PM&R and Climate Change Mini Course

After this module you will be able to:

• Identify the impacts of climate change on the general population

• Identify unique vulnerabilities of persons with disabilities in extreme temperature and weather

• Identify specific vulnerabilities of persons with spinal cord injury, multiple sclerosis, parkinson's disease and TBI in extreme temperature and weather

• Identify vulnerabilities of sports medicine patient and athletes in extreme temperature and weather

• Gain tools to improve the health care of persons with disabilities in extreme temperature and weather

• Identify ways to lessen healthcare’s impact on pollution, specifically for PM&R practice

Why should physicians care about climate change?

"Climate change is the biggest global health threat of the 21st Century"

Those most vulnerable are being impacted by climate change the earliest and hardest.

Studies show patient's want to speak to their physicians about climate change.

Physicians have the ability to influence public policy on climate change.

Our guiding principle is "First do no harm." Climate change is harm to the planet and human health.

Patients are experiencing illness directly caused by climate change right now.

Physicians can tackle the climate crisis on multiple levels. This module will mostly focus on how physicians can help in the clinical setting.

Part 1: General health issues related to climate change

No matter what region of the US you practice in,climate change impacts patients

Hover mouse over each region to see most prominent threat due to climate change in each location.

Learn about climate change on a state level

Alaska Permafrost thaw, loss of coastal sea ice, changing ecosystems, sea water rise

Northeast Temperature rise, more heat waves, more frequent and heavier precipitation, drought, increased allergy season, increased vector-borne disease, hurricanes, sea level rise

Midwest Temperature extremes of both hot and cold, intensified storms and rainfall, toxic algae growth in The Great Lakes

Southeast Increased temperature, heavy rainfall, increased hurricanes, dramatic sea level rise and eroding shorelines, poor air quality, harmful algal blooms and increased bacterial infections.

Northwest Increased temperature, decline in precipitation, drought, sea level rise and coastal flooding, increased wildfires, changing ecosystem and agriculture

Southwest Hottest and driest region in US, increased temperature, reduced precipitation, drought, wildfires, destruction of forests and ecosystems, decreased agriculture

The Great Plains Northern Plains with number of days over 100°F doubled by 2050. Southern Plains with days over 100°F quadrupled by 2050. Increased overall precipitation across the Plains. Dryer summers in central Great Plains. Decreased safe drinking water. Changing agriculture.

US Islands Rising temperatures, rising sea levels and flooding and damaged infrastructure, changing storm patterns, acidic coastal waters with changing ecosystems with invasive species, increase vector borne diseases.

In 2021, an unprecidented joint editorial was published simultaneously in The Lancet, New England Journal of Medicine and The BMJ.

The editorial warned against reaching a 1.5 ° C rise above pre-industrial temperatures stating this will lead to "catastrophic harm to human health that will be impossible to reverse."

In 2023 we reached 1.34 -1.48° C above pre-industrial levels, the hottest year on record by a wide margin

Click to see global temperature trend

HEAT

The impact of rising heat on human health is manyfold. In the last 20 years, heat-related mortality among those over 65 has increased by more than 50%. Heat effects by physiologic system:

California Highway 96, McKinney Fire, July 2022

Wildfires and Air Quality

• Climate change is driving wildfires, increasing their frequency and duration
• Wildfires release greenhouse gasses and particuate matter (PM2.5). These create a positive feedback loop leading to increased climate change.
• In addition to pollutants from burning forestry, there are also incinerated materials from urban encroachment leading to aerosolized heavy metal, plastic and other chemical exposures.
• Patients remaining indoors due to poor air quality days can experience social isolation and limit outdoor physical activity resulting in further health effects.

Wildfires and its pollutants have both short term and long term impacts on the cardiopulmonary system

Flooding and Water Contamination

Global Waterborn diseases that is increasing with temperature and precipitation increases:-salmonella -Vibrio (cholera) -vibrio vulnificus -parahaemolyticus-cryptosporidium -norovirus-campylobacter-Naeglaria Fowlerii

Non Infectious Water-Borne Disease Threats:-harmful algal blooms/cyanobacteria - aerosolized toxins and it damages fish -e.g. red tides that occurr in Florida's Gulf Coast

Climate change is leading to inland and coastal flooding for many reasons. Click on the image elements to understand how.

Increasing heat is leading to more evaporation and more frequent and heavy precipitation.

Increased temperatures is leading to heavier snow cap melting which runs off into our nation's rivers and streams.

Arctic sea ice, arctic glaciers, Glacier National Park, US lake ice and Alaskan permafrost are all melting - leading to rising sea levels.

Sea levels are rising not only due to global ice melt, but also water's molecular expansion due to increased heat.

Flooding and Water Contamination

The health impact of flooding and water contamination fall under two categories:

Infectious Disease

Non-Infectious Disease

Particularly monitor patients for:

• Wound infections
• Skin rash
• Gastrointestinal illness
• Tetanus
• Leptospirosis (not common)
• Melioidosis (particularly along the Gulf Coast)

Other Extreme Weather Hazards- Tropical Cyclones and Hurricanes

• Warmer oceans and more moisture in the air is leading to higher likelihood of hurricanes to advance from a weak storm to a major hurricane as it moves to the US coast comapred to the 1990s. The number of Category 4 and 5 Hurricanes in the U.S. is expected to continue to increase.

• Recent hurricanes, particulalry Maria, Harvey, Ian, Sandy, and Irma, have been billion dollar disasters that have both direct and indirect impacts on health.

• Those most vulnerable are people who lackaccess to evacuation routes including the elderly and those with physical disabilities

Hurricane Maria, Puerto Rico 2017

Overview of Climate Change's Impact on Health

Part 2: Unique vulnerabilities of persons with disabilities in extreme temperature and weather

• In 2019, the UN Human Rights Council recognized climate change and disability as a human rights issue.

• Persons with disabilities experience 2 to 4 times higher rates of mortality in climate emergencies.

• People with disabilities often reside in high-risk areas and endure more difficulties during disasters, such as institutionalization and disrupted access to healthcare and essentials.

• The intersection of climate change and disability encompasses a wide range of factors, emphasizing the need for inclusive action plans and the involvement of people with disabilities in pursuing disability climate justice.

The Critical Impact of Climate Change on Individuals with Disabilities

Click image to view some intersectional factors that put hose with disabilities at risk.

Image: 2019 UN Human Rights Summit

In climate disasters, those with disabilities are at a disadvanatge from:

1. Disability specific communication limitations leading to insufficient emergency messaging.

2. Limited mobility during evacuation.

3. Improper emergency shelter to accomodate needs.

Image: Hurricane Ian, 2022

4. Separation from necessary medical devices and caretakers.

• Individuals with sensory and cognitive impairments may struggle to recognize danger, understand verbal evacuation instructions, or read warning signs, putting them at significant risk during emergencies. Limitations can be:

Emergency Communication Challenges for Individuals with Impaired Cognitive and Sensory Functions

• Particularly in rural areas, people with disabilities face barriers to broadband and internet access, which are crucial for receiving timely alerts. Click Image below to see 2021 Pew Study.

• The difficulty in processing evacuation instructions is exacerbated by the lack of web and governmental compliance with the Rehabilitation Act of 1973, Section 508, which is the requirement for accessable information on government websites.

• Patients with physical disabilities face significant challenges in evacuation during natural disasters, including the risk of being trapped in high-rise buildings, difficulty moving through storm debris or floodwaters, and lack of familiarity with their care needs by emergency responders.

• Post-climate disaster migration poses additional risks for individuals with disabilities, including difficulties in finding accessible transit and housing, rebuilding support networks, transferring healthcare and social services, and facing refusal of entry or abandonment due to their disabilities.

• The economic impact of climate disasters can exacerbate mobility issues, with individuals unable to afford essential resources like air conditioning during heatwaves or facing barriers to accessing transit during relocation efforts.

Image: Evacuation Hurricane Katrina

Mobility Challenges During Climate Disaster Evacuation

Hurricane Katrina highlighted the disproportionate impact of natural disasters on over 150,000 people with physical, visual, or learning disabilities.

• People with disabilities face multiple challenges at evacuation shelters, including crowding with sensory overload, non ADA compliant set-ups, significant changes in routine and diet and separation from caregivers, service animals and assistive technology.

• Specifically, children with disabilities can become overwhelmed, separated from their caregivers and struggling with communicating their needs.

• Inadequate shelter options and services often deter evacuation efforts.

• The National Shelter System (NSS) is outdated, with incomplete or out-of-date accessibility assessments, leading to the selection of shelters based on poor information.

Image: Busy Katrina Evacuation Shelter

Emergency Shelter Challenges for Individuals with Disabilities

Steep, Broken or No Ramps to Enter Shelter

Inaccessible Shelter Bathrooms

• The United States experienced a 78% increase in significant power outages from weather-related incidents between 2011 and 2021.

• Power outages can be life or death. Patients may lose access to crucial assistive technologies during power outages, affecting their mobility, communication, respiration and more.

• The lack of refrigeration during power outages can lead to the spoilage of life-saving medications, posing serious health risks to patients reliant on these drugs.

• Patients using respiratory equipment are particularly vulnerable during power outages, as they are more exposed to smoke, vapors, and airborne toxicants, which can exacerbate respiratory conditions.

Image: Downed powerlines after Hurricane Ida, 2021

The Impact of Power Outages on Medical Needs During Emergencies

Click Image to read activist, Alice Wong's, first hand experience in San Francisco January 2023.

Part 3: The Impact of Heat on Specific Populations.

Physiolgy of Heat and it's Impact on Health

• Humans regulate their internal body temperature through means of conduction through surface contact, radiation from body, convection which is controlled by skin and muscle blood flow and evaporation through sweat and respiration.

• When sources of heat exposure or generation out pace these cooling mechanisms, core body temperature can become so high that problems begin to occurr, At core temperatures above 40°C, severe health isues can begin.

Physiolgy of Heat and it's Impact on Health

• Extreme heat is the leading weather-related killer in the US, with heat waves tripling the risk of death for individuals with pre-existing psychosocial disabilities. Mobility or communication impairments further complicate the ability to seek relief from heat or communicate distress.

Additional predisposing factors for the most serious of conditions, heat stroke, includes:

Environmental Factors

• High environmental temperature
• High humidity
• No air movement
• No shade

Constitutional Factors

• Age
• Overweight
• Low fitness level
• No heat acclimatization
• Dehydration
• Lack of sleep

Medication and Substance Use

• Alcohol
• Antihistamines
• Benzodiazepines
• Beta-blockers, and many more

Health Status

• Viral infection
• Diabetes mellitus
• Febrile illness
• Cardiovascular disease

Mental Factors

• Strong desire to succeed/overmotivation accompanied by (as yet) insufficient performance capacity, e.g., in athletes and military personnel

Heat Conditions Include:

• High environmental temperature
• High humidity
• No air movement
• No shade

• Age
• Overweight
• Low fitness level
• No heat acclimatization
• Dehydration
• Lack of sleep

• Alcohol
• Antihistamines
• Benzodiazepines
• Beta-blockers, and many more

• Strong desire to succeed/overmotivation accompanied by (as yet) insufficient performance capacity, e.g., in athletes and military personnel

• Viral infection
• Diabetes mellitus
• Febrile illness
• Cardiovascular disease

The Hypothalamus is key in controlling our core body temperature. Hypothalamic control can be damaged in SCI and TBI.

• Individuals with SCI experience alterations in thermal physiology due to decentralization of the sympathetic spinal cord from the hypothalamus, leading to:
• impaired blood vessel dilation/contraction
• Impaired skeletal muscle shivering
• Impaired sweat gland stimulation.

• SCI at T6 and above results in more severe thermoregulatory dysfunction as body temperature regulation is primarily influenced by central thermoreceptors. Those with T7 and below still has use of core and body surface temperature receptors.

• Relative immobility and potential dependence on others for self-care places individuals with SCI at a heightened risk of temperature dysregulation, leading to possible autonomic dysreflexia or heat-induced health issues.

• Those with TBI can experience direct damage to the hypothalamus, leading to similar impairments.

• Both those with SCI and TBI can experience a type of dysautonomia called paroxysmal autonomic instability with dystonia, which can lead to further hyperthermia.

• Heat related events like wildfires impact Individuals with SCI more than other populatrsions. Individuals with SCI with compromised respiratory status, face increased risks from short-term exposure to particulate pollutants, including exacerbated chronic obstructive pulmonary disease and higher susceptibility to obstructive lung pathology from long-term exposure.

Thermoregulatory Challenges in SCI and TBI

• Short term heat related exacerbation of MS is commonly recognized condition known as Uthoff's Phenomenon. Studies have also linked more prolonged MS symptom exacerbation due to heat.

• MS shows significant exacerbation of symptoms with just a slight increase in core body temperature (0.5 °C or less) due to high ambient temperatures.

• Exposure to a wider diurnal temperature range (DTR), an indicator of within-day temperature variations, has been linked to an immediate increase in the risk of emergency department visits for MS patients. This suggests that large temperature variations can disrupt temperature homeostasis and activate the innate immune system, leading to CNS inflammation.

• Heat can worsen symptoms of vision change, fatigue, numbness, tremor, confusion, imbalance and weakness. Symproms can last anywhere from less than 24 hours or remit slowly over weeks to months

Proposed mechanisms of this phenomenon include:1. Impaired thermoregulatory response: Studies indicate that MS patients have a significantly higher increase in core temperature than normal controls during heat exposure, suggesting a thermoregulatory dysfunction caused by brain lesions in areas responsible for regulating body temperature, such as the Hypothalamus. 2. Heat induced neuro-inflammation: Studies propose that changes in ambient temperature can induce neuro-inflammation through mast cell activation, exacerbating MS symptoms. This is analogous to the acute exacerbation seen in asthma patients due to temperature-induced mast cell activation in the respiratory tract.

Heat Sensitivity in Multiple Sclerosis

• As of 2016, Parkinsons Disease affected more than 6 million individuals worldwide, a significant increase from 2.5 million in 1990. This rise is attributed to the growing elderly population and environmental factors, with global warming identified as a critical contributor.

• Global warming exacerbates Parkinson's Disease (PD) through DNA damage, protein misfolding, neuroinflammation, and neuron degeneration, leading to an accelerated decline in neuronal health .

• Heat waves, influenced by global warming, are also linked to worsened neurological symptoms in PD patients and are considered risk factors that influence both morbidity and mortality of PD patients.

Neurodegeneration

The Impact of Global Warming on Parkinson's Disease

Click image below to see summary of Dec 2023 Nature study demonstrating the impact of global warming on neurodegenerative disease:

Global Warming

Heat Stress

Oxidant/antioxidant imalance

Misfolded proteins

Oxidative Stress

Neuroinflammation

Proposed mechanism:

• Those with disabilities are more prone to dual diagnoses, including depression, pain, and addiction. Climate change exacerbates depression and anxiety across the general population, with disabled individuals facing heightened risks.

• Climate change can induce a wide range of mental health reactions, including eco-anxiety, eco-depression, trauma, stress-related disorders, substance use disorders, and exacerbation of major mental health disorders, either new onset or pre-existing.

• Individuals who have adapted to manage their disabilities may find themselves unable to cope post-disaster, leading to mental health distress and "solastalgia," a sense of loss for the environment as it was known.

• The phenomenon of being "climate-jailed" describes persons with spinal cord injury (SCI) and potentially other disabilities becoming confined indoors for long periods due to weather extremes. This isolation can significantly increase morbidity from depression due to temperature imbalance and fatigue limiting community activities.

• The marginalization experienced by persons with disabilities is amplified by climate change, reducing access to healthcare, food, water, and accessible infrastructure. This scenario worsens mental health outcomes.

• Children with Autism Spectrum Disorder (ASD) and other cognitive disabilities are particularly vulnerable due to sensory processing challenges, cognitive rigidity, and co-existing anxiety disorders. Their ability to adapt to traumatic events and cope with disaster-induced stress is significantly impaired.

• The stress on parents of children with disabilities, exacerbated by disasters, can negatively affect their ability to support their children's needs post-disaster, further influencing the child's mental health outcomes.

Climate Change and Mental Health: The Compounded Impact on Individuals with Disabilities

Part 4: Unique vulnerabilities of athletes in extreme climate and weather

Part 4: Unique vulnerabilities of athletes in extreme climate and weather

• More than 9,000 cases of exertional heat illness in high school athletes are reported annually in the US, with football players experiencing the highest rates—11 times that of all other high school sports combined. Possible reasons include excessive gear and pressure to perform.

• In professional athletes, highest rates of heat related illness occurr in cycling and running.

• Athletes with disabilities face additional challenges in rising temperatures, underscoring the need for optimized prevention and treatment protocols for exertional heat illness in this population.

• Hyperthermia puts athletes at greater risk for exertional rhabdomyolysis as well as exertional hyponatremia through sweat sodium loss and subsequent overhydration.

Image: Marathoner, Callum Hawkins, collapse during race.

The Impact of Heat on Athletes

Notable events, like the US Olympic Track and Field Trials in 2021, have seen heat indices exceed 42.2°C (109°F), with surface temperatures on synthetic tracks surpassing 65.6°C (150°F).

Jun 27, 2021; Eugene, OR, USA; The temperature reads 108 degrees during the US Olympic Team Trials at Hayward Field

Heptathalon athlete, Taliyah Brooks, is helped off the track after collapse due to extreme heat during the US olympic Trials June 27, 2021.

• Athletes, particularly marathon runners, inhale significantly more particulate matter during races due to increased ventilatory effort.

• Training or competing at high intensities leads to mouth breathing, which bypasses the respiratory system's natural defenses against pollutants, contributing to increased respiratory stress and inflammation.

• Fine particulate matter (<2.5 µm) penetrates deep into the lungs, causing cellular damage, while larger particles (2.5−10 µm) have been shown to risk children's respiratory development and future endurance performance.

• Studies show that training and competing at elevated air pollution levels is associated with slower track and field race times.

• Athletes are at a heightened risk of asthma attacks triggered by air pollutants, including ozone and sulfur dioxide. Ozone exposure, in particular, is associated with increased emergency department visits for asthma attacks.

Air Pollution's Toll on Athletes: Risks and Performance Impacts

Click to see health impact of particulate matter (PM) exposure

Climate Change and the Rise of Infectious Diseases: Implications for Athletes

• Deforestation and climate change promote animal migration and habitat changes, raising the risk of spreading and new zoonotic diseases.

• Cases of Lyme disease are increasing and spreading to new geographical areas where they were previously uncommon, posing additional risks to outdoor athletes.

• The prevalence of Lyme disease and other tick-borne illnesses in endurance athletes is underreported, yet significant effects on the health and careers of professional and Olympic athletes have been noted, including fitness loss, reduced competitive ability, or forced early retirement due to chronic health problems from Lyme disease.

• Beyond tick-borne illnesses, climate change also promotes the spread of global waterborne and mosquito-borne diseases such as Vibrioparahaemolyticus, malaria, Zika, and dengue fever. These shifts in disease distribution and emergence set the stage for future outbreaks and pandemics that could significantly affect the health of athletes and the general population alike.

Part 5: What can Physiatrists do?

• Physiatrists lead and support teams that include a range of healthcare professionals, each bringing their expertise to support patients with disabilities.

• Their unique position allows physiatrists to deeply understand the psychosocial and home situations of their patients, enabling tailored advice and support.

The interdisciplinary team aids patients in preparing for the complexities of climate change. This includes:

• Natural Disaster Evacuation Plans: Assisting in the development of evacuation plans tailored to the specific needs of individuals with disabilities.
• Heat and Pollution Mitigation: Directing strategies to mitigate the effects of increased heat and pollution, which can disproportionately affect people with disabilities.
• Safe Exercise Practices: Encouraging exercise practices adapted to changing climate conditions, ensuring patients maintain their physical health safely.
• Proper medication management in the context of thermo regulation.

• Preperation for new and increased rehab needs after climate disasters.

Physiatrists as Leaders and Educators

• Out-of-Hospital: For heat stress with altered mental status, initiate external cooling and transfer to a medical facility promptly.

• In-Hospital: Continue cooling measures, monitor vital signs, and address any complications such as seizures, respiratory failure, or rhabdomyolysis.

Click Image below for additional recommendations:

Special recommendations for those with Poikilothermia

Primary Prevention

Secondary Prevention

Tertiary Prevention

Treating Heat Illnesses

Advising Patients on Preparedness, Evacuation and Shelter

• Disaster planning significantly reduces adverse impacts, yet households with disabilities often show lower levels of preparedness.
• Surveys among caregivers of children with developmental disabilities reveal a gap in emergency preparedness actions and a strong need for additional training and support.
• The physician should identify the patient's specific strengths and support needs in daily life. Counciling should be specific to the patient.

Tips for Disaster Communication

Help your patient make a survival kit

Tips for Evacuation and Shelter

Click image to see how medications can impact thermoregulation

General Medication tips:

• In climate emergencies, ensure patients have an adequate supply of medications, particularly those with withdrawal syndromes, such as baclofen.
• Advise on safe medication storage practices during power outages, recommending the use of medication coolers for temperature-sensitive drugs.
• Products of concern include refrigerated medications (insulin, biologics, vaccines), emergency medications (epinephrine, naloxone), delivery devices (metered-dose inhalers), and glucose testing equipment, which may show erroneous results in high heat and humidity

Physiciains must also be aware of what medications impair heat resilience by affecting crucial defense mechanisms:

• ACE inhibitors may impair the perception of thirst.
• Opioids, serotonin reuptake inhibitors, carbamazepine, anticholinergics, and tricyclic antidepressants can disrupt central thermoregulation.
• Antimuscarinic agents, including anticholinergics, tricyclic antidepressants, or antipsychotics, can trigger hypohidrosis.
• Sympathomimetics may cause cutaneous vasoconstriction, impacting the regulation of skin blood flow.
• Sedatives like benzodiazepines and opioids make early recognition of warning symptoms difficult due to altered attention and alertness.

Drug pharmacokinetics may also be altered by heat:

• Local heat increases cutaneous blood flow, enhancing the systemic availability of drugs administered transcutaneously (e.g., opioid patches).
• Subcutaneously administered drugs (such as insulin) are released more rapidly at higher temperatures, having a stronger effect.
• Renal and hepatic blood flow may decrease by approximately one third in high heat, affecting the bioavailability of orally administered drugs with a high first-pass effect, like betablockers.

Medication Management in the Context of Climate Change

Part 6: Systemic changes need to happen to make Healthcare more sustainable.

Image: Medical waste found in landfill

The Impact of the Healthcare System on Emissions and Climate Change

• Medicine's guiding pricinple is "First do no harm." However, the healthcare industry is directly causing harm to global populations through unsustainable practices, high carbon emissions and through perpetuation of climate change.

• The healthcare industry produces over 4 billion pounds of waste annually in the United States, making it the second leading contributor of waste.

• As of 2023. this contributes to 8.5% of the US carbon footprint and 9% of harmful non-greenhouse air pollutants annually.

A vicious cycle

Healthcare utilization leading to waste

Increased medical waste and emissions causing climate change

Climate change causing more health problems

Health problems leading to more healthcare utilization

• A waste audit at the PM&R Sports and Spine clinics at Stanford identified the outpatient surgical center and in-clinic procedure visits as major waste generators, producing 1,758g and 379g of waste per patient encounter, respectively.

• Pre-packaged procedure kits generated significantly more waste than using individual sterile components.

• Telemedicine is also a sustainable healthcare practice, reducing the need for travel and thereby saving energy, decreasing carbon emissions, and conserving time and costs.

• Key interventions include reducing the use of pre-packaged injection kits, developing educational materials to promote sustainable practices, doing more telehealth visits and working on quality improvement projects, like waste audits. This is something that residents can spearhead as QI projects at their institutions.

Making PM&R More Sustainable: Lessons from a Stanford Waste Audit

Stanford study showing difference in waste from pre-packaged procedure kits and individual sterile components.

• Physical dangers of flood water, floating debris and loss of power.
• Wastewater and industrial chemical runoff during floods leading to chemical, biological and radioactive exposures.
• Mold and sewage conamination in homes after floods.
• Exposure to toxic algea and cyanobacteria blooms in freshwater and saltwater that can impact health through inhalation, ingestion and dermal exposure.
• One of these toxins, BMAA, has been linked to ALS, Parkonsonism and dementia.
• Increased Ciguaterra poisoning is also linked to increased toxic algae blooms.

In 2019, the UN Human Rights Council called climate change a threat to the human rights of those with disabilities, highlighting the disproportionate impact of climate change on this population. They called for disability inclusive climate action.

Treatment for poikilothermia e.g. in SCI:

• If body temperature is high, get out of the heat if at all possible. Go to an air conditioned room or use a fan.

• Take off layers of clothes.

• Sponge off with cool water.

• Drink plenty of cool fluids.

• Avoid cold/ice packs. Patient may not sense the extreme temperatures of these packs and may experience frostbite.

• Take breaks from hot or cold environments and allow the patient's body to rest and regulate itself, in addition to the measures above.

• If your temperature remains high despite the measures listed, it may be due to another reason, such as an infection.

67% of waterborne disease outbreaks are preceded by precipitation above 80th percentile.These include:

• Wastewater contamination leading to Salmonella.
• Bacterial blooms in marine environments leading to increased Vibrio Cholera.
• Heavy rainfall and flooding can mobilize Cryptosporidium oocysts and increase Norovirus and Campylobacter transmission.

• Warmer temperatures are also increasing incidence of Naeglaria fowlerii infection in Northern US.

Activation ofcoordinatedstress response

Endothelial,epithelial,leukocyteresponse viacytokines, heatshock proteins

Increasedhypoxemia,cytotoxic injurylead todysregulatedimmune response

Distributedshock similar tosystemicinflammatoryresponsesyndrome

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Immune System

• Avoid Hot Days: Heed weather warnings and avoid exposure on particularly hot days. This can help prevent heat-related illnesses before they start.

• Limit Over-exertion: During hot weather, reduce physical activity to prevent overheating.

• Stay Away from Heat Sources: Minimize exposure to direct sunlight and hot environments.

• Have cooling measures on hand such as chemical ice packs and fans.

• Acclimatization: Understand that the risk of heat related illness is highest at the beginning of the season.

• Heat Acclimitization strategies can be applied to develop physiologic adaptations to develop decreased core temp, enhanced sweat efficiency and improve exercise capacity.

Smartphone weather applications can warn against excessive heat.

These phenomenon lead to:

1. River flooding

2. Coastal flooding

3. Flash flooding

Right now 21.8M U.S. homes and businesses are in harm's way.

e.g. 2022 Montana Yellowstone Flood

US EPA map showing average coastal flood days per year.

e.g. 2023 NYC flash flood

Peripheralvasodilation,centralvasoconstriction

Sympatheticnervous systemand local reflexpathways

Decreasedsplanchnic blood,tissue hypoxia,endotoxemia,bloodstreaminfection

Sepsis andseptic shock

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Vascular System

Many healthcare institutions and medical professional societies are calling for policies to:

1. Meet and strengthen the commitments under the Paris Agreement.
2. Transition away from the use of coal, oil and natural gas to clean, safe and renewable energy.
3. Transition to zero-carbon transportation systems with an emphasis on active transportation.
4. Build local, healthy and sustainable food and agricultural systems.
5. Invest in policies that support a just transition for workers and communities adversely impacted by the move to a low-carbon economy.
6. Ensure that gender equality is central to climate action.
7. Raise the health sector voice in the call for climate action.
8. Incorporate climate solutions into all health care and public health systems.
9. Build resilient communities in the face of climate change.
10. Invest in climate and health.

This implies that the lifetime emissions of an average American (1,276 metric tons) causes 0.29 excess deaths in expectation if all added in 2020.

The Mortality Cost of Carbon

R. Daniel BresslerNature Communications, 2021

Effective Communication Strategies:Essential communication aids include ASL interpreters for public announcements and accessible communication tools (TTY, CCTV) in shelters.Smartphones should be promoted for those able to recieve information through them.Wireless Emergency Alerts, FEMA mobile app, and purchasing NOAA Weather Radios ensures timely updates and alerts. NOAA emergency radios have alarm, speech, light and shake functions that can give warnings. Designate neighbors and friends to contact the patient in an emergency

Reproductive System

Reducedplacentalblood flow tosupportperipheralvasodilation

Sympatheticnervoussystem andlocal reflexpathways

Dysregulation ofthermalhomeostasisleading to coretemperature overteratogenicthreshold

Miscarriage,pre-term labor

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Click Images to make larger

The study employs three Shared Socioeconomic Pathways (SSPs) scenarios to predict future temperatures and assess their impact on neurodegenerative disease cases:SSP126 (Low Emission and significant sustainability efforts)SSP245 (Medium Emission and intermediate effort towards emission reduction) and SSP585 (Continued High Emissions).Under these scenarios, the study predicts that all examined neurodegenerative diseases are affected by temperature variations. Parkinson's disease is highlighted for its particular vulnerability to heat, with a significant increase in heat-related mortality and a decrease in cold-related mortality by 2090. Effects are most pronounced uncer high-emission scenario (SSP585). This is attributed to the expected rise in global temperatures, leading to more frequent and intense heatwaves.

• Diagnosis and Immediate Treatment: Heat illness diagnosis is primarily based on clinical assessment, including a detailed history of exposure and symptoms.

• Emergency Response: In the event of heat illness, call for medical help immediately.

• Basic Life Support (ABCs): Ensure airway, breathing, and circulation are maintained.

• Rapid Cooling Techniques: Initiate cooling immediately to prevent severe outcomes.Employ methods such as exposing the skin, wetting the body, and promoting evaporation to reduce body temperature quickly. Immersion in iced water is highly effective.

• Targeted Cooling: Apply ice packs to areas with abundant blood supply, such as the groin and armpits, to cool the body efficiently.

Sideline ice bath and targeted spots for icepack placement for cooling.

Behavioral andphysiologicresponses toreduceexogenousheat exposure,increase heatloss

Multiplethermoregulatory pathwayscoordinated bythe preoptichypothalamus

Cerebralhypoperfusion anddysregulation ofthermalhomeostasis

Confusion,delirium, dizziness,weakness,agitation,combativeness

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Central Nervous System

The survival kit list:Water: One gallon per person, per day (3-day supply for evacuation, 2-week supply for home).Food: Non-perishable, easy-to-prepare items (2-week supply for home).Flashlight & Extra Batteries: Ensure functionality and long-term use.Battery-Powered or Hand-Crank Radio: To stay informed on current conditions and emergency broadcasts.Entertainment: Books, games, or other activities to maintain morale.Medications: A 14-day supply, along with any necessary medical items.Multi-Purpose Tool: Can be used for various tasks in survival situations.Sanitation and Personal Hygiene Items: Including detergent to maintain cleanliness.Personal Documents: Medication list, pertinent medical information, proof of address, deed to home, passports, birth certificates, insurance policies.Solar Chargers: To maintain power for electronic devices.Extra Set of Car Keys and House Keys: Avoid being locked out in emergencies.Manual Can Opener: For non-perishable food items.Printed Family and Emergency Contact Information: Essential for staying connected or if digital devices fail.Extra Cash: For situations where electronic payment systems may be down.Blanket/Towel: For warmth and various other uses.Map(s) of the Area: In case GPS or digital maps are unavailable.Whistle: To signal for help.Matches: Preferably waterproof, for starting fires for warmth or cooking.Rain Gear: To stay dry during inclement weather.Duct Tape/Scissors: For repairs and cutting needs.Extra Clothing, Hat, and Sturdy Shoes: To prepare for various weather conditions and protect against elements.Portable Generators and Chargers: Especially those charged by solar power, to ensure continuous power supply.Label for Assistive Devices: With “how-to” instructions on complex devices.Coolers and Chemical Ice Packs: To keep medications and perishables at safe temperatures.Back-Up Non-Electric Devices: As alternatives in case of power failure.

Increased cardiacoutput to meetincreasedmetabolic demand

Increasedinotropy andchronotropy viabaroreceptorsand otherpathways

Decreased cardiacoutput due todecreased strokevolume

Peripheral,centralhypoperfusion;acute coronarysyndrome;myocardialinfarction

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Cardiac System

Initial increase,then decrease,in plasmavolume

Sympatheticnervoussystem,activation ofcoagulationand fibrinolyticpathways

Increased viscosity,altered coagulation

Disseminatedintravascularcoagulation,tissuehypoxemia andcell death

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Hematologic System

• Recognize Early Symptoms: Be aware of the early signs of heat illness, including fatigue, dizziness, and excessive sweating.

• Cool Down: Take breaks to cool down in shaded or air-conditioned areas. Ice water bath may be necessary. Help patients identify cooling center.

• Hydration Monitoring: Stay hydrated and monitor for signs of dehydration, such as dark-colored urine.

• Provide Shade and Water: Ensure access to shaded areas and sufficient drinking water, especially during outdoor activities.

Early symptom cooling techniques

The terms atmospheric river and bomb cyclone were not in my vocabulary until recently. During the first two weeks of 2023, however, the San Francisco Bay Area was deluged with a series of storms. I am a disabled person who depends on power to live. When I came home after four weeks in the ICU last summer, I was tethered to a feeding machine that pumps food into my stomach, as well as to a ventilator that’s attached to a hole in my throat, among numerous other devices. The stakes for potential harm during a power outage have exponentially increased. My anxiety, vulnerability and fear are real.Jan. 3, 2023, 10:44 p.m.: Texted my caregivers on what to do if a power outage happens while I am in bed tomorrow night. Air mattress will deflate, and I will immediately need to be transferred into my wheelchair. I will need to use my backup electric batteries for medical devices such as my suction machine, since I need to suction hourly every day.Jan. 4, 10 a.m.: Mentally calculating how much battery life some of my machines need before needing to use my backup electric battery. My other devices do not have a built-in battery.1 p.m.: Bookmarked the link to Pacific Gas & Electric’s (PG&E) Outage Center, so I can look up all the outages by location and report one if it happens in my neighborhood.1:30 p.m.: Asked my father to make sure my backup electric batteries are fully charged.2 p.m.: Let my morning caregiver leave her shift early so that she can get home safely before the brunt of the storm arrives. Did not hydrate today, because my nighttime caregiver will not arrive until 9 p.m. Worried for her, and worried for me. I hope I don’t get a full bladder.3:02 p.m.: Tweeting information about the storm. Noticing that many weather-related Tweets do not have alt text in graphics and captions in videos that contain vital information about the storm, evacuations and road closures.3:30 p.m.: Watching the news and scrolling Twitter. My father, who thinks I’m being an alarmist, said, “The news always exaggerates the dangers.” After living with me for decades, he still doesn’t understand.6:01 p.m.: Pre-emptively charging some of my devices, topping them up with power tonight, just in case.6:19 p.m.: Uh-oh. My bladder feels a little full. Let’s see if I can hold on until 9-ish when my caregiver arrives. I hope she makes it.7:57 p.m.: Caregiver texted me saying she won’t be able to arrive until 10:30 due to a delay from her other job. Bladder, don’t fail me now! Can’t wait to be catheterized.10:18 p.m.: Praise be, my caregiver arrived! Time to pee. Sweet relief!Jan. 5, 2:15 a.m.: Time for bed. Feeling thankful and safe that my caregiver is here for her overnight shift.

2021 IPSOS Poll on who people trust for information:

Increasedreabsorption tocompensate forinsensible waterand electrolytelosses

Vasopressin,Renin-angiotensin-aldosteronesystem, renalsympatheticnerve activity

Insufficient renalperfusion, inabilityto maintainadequate waterand electrolytereabsorption rates

Dehydration,electrolyteabnormalities,acute kidneyinjury

Physiology

Mechanism

Decompensation

Outcome

Credit: Jeremy Hess, MD MPH, UW Medicine

Renal System

Long Term

Short Term

Cardiopulmonary Effects of Wildfires

• Consistent association between level of particulate matter during wildfires and risk of death from any cause for up to 4 days after exposure.

• Increaed risk of asthma, COPD and respiratory infection.

• Living within 200km of wildfires causes increased cardiovascular risk similar to those associated with urban air pollution.

• Increased low birth weight and preterm birth.

• Data are lacking to quantify the long term health risks of wildfire smoke.

• Study of 1759 children from Southern California communities found increased air pollution exposure over 8 years results in reduced FEV1.

• A follow up study 10 years after the 1997 Indonsesian forest fires showed that those exposed had reduced lung capacity and poorer self reported general health nd physical functioning.

Some hope from the Intergovernmental Panel on Climate Change

In the aftermath of a disasterResume provision of outpatient care as soon as possible.Assist patients with the replacement of damaged or lost equipment and supplies.Help persons displaced from usual sources of care obtain necessary care elsewhere. Ensure timely refills of intrathecal baclofen pumps to prevent withdrawal.Refer patients for social support and mental health services as appropriate.

Additional Preparedness Tips:Encourage patients to develop a personal support network of people who can assist in emergencies.Teach patients to instruct emergency responders on their specific needs, ensuring a clear understanding of individual requirements during evacuation.Register with power providers for priority restoration and inform patients about manual feeding techniques and equipment management during emergencies.Promote awareness of local air quality and encourage patients to stay informed for better decision-making regarding outdoor activities

Evacuation Protocols:Creating a detailed evacuation plan with family, caretakers, and neighbors, including giving someone a key, is crucial.Identifying and registering for accessible transit options and emergency assistance ahead of disasters is advised.Patients in wheelchairs should instruct responders on proper handling techniques to avoid injuries and complications. Label all assistive devices with clear instructions for use.Shelter Considerations and Post-Disaster Recovery:Advocate for shelters accessible to all, including those at risk of autonomic dysreflexia, and ensure that emergency staff are trained in disability awareness.Following a disaster, promptly resume outpatient care, assist in replacing lost or damaged equipment, and ensure access to social support and mental health services.Encourage patients to keep a 7-day supply of essentials, including food, water, and medications. Battery-operated fans and backup non-electric devices are recommended to cope with power outages.