Preparing individuals with spinal cord injury for extreme storms in the era of climate change

Increasing population exposure to extreme weather conditions, a hallmark of this era of progressive climate change [1Watts N. Amann M. Arnell N. et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (543) Google Scholar], creates a compelling urgency to safeguard individuals living with special medical needs who may be particularly challenged by such events. Here we discuss the heightened vulnerabilities and unique preparedness needs of individuals with spinal cord injury (SCI) in the context of climate-driven hurricanes. We outline a set of physician roles aimed at preparing patients, caregivers, and providers to proactively mitigate these risks. Since the 1970s, anthropogenic climate change has very likely contributed to increasing Atlantic hurricane activity [2Knutson T. Camargo S.J. Chan J.C.L. et al.Tropical cyclones and climate change assessment: Part I. Detection and attribution.Bull Amer Meteor Soc. 2019; 100: 1987-2007Crossref Scopus (176) Google Scholar]. Powered by anomalously warm ocean temperatures, climate-driven hurricanes are trending stronger (intensifying rapidly and attaining uncommonly high peak wind speeds) and wetter (producing extraordinary precipitation rates and rainfall totals - and triggering floods) and slowing down as they move across land [2Knutson T. Camargo S.J. Chan J.C.L. et al.Tropical cyclones and climate change assessment: Part I. Detection and attribution.Bull Amer Meteor Soc. 2019; 100: 1987-2007Crossref Scopus (176) Google Scholar,3Hall T.M. Kossin J.P. Hurricane stalling along the North American coast and implications for rainfall.npj Clim Atmos Sci. 2019; 2: 17https://doi.org/10.1038/s41612-019-0074-8Crossref Scopus (43) Google Scholar]. Hurricane Dorian's catastrophic passage over the northwest Bahamas exemplified all three trends [4Shultz J.M. Sands D.E. Kossin J.P. Galea S. Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2019; (Epub ahead of print)https://doi.org/10.1056/NEJMp1912965Crossref PubMed Scopus (18) Google Scholar]. Individuals with SCI will suffer more than most. In the pre-impact phase, as a hurricane approaches, individuals with SCI grapple with complicated logistics. For example, the choice to evacuate requires pre-planning and a team effort. Coastal and island-based SCI patients may have no viable evacuation option unless special transport can be prearranged, and those who cannot evacuate may be subjected to the full fury of the hurricane. When a hurricane strikes, persons with SCI face daunting mobility challenges. Patients living in high-rise buildings may become trapped if elevators are not operating. Emergency rescues for patients with paralysis are complex even when performed by professional responders - and much more so when lay rescuers are the only available resources. Propelling wheelchairs around storm debris or through floodwaters is physically demanding and dangerous, especially for persons with impaired or absent tactile sensation. Wind and flood damage may deprive individuals with SCI of access to their customized living quarters, designed to facilitate mobility and maximize independent functioning. Hurricanes dismantle infrastructure, frequently producing widespread power outages that can disable healthcare systems. Hurricanes also impede access to health services, thereby elevating risks for individuals living with SCI, especially those who depend on others for assistance with mobility and activities of daily living. Home health providers are generally unavailable during a disaster. Personnel staffing medical shelters lack familiarity with the care needs of this population. Physician offices and outpatient therapy clinics may be closed for weeks, interrupting both routine SCI care and treatment for storm-related medical issues. Post-storm, hurricane survivors are exposed to such adversities as hazardous debris, impassable roadways, fuel shortages, unrelenting heat and humidity, contaminated water supplies, food insecurity, insect vectors, and air pollution [5Shultz J.M. Kossin J.P. Shepherd J.M. et al.Risks, health consequences, and response challenges for small-island-based populations: Observations from the 2017 Atlantic hurricane season.Disaster Med Public Health Prep. 2019; 13: 5-17Crossref PubMed Scopus (33) Google Scholar]. During the post-impact phase, persons living with SCI who have impaired thermoregulation are at increased risk for heat- and cold-related illnesses when the temperature of their environment cannot be controlled. Extremely humid conditions may contribute to moisture-related skin damage. Individuals’ abilities to perform their bladder or bowel programs may be diminished by the unavailability of a caregiver and lack of supplies. This may result in autonomic dysreflexia with increased risks for complications, including seizure, stroke, and death. Abrupt discontinuation of spasticity medications may lead to dangerous withdrawal syndromes. Patients with intrathecal baclofen pumps for spasticity management may face barriers to obtaining pump refills. Hurricane-related psychological stress is exacerbated for persons living with SCI. This population has higher pre-storm prevalence rates of major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and anxiety disorders, likely related to the initial traumatic injury and stressors inherent in living with life-changing disability [6Fann JR, Kennedy R, Bombardier CH. Physical medicine and rehabilitation. In: The American Psychiatric Association publishing textbook of psychosomatic medicine and consultation-liaison psychiatry, 3rd ed. Washington DC: American Psychiatric Association Publishing; 1055–1104.Google Scholar]. When a storm strikes, direct exposure to hurricane hazards makes persons living with SCI hyperaware of their physical limitations and profound dependence on the actions of caregivers to safeguard them, and elevates risk for new-onset PTSD [7Espinel Z. Kossin J.P. Galea S. Richardson A.S. Shultz J.M. Forecast: increasing mental health consequences from Atlantic hurricanes throughout the 21st century.Psychiatr Serv. 2019; 70: 1165-1167https://doi.org/10.1176/appi.ps.201900273Crossref PubMed Scopus (10) Google Scholar]. Perception of life threat – a common experience for persons during the impact phase of a severe storm - is magnified by their SCI condition. Climate-driven storms can be extremely destructive, resulting in post-impact resource losses and life changes that amplify risks for new-onset MDD [7Espinel Z. Kossin J.P. Galea S. Richardson A.S. Shultz J.M. Forecast: increasing mental health consequences from Atlantic hurricanes throughout the 21st century.Psychiatr Serv. 2019; 70: 1165-1167https://doi.org/10.1176/appi.ps.201900273Crossref PubMed Scopus (10) Google Scholar]. Given the increasing prospects for hurricanes wreaking havoc in this era of climate change, healthcare providers who support individuals with SCI can engage in personal, provider, patient, and community hurricane preparedness [8Preparing for disaster for people with disabilities and other special needs. U.S. Department of Homeland Security, FEMA, Washington, DC2004https://www.fema.gov/media-library/assets/documents/897Date accessed: September 28, 2019Google Scholar]. Ideally, health professionals should develop an all-hazards household plan for likely disasters in their communities, stockpile and replenish supplies, determine contingencies regarding sheltering versus evacuation, and design a family communication and reunification strategy. Clinical care facilities should be retrofitted to withstand stronger storms. Personnel should be educated and ready for predictable disaster scenarios. Patient preparedness includes several necessary components (see Fig. 1). Health care professionals experienced in the care of patients with SCI can provide valuable consultation to public health and emergency management partners, educating them on how to best protect and maintain care for populations with special medical needs, including SCI [9Burns A.S. O'Connell C. Rathore F.A. Meeting the challenges of spinal cord care following sudden onset disaster – lessons learned.J Rehabilitation Med. 2012; 44: 414-420Crossref PubMed Scopus (15) Google Scholar,10Mills J.A. Durham J. Packirisamy V. Rehabilitation services in disaster response.Bull World Health Organ. 2017; 95: 162-164Crossref PubMed Scopus (7) Google Scholar]. Optimally, health professionals can have a seat “at the table” throughout the preparedness and response process and provide real-time guidance during hurricanes. Climate change is altering the hazard properties of hurricanes while increasing the vulnerability of island and coastal populations. Health professionals can play a vital role in enhancing the level of hurricane preparedness for individuals living with SCI and other special medical needs and can help ensure that their needs are met in the aftermath. We have no competing interests.