Pam Harrison

November 02, 2017

NEW ORLEANS — There was no power, no way to communicate, virtually impassable roads, and dodgy supplies of water, diesel, and gasoline in most parts of Puerto Rico in the aftermath of Hurricane Maria.

There were, however, 6000 patients with end-stage kidney disease who required dialysis.

Immediately after the category 4 hurricane struck the island on September 20, the two key providers of dialysis on the island — Fresenius Kidney Care and the Atlantis Health Care Group — had to ration dialysis treatments. Because there was not enough water or power to provide full treatment sessions, typical 4-hour sessions were cut to 3 hours.

"Dialysis patients living through a natural disaster face challenges that others do not," said Michael Spigler, vice president of patient services at the American Kidney Fund in Rockville, Maryland, here at Kidney Week 2017.

"Many patients take multiple medications, some of which, like insulin, have to be kept cool, and they have to eat special foods that are typically not available from food banks or emergency relief organizations," he told Medscape Medical News.

"And, regardless of what is going on around them, they have to get to dialysis," he added.

Dialysis patients living through a natural disaster face challenges that others do not. Michael Spigler

"The challenge in this disaster is that it was in Puerto Rico," said Robert Loeper, vice president of operations support and business continuity planning and head of disaster response at Fresenius Medical Care North America in Tampa, Florida.

When disasters strike the US mainland, relief teams are often able to stage, in advance, equipment, supplies, water tankers, mobile generators, diesel trucks, and gasoline — everything dialysis clinics will need after a storm has blown over.

"We make sure the clinics are closed as the storm passes by, but the next day, we assess the damage and try to get back up and running," he explained.

But in Puerto Rico, "there was no staging because you have about 1300 miles of ocean between Jacksonville, Florida — where supplies are normally shipped from — and San Juan," said Loeper.

In the early aftermath of Hurricane Maria, Fresenius Medical Care North America did the only thing it could: it transported thousands of tons of supplies on cargo planes, including diesel fuel to get generators running at the company's 28 clinics and gasoline so that staff could get to work.

Of course, the power outage affected not only dialysis clinics, many of which remain off the grid or are on the grid only sporadically, but also businesses, including banks. So, for at least a few weeks, cash became king.

The diesel sources Loeper and his command team had managed to secure were no match for the opportunists who roamed the roads, offering drivers headed to Fresenius clinics more money than clinic operators had promised to pay, Loeper explained.

"So every day for the first few weeks, we had at least one clinic that had to stop operations because of a lack of either diesel or water," he said.

"Communication was also very challenging. The cell towers were all knocked down and the satellite phones we brought with us don't work inside buildings," he added.

Eventually, the command team at Fresenius was able to secure a reliable source of diesel, along with security guards to make sure the fuel was not stolen from outside the clinics.


Patients undergoing dialysis at a Fresenius Kidney Care clinic in Puerto Rico (Source: Fresenius Kidney Care)

Staff working at the dialysis clinics were also affected by the hurricane.

"Some of our nurses lost their homes and most of their property, yet they came out to treat our patients, and have continued to do so during these difficult times," said Lisandro Montalvo, MD, medical director of Fresenius Kidney Care in Canovanas.

Dr Lisandro Montalvo

Washers and dryers were brought into the clinics so that staff could at least wash their scrubs.

At Atlantis Health Care Group, staff who needed accommodation could bunk at the clinics or stay in lodgings nearby and then carpool to the clinics to save on gas. In addition, play rooms were set up for the children of employees who stayed with their parents as they worked in the clinic, and food and snacks were provided for all.

"We created what we call 'wraparound services' so that staff would be able to stay in the facilities and provide treatment for patients the next day," said Ruby Harford, RN, PhD, chief executive officer and president for Atlantis Health Care Group.

Atlantis has 17 dialysis units across the island. The company is run by physicians and nurses, and medical directors are well trained in the operations side of the business, which is invaluable when it comes to disasters, Dr Harford told Medscape Medical News.

To get around the diesel shortage, workers drained the boat of one of the medical directors and distributed 100 gallons of fuel to staff so they could get to work, she reported.

In addition, Atlantis biomed technicians drove to diesel distribution centers themselves and filled pick-up trucks with barrels of fuel so they could deliver it to Atlantis clinics on a daily basis.

But "when the rain came, there would be more flooding, and when there was more flooding, trucks would get to the clinics late," Dr Harford pointed out.

Medical directors at the clinics had to offer dialysis "blind" because none of the local laboratories were open. "This meant that we managed patients 'old school' by assessing symptoms," she told Medscape Medical News.

Army of Nurses

By about the third week of October, an army of volunteer nurses from Fresenius Medical Care North America were able to get to the clinics in Puerto Rico.

"It was hard to come out on a commercial airline, so we didn't want to send nurses in until we were certain we could get them out," Loeper explained.

The nurses did 2-week stints in Puerto Rico, giving local staff a much-needed respite from what has been an all-hands-on-deck effort from the beginning.

"We now have close to 200 nurses who have volunteered or who are in the queue to go down to Puerto Rico through to the end of December, and most of them are bilingual," Loeper reported.

Miguel Neris Adorno

One such volunteer nurse is Miguel Neris Adorno. He is originally from Puerto Rico and was among the first to offer his services. He said he was willing to go anywhere his company wanted to send him, for as many hours a day, as long as it took, 7 days a week.

"When I first came here, patients were frightened that they weren't going to receive dialysis. But now, about a month later, they are very confident and very grateful for the dialysis we can provide," he told Medscape Medical News.

His family still lives in Puerto Rico, and he stays with them while he is helping out at one of the Fresenius clinics. And he gets to work every day courtesy of company-purchased gas.

Adorno said he is not at all sure that the power will come back anytime soon, especially in more rural areas of the island. But he doesn't really care: As long as he can help get dialysis to those who need it, he's happy to be there.

"I would have come here and worked for free. It's an honor to be here, helping my people," he said.

The American Kidney Fund has already provided more than $600,000 in emergency grants to dialysis patients affected by hurricanes Harvey, Irma, and Maria, Spigler reported

"And we hope to be able to help every patient in Puerto Rico who needs our assistance," he added.

Any dialysis patient who needs emergency assistance should speak with the social worker at their dialysis clinic or call 1-800-795-3226. And resources for dialysis patients are listed on the American Kidney Fund website.

Spigler is vice president of patient services at the American Kidney Fund. Loeper, Dr Montalvo, and Adorno are employees of Fresenius Medical Care North America. Dr Harford is chief executive officer and president of the Atlantis Health Care Group.

Kidney Week 2017: American Society of Nephrology Annual Meeting.

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