October 2017

Lower extremity clinicians absorb hurricanes’ impact

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Clinicians in areas affected by hurricanes Harvey and Irma were prepared for issues involving preexisting lower extremity concerns, but were surprised by the number of cases they saw in the storm’s aftermath involving healthy people trying to function under extraordinary conditions.

By Nancy Shohet West

As government officials and residents alike in Houston, TX, prepared in late August for what was correctly predicted to be the most significant rainfall the region had ever known, hospitals took their own precautions. With Hurricane Harvey bearing down, planned surgeries were rescheduled, medical staff were urged to stay on-site at their hospital posts, and power generators were prepared in anticipation of power outages.

Meanwhile, medical personnel who treat patients for lower extremity problems worried about what it would all mean for their patients, such as those with diabetes and the skin ulcers and open wounds that often accompany the condition, those with decreased mobility due to injuries or degenerative diseases, and those with chronic problems like tendinitis.

Hurricane Harvey, which arrived in the US on August 25 near Rockport, TX, was responsible for more than 80 deaths and deluged the Houston area with more than 30 inches of rain. Less than two weeks later, another powerful Atlantic hurricane targeted Florida, making landfall in Naples on September 10, killing more than 70 in that state. Damage from Irma is estimated at $100 billion, and Harvey at $190 billion, which would make the storm that hit Texas the most expensive weather event in US history, according to accuweather.com. (The Atlantic storm-related destruction continued after this article was written, as Hurricane Maria pummeled Puerto Rico on September 20 and Hurricane Ophelia was approaching the coast of Ireland at press time.)

Nadim Islam, MD, an emergency medicine physician and director of emergency services at Houston Methodist St. John Hospital in Nassau Bay, just southeast of Houston, recounted that at his hospital, medical personnel who were in place on the morning of Saturday, August 26—when the storm first reached the Houston area—couldn’t be relieved until sometime late Sunday, when doctors and nurses were transported to the hospital via government boat to cross an otherwise impassable flood zone.

Storm survivors, focusing on what they view as more immediate concerns, may make poor shoe choices and ignore lower extremity symptoms until they are severe.

Inside the emergency department (ED), things were relatively quiet during that time, Islam said.

“During the storm, we didn’t see a tremendous number of patients,” Islam said, pointing out that local residents had plenty of warnings about either leaving the city or sheltering in place, and hardly anyone was taken by surprise when the storm hit.

However, he said, those who did show up in the emergency department generally had good reason.

“The patients we did see tended to be much more complicated, either because their symptoms were severe enough to require a hospital visit despite the conditions or simply due to the social circumstances that accompanied the storm,” Islam said. “Maybe they couldn’t get home after being discharged, or maybe they’d lost their home in the storm and they had nowhere else to go. Even some of the shelters were inaccessible by that point.”

Pedro Cosculluela, MD, a foot and ankle orthopedic surgeon at Houston Methodist Hospital, said the initial storm preparation efforts there centered on how patients who had already been admitted to the hospital could be kept safe. The next level of preparedness focused on people who developed symptoms severe enough to warrant a trip to the hospital even in the direst of weather conditions: those with chest pains, breathing problems, or signs of a stroke.

“The hospital’s efforts then go into putting those specialists in place: surgeons, ER doctors, ICU doctors,” Cosculluela said. “By contrast, a lot of the problems we see as orthopedic specialists can wait.”

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And so while the facility’s ED doctors attended to patients with heart attack or stroke symptoms, orthopedists and podiatrists were left to worry about their chronically ill patients whose conditions impacted their lower extremities even in the best of circumstances.

Patients with diabetes, for example, were of particular concern, given their propensity for ulcers, fungal infections, and bacterial infections in the legs and feet. Floodwaters, according to bulletins put out by the National Institutes of Health and other official agencies, are prone to contamination by sewage, thereby increasing the likelihood that they carry E coli bacteria, which can cause severe infections and illnesses.

But, for the most part—according to clinicians not only in Houston but also those in Florida, who dealt with horrific weather conditions of their own when Hurricane Irma struck—patients with serious preexisting conditions were fairly well prepared for the storm and had taken precautions that prevented their problems from growing any worse during the ensuing municipal emergencies. Most patients, or their caregivers, checked ahead to ensure they had enough of the insulin and other medications they would need, that they had a safe place to stay, and that they wouldn’t be required to do more walking or other activity than their conditions safely allowed for.

“Early on in a severe weather event, the incidence of orthopedic trauma we see in the hospital is lower than usual,” Cosculluela said. “When it’s pouring, people don’t go outside and are therefore less likely to fall.”

By contrast, hospital personnel covering emergency departments during the storms, as well as specialists who saw patients in the days and weeks that followed, were surprised to find the biggest lower extremity issues they saw didn’t involve patients with pre-existing conditions but people who considered themselves in fine health. It was that very perception of strength and wellness that led many of them into careless behavior that resulted in injuries.

“With all the frantic movement as they rushed around trying to take care of their homes and belongings, people were twisting ankles. We even saw people who had climbed up to their attics for safety, not realizing the plywood floor couldn’t hold them, and had fallen through, resulting in fractured ankles, broken legs, or broken hips, as well as scrapes and open cuts that led to infections,” Islam said.

Cosculluela observed the same phenomenon.

“We saw a minor spike in ankle sprains and ankle fractures,” he said. “In the midst of the floods, people were jumping into the water without knowing what was underneath. People who were carrying their belongings were dropping heavy objects, damaging their feet and toes. Rescue workers hurrying in and out of boats and reaching into difficult places incurred twists and sprains and breaks.”

Once the storm ended, said Islam, hospital personnel started to see patients with infections.

“People had been working throughout the night as water levels crept up. They were frantically running around trying to keep water away from their homes, and often they did so in sandals or water shoes,” he said. “As a result, they’d get cuts on their feet, which would then become infected in the dirty flood waters. We saw many infections that we had to treat like MRSA [methicillin-resistant Staphylococcus aureus] because we weren’t sure what was causing them.”

Maria Buitrago, DPM, of Podiatry Associates of Houston, also said she’s seen a lot of patients with infections since the hurricane, including patients with open wounds related to diabetes or vascular problems, who may have picked up new infections during the flooding. Moreover, slogging through muddy, opaque, swirling flood­waters lends itself to scrapes and lacerations, another source of infection.

“I saw one lady with a fifth metatarsal fracture in one foot and infected sores on the opposite leg from the floodwaters,” Buitrago said. “I also saw a lot of cellulitis, some of it caused by the rubbing and blistering incurred by people walking around in wet boots. But so far, all the infections I’ve seen in my patients could be successfully treated by antibiotics. I haven’t seen any cases of necrotizing fasciitis, though I understand from news reports that it’s out there.”

The Houston Chronicle reported two Houston-area residents developed necrotizing fasciitis related to storm conditions. One, a woman aged 77 years, died on September 15; a former firefighter and medic who was involved in rescue efforts survived his bout with the infection.

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“This is when infections can happen,” agreed Jairo B. Cruz Jr, DPM, a podiatrist with Advanced Podiatry in Tampa, FL, whose practice closed for about a week following the destruction of Hurricane Irma in early September. “Any kind of increase in moisture in the foot can lead to infections from bacteria that thrive in water. And, sometimes people overlook the signs of bacterial infections in their feet. That’s when they run into trouble by not treating it fast enough. The very young and elderly, with compromised immune systems, are particularly vulnerable to these infections.”

Like his peers, Cruz was especially concerned about his patients with diabetes and vascular disease.

“Both of those diseases put patients at greater risk for amputation,” he said. “But so far our patients have done OK.”

And the orthopedic injuries resulting from the storms may well have yet to peak, Cosculluela said in late September.

“What we expect to see in the upcoming weeks is a large number of injuries caused by the work people do as they try to put their homes back together—falls from ladders, for example, that lead to heel and ankle and leg fractures,” he said. “This same kind of spike happens around Christmastime, too, when people are up on ladders putting up lights and decorations.”

More injuries to feet and legs may well have occurred during debris clean-up than during the storms themselves, Islam agreed.

Hurricane relief: How you can help

A number of lower extremity organizations and business have already stepped up to donate resources and funds to victims of hurricanes Harvey and Irma. Rockford, MI-based Wolverine Worldwide, for example, partnered with the American Red Cross, United Way, and the footwear industry charity Two Ten Footwear Foundation to pledge more than $2.6 million to disaster relief efforts (see “Lower extremity orgs help hurricane victims,” October 2017, page 61). More recently, Mequon, WI-based Dr. Comfort donated more than 500 pairs of shoes to the American Red Cross and Soles4Souls for hurricane relief (see TKTKTK, page 61).

A few ways others can help:

Soles4souls is accepting donations of products including shoes, clothing, socks, underwear, and diapers, but they are also in need of monetary donations to help get the products to those who need them. Visit souls4soles.org for more information.

Donating blood is always a critical need after a natural disaster. To find a blood drive near you, go to redcrossblood.org.

Insulin for Life is collecting unexpired and unopened diabetes supplies (especially test strips and insulin) for those affected by hurricanes. For information, go to ifl-usa.org/what-we-need.

“When amateurs attempt to do heavy lifting, the result is often cuts, sprains, and fractures,” he said.

This was a factor leading up to the storm as well, as homeowners climbed on ladders to cut branches or put up shutters.

“It’s a high-risk situation, and when you combine the nervousness and jitters and sense of urgency that people feel when a storm is coming, the probability of injury grows,” Islam said. “So people shouldn’t wait until the last minute to prepare for a storm, and when they do, they should exercise extra caution.”

Buitrago noted some patients she had been treating for on­going conditions exacerbated their existing problems by prioritizing clean-up efforts over good judgment.

“People with conditions such as tendinitis who normally give their feet a rest were on their feet all day cleaning up their yard or helping neighbors. Then they’d come see us in pain,” she said. “I’ve seen a lot of stress fractures in the past couple of weeks also, and even blisters. Some of the patients are flood victims, and others are people who were just helping neighbors and friends.”

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Not only are patients with preexisting conditions spending too much time on their feet; they’re also doing so in the wrong footwear, Buitrago said.

“People are wearing rain boots that don’t have a lot of support as they spend hours working on their feet,” she said. “This results in not only stress fractures and blisters, but also in overall pain.”

Footwear that exposes a lot of skin is another culprit, several medical professionals said. Some flood victims donned sandals to walk through the floodwaters, exposing their feet to debris in the water and increasing the risk of cuts and abrasions. Others automatically reach for their oldest sneakers when it comes time to clean up the debris.

“Wear your newest sneakers for this job,” Buitrago urged. “You’ll need the support. Then just replace them when you’re done.”

Making matters worse, Buitrago said, is that storm survivors focused on what they perceive as more immediate concerns sometimes will ignore pain and discomfort in their lower extremities.

“We treated one lady who had been on her feet for hours wearing heels. An x-ray revealed that a bone was dislocated and she would need surgery,” she said. “After a crisis like this, some people run on adrenaline, not thinking about themselves or how they feel.”

Of course, few people who endured hurricanes Harvey and Irma would dispute that hurricanes and other storms are increasingly becoming a fact of modern life, and medical personnel emphasize that, as with so many other things, prevention is the best cure when it comes to protecting feet, ankles, and legs. People with diabetes and others who are prone to ulcers or have unhealed wounds need to be particularly ready when flooding is a threat.

“You have no idea what’s in that water,” Cruz said. “Once an infection starts to grow, it becomes increasingly difficult to treat. To resolve it efficiently and effectively, treatment needs to begin almost immediately. High-risk patients, many of whom have comorbidities, can develop massive infections in the space of twelve hours.”

And even while he was counseling his own patients about hurricane preparedness, Cruz was trying to learn from the experience and expertise of those who had been through the process many times.

“My eighty-year-old patients were giving me advice on how to prepare,” he said.

Ultimately, clinicians say, most hurricane-related injuries come down to a lack of caution and awareness—whether patients were trimming branches ahead of a storm, wading through water during an evacuation, or dragging out debris afterwards. Even the best-intentioned activities require vigilance when the circumstances aren’t normal, noted Buitrago, who counts many runners among her patients and is a marathon runner herself.

“I saw people out for a run after the rain ended, jumping over the puddles,” she said. “Even that carries a risk of slipping. It’s good to get out, but people should continue to be careful.”

Nancy Shohet West is a freelance writer in the Boston area.

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