Internal Medicine Physicians Now Play a Critical Role in Natural Disasters

As primary care physicians, internists serve as the backbone of the U.S. healthcare system, and their role during natural disasters is multifaceted and indispensable. They can significantly reduce morbidity, support resiliency, and restore hope within their communities. As natural disasters grow in frequency and complexity, the integration of primary care into all phases of disaster management is essential. In an era of increasing frequency and intensity of such events, the role of primary care physicians has never been more pivotal in supporting not only individual patients, but also the broader public health infrastructure.

The frequency of natural disasters has increased from less than 10 per year to several hundred per year, resulting in increased morbidity, mortality, and financial costs. Hydrologic hazards (floods and landslides) account for 50%; meteorologic hazards (temperature extremes, storms) account for 40%, and climatologic hazards (drought and wildfire) account for 10% of these events.  

The seniors we care for are vulnerable due to physiologic changes including: decreased cardiac output, decrease in age-predicted maximal heart rate; decrease in vo2max; increased incidence of coronary artery disease; decreased muscle mass and loss of muscle power and endurance; decline in cognitive function; slower reaction times, and greater incidence of  sensory (hearing and vision) impairment; increased risk of falls; and being on medications that complicate treatment. One in 6 lives in poverty. 96% live independently. 20% do not drive. 1 in 9 live with dementia. 20% need help with activities of daily living. 40% have ambulatory limitations. Less than ½ have taken the steps recommended by disaster preparedness agencies. Evacuee meals can worsen health risks in these patients (nutrition, sodium load, fat). Although people aged 75 or older made up about 6% of the populations in New Orleans in 2005, they accounted for 50% of those who died during Hurricane Katrina. In northern California's Camp Fire in 2018, 71 of the 84 fatalities were people 60 or older. When Hurricane Sandy struck the New York tri-state area in 2012, nearly half of the fatalities were among people 65 or older. People 60 or older accounted for 60% of the 246 deaths from subzero temperatures in Texas in 2021. Florida is projected to be the hardest hit in the coming decades with two out of every three care facility beds located in areas that will experience frequent flooding from now through 2050. Hospitals and Clinics may be severely damaged along with homes of staff.

Each disaster is unique. Each community is unique. Each patient is unique. Osteopathic internal medicine physicians offer continuity, trust, and accessibility—qualities that become even more critical in times of crisis. They maintain longitudinal relationships with patients, understand individual and community health needs, and often serve as the first point of medical contact. Their involvement can mitigate the fragmentation of care that is common in the wake of disasters, improving outcomes and facilitating more efficient resource utilization.  

Preparedness is the foundation for effective response. The Sendai Framework for Disaster Risk Reduction reinforced the shifts in disaster management to disaster risk prevention, based on the four dimensions of disaster risk: hazard characteristics; exposures; vulnerabilities; and capacities. According to the Health Emergency and Disaster Risk Management (H-EDRM) Framework from WHO, all phases of disaster management should be closely linked together. They suggest critical roles for integrating primary care providers, medical students, and residents in ensuring continuity of care during disasters.  

Primordial Care

Provide individualized advice to people with impairments and co-morbidities to improve their preparedness and ability to cope with disasters. Proactively identify high-risk patients (elderly, disabled, homebound, or reliant on medical equipment) and create contingency plans for their care. Patients should have an essential medications supply in case of disaster. Patients with higher levels of vulnerability can be referred by their PCPs to support services that can help strengthen their preparedness, build resilience and reduce the risk of harmful consequences in the case of a disaster. Use the SWIFT (Seniors Without Families Triage) Screening Tool.

Prevention and Mitigation

Provide resources and counseling to patients about personal and family disaster preparedness, including evacuation planning, medication storage, and emergency contacts. Patients do better when they have action plans for what to do in case of emergency, including environmental disasters. Disaster response programs should also account for interruptions in care–appointments, home visits, medication refills–and plan to mitigate them. Great emergency prep kit handouts can be found here, here, and here.  AARP also has a resilience toolkit.

All patients should have at least seven days of medications, equipment for their disease, and seven days of food and water. The Renal Disaster Relief Task Force (RDRTF), created in the early 1990s, provides chronic dialysis patients living in disaster-prone regions with plans including diet, fluid restriction, exchange resin use, and dialysis modification information on how and where to seek alternatives –pre-determined, in-city or outside dialysis care for at least a limited period. Peritoneal patients may lack water and electricity and may also need to go to hemodialysis centers. Cancer patients can call 1-800-422-6237 or use this link.  Diabetics and heart patients also need special instructions.

Clinic-Level Preparedness  

Preparedness should include disaster protocols, electronic health records readiness, medication and supply stockpiling, staff training, and simulation drills to foster readiness and teamwork. A good downloadable step-by-step reference discussing what to do for your medical practice in the case of a disaster was created by Drexel. 

Response  

Triage and Acute Care

When disaster strikes, the demand for medical attention often exceeds available resources. PCPs play a unique role in triage, acute care, and maintaining continuity for non-disaster-related health needs. It is important to realize that there is a disaster health impact timeline.  

Clinics may serve as first-line triage centers, diverting non-critical cases from overwhelmed hospitals and emergency departments. It is important to remember that anything taking more than an hour to get to definitive care during a disaster needs to be addressed in an austere context. All disasters are considered austere environments where both victims and rescuers could be at risk for injury and illness. It has been suggested that disaster/wilderness medicine training is needed since definitive medical care may not be available for hours or days. Some injuries and illnesses are more common in remote and austere locations, and difficult decisions must be made in terms of triage. There are several places you can get this training. Options include: Advanced Wilderness Life Support (WMS, NOLS, Outward Bound), several osteopathic medical schools; Disaster Life Support classes (Core, Basic, Advanced); ATLS and CERT training.

Hospitals may be overwhelmed. Internal medicine physicians can play a key role in offloading the emergency room, triage, and management of a patient’s intensive care unit care and on the wards, and reverse triage as many of these people will need to be sent to other centers for care.

During the impact phase in the clinic, you may be forced to deal with burns, smoke inhalation, drowning, trauma, heat stroke, and exacerbation of chronic conditions as well as lack of access to health care and overwhelmed systems and displaced populations.  At this point, logistically you need to ask, “What do I have? What will I need? Where is it at? When will it arrive? What if it is unavailable? How do I improvise?” You need to think about stuff and staff. In terms of stuff think about first aid trauma kits, medical equipment, medical consumables, controlled drugs, as well as marking logistic support storage transport and containers. In terms of staff, you need to think about volunteers, rotation of staff, provision of downtime, whether you'll need to go to a shelter, security of the staff, medical evacuations, and neutral nationalities. There is a range of roles for office based PCP's providing disaster healthcare including: addressing modified patient presentation and populations; supply issues responding to changed patient care needs; adjusting to changes in types of presentation; patient numbers; consultation lengths and patient populations; protecting or prioritizing immediate health care requirements and targeted preventive activities during high demand periods; changing practice processes and systems temporarily; extending medical outreach telephone calls and home visits; replacement of medications especially as they relate to addiction services; and health care provisions in alternative environments, such as evacuation centers, residential care facilities, and temporary medical clinics on site. There will be more muscular/skeletal issues and a lack of medications, making OMT a viable treatment option. In this phase there may be a potential use of disaster telemedicine, including remote consultation and help with direct patient care. If your clinic is damaged, there is help available from the American Osteopathic Foundation.

Continuity for Chronic Disease Management is Key

The greatest medical need for displaced adult disaster victims is continuation of chronic disease care, not acute care. After two weeks, 44% of the evacuees eventually seek medical help, most often for chronic disease care. Many admissions are for exacerbations of chronic illnesses in evacuees who were unable to retrieve medications from their homes.

Myocardial infarction, heart failure, pulmonary embolism and cerebral vascular disease all increase following a disaster, as do hypertension and hyperlipidemia. Takotsubo Cardiomyopathy syndrome also increases. There is some evidence that coagulation changes also occur during this phase. Renal problems also increase. Numerous studies have shown that hemoglobin A1C levels and insulin requirements increase significantly during this phase. In fact, there is a dramatic surge in the number of admissions due to newly diagnosed insulin dependent diabetes during this phase. It is at this point that you will need to deal with environmental health hazards including water-related illnesses, mold growth and air quality issues, as well as the possibility of carbon monoxide poisoning and control of mosquito populations and associated illnesses. Mental and behavioral health impacts increase. In addition, you need to deal with problems obtaining prescription medications, short term displacement, stress and emotional trauma, and risk of interpersonal violence. There will be several soft tissue complaints which will be a good use for OMT. Respiratory infections with odd organisms or tuberculosis may increase. Norovirus spread has been an increasing problem in post disaster shelters due to overcrowding. Hospitalizations for older adults increase significantly in the month after a major disaster.

The long-term recovery phase can last years. It is important to consider changes in chronic care issues, ongoing environmental risks (such as long-term respiratory issues because of exposure to particle and VOC pollution during wildfires), and delayed onset of mental health disorders. There is some evidence that mortality is increased after hurricanes among older adults with dementia. Additionally, there are changes in long term cancer survival and in general less healthy behaviors and people who have been through a disaster. There may be delayed care or misdiagnosis, changes in infectious disease epidemiology, missed routine vaccinations with subsequent issues, and increased rates of associated autoimmune diseases. Natural disasters often exacerbate existing health disparities. PCPs are advocates for vulnerable populations, ensuring equitable access to resources and care.  

Self-care during all this is important. The MEDIC model for disaster recovery can be reviewed here. Additionally, there is at least one study suggesting that osteopathic manipulative treatment as an intervention for stress in all first responders has been helpful.

Therefore, the involvement of osteopathic internists is crucial in building a resilient healthcare system capable of responding effectively to natural disasters. The overall health of our patients, our families, and ourselves will depend on our actions.

ADDITIONAL REFERENCES:

Aldrich N, Benson WF. Disaster preparedness and the chronic disease needs of vulnerable older adults. Prev Chronic Dis 2008;5(1).

Badger MS. The Intersection of Geriatrics, Climate Change, and Wilderness Medicine: Education is Critical. Wilderness Environ Med. 2025 Mar;36(1):27-34. Doi: 10.1177/10806032241245399. Epub 2024 Jun 7. PMID: 38850046.

Burns P, et al, editors. Disaster health management: A primer for students and practitioners. Routledge, 2024; p. 129–48. Doi: 10.4324/9781032626604-13.  

Disaster relief for your practice

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Emergency and disaster preparedness for chronically ill patients: a review of recommendations. Emerg Med. 2014 Dec 8:6:69-79. Doi: 10.2147/OAEM.S48532. eCollection 2014.

https://files.asprtracie.hhs.gov/documents/aspr-tracie-medical-surge-and-the-role-of-primary-care.pdf

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Miller AC, Arquilla B. Chronic diseases and natural hazards: impact of disasters on diabetic, renal, and cardiac patients. Prehosp Disaster Med. 2008 Mar-Apr;23(2):185-94. doi: 10.1017/s1049023x00005835. PMID: 18557300

Mo Med.2021; 118(5):435-441. Osteopathic Manipulative Treatment as an Intervention to Reduce Stress, Anxiety, and Depression in First Responders: A Pilot Study

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Scoping review of exploring the roles of primary care providers to increase disaster preparedness of vulnerable populations, Progress in Disaster. Science, Volume 23,2024, https://doi.org/10.1016/j.pdisas.2024.100339) (AnnalFamilymedicine 2007 Mar;5(2):170–174. Doi: 10.1370/afm.646).

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Wiskel T, Dresser C,Sergienko E, Keheley K, Schroeder A and Balsari S (2025). Preparedness, Information Needs, and Interruptions in Medical Care after the California Oak Fire. Disaster Medicine and Public Health Preparedness, 19, e137, 1–8 https://doi.org/10.1017/dmp.2025.10063