Which medical supplies are most likely to run out during disasters?
September 8, 2017 8:54 PM Subscribe
When a hospital or clinic is in a natural disaster and can't resupply in a timely manner, what are the key medicines/medical supplies they will be most concerned about depleting?
While reading the recent threads in Hurricanes Harvey and Irma, I was again impressed by how such natural disasters place an enormous burden on hospital E.R.s and other medical care infrastructure. When one commenter said that a hospital might run out of medications in a hurricane, it really had me thinking: what are the meds most likely to run out of before they might get re-stocked.
So my question is: in case if a natural disaster such as a hurricane accompanied by flooding, if a hospital's resupply line were impaired for a few days or a week, what are the top (ten? twenty?), most critical medicines/supplies that they might conceivably run out of before they could get restocked? And then how might you handle doing without those supplies? (Substitutions, etc.?)
I'm not so interested in supplies like toilet paper, but more curious to know about the medications and medical supplies that are the most likely to be in danger of running out in such a scenario. Thank you for your insights!
While reading the recent threads in Hurricanes Harvey and Irma, I was again impressed by how such natural disasters place an enormous burden on hospital E.R.s and other medical care infrastructure. When one commenter said that a hospital might run out of medications in a hurricane, it really had me thinking: what are the meds most likely to run out of before they might get re-stocked.
So my question is: in case if a natural disaster such as a hurricane accompanied by flooding, if a hospital's resupply line were impaired for a few days or a week, what are the top (ten? twenty?), most critical medicines/supplies that they might conceivably run out of before they could get restocked? And then how might you handle doing without those supplies? (Substitutions, etc.?)
I'm not so interested in supplies like toilet paper, but more curious to know about the medications and medical supplies that are the most likely to be in danger of running out in such a scenario. Thank you for your insights!
Best answer: Here you can find the World Health Organization's Model List of Essential Medicines - these are considered critical in a disaster situation and are stockpiled for mobilization in disaster situations.
It's impossible to consider all the iterations of substitutions one could make depending on what was left in stock, but in general, people would do things like when one class of BP medications is gone, give another as a substitute (beta blockers gone, give them ACE inhibitors), if one statin for cholesterol is gone, let's say atorvastatin, you can give whatever statin you've got in stock. If you need baby aspirin but you run out, you could cut up full strength aspirin pills. If you ran out of the first line antibiotics for any given infection, give the second or third line antibiotics if you have them in stock - example I think a person has a MRSA infection and I want to give Bactrim, but it's gone, my other options are doxycycline, or clindamycin. If all my IV antibiotics are gone I will give them oral. If they can't swallow pills I can crush them and put them in applesauce (depending on the pill, this can't be done with controlled release formulations for example). Which brings up that when controlled release formulations run out, we can give immediate release. For anti-emetics (against nausea and vomiting), I could give ondansetron, prochlorperazine, metoclopramide depending on what's on hand. If those run out I could consider promethazine, which has a higher incidence of side effects but is a similar anti nausea med. Could go to something like Dramamine or something less typical to use for nausea and vomiting, like the antipsychotic Haldol.
In emergency medicine we have a lot of hacks for when supplies are scarce or missing for some reason. I would recommend searching on medical practice in low resource settings. Here is an example of an improvisation using a latex glove as the valve at the end of a chest tube. This "Tricks of the Trade" category on a popular emergency medicine blog often features different ways of addressing a problem that involve low cost supplies or substitutions.
posted by treehorn+bunny at 11:48 PM on September 8, 2017 [17 favorites]
It's impossible to consider all the iterations of substitutions one could make depending on what was left in stock, but in general, people would do things like when one class of BP medications is gone, give another as a substitute (beta blockers gone, give them ACE inhibitors), if one statin for cholesterol is gone, let's say atorvastatin, you can give whatever statin you've got in stock. If you need baby aspirin but you run out, you could cut up full strength aspirin pills. If you ran out of the first line antibiotics for any given infection, give the second or third line antibiotics if you have them in stock - example I think a person has a MRSA infection and I want to give Bactrim, but it's gone, my other options are doxycycline, or clindamycin. If all my IV antibiotics are gone I will give them oral. If they can't swallow pills I can crush them and put them in applesauce (depending on the pill, this can't be done with controlled release formulations for example). Which brings up that when controlled release formulations run out, we can give immediate release. For anti-emetics (against nausea and vomiting), I could give ondansetron, prochlorperazine, metoclopramide depending on what's on hand. If those run out I could consider promethazine, which has a higher incidence of side effects but is a similar anti nausea med. Could go to something like Dramamine or something less typical to use for nausea and vomiting, like the antipsychotic Haldol.
In emergency medicine we have a lot of hacks for when supplies are scarce or missing for some reason. I would recommend searching on medical practice in low resource settings. Here is an example of an improvisation using a latex glove as the valve at the end of a chest tube. This "Tricks of the Trade" category on a popular emergency medicine blog often features different ways of addressing a problem that involve low cost supplies or substitutions.
posted by treehorn+bunny at 11:48 PM on September 8, 2017 [17 favorites]
Best answer: So I work in the pharmacy at a hospital that has a...not so great purchasing department, in terms of their ability to keep certain products in stock (it's a hard thing to do, to be sure, but this isn't a 10 bed hospital in the middle of nowhere, and the med will get used). So to some degree I can tell you what a big hospital would run out of because we run out of things all the time. I apologize, this got long and probably more ranty than you want, and very specific on the drugs (but not in a "exactly these 10-20 meds". More of a smattering.)
Our most frequent "out" items are antibiotics. In hospitals, many antibiotics are not oral, and thus not shelf stable. Many are shipped and stored frozen, and then thawed to fridge temps when needed.
In the last week, we have been out of (not all the time, but at least 1 day in the last 5): Zosyn 4.5g (fine, switch to 2x2.25g bags), cefepime 1g (give half a 2g bag), nafcillin 2g (2x1g bags), nafcillin 500mg (send a 1g bag, give half), and cefazolin 3g. Zosyn, cefepime, and cefazolin are really commonly used (nafcillin a little less). Vancomycin is also really commonly used, though somehow we also manage to have it in stock.
At the start (and if electricity is still going), we'd start by swapping for what size bags we have available. Without electricity, most premixed IV antibiotics are good for 24 hours or less at room temperature. After we run out, we do have a limited supply of vials that can be used to make more, but we're talking about not a lot of vials (and thus not a lot of doses). Those vial-based doses could be made right before giving them, which is excellent in terms of not wasting them. If there is an oral option of the same antibiotic, that could be used instead. After that, we're talking about switching to different antibiotics, which depends on what you're treating, allergies, etc. (Hospitals that make more of their doses from vials to begin with will have less of an issue with the above.)
Most insulin is stable at room temp for 28 days, so we'd be okay in terms of it not expiring right away. In my hospital, we use more Humalog than Novolog (both fast-acting insulins) but keep pretty even numbers on hand, so we'd run out of Humalog first. At that point, we'd have to contact the prescriber to have them change it to Novolog. Same thing with Lantus and Levemir (long-acting, basal insulins). NPH and 70/30 mix would probably "last" the longest because I get so many fewer orders for it. Regular insulin gets used fairly regularly in hospitals (it is used to make insulin drips). In my hospital, 1 vial of regular insulin makes 10 insulin drips. In a given day, we might make between 10 and 30 insulin drips (we like to have 10 always on hand, but make additional bags depending on how many patients have an active order).
Frequently we do carry multiple presentations of medications (magnesium sulfate IV bags and vials, different strengths of tablets), so we would switch between presentations, split or crush tablets if needed and possible, and switch between different medications within a class.
From a "people are likely to be injured standpoint;" the Tdap vaccine, which requires refrigeration, and injectable lidocaine (with or without epinephrine) products (especially since there are already shortages on many lidocaine products).
From an ICU-specific product perspective, I can see my hospital in particular running out of Precedex (a sedative) fairly quickly (there are alternative sedatives, though). Sodium bicarbonate has been on national shortage for months; we aren't able to keep as much in stock as we'd like already so I can see that being gone in a matter of days (probably less). As far as paralytics go, most fridge items have weeks-long stability at room temp, but some are our prefilled syringes have fairly short dating right now because we haven't been able to get more in. I've never had issues with our anticonvulsants, but Keppra & phenytoin are our biggest movers (both are available in IV and oral forms) so they'd probably go first, but there are other anticonvulsants.
If the electricity goes out, commonly-used items like nebulized albuterol would have to be changed to albuterol inhalers. Hospitals often have a "formulary" of medications they carry. For example, we carry Advair and Symbicort inhalers, but not Dulera inhalers. We carry DuoNeb (ipratropium&albuterol), but not the inhaler form (Combivent). So the lack of electricity there would be pretty bad. We carry a few statin medications, not all of them.
From the "everyone comes to us for their home meds side," my concern is less on the tablets and capsules, and more towards "bulk" items like inhalers because we can only physically hold so many. (We'd be out of Advair very quickly.)
From a painkillers standpoint, many are controlled substances which are ordered separately and which are often stored separately from the rest of the medications. My hospital genuinely can't say "We want 4000 extra oxycodone 5mg and 1000 extra oxycodone 10mg and 3000 extra morphine 2mg syringes and 3000 extra morphine 4mg syringes and 3000 extra hydromorphone 0.5mg syringes and 3000 extra hydromorphone 1mg syringes and 3000 extra hydromorphone 2mg syringes and 2500 fentanyl vials and 1200 lorazepam vials and 3000 midazolam vials and and and" because we we genuinely don't have the space to store all that extra (we can store a few of those extra, but not all of it). It's like to throw up a lot of red flags with regards to our usual usage. Also, frankly, some of those items on that list are on national backorder. We can't get them right now, even without storms affecting us. Hell, we run out of certain sizes of liquid Tylenol and Motrin because who knows. So I could see us running out of that (Tylenol in tablet form would last much longer).
Other things we'd run out of more quickly than I'd like: bags of IV fluids (for both patient hydration and medication preparation). Maybe there's many, many bags; maybe they aren't actually stored in the physical hospital. If we have electricity, we can pump to make some of them, but not on the scale of a whole hospital. Dextrose syringes are on national backorder already, so that will be bad within a couple of days.
I kind of realize I haven't given you a precise list, but I go into work and part of what I do before I sit down is figure out a.) if we have any of what we've been out of and b.) what we're out of today that's new. My coworkers and I have have questioned more than once about how we're supposed to run a hospital with all these shortages. So it wouldn't be new, it'd just be brought to a new depth of annoying.
A bonus: things that I know will be super annoying to run out of (from a "I am going to get 20,000 calls about it, but it will not matter in the long run" perspective): chloraseptic spray, miconazole powder, nystatin cream, Sarna lotion, Eucerin, Blistex. (I'm going to be honest, these are the things I get asked to send immediately, and which I do send, but with a sarcastic "Saving lives!" when the tube goes.)
posted by smangosbubbles at 1:06 AM on September 9, 2017 [28 favorites]
Our most frequent "out" items are antibiotics. In hospitals, many antibiotics are not oral, and thus not shelf stable. Many are shipped and stored frozen, and then thawed to fridge temps when needed.
In the last week, we have been out of (not all the time, but at least 1 day in the last 5): Zosyn 4.5g (fine, switch to 2x2.25g bags), cefepime 1g (give half a 2g bag), nafcillin 2g (2x1g bags), nafcillin 500mg (send a 1g bag, give half), and cefazolin 3g. Zosyn, cefepime, and cefazolin are really commonly used (nafcillin a little less). Vancomycin is also really commonly used, though somehow we also manage to have it in stock.
At the start (and if electricity is still going), we'd start by swapping for what size bags we have available. Without electricity, most premixed IV antibiotics are good for 24 hours or less at room temperature. After we run out, we do have a limited supply of vials that can be used to make more, but we're talking about not a lot of vials (and thus not a lot of doses). Those vial-based doses could be made right before giving them, which is excellent in terms of not wasting them. If there is an oral option of the same antibiotic, that could be used instead. After that, we're talking about switching to different antibiotics, which depends on what you're treating, allergies, etc. (Hospitals that make more of their doses from vials to begin with will have less of an issue with the above.)
Most insulin is stable at room temp for 28 days, so we'd be okay in terms of it not expiring right away. In my hospital, we use more Humalog than Novolog (both fast-acting insulins) but keep pretty even numbers on hand, so we'd run out of Humalog first. At that point, we'd have to contact the prescriber to have them change it to Novolog. Same thing with Lantus and Levemir (long-acting, basal insulins). NPH and 70/30 mix would probably "last" the longest because I get so many fewer orders for it. Regular insulin gets used fairly regularly in hospitals (it is used to make insulin drips). In my hospital, 1 vial of regular insulin makes 10 insulin drips. In a given day, we might make between 10 and 30 insulin drips (we like to have 10 always on hand, but make additional bags depending on how many patients have an active order).
Frequently we do carry multiple presentations of medications (magnesium sulfate IV bags and vials, different strengths of tablets), so we would switch between presentations, split or crush tablets if needed and possible, and switch between different medications within a class.
From a "people are likely to be injured standpoint;" the Tdap vaccine, which requires refrigeration, and injectable lidocaine (with or without epinephrine) products (especially since there are already shortages on many lidocaine products).
From an ICU-specific product perspective, I can see my hospital in particular running out of Precedex (a sedative) fairly quickly (there are alternative sedatives, though). Sodium bicarbonate has been on national shortage for months; we aren't able to keep as much in stock as we'd like already so I can see that being gone in a matter of days (probably less). As far as paralytics go, most fridge items have weeks-long stability at room temp, but some are our prefilled syringes have fairly short dating right now because we haven't been able to get more in. I've never had issues with our anticonvulsants, but Keppra & phenytoin are our biggest movers (both are available in IV and oral forms) so they'd probably go first, but there are other anticonvulsants.
If the electricity goes out, commonly-used items like nebulized albuterol would have to be changed to albuterol inhalers. Hospitals often have a "formulary" of medications they carry. For example, we carry Advair and Symbicort inhalers, but not Dulera inhalers. We carry DuoNeb (ipratropium&albuterol), but not the inhaler form (Combivent). So the lack of electricity there would be pretty bad. We carry a few statin medications, not all of them.
From the "everyone comes to us for their home meds side," my concern is less on the tablets and capsules, and more towards "bulk" items like inhalers because we can only physically hold so many. (We'd be out of Advair very quickly.)
From a painkillers standpoint, many are controlled substances which are ordered separately and which are often stored separately from the rest of the medications. My hospital genuinely can't say "We want 4000 extra oxycodone 5mg and 1000 extra oxycodone 10mg and 3000 extra morphine 2mg syringes and 3000 extra morphine 4mg syringes and 3000 extra hydromorphone 0.5mg syringes and 3000 extra hydromorphone 1mg syringes and 3000 extra hydromorphone 2mg syringes and 2500 fentanyl vials and 1200 lorazepam vials and 3000 midazolam vials and and and" because we we genuinely don't have the space to store all that extra (we can store a few of those extra, but not all of it). It's like to throw up a lot of red flags with regards to our usual usage. Also, frankly, some of those items on that list are on national backorder. We can't get them right now, even without storms affecting us. Hell, we run out of certain sizes of liquid Tylenol and Motrin because who knows. So I could see us running out of that (Tylenol in tablet form would last much longer).
Other things we'd run out of more quickly than I'd like: bags of IV fluids (for both patient hydration and medication preparation). Maybe there's many, many bags; maybe they aren't actually stored in the physical hospital. If we have electricity, we can pump to make some of them, but not on the scale of a whole hospital. Dextrose syringes are on national backorder already, so that will be bad within a couple of days.
I kind of realize I haven't given you a precise list, but I go into work and part of what I do before I sit down is figure out a.) if we have any of what we've been out of and b.) what we're out of today that's new. My coworkers and I have have questioned more than once about how we're supposed to run a hospital with all these shortages. So it wouldn't be new, it'd just be brought to a new depth of annoying.
A bonus: things that I know will be super annoying to run out of (from a "I am going to get 20,000 calls about it, but it will not matter in the long run" perspective): chloraseptic spray, miconazole powder, nystatin cream, Sarna lotion, Eucerin, Blistex. (I'm going to be honest, these are the things I get asked to send immediately, and which I do send, but with a sarcastic "Saving lives!" when the tube goes.)
posted by smangosbubbles at 1:06 AM on September 9, 2017 [28 favorites]
One of the humble unsung heroes that make modern medicine possible are gloves. In a disaster zone, there will be blood and bodily fluids to deal with, labs to run, IVs to start, injections to give.... disposable gloves make all that possible with a minimum of contamination and spreading of disease. In resource-limited settings, gloves are so valuable that rather than throwing them out, they are washed, sterilized, and hung up to dry.
posted by basalganglia at 5:39 AM on September 9, 2017 [3 favorites]
posted by basalganglia at 5:39 AM on September 9, 2017 [3 favorites]
Response by poster: Truly outstanding, thank you all for your insights! Definitely helps to get a better sense of what hospitals might be dealing with, supply-wise.
Many communities so often just trust that a hospital is going to be there, functioning, that it's a little unnerving to think that they might be dealing with their own problems due to a local disaster.
posted by darkstar at 6:53 AM on September 9, 2017
Many communities so often just trust that a hospital is going to be there, functioning, that it's a little unnerving to think that they might be dealing with their own problems due to a local disaster.
posted by darkstar at 6:53 AM on September 9, 2017
Best answer: If you're interested in hospital worst-case scenarios, and haven't already, I highly recommend reading the first half of Sheri Fink's Five Days at Memorial. They ran into big problems because they were running out of oxygen tanks.
posted by juliapangolin at 10:02 AM on September 9, 2017 [6 favorites]
posted by juliapangolin at 10:02 AM on September 9, 2017 [6 favorites]
Response by poster: From treehorn+bunny's "Tricks of the Trade" link above, this was pretty interesting, and on-topic:
Isopropyl alcohol vapor inhalation as an effective anti-nausea treatment.
posted by darkstar at 10:05 AM on September 9, 2017 [2 favorites]
Isopropyl alcohol vapor inhalation as an effective anti-nausea treatment.
posted by darkstar at 10:05 AM on September 9, 2017 [2 favorites]
Many communities so often just trust that a hospital is going to be there, functioning, that it's a little unnerving to think that they might be dealing with their own problems due to a local disaster.
I used to be part of a first response logistics team (through work) and they definitely worked with us on what hospitals would want and need and what to prioritize. There are a lot more people involved in all this stuff than you'd think. Our whole consulting firm was on tap for various types of disasters and did training once a year. I've had similar training as a govt employee too.
posted by fshgrl at 10:41 AM on September 9, 2017 [1 favorite]
I used to be part of a first response logistics team (through work) and they definitely worked with us on what hospitals would want and need and what to prioritize. There are a lot more people involved in all this stuff than you'd think. Our whole consulting firm was on tap for various types of disasters and did training once a year. I've had similar training as a govt employee too.
posted by fshgrl at 10:41 AM on September 9, 2017 [1 favorite]
Response by poster: Fascinating...I wonder what kind of outreach a hospital might do with local citizens for help in a disaster. I don't expect a hospital in a disaster would ever put out a call in the community for medications, but maybe things like gauze, gloves, etc. (assuming they were sterile), or wheelchairs, crutches, etc.
I know calls for blood donation happen regularly in disasters. I also recall while traveling in a very remote area of Cameroon, when a local clinic found I was in the village, they sent someone to the family I was staying with to specifically ask me for a blood donation. It seems a young girl at the clinic needed surgery for an intestinal blockage but they were out of blood. I was happy to do so (type O- ftw!).
I can imagine in a very isolated area, a clinic would probably be eager to have even donated medicine in an emergency (donated insulin being better than none, presumably). I can't recall of such a situation, and I imagine the disaster or emergency would have to be pretty bad for an administrator to even contemplate asking around the community for critical medical supplies, though.
posted by darkstar at 10:58 AM on September 9, 2017
I know calls for blood donation happen regularly in disasters. I also recall while traveling in a very remote area of Cameroon, when a local clinic found I was in the village, they sent someone to the family I was staying with to specifically ask me for a blood donation. It seems a young girl at the clinic needed surgery for an intestinal blockage but they were out of blood. I was happy to do so (type O- ftw!).
I can imagine in a very isolated area, a clinic would probably be eager to have even donated medicine in an emergency (donated insulin being better than none, presumably). I can't recall of such a situation, and I imagine the disaster or emergency would have to be pretty bad for an administrator to even contemplate asking around the community for critical medical supplies, though.
posted by darkstar at 10:58 AM on September 9, 2017
Radiolab did an episode, Playing God, based on Five Days at Memorial (recommended above by juliapangolin). Podcast description:
When people are dying and you can only save some, how do you choose? Maybe you save the youngest. Or the sickest. Maybe you even just put all the names in a hat and pick at random. Would your answer change if a sick person was standing right in front of you?posted by JackBurden at 11:25 AM on September 9, 2017 [1 favorite]
Response by poster: Awesome - just bought the book (e-text format) based on juliapangolin's recommendation!
posted by darkstar at 11:32 AM on September 9, 2017
posted by darkstar at 11:32 AM on September 9, 2017
Here in my corner of the world I regularly see clinics running low on Oxygen (after some high profile incidents they now all supposedly have concentrators, but these are also power intensive). I have seen them run out of antidotes for toxic exposures, IV fluids, and sedation medication/high power antipsychotics. It's terrifying to be sent to do a retrieval because 'the facility has run out of sedation for this violently psychotic individual' (needless to say, we bring our own).
posted by Northbysomewhatcrazy at 1:51 PM on September 9, 2017 [1 favorite]
posted by Northbysomewhatcrazy at 1:51 PM on September 9, 2017 [1 favorite]
In case anyone would like to read a free version of the story referenced above (Five Days at Memorial by Sheri Fink), it is a classic in recent disaster medicine literature! Available in shortened form in this excellent essay from the New York Times: The Deadly Choices At Memorial.
posted by treehorn+bunny at 5:20 PM on September 9, 2017 [3 favorites]
posted by treehorn+bunny at 5:20 PM on September 9, 2017 [3 favorites]
Response by poster: Jeez - I just finished the first part of the book.
What a nightmare.
Moral of the story: if humanly possible, stay away from a hospital in times of natural disaster - it's quite possibly going to be even more catastrophic and harrowing than the surrounding area, due to its function as a locus of emerging crisis in even the best of times.
posted by darkstar at 12:15 AM on September 11, 2017
What a nightmare.
Moral of the story: if humanly possible, stay away from a hospital in times of natural disaster - it's quite possibly going to be even more catastrophic and harrowing than the surrounding area, due to its function as a locus of emerging crisis in even the best of times.
posted by darkstar at 12:15 AM on September 11, 2017
Response by poster: The book actually has disabused me of one notion: that pharmacy meds might be the biggest challenge in such a disaster. In the book, Memorial had plenty of meds because that was relatively easy for rescue helicopters to drop off while they were stuck after the storm. And they still had line oxygen from the walls, too, as long as they didn't need to move people immediately.
Rather, it was the challenges posed mainly by the power outage that made the scenario truly nightmarish. No power meant the AC and ventilation was shut down, lights and elevators no longer worked, medical suction, dialysis, IV pumps, ventilators, diagnostic testing machines, and refrigeration for blood and IV fluids was gone.
Had the power stayed on at Memorial, the scenario they faced would have been still very challenging, but much more manageable and the question about possible euthanasia (or, "making terminally ill patients comfortable") would probably never have arisen.
posted by darkstar at 10:53 AM on September 11, 2017
Rather, it was the challenges posed mainly by the power outage that made the scenario truly nightmarish. No power meant the AC and ventilation was shut down, lights and elevators no longer worked, medical suction, dialysis, IV pumps, ventilators, diagnostic testing machines, and refrigeration for blood and IV fluids was gone.
Had the power stayed on at Memorial, the scenario they faced would have been still very challenging, but much more manageable and the question about possible euthanasia (or, "making terminally ill patients comfortable") would probably never have arisen.
posted by darkstar at 10:53 AM on September 11, 2017
This thread is closed to new comments.
You can store a metric assload of antibiotics and other shelf stable stuff like pain killers and malaria meds ahead of time and it'll last till the power comes back on in a couple weeks if needed. So the above are the general classes of what I'd expect to run short of first in a hospital.
Also most hospitals depend on regular deliveries of linens, scrubs and gear like gauze and syringes, leads, etc. Probably daily is the norm or weekly at the most so they'd need to stock up not to run short but that's easily done.
posted by fshgrl at 9:49 PM on September 8, 2017 [5 favorites]