ON THE FRONT LINES OF DISASTER RECOVERY: NURSE PRACTIONERS FILL THE HEALTH CARE VOID

By Kathleen P. Wilson, PhD, APRN, CPNP, FNP-BC, BC-ADM, FAANP

Region 1 Director, Florida Nurse Practitioner Network (FNPN)

GREETINGS from Region 1 of the Florida Nurse Practitioner Network (FNPN)!!!  Region 1 covers North Florida from Escambia through the Big Bend area and down to Alachua/Levy counties.  It includes the 27 counties:  Escambia, Santa Rosa, Okaloosa, Walton, Holmes, Jackson, Washington, Bay, Calhoun, Gulf, Liberty, Franklin, Gadsden, Leon, Wakulla, Jefferson, Madison, Taylor, Hamilton, Suwannee, Lafayette, Dixie, Columbia, Union, Gilchrist, Alachua and Levy counties.

 

Region 1 was blasted by Hurricane Michael on 10/10/18 causing massive destruction to nine (9) counties of Jackson, Washington, Bay, Calhoun, Gulf, Liberty, Franklin, Gadsden, Wakulla. This Hurricane Category 4 (nearly a Cat 5); Hurricane Michael was the first Category 4 storm in recorded history to make landfall in the northeast Gulf Coast and the third most destructive hurricane to hit the continental US. The primary area was a 90-mile area on the Gulf of Mexico on the south side of the Florida panhandle which has been was dubbed the Forgotten Coast due to the fact that developers ignored that remote section of north Florida coastline leaving it free of mass development the area is filled with quaint old-Florida style beaches and towns.

Local healthcare infrastructure was severely damaged with four (4) hospitals and eleven (11) nursing homes and other facilities gravely affected across this region.   Death toll of 43 persons, with initial estimates of property damage in excess of and an initial $4.5 billion.  This part of Florida has previously been referred to as the Forgotten Coast due to its pristine uncommercialized developments and visions of “old Florida”, but with resident relief efforts these affected communities are now referred to as Resilient Coast with the rebuilding of this once peaceful area. 

On the disaster front lines, nurse practitioners have filled the health care gap as the primary health care force in the hurricane ravaged area of north west Florida.  Here below are the stories of four (4) courageous trailblazing nurse practitioners as they recreated themselves in such a way to provide needed health care to several communities ravaged by Hurricane Michael one mid-October day in 2018.  With the collapse of the medical infrastructure including two main acute care hospitals - Bay Medical Sacred Heart and Gulf, Coast Medical Center, shut down for the past 3 – 4 months with large staff layoffs, many heath care facilities and clinics closed as many physicians left the area due lack or support.

Having driven through these affected communities, I am so moved by the devastation and am in awe of the nurse practitioners who have stepped up to continue needed are for their communities.  I am humbled and honor to have had the opportunity to interview these nurse practitioners and to help tell their stories: 

#1

Christine Bottkol DNP, FNP – C; President of the Panama City Beach NP and PA group, home town of Mexico Beach and works in Wewahitchka north of Mexico Beach as an NP at a regional correctional institute.   Work history includes serving as the top administrator/Nursing Coordinator for a local nursing program for seven (7) years and then returning to private practice. Is a veteran and served 6 years in the Air Force.

Personal challenges (family, job, etc.) in your community due to the hurricane devastation?

She states “feeling lucky as she just got a roof just yesterday (mid – January 2019)” noting that she was one in Mexico Beach to get a roof – now 3+ months after Hurricane Michael came ashore as a Category 4 – 5 Hurricane! For her it was a wind event, and being just .9 mile from ocean’s edge, water did not get in her home.  Her family, two daughters of which one lives at home and is a recent graduate and her friend, as well as her husband had been camping out since the hurricane wiped out their community.

Ability to continue your job as an APRN in your community?

Works as one of the two nurse practitioners at a regional correctional institution providing medical care to a prison population.    When the hurricane approached, quickly transitioning from hurricane category 2/3>>4+ she had to stay for three (3) uninterrupted days to provide medical care at this correctional institution until additional medical relief arrived. As a veteran with 6 years in the Air Force with experience in neuro ICU, Trauma, et., her motto is “duty trumps all” - as she had to stay and would not abandon my post even without knowing how her family was.  She stayed out of duty to her employer and prisoner population without being able to contact her family due to the communications networks being inoperable.  Upon learning that Mexico Beach obliterated, she had no way of learning about her family’s status, which obviously caused much distress until she was able to hear from her family that they were unharmed and alive.     

Over the next several months, she has continued to travel to her place of employment, the correctional institution, which required a 1 hour 30 minutes to a 1 hour 45 minutes commute through roads that had been blocked debris and trees, etc.  - She shares that her employer, a contracted agency for correctional health services, gave her much support and took excellent care of her and those in the institution over the past several months.  They provided her with a rental car, paid for her travel time for the nearly 3 – 3.5 hours of travel time, and provided her 10 shifts – 4 days/week to allow her some time to support her family in blocks of time for their recovery.  

Disruptions of health infrastructure serving your community?

Had learned from other providers in the area that many of them have fled the area and relocated or took locum tenens positions to earn a living since two Panama City hospitals: Bay Medical Sacred Heart and Gulf Coast Medical Center were severely damaged, Bay Medical Sacred Heart closed until recently with prior significant layoffs (~800 staff. – including physicians), while Gulf Coast Medical Center Gulf Coast Regional Medical Center reopened in mid - November for partial outpatient services and inpatient services, and as of January was fully functional with a focus on cardiac care.  Several nurse practitioner colleagues have been laid off in other facilities after having to use their PTO for days used when facility was closed due to damage, and then due to long periods of time to re – open had been laid off.  Surgical services have been distributed to surgery centers west in Destin, Florida or east in Tallahassee.  Additionally, there are no places to work, and no places to stay for providers who are coming into the community either as a returning provider or those coming in for temporary support and relief. “Would love to have more providers, but there is nothing and no one left”.   She said – “Sounds like a good time to permit nurse practitioners to practice to the fullest extent of their education, so if there is a time and event that would demonstrate this, Hurricane Michael certainly did. 

“The entire medical infrastructure has been uprooted.  So many providers have left – It is like a ghost town, as an APRN, ‘you are it’ for you, your family, and your community are relying on you as an APRN to carry on the medical care for the community.”  Patients who have lost their contacts with providers, have had to also rely on samples of medication including inhalers, insulin, etc. from the Red Cross.  Those providers left in the community have worked hard to maintain themselves and their services to the community, just as neighbors pulling together to help each other.

Professional challenges?

As the President of the local Panama City NP and PA Group - we have not been able to communicate with each other due to initial lack of electricity, and with continuing lack of internet services.  No physical place to meet and no virtual means to meet either.  Have been using phones to reach out to colleagues to check on their status of survival.  However, has been thankful of the opportunity to help her community. 

 “Thank you for reaching out and supporting us – to tell the story”….

#2

Janet Gysi, APRN, FNP – C; For 20 years has been a nurse practitioner of which the 10 most recent years have been as an independent contractor providing health care services to long term facilities.   Has been a nurse educator in both 2 and 4-year nursing programs, always enjoyed fostering professional growth across the health care continuum of nursing. 

Personal challenges (family, job, etc.) in your community due to the hurricane devastation?

Lives in Panama City Beach where she was on the western side of the hurricane, and she sustained a tree falling on her home.  Was able to get the tree of her house with a few torn shingles, reports not sustaining any water intrusion.  Fence had to be fixed.  Although did not have personal loss of her home but had a loss of her practice with “no place to practice”, felt the angst in the area for those who were going through much worse loss than she, maybe because she is a nurse with empathy.

Ability to continue your job as an APRN in your community?

Disruptions of health infrastructure serving your community?

Practice locations – both damaged.  One of the practice settings – a community health and rehabilitation facility which is now being repaired, did not evacuate.  This included staff and 105 residents living through the hurricane with water intrusion, roof and windows were blown out, which required shifting the residents from one side of the building to the other staying in place for 3 days until post hurricane evacuation due to the deplorable living conditions.  Many of these residents had dementia, some were bed bound, but they were all placed on busses with the staff for whom they were familiar, as they were distributed to other associated long-term care facilities in neighboring communities to the west such as Pensacola, Niceville, etc.

The other facility, a small assisted living facility with skilled nursing unit of 22 beds evacuated

prior to the hurricane landfall to Altoona in central Florida into associated continuing care retirement locations.  Janet reports that she has been going on Friday’s twice monthly to these facilities which is a five (5) hour drive each way to visit and care for her residents!

Janet states that through networking with administrators in the neighboring towns of Bonifay and Callaway - she has been able to create an opportunity for herself to be their onsite provider as an independent contractor with physician oversight by the Medical Director.  In the area there is typically a nurse practitioner in every long- term care facility. 

As far as the rest of the community, it is truly a catastrophic situation.  With many clinics and the two major hospitals severely damaged and not yet fully operational, with one having to layoff 800 staff members, many of the providers were driven away to relocate due to lack of infrastructure.  A couple of community events have mobilized in the Panama City area to provide some health care services during this provider void.  One short term, temporary relief opportunity to provide health services came to the community from the Remote Area Medical Clinic (RAM) one weekend in December 2018.  This is an organized program including dental services (teeth cleaning, oral care), vision services (made onsite and provided glasses), medical (along with local partners - health department vaccines, Sacred Health mobile unit with a physician and provisions for EKGs, and clinic services through the local Islamic Society/Baptist church).  All services were free, and supplies/equipment brought to the area through RAM.  Typically, RAM runs programs in Appalachia, and one is held each October in Bradenton spearheaded by nurse practitioners, and Pensacola/Milton area.  Janet was the only local licensed provider along with some additional non-local nurse practitioners from Tallahassee, and the two NPs from the Bradenton program.   Secondly, PAN CARE of NW Florida provided medical and dental clinics on mobile bus units as set up in sponsoring grocery store parking lots. 

Professional challenges?

Student NP preceptorship settings have also been reduced if not eliminated with the loss of these many health care settings and will also gravely limit nurse practitioner clinical education until these settings recover.  If asked to serve as a preceptor for an NP student, please be gracious and assist in any way possible. 

 Janet recommends that in times as these with a community crisis, nurse practitioners may have the opportunity to recreate themselves into roles that would help fill the health care gaps.  Look for the gaps and create the opportunity.  Consider alternate practice strategies.  

#3

Sarah Beth, Guy, DNP, APRN, FNP – born and raised in the Panama City area.  Most of her career in nursing first working in the hospital since 1972   Became the first NP in Bay county, acquiring a Masters’ degree in 1999 and then the DNP from Florida State University in 2011.  Had been a nurse educator through the FSU College of Nursing BSN program offered through Chipola College. 

Currently owner and operator of Sister’s Clinic in downtown Panama City. ”– located in one of the hardest hit areas.  Sister’s Clinic is one of the first NP owned and operated clinics in Bay County and she considers herself the “CEO, CFO, and CNO of the clinic.  Currently only accepts cash payment. Has a collaborative MD and an awesome office manager who had been with her since 2000.  Originally started her practice in and underserved area with funds borrowed from a physician friend.  Took a short course on taxes and business; worked with a CPA to develop her business plan initiated and a tax ID to get started.  Had “good people to grow her business.”  Acquired the majority of office furniture from Gulf Coast Hospital as she went to materials manager with a list of what she was looking for and it was approved by administration, then completed getting more items when Gulf Coast Hospital had a “garage sale”. 

Personal challenges (family, job, etc.) in your community due to the hurricane devastation?    Panama City was hit hard with the eastern communities of Parker, Callaway, Springfield devastated with damage at the Hathaway Bridge which disconnected the east/Panama City for the west/Panama City Beach.  A typical 20-minute drive to Callaway took 1.5 hours.  The fire department staff went house to house with chain saws.  Has a 23 year -old niece who is a firewoman on duty in Bay County.

Lives in a 100-year-old house with a metal roof.  Many trees down, lost back porch, but the house was livable.  Lived off a generator for 4.5 weeks as the entire power grid down in Bay County and not restored until the week of Thanksgiving.  Apparently, Gulf Power Company anticipated the need and stored 6000 electric line poles which were place in the weeks following the hurricane.  It was noted that the Hurricane was actually a category 5 with winds in excess of 155 with gust to 200 – 225 mph so this storm was a big wind event.  

Sister’s Clinic was shut down until November 5th.  In order to reopen the clinic required clean-up to remove the water intrusion and mold which was removed with a vinegar/water spray and left to dry.  Roof required repair. 

Additional concerns included the lack of internet and strangers in town.  Regarding the internet it was during the first few weeks – lucky to find a hot spot, finally finding one at the local Home Depots.  Due to the area being considered a disaster area 30 days of internet provided – but it was intermittent in areas requiring a drive around to find a good spot for connectivity. Also due to many new people who were in the area and those “flushed” out by the storm, concerns about break-ins arose.  She had someone break into her home, but only food items were taken. 

Ability to continue your job as an APRN in your community?

Disruptions of health infrastructure serving your community?

Sister’s Clinic, a family practice clinic, is up and running seeing about 20 -30 patients daily.  Services are provided by herself and two (2) nurse practitioners, although one of the nurse practitioners is on maternity leave.  Most of her patients have had their lives so disrupted that it has been difficult to care for their health care needs. 

The medical community resources were devastated with the two hospitals damaged. In particular when Bay Medical Sacred Heart laid off more than 800 of the 1800 employees although they were promised to be paid through February 2, 2019, many physicians left the area.  With this physician loss, about 15 – 20 associated nurse practitioners who worked with them also lost jobs and had to find positions out of the area.  Although about 95% of nurse practitioners in Bay county are not associated with independent clinics, several more have started their own clinics to serve the health care needs of the community.  With transitions occurring, Bay Medical Sacred Heart Hospital (public hospital) has reopened now with limited services including seventy-five (75) in-patient beds and eight (8) operating room suites of which four (4) are devoted to cardiac services as cardiac catherization labs. In Bay county alone nearly 3000 students left the school system and with them their parents many of whom had been engaged in the health care arena for Bay county.   

Professional challenges?

One challenge has been her efforts to get nationally certified by AANP as when she first practicing as a nurse practitioner national certification was not a state of Florida requirement and she was eventually “grandfathered in” when it became a requirement.  Now in an effort to be fully recognized on Medicare and Medicaid panels, she is seeking national certification through the American Association of Nurse Practitioners (AANP).  In preparation for the exam she had been preparing through an online review course program which was interrupted due to the loss of internet when the Hurricane Michael came ashore.   She hopes to get restored internet service soon in order to be able to resume her review course and then take the certification exam.  Thus, eventually she will be able to broaden her ability to provide more services to those on other insurance panels. 

 

#4

Sharon Wolford, APRN, FNP -C is the owner and operator of the Wolford Family Clinic, in Lynn Haven, Florida.  Currently working on completion of her DNP.  Her DNP project is addressing hospital safety net tracking directly linked to specific diagnosis pathways aiming to decrease return hospital visits.  She is in the Air Force Reserve with drill weekends at Keesler Air Force base in Biloxi, Mississippi. She has three children.

 Personal challenges (family, job, etc.) in your community due to the hurricane devastation?

Prior to the story she was working as an independent contractor for a skilled nursing facility with 115 beds providing dementia care, skilled nursing services, and rehab services.  When Hurricane Michael landed and blew across the area, the roof of this facility was blown off the entire building and the residents were evacuated to Pensacola while she stayed with them until either picked up by a family member or placed in an associated rehabilitation facility. Along with her three children) she stayed for one (1) month in the Red Roof Inn in Pensacola to get these residents settled into their new locations. She stayed with her residents in Pensacola and discharged each one to home setting or to another facility setting.

Ability to continue your job as an APRN in your community?

Disruptions of health infrastructure serving your community?

Following the storm, she took immediate action to fill and health care void in one of the most heavily storm damaged areas in the path of Hurricane Michael.  She opened the Wolford Family Clinic to provide family practice services.  She was able to get credentialed with her health care clinic/medical license. Currently she accepts Medicare and cash payments.  Currently she is the only provider seeing 10 -12 patients daily with Walk-in-Wednesdays.  Until just last week, when she was able to hire a staff member, she was functioned solo and did all procedures rom drawing her own labs, assisting patients with intake histories, procedures as appropriate etc. 

In addition to managing a busy family practice clinic, she also manages a total of four ALFs in the bay county area including Lynn Haven, a community that was gravely destroyed by Hurricane Michael.   At these facilities, she has been very resourceful to the residents such as when needed, using mobile imaging for X-rays in house to avoid transport of these frail residents, many of whom are DNR’s.  She continues to expand her credentials with other insurance panels. 

Professional challenges?

The continues to work with home health agencies especially for the many individuals who were “flushed” out of their homes in this community, many who not have been engaged with the health care community for many years.  She notes that there had been individuals with significant mobility issues, COPD, and other chronic illness in great need of heath care support but for many reasons such as lack of transportation, family support, etc., had not been connected to a health care provider for many years. Many of these individuals were taken to available hotels until they were triaged in order to receive a comprehensive assessment for a transition plan of care for home health and subsequently establishment visits.  Due to so many individuals being identified as have chronic health care issues, many of the facilities set up for their care are now to full capacity.  Sharon continues to make rounds and direct their care.

SUMMARY along with others, the caliber of nurse practitioners as demonstrated in these accounts and what they continue to do for their communities, there is no wonder that the Forgotten Coast has been renamed the Resilient Coast. Recovery has only just begun and there will be years before it is complete, so these nurse practitioners and others will be continuing their efforts of rebuilding the health care infrastructure for years to come.

In summary, please think about what you would do if you ever found yourself in a similar natural disaster. What would you do?  How would you have to recreate yourself in order to survive and thrive?

Please join me in thanking these nurse practitioner colleagues for their commitment to the care of their communities; for not giving up and for forging ahead under very difficult situations.  For me, each one of these nurse practitioners is “MY HERO.  It is a testimony for nurse practitioners across the state of Florida to be able to practice to their full extent of their education and preparation.  Please reach out to your local legislators and share these stories and yours as to the value of the nurse practitioners statewide.

These accounts were acquired by interview by the author and represent that which was best understood by the author.  Photos have been generated by the author and/or printed with permission from the author.