam Z. Allende-Vigo, MD, an internist and endocrinologist at the University of Puerto Rico and governor-elect of the Puerto Rican chapter of the American College of Physicians, described the situation:

"Puerto Rico has the highest prevalence of type 2 diabetes in the US, at 17%, and many patients are on insulin. After Hurricane Irma most of the island was without power. One week later came the even stronger Maria and 100% of the island was without power. Only 35% of the people had cell phone communication and 50% had running water. Most of the people on insulin were unable to keep their insulin refrigerated. One week after Hurricane Maria, most of the insulin had spoiled."

The endocrinology community set up six insulin distribution centers, first at the largest hospitals that had power, and expanding as other places were back in business. Doctors drove to the more remote areas, bringing insulin and glucose meters.

Other great needs right now, Dr Allende-Vigo told Medscape Medical News, are medications for hypertension, skin infections, conjunctivitis (there's been a surge of cases), and asthma. Cholera is not a concern, but outbreaks of mosquito-borne diseases such as Zika, chikungunya, and dengue are possible.

The stress of living through the double-barreled hurricanes has brought psychological challenges, too. "Normal responses in children immediately after such a huge disaster are fear, anxiety, problems eating and sleeping, nightmares, and regression. Kids who were toilet-trained at 3 might wet their bed. These effects lasting more than a few months become more like PTSD [post-traumatic stress disorder]," said Saneya H. Tawfik, PhD, director, Psychological Services Center, University of Miami, Coral Gables, Florida.

With houses destroyed, many people were at first without any medications at all, including psychoactive drugs. While a few days without antidepressants or antianxiety medications would not be catastrophic, the situation is more serious for patients with schizophrenia or bipolar disorder. "When they stop their meds they really do have great difficulties, not unlike the people with diabetes or hypertension," said Jack Ende, MD, president of the American College of Physicians and the Adele and Harold Schaeffer Professor in Medicine at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia. (The ACP has 600 members who practice in Puerto Rico.) He and Dr Allende-Vigo told Medscape Medical News that they are very concerned about PTSD in the coming months and predict a growing need for psychologists and psychiatrists on the island.

Communication Breakdown

Persistent communication problems remain a huge issue. "Some small towns and communities in the middle of the island have completely lost communication with the world. Because roads are closed, reaching these people and bringing them food and water and meeting their basic needs has been a nightmare. Puerto Rico has more than 7000 miles of roads, mostly in the mountains, and some small roads are difficult to clean up," Edgar Colon, MD, a radiologist and dean of the school of medicine at the University of Puerto Rico, told Medscape Medical News. However, media reports of entire towns buried under mud are exaggerated, he added.

Daily routines have vanished. "People cannot contact their doctors. Many medical offices are not open. The pharmacy system is down, so patients come in to refill their insulin prescriptions and the pharmacists say fine, but you have to pay $150 out-of-pocket, which of course they don't have," said Dr Carlo.

In addition to the challenges of obtaining everyday medications and services, Dr Colon pointed out the danger of the disruption of the referral pattern that patients normally use to get medical services. Continuing limited phone coverage is exacerbating the situation. For some people along the south coast and in the west, he said, "If there is a medical emergency and they need to reach out with a phone, it's just not going to happen. The situation in San Juan is completely different."

Power to the People

Cancer patients requiring timed infusions of chemotherapy in hospital suites and patients in kidney failure needing hemodialysis faced the most immediate danger in the days after Maria wiped out power. Radio stations directed patients where to go for hemodialysis when the facilities they normally use were shut, said Dr Allende-Vigo. "Dialysis is typically done three times a week for 4-hour shifts, and without power a patient who has no renal function cannot do without it," said Dr Ende.

In the remote communities, expected to be off the power grid for months, said Dr Colon, getting generators up and running was imperative. During the first week, gasoline was scarce.

But there's been "an amazing outpouring" of help, said Kim Yu, MD, past board chair of the Michigan Academy of Family Physicians. In just one week, the Indiana Academy of Family Physicians and the Puerto Rican Academy of Family Physicians and other chapters, including the parent organization, raised more than $59,000. "They sent 51 generators to Puerto Rico so they could open the clinics for the family doctors and see patients and not have to burden the [emergency rooms]," she told Medscape Medical News.

The family physicians have divided the island into regions, appointed regional leaders, and established an organized structure to distribute aid, Dr Yu said. "Doctors at the airport are collecting supplies, inventorying and sorting them, and figuring out which areas need the aid first. Logistically it's been challenging but they're doing a phenomenal job." She also credits the Baton Rouge Emergency Aid Coalition ( and Physician Relief Network for rushing medication and supplies, including generators, to the island, and requests designating Hurricane Maria relief when donating to the network.

Taking It to the Streets

When and where patients can't reach their providers, the providers are coming to them. "Doctors with grassroots experience from Hurricane Katrina are helping to put everything together in a mini-warehouse. Doctors can come in to get medications handed out in bags and they are going to towns on foot to reach their patients," said Dr Carlo.

Social media has spawned #grassrootsmedrelief, a group that claims to have been the first responders to Maria. "We have helped coordinate the delivery of nearly 40 tons of medical supplies to Puerto Rico, the largest shipment possible thanks to the generosity of the mayor of Houston, who yesterday sent 20,000 pounds of medications and 30,000 pounds of emergency supplies," said Rafael Guerrero-Preston, DrPH, MPH, assistant professor of Otolaryngology-Head and Neck Cancer Surgery at the Johns Hopkins University School of Medicine in Baltimore, Maryland.

"Teams of physicians receive, store and distribute the meds, based on lists of supplies from hospitals and clinics, as well as lists that our team on the ground has ascertained as we visit hospitals, clinics, shelters, nursing homes, and children's homes throughout Puerto Rico," he told Medscape Medical News.


Slowly, people are getting what they need, from insulin to surgery.

Iván González Cancel, MD, who performed the first ever heart transplant in Puerto Rico, said that on Saturday, September 30, Centro Medico and Centro Cardiovascular recovered power and water services. "That same day, we were able to transfer two babies needing heart surgery to Miami."

On October 2, he resumed patient office visits and performed the first heart surgery posthurricane. "In the eastern town of Humacao, the busiest hospital that serves that region was closed due to electric generator problems. The patients have been transferred to the USNS Comfort," he told Medscape Medical News.

But with the extent of destruction, it's still hard to know who's been missed. And so medical efforts will be ongoing for a long time.

Dr Colon is more optimistic than he was just a week ago. "We've learned from this experience. The community is doing a great job helping each other. People are coming together and trying to reach out however they can. This is an island of very hardworking, proud people. Down the road we're going to be fine."

Dr Ende added, "Within the American College of Physicians we fully appreciate what a difficult year or maybe two this is going to be for our colleagues. We are doing everything we can to stay in touch, to help in all possible ways. We want them to know that we're in it together."

The sources have disclosed no relevant financial relationships.

Correction: In the statement concerning the number of dead in the western part of the island, "200" has been changed to "many."

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