My post-fellowship career journey has provided me with an opportunity to live in at least two of the five Köppen climate classifications for a decade each: continental (Kansas City) and temperate (Orlando), and now in northeast Ohio in Akron. While Florida enjoys perfect winter weather and the Midwest boasts stunning fall colors, Florida faces hurricane season from June to November, and the Midwest contends with tornadoes and ice storms.
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February 2025From 2013 to 2023, hurricane preparedness and logistic challenges occurred both at my home and work. Most colleagues and friends are amused when I explain what “hurricane call” is. It can be overwhelming, emotionally exhausting, and a challenge both professionally and personally. Today, hospital- and system-based training on emergency preparedness is likely a mandatory learning module for the healthcare workforce due to the increasing frequency of both natural and man-made disasters, from wildfires, floods, hurricanes, tornadoes, and snowstorms to mass casualties. There are also lessons to be learned about treating patients in situations of sexual abuse and custody battles, and how to handle “late” patients and supply shortages. Providing safe and effective care for medically complex and vulnerable patients/families requires so much more than the medical and surgical expertise we spent decades building.
While I feel guilty judging myself for being desensitized to daily headlines and images of escalating climate change-related humanitarian emergencies around the world, I try to practice self-compassion instead of guilt. As someone who’s experienced hurricanes, pandemic-related supply chain shortages, and myriad complications with vulnerable population patients, I’ve come to appreciate how multi- and interdisciplinary teamwork, novel ideas, anticipating the unexpected, and learning one’s local, regional, and state emergency management plans are examples of what it takes now to provide the care our patients and families need.
Here are some things I’ve learned along the way about treating various vulnerable patient populations and handling potentially crisis-inducing situations. I hope these examples will help you in your care of vulnerable patient populations in otolaryngology.
Tracheostomy- and ventilator-dependent patients: Technology-dependent patients may not be accepted at county or local shelters. The shelters may not have generators or may be at high risk of losing power. Patients should check with local shelters or agencies preemptively, so they’re prepared in case of an emergency. I will never forget a family calling to let me know that they were turned away from such a shelter despite the assumption by both of us that they would be able to find safe harbor there.
Discuss with your hospital and executive leadership whether you have the ability, capacity, and staffing to provide “shelter” for patients and families who are technology-dependent and may not find access to another home or facility with generators. I am forever grateful that the last hospital I worked at in Florida was able to turn post-anesthesia care and other units into a shelter option for this population, as long as one trained caretaker came in with the patient and they brought their own supplies and home medications, and provided nearly all necessary care for the child.
Using a database to track all children who had a tracheostomy tube, with and without ventilator dependence, proved highly valuable. This database was updated regularly, with new patients added prospectively. In addition to tracheostomy tube brand, size, and ventilator need status, that database also included the brand and type of patients’ home ventilators. During an urgent medical device recall by Philips in December 2022, the database allowed our team (in collaboration with pulmonology) to contact affected families to ensure a timely and safe transition to alternate ventilators. Families were given contact information for customer service for the medical device company, and we were able to identify patients who needed clinical follow-up.
Before, during, or after severe hurricanes and related flooding, medical and surgical emergencies may occur. Emergency services will be under massive demand, as large regions may be without power, may need help to evacuate, and may not even have access to food/water. Emergency responders may be limited based on staffing, the need to prioritize demands, and their own safety during rescue missions. To help with this, one of our nurse practitioners created instructions on how families could register with the Florida Special Needs Registry. Many states have these registries or provide similar information on their department of health websites. Registering can help expedite assistance and responses for those with special needs during any disaster.
It’s also important for families to create an emergency preparedness checklist specific to their child’s needs and an evacuation plan, and to make sure they have enough durable medical equipment supplies and medications.
Children with a known history of being sexually abused: Recently, a three-year-old girl came to our clinic for a known ear canal foreign body. The child was initially scheduled with one of our male surgeons, but upon arrival, the mother explained that the child had been sexually abused and, as such, couldn’t be in any room with the door closed. The mother also respectfully requested to switch to a female provider to prevent triggering the child’s trauma. Our advanced practice provider saw the patient and deemed removal under brief general anesthesia necessary. I would be the surgeon of record, and I reassured the mother that we would do all we could to minimize any trauma associated with the care needed.
We scheduled the surgery first thing in the morning when fewer people were around; we had an all-female staff; and from check-in to the OR to PACU, I was proud we were able to provide an experience that was as comforting as possible, giving the child and mother as much psychological safety as possible. The mother was beyond appreciative and grateful for this level of coordination and care. As a mother, I couldn’t imagine a child enduring such abuse. It felt terrific to know that we do have options that enable us to provide the same level of care we would want for our own children. Engaging child life specialists and social workers and ensuring access to counseling for both patients and families are critical above and beyond the routine medical/surgical care.
The “late” patient: In three hospitals and systems I have worked at, patients and families arriving late against their appointment time always comes up for discussion. I recall an uncomfortable conversation with a more senior faculty over a decade ago, when I had just become division chief, about how to deal with late patients. He was adamant and would tell the staff to turn away patients who arrived more than 15 minutes late or turn away those who arrived at the wrong location if the appointment was scheduled at another satellite. The privilege of being the chief was being able to set division expectations that we would stop turning away patients who arrived late during the workday hours; nor would we make those who showed up at the wrong location get back in the car and drive to the scheduled location. As long as there was a provider on site, they would see the patient as an add-on to the clinic schedule.
The faculty insisted I was rewarding “bad behavior” by allowing late patients to be seen regardless of how late they were, and that refusing to see late patients might “teach” them to be on time. Given that my chosen subspecialty involves children who can’t influence what time they arrive at the hospital, denying care was not acceptable. The most compelling reason I shared with my then-partner was that we as the providers simply do not know the “story” of why they were late, and it really didn’t matter. Traffic congestion was notorious in Orlando from construction that lasted decades. Often families told me they had to intentionally drive through local roads to avoid paying tolls. Others had multiple children, some with medical issues or special needs, and simply getting all the children into the car to come to an appointment was beyond taxing.
System issues may also result in patients showing up at the wrong location. For example, I Googled myself, and, sure enough, the location that popped up was not my primary practice, even after I stopped going to that satellite. For some patients, getting from the parking lot to the lobby check-in of the correct clinic is a challenge. How can anyone accurately predict the time needed for travel and the actual time to enter an exam room? It’s ironic that when we, as providers, run late—regardless of the reasons—we expect our patients to wait patiently without becoming upset.
The most humbling story was about a mother who arrived two hours late with the patient and two siblings. She thanked me profusely for seeing them and apologized for being late. I told her I was glad to see them and glad they made it. When I asked if there was perhaps something on our end that misinformed their appointment time, she shared they had endured a house fire that morning and were grateful they were able to get out unharmed. Hearing such stories, and serving an almost 80% Medicaid population in Central Florida, was beyond humbling. Most families clearly endure greater hardships than my own. These stories further convinced me that penalizing patients and families by decreasing their access to care isn’t the answer.
While independently owned practices and some hospitals may impose a “late” fee, in pediatrics and for those with Medicaid insurance, charging late and “no show” fees isn’t allowed.
Custody battles: I’ve experienced a handful of challenging situations in which parents are in the process of getting divorced and fighting for custody of their children. Sadly, you can walk into a clinic appointment completely unaware of such situations until either a subsequent appointment when both parents are present with differing histories and demands or, worse, when you arrive to pre-op to perform an elective procedure with consent given through court order but are surprised by a parent who opposes the procedure. I wish I had formal training in this type of situation.
Several years ago, I was in a situation in which I met the mother and patient for routine evaluation for possible obstructive sleep apnea and scheduled an elective tonsillectomy and adenoidectomy. The father found my professional social media Facebook (established in 2012 with blogs, online courses, and resources for families), and posted a violent threat a day before the procedure. I wasn’t aware of his post until a day after the encounter in pre-op. Both parents arrived and were checked into pre-op. I walked into the exam room to see the child, mother, and father, whom I had never met. He was holding two Bibles and repeatedly warned I must not touch his child. After a discussion with anesthesia and peri-op staff, I canceled the procedure and discussed the next steps with the hospital public safety officers. All I can remember now was the fear that lasted weeks whenever I walked to the parking garage and the paranoia that made me far more aware of my surroundings.
Since then, I’ve learned that it’s critical to speak to legal and risk specialists in your hospital, engage social workers, and not schedule any procedure for children during custody battles until such disputes have been resolved. Beware of parents or caretakers who attempt to contact you through alternate modes of communication rather than through routine electronic health records or clinic channels. Finally, even when custody has been awarded to one parent, beware of the parent who does not have custody. You must escalate any direct threat or implications of threat, regardless of the method of threat. Such experiences are psychologically and emotionally taxing. Given recent increasing examples of random violence against physicians and healthcare workers in hospitals and clinic settings, teams need to discuss what to do to support one another in real time and mitigate risk.
Supply shortages: The recent hurricane/flood-related impact on intravenous fluid supplies across the nation was an unprecedented experience for U.S. healthcare systems and impacted all areas in a hospital. For surgeons and anesthesiologists, this shortage was particularly impactful; I dealt with such discomfort, having so little fluid for countless children after elective adenotonsillectomy procedures. While production has resumed at the Baxter plant in North Carolina, the shortage enabled us to discover where routine IV fluid waste was occurring and to find alternate ways to hydrate a child in acute and post-op/post-acute settings.
Small changes add up. My favorite bobbin tympanostomy tubes seem to be of lower quality now; if the surgical technician holds the bottom edge with even a hair too much force, the smooth edge becomes bent. When I ask, I am told, “This is what we have,” but without specifics on why, when, or if the higher-quality tubes will ever come back. Once latex was eliminated, the flexible soft 10Fr red rubber catheters I have used for almost 20 years to elevate the soft palate to perform adenoidectomy have now been replaced by rigid, inflexible ones that often cause epistaxis no matter how gently and carefully I slide it through the nasopharynx.
Nostalgia for the “good old days” seems to serve as a constant reminder that I’m getting older. It’s humbling to reflect and recognize that what used to frustrate me during daily practice seems to pale in comparison to current-day challenges for the healthcare system and for the patients we care for. The only path forward that makes all this bearable is knowing that as long as my team and I keep showing up, being in the moment, and doing the best we can with what we have, we can always make a positive difference in the lives of patients and their families, especially those who are vulnerable.
Dr. Wei is the Alfred J. Magoline Endowed Chair in Otolaryngology–Head Neck Surgery, division director of pediatric otolaryngology at Akron Children’s Hospital, and professor of otolaryngology at the University of Cincinnati College of Medicine and Northeast Ohio College of Medicine in Ohio.