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My wife and I live in the northwest corner of South Carolina, in Oconee County. We are solidly in Appalachia, as far from the sunny Carolina coast as you can get and still remain in the Palmetto State. We're very close to Greenville, South Carolina and Asheville, North Carolina, where Hurricane Helene recently hit with incredible fury. We lost power but fortunately still had our cellphone service.

Watching the devastation of the storm is heart-rending -- first because of the scale of human tragedy, and second because we have driven past these places, have loved their beauty and their people. I looked at news photo after news photo of Unicoi County Hospital, in Tennessee. I once inquired about working there because it seemed like a garden spot as hospitals go. I wonder if it will ever re-open. Staff were carrying patients to the roof on their backs in order to have them evacuated by helicopter.

I have spent most of my career working in emergency departments in Appalachia. As such, I have some thoughts based on my understanding of disasters, of emergency medical care, and of Appalachia itself.

I don't need to say anything about rescue, or traumatic injuries. That's a given and there are true, courageous experts on the ground. However, since medicine has changed and patients have changed in the 31 years of my career, I believe there are some issues that need to be discussed. If not relevant to the current disasters -- Hurricane Helene and now Hurricane Milton in Florida -- these thoughts may be relevant to some future planner.

I recently wrote about how medically fragile many Americans are these days. That medical fragility makes the disaster response more complicated. Appalachia, which is my beloved home, is also a place of many health challenges. From diabetes to addiction, from cancer to heart disease, the list is long and difficult to manage.

There are many very sick, very fragile individuals who are dying and still in need of rescue. Here are some examples of the challenges these disasters create, in no particular order:

It is imperative that renal failure patients on dialysis actually make it to dialysis. They typically go three times each week. Many require ambulances or at least friends or family to transport them. A few days without dialysis is very dangerous. They typically have a host of other medical problems associated with their renal issues, so time is of the essence.

Cancer patients or those with complicated infections often need their regularly scheduled infusions of chemotherapy agents or antibiotics. In Appalachia, these people don't usually live downtown in accessible apartments. They may live at the end of Rock Springs Road, or up in Copperhead Valley, across two narrow bridges that have already washed away.

Diabetic patients need insulin. And it's typically difficult to get a "supply" of insulin due to the ridiculously high cost. Furthermore, it has to be kept cool. Without power, the refrigerator won't stay cool long and the ice won't stay ice long. And thus, the sugar won't stay low long. Insulin-dependent diabetics without their medication develop diabetic ketoacidosis, which can easily be fatal and often requires care in an ICU. (This is of particular interest to me as the father of an adult diabetic son.)

Some individuals who might self-rescue to neighbors or main roads are unable to do so because they are old, frail, and weak from stroke or dementia. Some have no family, or family may be geographically isolated from them. With the amount of water that swept through these hollows, with the downed trees, labyrinthine brush, mud, and washed-out roads, even half a mile can seem an insurmountable distance.

Others are fully wheelchair- or bed-bound. Some are simply too obese to move without help. These people are in dire straits and can only count on the help of those close by until professionals arrive. But due to choppy -- or no -- cell service in some areas, many cannot even reach 911 for help.

Those on oxygen for the ubiquitous chronic lung disease of Appalachia have limited supplies. Some have swapped tanks for oxygen concentrator devices, which require electricity.

Of extraordinary importance is the issue of pain control. While it can seem like a secondary concern in the big picture, it really isn't. Those with chronic pain, such as the pain of rheumatoid arthritis, spinal injury, cancer, and other conditions, count on pain relief. Without access to refills, to open and functioning pharmacies, this is what many will face. For decades now, we have emphasized the importance of pain control. That simply can't be dismissed during a disaster. ("Oh, pain; that's not a problem now.")

The opposite side of this issue is that there will be many who are unable to obtain fentanyl, methamphetamine, or other substances to which they are addicted. Withdrawal from stimulants and opioids is miserable and may produce desperate behaviors. Withdrawal from benzodiazepines can be fatal.

Refills of all sorts of medicines will matter. Diuretics for heart failure, antihypertensives, oral medications for diabetes, medications for seizure control, anticoagulants for heart disease, blood clot, or stroke prevention. The list is long.

Soon enough, infectious diseases will likely emerge due to the fact that it's still very warm in the south, insects abound, hygiene is poor to non-existent, and refugees will be in close proximity in hospital waiting rooms or shelters. Look for clusters of flu, COVID, meningitis, pneumonia, perhaps encephalitis, and certainly intestinal illness. In addition, wounds in feet from immersion in dirty water (think combat trench foot) may also develop.

Normal, day-to-day care of car crashes, strokes, heart attacks, and everything else will be disrupted as EDs will be full of those displaced and seeking care for the things I've listed above, as well as for injuries sustained while performing rescue and reclamation.

Finally, we have to remember that this is also a mental health event. Those with chronic mental illness will be especially distressed.

But those who are responding, those overwhelmed with human suffering and need, those extricating the dying and dead, they'll need our help. Hospitals, EMS, fire, and law enforcement groups and churches all need to pay close attention as this is a massive generator of PTSD. If you need help, don't be ashamed. This is like nothing most have ever seen.

I haven't been directly involved in disaster planning for many years, but a few things come to mind.

1. The preppers weren't crazy; they were spot-on. Food, water, generators, medications, etc. are life-saving.
2. Every EMS system and every community should keep a list of those who are especially vulnerable, whether children or adults. We should know where new moms and babies are, and where the older adults and infirm are to be found. We need to care for each other.
3. We can't rely solely on cell signals to get critical help. Landlines should make a return. CB radios might be an option. Those so inclined, especially those with limited mobility or health/fitness, would be well served to learn how to do in order to expedite communication for communities.
4. Rescue in these heavily forested mountains, narrow valleys, and endless small and large watercourses is complicated and dangerous. Props to all of those who are out there engaged in it. I continue to pray for their safety and success.

My wife, Jan, is recuperating from her recent 12-day hospitalization for severe pancreatitis. We're so sad that we can't currently be part of the response. However, I fear there will be ample needs, as recovery will take years. We had a few days of anxiety about our firstborn, Sam, who lives and works just north of Asheville. He had no power or cell service but he and his friends are a mountain tribe and took care of one another.

I'll close with this: people throughout the country are resilient and determined. But Mother Nature can be malevolent. Never underestimate her ability to cause surprising devastation. Always, always respect her. And take care of yourselves and one another.

A version of this piece originally appeared in the Substack, .

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