Thanks, John, and thanks, Tina, for those awesome talks. I think so far I've heard a lot about really concerning signals about air pollution and really concerning signals about a changing climate on the things we see and do every day in the ICU. And Tina, you didn't end on a terribly, I think the hopeful note is good. I remain scared. I'm just going to put that out there. I'm going to shift gears a little bit and talk about climate disasters in sort of the more acute catastrophic event sense and how that might impact our ICUs. And I think hopefully end also on what we might be able to do within our ICUs to make us more capable and more resilient at withstanding this type of insult that might happen to, honestly, any of us. I don't have any relevant financial conflicts of interest for this talk. I think we feel this anecdotally in our day-to-day lives that there is a clear rise in extreme weather and natural disasters. This is actually data from Munich, which is a reinsurance company, a global reinsurance company from that that was reprinted in The Economist. And this only goes up to 2016, but you can see it's broken down by meteorologic events, hydrologic events, which are predominantly flood, and extreme temperature events, which Tina was alluding to. And there's a clear trend line in this. They don't test for significance in this, but I think this also mirrors our lived experience with the number of days at extreme heat, with the number of extreme flooding events that we feel. And I think we can expect that when this data is updated, we will continue to see a trend in this rise in major natural disasters. It's also very clear that when these disasters occur, it disrupts populations. And so this is data that looks at people who are internally displaced by natural disasters. So they haven't left their country of origin, but they've been displaced within their country of origin in response to a natural disaster. And obviously, the terrible flooding in Bangladesh is the event that's practically off the chart here. I think it's very interesting for us to note, as predominantly a North American audience at this conference, is that the United States, there is the second line on this graph in terms of the highest numbers of internally displaced persons due to climate or due to natural disasters. In this case, you can't obviously distinguish what might be a climate-induced natural disaster compared to a non-climate-induced natural disaster. And this is essentially that same graph represented on a global heat map, where you can see that North America, or the United States in particular, is kind of that second dark red compared to Asia and the Indian subcontinent. Tina also covered this a little bit, but mirroring these events, this increase in natural disasters, what we can also see is that there's an increasing number, and this is, again, older data, this sort of terminates about a decade ago, in the rise in human infectious disease outbreaks. And it's pathogen sort of independent by category. You see this in zoonoses, you see this in vector-borne diseases, you see this in parasites. And that may also be a continuing trend to see, and we see that now in some emerging pathogens in regions where we didn't previously note them. And some of you may have seen the reports that we now have documented meleodosis in Mississippi. That was not thought to be a disease that existed in North America previously, but now has been documented in the soil in Mississippi. And there's an interaction of all of these events, right? Climate, technology, and demographics all impact how infectious diseases impact us. So climate change is what we're focusing on here. But again, so climate change may drive changes in the distribution of a pathogen, it may affect the transmissibility and susceptibility of populations to pathogens, and it affects also the sort of reservoir for pathogens. Technological change also facilitates some of this changing infectious disease burden spreading more easily, right? You just have to look at a map of global travel from 50 years ago to 20 years ago to today with its resumption and with the sort of waning of the COVID-19 pandemic. And we think about this, I think, kind of in the abstract and, oh, isn't that a terrible event? But it really does affect people on the ground. And this is just a few instances. This is a rare event where there were three hurricanes in the Atlantic Basin at the same time. You have flooding below that, flooding again, and I believe the middle picture is flooding in Houston. You have the tsunami that hit Japan. And then you have the Northern California wildfires. So you can see the geographic spread of these events is not limited to one continent, it's not limited to one region. I found this report, this is an older report now, and if you haven't read this, I would really, really encourage you to look this up. This is a piece of reflection that Ben Dubois Blanc wrote and published in the Blue Journal in 2005 after his experience at Charity Hospital in New Orleans with Hurricane Katrina. And the piece is entitled, Black Hawk, Please Come Down. And I don't know why it's displaying text as opposed to the title, but the picture here, I think we can all kind of envision what it might feel like to be that healthcare worker on the roof of a parking garage where they have evacuated patients through a hole in the wall of the building to a parking garage and awaiting for medical evacuation for these patients. So we're gonna move into a section of what can we do in terms of helping ourselves get prepared. This is, fortunately, I didn't live an experience quite as dramatic as Hurricane Katrina evacuation, but we have some New Yorkers in the room who remember Superstorm or Hurricane Sandy in New York City in 2012. And we wrote a piece afterwards about our experience at Bellevue Hospital with the evacuation of our medical center after catastrophic water and power loss in the aftermath of Hurricane Sandy. And I've put this picture in that was taken by a colleague of mine sort of as the storm started to surge. And this is, for those of you who are familiar with Manhattan, this is the FDR Drive adjacent to the East River. And so there's a footbridge that goes just south of where this person taking the picture standing on the footbridge that crosses over the FDR Drive there. And the building that you can see illuminated there is Bellevue Hospital when we still had power. And so we lost power shortly thereafter from that. So I say this not to terrify you, but also to spur you to action to think about as you work in your day-to-day job, it may not be your role in your healthcare system or in your day-to-day life to think, to be the person who develops the disaster plan. But we do all have a role to play in thinking about how we would respond and be an effective contributor to a better outcome and how we might prepare to be more resilient and respond better. So you can kind of frame this as disasters might be an internal disaster where they really just affect the internal functions of your medical center or your ICU, and that may be a fire. Now, actually, probably fairly relevantly might be a cyber attack on your medical center and disruption in your electronic health record system. You can have a totally external disaster, right, that then the medical center is the receiver of a mass casualty incident. Or what we've all just lived through, right, is this sort of mixed disaster that has both internal effects and external effects. So a pandemic is sort of a classic example of that, right? You have external effects, you have disruption of society, you have surges of illness, and you have a workforce that's internally affected as well. So I want to transition into thinking about what does a prepared ICU potentially look like. And I think some of the principles in this are probably also applicable to the points that John raised and the points that Tina raised in terms of how do we think about this in terms of our approach to things that we see all the time in the ICU. And I think there's a really nice body of work around what a prepared ICU might look like. And this is work from Lee Bidison and Lou Rubinson. It's on the older side now, but I think the principles are very valid. And so they kind of define characteristics of what prepared ICUs might look like. And I think it will resonate with you and make sense. So these are, you have to clarify what hazard your community is most at risk for. I live in Seattle, right? We are unlikely to have a major hurricane. Knock wood, right? It's just not the risk where the, however, we're pretty likely to experience an earthquake. And so thinking through what hazards are you most likely to experience, because that will help you decide what you need to do to prepare. And identifying where your vulnerabilities may be. And then develop a plan. These plans are probably best used just as a structure. You're never gonna follow a written plan to the letter, and every written plan is likely to fail. However, a written plan will at least help you take into some of the considerations of what you may need to do to prepare, including how to use your space, how to use your equipment, how to potentially staff, with that, how to allocate resources under conditions of scarcity. We had heard a fantastic talk on that earlier today. How to potentially evacuate your intensive care unit in the sense of if there's a catastrophic internal damage from that, and how to best communicate with one another in a disaster. There are structured ways that these risk assessments happen. And so this is one example. This is, New York City does this on a five year cycle, where this is led by the public health department of New York City, and they group disasters by multiple factors. How severe a disaster is likely to be? What's their best estimate of the probability of such a disaster? And how manageable will it be when this happens, or if this happens? So this one, the most recent one from New York City is from 2018. They're due this year, and it'll be interesting to see how this was obviously informed by the recent pandemic event. And you can see along the slide from left to right, are these events in sort of rank order by the perceived impact to New York City. And so at that point in the 2018 assessment, cyber attack was deemed to be the highest priority or highest risk event overall by a combination of these factors of severity, probability, and manageability. A respiratory virus with pandemic potential came in third. So it was deemed to be very severe. You can see by the orange red bar there, but less probable than some of these other events, right? Shows you how good probabilities are, right? When it actually happens to be a dichotomous outcome that happens or it doesn't. So those are great tools to have because those exist for communities, right? So you can go back to your community, and your community should have a jurisdictional risk assessment that helps gauge what are the things that are most likely to happen in this community? Then within medical centers, there's also really, really good tools around that your emergency management colleagues can help use to gauge hazard vulnerability. And Kaiser has a free tool, it's available. There are buckets and buckets of resources around how to gauge risk on ASPR TRACIE. So ASPR is a US Health and Human Services Assistant Secretary for Preparedness and Response. TRACIE is their technical assistance website, and it's a fantastic resource repository, and there's a lot in there. But you can see here that this Kaiser tool lists all kinds of events, right? This is not limited to natural disasters. This is not limited to climate change. It includes all types of potential events from that. But it can help an institution understand where to spend our limited time and our limited funds on what we think is the most likely threat to our environment. And then you have to do something with that information, right? So after you've done a risk assessment, you can take that and say, okay, I'm gonna take this information and I'm going to use it to help prepare. So this is another tool from FEMA. This is a preparedness cycle, and it should be a continuous cycle where you're planning actions to manage and counter risks and building capability to implement the plans that you make. And it's just one component of emergency management that also includes mitigation, recovery, and response. So mitigation is a really important component because it is by and large believed to be the most cost efficient method to reduce the impact of a hazard. If you can do something, so think about this like a vaccination, right? Vaccination is a mitigation impact, right? You are reducing the impact of an infection. The goal of mitigation is to reduce loss of life and property to that, and the higher the risk, the more urgently you should approach mitigation efforts from that. So an example for us in the Pacific Northwest might be if we think our greatest hazard is an earthquake, we want to make sure that our buildings have seismic retrofitting to make them better able to withstand what we perceive to be our greatest hazard from that. You know, in New York City and Bellevue, that was the installation of a flood barrier because flooding was thought to be a substantial risk there. Vaccination is an example again of that. And then there are also criteria that help us define what may help our communities, and this can be communities where we live, this can be communities where we work, this can be communities on our unit that help define what may be associated with greater resilience in these communities, right? And there's themes that come out of this, but basically it assigns communities that prepare. So when you assess risks and you have a plan, when you as a community are able to come together and anticipate possible changes, working together, engagement of stakeholders, so this isn't a top-down process of preparedness, when our community has goals, and I think perhaps the last bullet point on this slide is perhaps the most important, which is that resilient communities have leaders who are committed to improvement and accountability. So if you don't have that leadership, your community is going to have a much harder time withstanding an event and have a much more difficult recovery from an event from that. So I think the other piece is that we have learned an enormous amount in the last three years of our response and experience of the COVID-19 pandemic, and one of those has been the impacts of a pandemic on our workforce. And this talk is not about that, but I think one of the things that's really important to take home and is a very tangible thing that you can walk out of this room with is to make one yourself and encourage your colleagues to have a personal or family disaster plan. So without a plan in place, we are much less likely to be able to come to work, stay at work, concentrate on work, and it will magnify the impacts of whatever event we're experiencing. There are lots of tools out there to help you do this, right, it's from what would you do in terms of where would your children go, where is your family meetup spot, what do you do with pets, how would you get a place if transportation is disrupted? I put this link up there, this is an old picture that no longer exists, but when the CDC first started to really promulgate this idea of having a personal or disaster plan, they actually had it sort of, their catchphrase was a campaign to prepare for the zombie apocalypse. They have now phased out that campaign, I guess zombies are no longer hot, but I still think it's a fun picture from that. So the CDC is a great place to look at this, ready.gov is another place to look at this, Red Cross, and then obviously your local emergency management is group. So we as individuals, not as institutional leaders, not as attendees at a CACM, can come, we can go home, and we can become at least familiar, even if we're not responsible for preparing our own institutional hazard analysis and our emergency response plan, we can become familiar with what that plan might be. And if you go home and there isn't a plan, you can start to advocate that there should be. You should make sure that critical care areas are addressed in this plan. I think that's often a common gap, is typically these address the emergency department first, which makes perfect sense, but don't address areas beyond the emergency department. So critical care has to be included in this plan making, and your critical care leadership needs to be included in making these plans. Another way is to ensure that there's a means for contact, even if it's an informal communication network, that you have secondary means of communication beyond your work-based means of communication. And incorporate disaster planning, or at least disaster awareness into your educational curriculum, and use that hazard analysis to inform what you might train to. When you are doing preparedness events, and hopefully you're doing some, there's a real importance around debriefing after a drill, including operationally debriefing after if you do experience an incident, that's really hard to do, right? They don't give you dedicated recovery time. We're experiencing that now, right, with COVID. The surges are over for the most part, but it's not like we got a three-month gap to plan our recovery. We're just doing it while we're doing everything else. So taking whatever opportunities you can to operationally debrief to define what resources are available, and use these processes to drive change moving forward. And I'm gonna just conclude with a bunch of resources. These slides will be online. You can do that, SCCM has resources, the UN has resources, CHEST has a fantastic consensus statement, and I'm gonna stop here and hopefully get some questions and discussion.

climate disasters

intensive care units

impact

preparedness measures

resilient communities