Better recovery rates from bowel disease; prepping for disaster; explaining pulmonary hypertension: Upstate Medical University's HealthLink on Air for Sunday, Jan. 29, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pediatric gastroenterologist explains the improvement in recovery rates for children with inflammatory bowel disease.

Prateek Wali, MD: Gastroenterologists have pushed for what's called endoscopic remission, which means that not only are you feeling better and your labs are better, but we actually have healed the tissue.

Host Amber Smith: Upstate's director of emergency management tells how hospitals prepare for disaster.

Chris Dunham: If we were in the West Coast, earthquakes would certainly be higher than it is right now. Where, if we were in Florida, it'd be hurricanes. Now, we do get hurricanes up here, but usually we're on the tail end of things, and it's more heavy rain, storms, things like that.

Host Amber Smith: And we'll learn what makes pulmonary hypertension so dangerous. All that and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn how hospitals prepare for blizzards and tornadoes and other potential disasters.

But first what's behind the dramatic improvement in rates of recovery for children with inflammatory bowel disease?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." The remission rate for children with inflammatory bowel diseases who are seen in the Karjoo Family Center for Pediatric Gastroenterology improved from 60% in 2013 to 87% in 2022. Here to explain how that happened is Dr. Prateek Wali, the director of the pediatric IBD program at the Upstate Golisano Children's Hospital. Welcome back to "HealthLink on Air," Dr. Wali.

Prateek Wali, MD: Well, thank you for having me.

Host Amber Smith: A more than 20% improvement seems huge to me, but let's first start with a description of the inflammatory bowel diseases that you see in children.

Prateek Wali, MD: Inflammatory bowel disease is mainly two major disorders -- ulcerative colitis and Crohn's disease. Ulcerative colitis affects the colon and is more superficial, while Crohn's disease can involve any component of the GI (gastrointestinal, or digestive) tract and often affects the deeper layers of the gut. So it goes a little further into your muscle layers than ulcerative colitis does.

Compared to adults, children with inflammatory bowel disease tend to have more extensive disease, and they tend to have aggressive progression, which means that they're sicker. This means that often they require more potent therapy. That's a good thing because kids need to grow, which is different than in adults. So if you get them into remission and feeling better, they also start growing again, and they don't miss those critical years of puberty. I think some of the typical symptoms that you'll typically see with inflammatory bowel disease are chronic diarrhea -- it can have blood or no blood --belly pain, with and without stooling.

Again, growth is such an important part of pediatrics. So weight loss, height stunting, delayed puberty. Other non-GI symptoms are fever, joint pain, oral sores that can be sometimes seen with inflammatory bowel. So I think it's, a tricky thing at the beginning to put together this picture. The first step is to arrive at a diagnosis and figure out where the disease is, and we use different tools for that. Some of the tools are blood work, stool testing, endoscopy, which is a camera where we look at the upper part of the GI tract under anesthesia and a colonoscopy, which looks at the lower part of the GI tract with a camera under anesthesia.

Some of the newer things that we were going to talk about today are developments that have improved our ability to look at the small intestine, such as MRI technology and capsule endoscopy, which uses basically a camera that's in the shape of a pill to look at the small intestine.

Host Amber Smith: Do you see a lot of children with these diseases?

Prateek Wali, MD: Well, the peak incidence of inflammatory bowel disease is between the ages of 15 and 30. So if you think about it, you're going to see a lot of teenagers in that age group. We often see patients up to 19 to 21. The incidence of pediatric IBD is unfortunately increasing, around the world and especially in the United States, and the fastest rate of increase is children under 12, which is even more worrisome. There's probably about 50,000 children in the U.S. currently with inflammatory bowel disease.

Host Amber Smith: What are the reasons for the increase in frequency, especially in the kids under 12?

Prateek Wali, MD: I don't think we know the answer to that question. I think there's an interplay between having predisposition genetically, to our diets, our environment. You know, there's discussion about the microbiome and what the bacteria and viruses and fungi, what their effect in our GI tract is. And we're learning on a regular basis some of the things that might affect those protective layers we have in our intestine. And when those protective, layers are broken down, it puts us at risk for some of these inflammatory reactions to happen. And then once your body loses that tolerance, your immune system is, unfortunately, confused and starts to attack itself rather than the bacteria and the viruses and the fungi. So I don't think we have a clear understanding, but I think some of our more targeted therapy is looking at what might be some of the reasoning behind it.

Host Amber Smith: So what does remission look like in inflammatory bowel diseases?

Prateek Wali, MD: That's a great question, but complicated.

There's clinical remission, which means you're feeling good. There's biochemical remission, which means your labs (laboratory test results) are looking better, your stool testing, which also looks at inflammation -- we have a specialized stool test called a calprotectin -- looks better. Over the last five to 10 years I think that gastroenterologists have pushed for what's called endoscopic remission, which means that not only are you feeling better and your labs are better, but we actually have healed the tissue. And so we're looking to see, have we healed the areas? And I think we're doing that more and more. We're looking to see how well patients are healed a year after they started therapy.

Along with that goes histologic remission, where we look at the biopsies under a microscope to see if they're better. The gold standard would be that on imaging, not only is the endoscopy better, but the finer layers of the gut are healed. That's called transmural remission. And the goal of all of this is that if you're in remission, not only feeling better but actually healed, that you prevent long-term complications, which we know is the natural history of the disorder.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Prateek Wali. He's the director of the pediatric inflammatory bowel disease program at the Upstate Golisano Children's Hospital.

Let's talk about how you and your team have been able to improve the remission rates so much. What can you tell us about Improve Care Now?

Prateek Wali, MD: Improve Care Now is a really novel, collaborative community where clinicians, researchers, patients, parents, dieticians, social workers are empowered to learn and continuously improve the care of children with inflammatory bowel disease. It's dynamic IBD care, and I think that there are multiple things that are involved in this collaborative. But the key is to share. One of their key mottos is that they steal shamelessly and share seamlessly. And that's a really wonderful statement because we use resources from all these different centers, and they use our resources. It's a great way to provide care all around the country and actually internationally for this group of patients.

And it's become a really a model for what modern medicine should look like. It's also been awarded the Drucker Prize for quality improvement in medicine.

Host Amber Smith: So this is like a real time database?

Prateek Wali, MD: Yeah. You got it. One of the components is a realtime database. So when a patient comes to clinic, we consent them and ask them if they're willing to be in it, which I have to tell you it's hardly anybody that doesn't want to be in it, when they see the numbers of what it can provide. And we input their symptoms, their labs, their imaging, endoscopic details, their treatment into this database each time they actually come to the clinic.

And then we can actually in real time look at how that patient with that disease process and location and age is doing compared to a similar patient around the country or world with the same disease. And we can make fine changes that maybe will help us. And it gives us, like, almost like a report card for how we're doing as a center.

Host Amber Smith: So you might see how a fellow doctor is treating someone in another part of the world that's having some success, and it might give you an idea of something that might work with one of your patients?

Prateek Wali, MD: Yeah, exactly.

Host Amber Smith: Have any new discoveries about pediatric IBD come out of that database?

Prateek Wali, MD: Another component of the database or the collaborative is, if you can imagine with 30,000 children in the database, that we are able to have much better luck with looking at research. And one of the research studies that's recently been completed that we were a part of ... we were one of 28 centers looking at whether methotrexate -- which is an immunosuppressive drug, would help one of the biologics, which is another treatment, and actually biologic therapy or biologic drugs are what have kind of revolutionized IBD care over the last 10 to 15 years -- whether that methotrexate would be helpful as an adjunct drug to these biologic therapies. And it just completed, and there were over 400 kids in the study, which is one of the largest pediatric IBD studies ever completed, and it had great results that we could really answer that question. And that's the kind of thing we're looking for is, if you have a really good question that can really change the care, you have a way of doing that because you have this collaborative.

Host Amber Smith: Interesting. Well, what can you tell us about the personalized approach that you use at Upstate? I'm curious, too, about the team members that are part of this.

Prateek Wali, MD: Yeah. Well, we have a wonderful team. So we try to meet every week to every two weeks to go over the patients that are going to be coming into our clinic, and we also go over the patients that might be ill, in other words, patients that have not been doing well recently. We call that care stratification. And, at these meetings, you have a physician lead, which is usually myself. We have an IBD nurse. We have an IBD nurse practitioner. Our IBD nurse practitioner is also in charge of infusion care, and so some of these biological medicines are given by IV, so she coordinates that.

And actually one thing we've recognized over the last five to 10 years is that it's important to monitor the drug levels of these biological therapies so that you get the most optimal remission. And so she's also in charge of what's called therapeutic drug monitoring, or looking at these levels.

Another component obviously is growth and nutrition, so we have a pediatric dietician at our meetings. And we have a clinical research coordinator. That's who kind of pulls everything together for us to have these meetings. When we meet, we talk about what monitoring looks like in those patients that are coming in in the next two weeks, how they're doing, what their labs look like, what their levels look like, what their growth looks like.

But we also talk about preventative health. Are they taking their vitamin D? Have they gotten their eyes checked? Have they gotten their bone density? Have they gotten their vaccines, flu shot, COVID vaccines? And this is a great way to not miss any of their preventative health. Have they seen their pediatrician regularly? And then we go into patients that are maybe not doing so well -- that care stratification piece -- where we look at, can we suggest to the primary GI doctor ways that we could augment the care so that they have a better chance of getting into remission.

Host Amber Smith: Please stay tuned to Upstate's "HealthLink on Air." we'll be back after this short break.

Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith. My guest is Dr. Prateek Wali. He's the director of the pediatric inflammatory bowel disease program at the Upstate Golisano Children's Hospital.

I understand your team has had success with a therapy for Crohn's disease in children. Can you tell us about that?

Prateek Wali, MD: We're really blessed to have a lot of therapies in inflammatory bowel disease at this current moment compared to 10 years ago. If you look at 15 to 20 years ago, it was pretty bleak as to what medical therapies you could provide, and a lot of patients went to surgery.

And now with all of the medical therapies we have, we really have the ability to look at each patient differently and say this patient with this disease in this location with this growth pattern would benefit from this drug better. Unfortunately, drugs have side effects. And one of the most common drugs that have side effects are oral steroids, and we try to avoid using them as much as we can. Unfortunately, oral steroids in the United States are often the drug of choice for what we call induction therapy, or getting you into feeling better. Because therapy is often divided into induction, which means you're going to get them better, which is usually about eight to 12 weeks. And then what's called maintenance therapy, or keeping them better.

And because these are chronic disorders, you have to be on some type of medication to keep that immune system quiet. So when I arrived in 2010, we started to use something called enteral therapy for Crohn's disease. Enteral therapy was something I learned in fellowship (specialist training). And what it entails is using formula for 80% of your calories through the day, with 20% being either a snack or a small meal that is about 300 or 400 calories. And you do that for eight weeks. And it's quite challenging. If you think about eating as a very social activity. You sit down at the table with a family. And so this is difficult to explain and carry out to with families.

But what we found is that if you use enteral therapy for induction, it has the same rate of remission as steroids, about 80 to 85%, and the huge benefit is that you don't have the side effects of oral steroids. And on top of that, you have these wonderful nutritional recoveries. You know, these patients who have had malnutrition for quite some time now are feeling better, back to sports, back to school. And so we've had more than 30 kids do enteral therapy in this time period. And it's a wonderful alternative to oral steroids. And of course, you have to say that it's the standard of care outside the United States.

Host Amber Smith: Wow. So that has helped, also, improve the remission rates among your patient population, right?

Prateek Wali, MD: It absolutely has helped to improve the nutritional status of these patients dramatically compared to using oral steroids for induction.

Host Amber Smith: Now, you've also pioneered the use -- you mentioned it earlier -- capsule endoscopy. Can you describe what that is and when it's used?

Prateek Wali, MD: So when we use endoscopy, which is the camera under anesthesia, to take a look at your upper GI tract and lower GI tract, there's a large portion of the small intestine that we are not able to get to because your small intestine is very curvy. And therefore, we use other technologies.

And so we've been able to start two new programs at Upstate since 2010. One is called MR enterography, where we look at the small intestine using a specialized MRI (magnetic resonance imaging) that looks to see if you have inflammation or thickening in those areas in the small intestine, which is very important. And then if you have signs that there are areas that are inflamed or that are at least suspicious, then we can use something called capsule endoscopy, which sounds really interesting, from a technical aspect. But basically it's a pill cam. So it's a camera that looks like a pill, and it takes close to 50,000 pictures as it goes through your intestine. The kids, if they're older, can swallow it. If they're younger, we can place it endoscopically. And it basically brings all these pictures together into a movie, a video. It's a really long video, and it takes us about four hours to watch it all, but the advantage is we can see the entire small intestine, which we're not able to do during endoscopy. And those images can help us to, decide where the disease is located in the small intestine, and then that actually tailors your therapy plan as to what medicines would work better.

Host Amber Smith: I'm assuming that most of your patients are referred to you or the pediatric IBD program from their pediatrician. Can you walk us through what to expect at the first visit?

Prateek Wali, MD: That's a complex question because when pediatricians and family practice doctors and nurse practitioners send us patients, they suspect inflammatory bowel disease sometimes, but they're also just sending us patients for belly pain or blood in the stool and weight loss, without a clear understanding of whether that's the diagnosis. So at the first visit, often there's a discussion of a very good history and physical exam, blood work, sometimes stool testing, and then discussion about doing an endoscopy, so setting them up to do an endoscopy if we feel that this is suspicious for inflammatory bowel disease.

After we come to a diagnosis -- which may be Crohn's disease, which may be ulcerative colitis -- then we can discuss starting therapy. And we go over all of the different therapies that are available, and we tailor that therapy to the patient, and that's complicated. It sometimes is the age of the patient, the accessibility of services, the side effect profiles of the different medications, the growth potential of the patient ... and so there's a lot of things that go into what therapy we might choose, but it's a discussion with the family. And I think it really is great when we have that discussion because you get buy-in from the family because they choose what they feel like is also going to be the next best step for them.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Prateek Wali. He's the director of the pediatric inflammatory bowel disease program at the Upstate Golisano Children's Hospital.

Is there any difference in an adult who comes in with new symptoms versus an adult who has had IBD since childhood?

Prateek Wali, MD: There have been studies that show that the T-cells do change over time. So that means that. If you've had the disease for a long time, you're not actually having the same reaction of T-cell inflammation that you had at the beginning, which means that your ability to benefit from therapy changes with the amount of time you've had it.

One of the big things that we're seeing in kids, and I think this is where pediatrics has kind of led the field: We're much more aggressive with our therapies than adults are. So we often start with very potent therapies versus adults, which will often wait until you failed a few therapies -- or I guess the the therapies have failed you -- to go to a more potent target. The issue with that is that often, then, you've caused damage already, and often now you're repairing damage -- and they don't do as well.

And actually the big adult studies now show that what we call "biologically naive" patients do better with new drugs. So the newer drugs that are coming out, if they haven't had those other drugs before, they're actually doing better in getting into remission, which probably means there really is a different pattern that's developing, whether you've had it for one year versus five years versus 15 years.

Host Amber Smith: Is the pediatric version something that you would grow out of as you mature, or once you have it, do you have it for life?

Prateek Wali, MD: You have it for life. It's like a switch that's turned on. We haven't figured out how you're going to turn that switch off.

Host Amber Smith: I know everyone's always hopeful for a cure. I'm curious. What do you expect a cure might look like, and how close do you think scientists are?

Prateek Wali, MD: We always are pushing for a cure, and this disease is really devastating for these children when they're ill. And it really affects their daily life. And often we have children that really push through it, and they'll go to school not feeling well on a daily basis because they want to get back to their lives and their sports and their activities. A cure, I think, will look like personalized medicine. I think at some point in the future we'll have a profile of what type of inflammatory bowel disease a patient has. I think Crohn's disease and ulcerative colitis is a very gross, generalized approach. I think that in the future it'll be, "you have inflammatory bowel disease 10 or 9, and your genetic profile fits this, and the best medication for you will be A, B or C." And I think that personalized approach will be based on looking at your genetics, but also what proteins are involved and how your pharmacokinetics, in other words, how do you as an individual break down drugs and use drugs, and what effect that has. And if we are able to find a way to identify the cause, then of course prevention would be the best cure for this disease.

Host Amber Smith: Do you think there'll be a day where there'll be a test to see whether you're at high risk for a bowel disease of some sort, and that there might be a way to prevent it from developing at all?

Prateek Wali, MD: Yeah, I mean, I think it's challenging because there's over 200 genes identified that may be involved in that predisposition for inflammatory bowel disease. So, I hope that at some point there will be an ability to say you are at a little bit of a higher risk, and these are risks that you can avoid so that you may not develop inflammatory bowel disease. And so therefore we don't have to worry about personalized medicine and how to treat it. We can just prevent it all together.

Host Amber Smith: Well, this has been very interesting, and Dr. Wali, I appreciate you making time for this interview, and congratulations on the big improvements.

Prateek Wali, MD: Oh, thank you. We have a wonderful team, and we have wonderful support from the community, and we appreciate all of the families that really help us on a daily basis to learn from this.

Host Amber Smith: My guest has been pediatric gastroenterologist, Dr. Prateek Wali. He directs the pediatric inflammatory bowel Disease program at the Upstate Golisano Children's Hospital. I'm Amber Smith for Upstate's "HealthLink on Air."

What lessons can you learn from how hospitals prepare for disaster? Next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." When disaster strikes, a community's hospital is an important part of the emergency response for that community, along with the police, fire and ambulance service and local government. To help us understand how Upstate University Hospital is prepared, I'm talking with Chris Dunham. He's the director of emergency management at Upstate. Welcome back to "HealthLink on Air," Mr. Dunham.

Chris Dunham: Oh, thanks for having me, Amber.

Host Amber Smith: Now Upstate has a director of emergency management. Do all hospitals of any size have someone who oversees disaster preparedness?

Chris Dunham: Yeah. It's actually mandated through a lot of our regulatory functions. Most smaller hospitals have sort of a dual role. In other words, the disaster management is applied to somebody who is doing other duties. Upstate's very fortunate. We have not only myself, but one other person who this is our full-time job.

Host Amber Smith: Well, we've seen hospitals in the U.S. that have been hit by tornadoes, hurricanes, blizzards, all relatively recently. We've seen them flood. So we know they're not invincible to natural disasters. What do hospitals like Upstate have to do to ensure that they're prepared for anything?

Chris Dunham: A lot of it, from my perspective, comes back to training. We spend a lot of times creating these plans and procedures of what to do when certain things happen. We spend years, sometimes, working on these plans, and ultimately, they're very, I think, well-written. But if the front-line staff does not know what to do or how to apply the plan, realistically the plan doesn't work.

One thing about Upstate is, we're always growing, expanding, changing. The plans consistently update along with them. It is a yearly process where we go through everything every year to kind of go, "OK, what's changed? What's a best practice that we need to include?" Even new technology in the hospital will sometimes change our plan.

Host Amber Smith: So do you and your staff determine the types of things that the institution needs to prepare for? Or is it that the preparation's the same no matter what it is?

Chris Dunham: That's actually kind of a twofold thing. So we have an emergency preparedness committee, and there's about 40 different people on it from various walks of life at Upstate or experience, both clinical and non-clinical. So it is not merely just me and my staff deciding what's important. We actually pull together everybody and do what's called a hazard vulnerability analysis. So it is a prescripted kind of spreadsheet that hospitals use across the country, and we plug different events in, and it's based off of not only what we've prepared for in the past.

It takes into account what we've had happen to us recently and also too, certain geography plays into it. So in other words, if we were in the West Coast, earthquakes would certainly be higher than it is right now. Where, if we were in Florida, it'd be hurricanes. Now, we do get hurricanes up here, but usually we're on the tail end of things, and it's more heavy rain, storms, things like that. Our HVA (hazard vulnerability analysis) has a lot more emphasis on, let's say, snowstorms and blizzards than, let's say, somebody in Florida.

Our relative distance to a major airport, public places like the Dome, places like the Amp (amphitheater) at St. Joe's out on Onondaga Lake. Realistically, we go through this every year because obviously it changes. It takes also into consideration vulnerable populations, so folks who are medically dependent at home, either on oxygen or some sort of electricity powered device. That's stuff we need to take care of or think how do we provide.

Host Amber Smith: What can you tell us about the Storm Ready University designation?

Chris Dunham: Upstate was the fourth in the New York state area to receive this designation. Realistically, it's a partnership and a certification through the National Weather Service. They come out and audit all of our plans, our weather preparedness, and how we would react to storms. What's really great about it is, it's designed for universities -- which obviously SUNY Upstate is one -- but you also see counties that are starting to get that sort of designation as well. As a result of that, we have a really good relationship with the National Weather Service in Binghamton, where we participate in conference calls and things like that.

So the winter storm we had just before Christmas, we actually ramped up and were part of the conference calls from the National Weather Service, where we knew really before the local news did what was going on, how it was going to play out, what they thought would happen, and we can plan accordingly -- and more importantly, communicate to other decision makers at Upstate.

Host Amber Smith: Now, you organize and participate in drills throughout the year, so that staff practice for the real thing. Can you tell us about some of those?

Chris Dunham: Sure. We actually have a couple different layers of that. So we have some layers of what I like to call surprise drills for frontline staff where myself or my staff will show up in a department and say, "Hey, congratulations, this just happened. What are we doing?" Those are done a few times throughout the year.

Also, we have a pretty significant training program for our mid-level managers who are our primary incident commanders. They're called our administrators on call. They are required to actually show up to about four or so what I call tabletop exercises. So we'll gather, be it virtually or in person, and I'll put a problem on the whiteboard. And we'll just kind of noodle through how we respond to something like that. Something, as an example, we can simulate or talk through losing water in the hospital, or losing electricity for a significant amount of time, or, hey, we have a blizzard coming. What are we, what are some things we want to talk about?

That has been hugely successful, especially with our newer folks, to really get them used to all the resources and plans that we already have in place, so they don't feel like, in the moment, they're re-creating the wheel. And it helps them.

And also too, we do full-scale exercises. This past fall we did a full scale decontamination exercise at our community campus for a hazardous materials response, where we had to actually wash patients, do some triage, and also integrate with the community as well.

Host Amber Smith: Now University Hospital is part of the Upstate Medical University campus. So in addition to the clinical care, there's also research and academics. Are the people involved in those sections of Upstate involved in disaster planning, too?

Chris Dunham: Yeah, absolutely. There's actually a large research component. The academic side of things, especially with, let's say, our student population, is very involved. An example of this that really worked very well for us was the COVID response, because it was obviously organizationwide, and we were able to integrate the academic, the student life, and also the research side of things, which was impacted. And it was coordinated under one umbrella via the "incident command" process.

Host Amber Smith: I'm going to talk to you a little bit more about that. Let me remind listeners, this is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Chris Dunham. He's the director of emergency management at Upstate.

In Central New York in winter, we always have the potential for a major snow event that impacts travel, electricity, whatever. What does the hospital do to be ready for this? You already mentioned the National Weather Service that you're connected with, so you're paying close attention to the weather reports, but what else goes on?

Chris Dunham: If we see that, if we get a weather report or we get an inclination that it will be a more-than-average winter storm in the Central New York area, because we're also kind of used to winter weather, certainly every time three inches of snow hits the ground, we don't do this. But if it we're talking 12 to 18 (inches) in a 24-hour period, that's significant for us. So what we do is we try to warn our workforce. In other words, to have them be prepared themselves. Also we try to ramp up not only have enough supplies on hand, stuff like food, extra food, extra pharmaceuticals and extra supplies for our normal workload. We would have that stuff on hand before the storm hits because we don't want the storm to hit and then run out. That's the worst-case scenario.

Also, the hospital can, in a large part, run on generators, and we have a number of those throughout the facility, and we make sure all the tanks are topped off, and they can run for the maximum amount of time. We also staff up our grounds folks to do plowing and snow blowing and things like that.

One of the important things too is to remember about SUNY Upstate is, we cannot put a "closed" sign on the front door. We always must remain open. So that is really sort of the basic tenet of every preparedness piece we do. We either need to figure out how we can keep what we have open or alternate or move stuff or be flexible in terms of how we approach a winter storm. But we've been through a couple pretty significant weather events even in my tenure. I've been at Upstate almost 12 years. And we kind of turn into a Hotel Upstate for our staff. Certainly, if folks can't get home, they stay with us. We set up cots in sleeping areas and provide food for our staff and make sure they're OK. Also too, we make sure we have enough staff for the duration of the storm is impact. Because the assumption is, is staff that need to come in won't be able to come in, and staff that's already there might not be able to get home -- so trying to provide a safe environment for not only staff but patients as well.

Host Amber Smith: What have you heard from your colleagues in Buffalo about the impact of the recent blizzard? I think the airport was shut down for five days. What was the impact on hospitals there?

Chris Dunham: Significant. The anecdotal stuff that I've heard is, it was pretty much "shelter in place," as a term. They did have enough supplies. Obviously the state activated its own incident command processes and helped the hospitals out in terms of snow removal and things like that. But that is probably a once-in-a-hundred-year event, thankfully.

Really, once the storm hits, you can't do anything. You should have already done everything you needed to, to kind of hunker down. The problem is, is usually with a hospital, critical people come to you somehow, and you've got to kind of work through that. I'm just thankful it wasn't Syracuse. I mean, that snowfall was amazing. Absolutely amazing.

What do you do to prepare for an emergency, like a plane crash where there are many victims coming all at once?

Chris Dunham: We actually train for this pretty extensively. So we train for not only the plane crashes or the bus crashes. We call them mass casualty events. So these mass casualty events, we not only have special resources we can push down to our emergency departments, but also we practice mass notification of our staff to do a quick recall of physicians, nurses, other critical patient care folks. We do this realistically at least twice a year, because our hospital's the Level 1 trauma center. We're pretty much going to get one if one happens. And we've had some, in recent memory that have gone pretty well, where we've had, upwards of 20 patients coming to us at once from one particular incident.

The thing about Upstate is, is we're always busy. We always have a lot of patients, and how we flex up to the incoming patient number is usually an incident command event. It takes a lot of resources and coordination to do so.

Host Amber Smith: You mentioned incident command earlier. And for the past three years with the pandemic, that was in place for many weeks or months at a time. Can you explain what it is and how it works?

Chris Dunham: So incident command is merely a process. It was developed in the 1970s as a response to the wildfires out West. So they would have these wildfires that would not pay attention to political or geographic boundaries, and it would go across large areas. What they found is, is there was a lack of coordination and command and control, much less communications in terms of county A would fight the fire one way. County B would fight the fire another way. And they rarely would talk.

So by using the incident command process, there's a couple fundamental tenets. In other words, everybody uses the same terminology for certain things, and there's a heightened awareness to plain language communications, activation, demobilization once it's over. Hospitals actually really started using this after Sept. 11. (Hurricane) Katrina certainly pushed it to the forefront, and we continue to use it. Upstate's been using it, really, pre 9/11. And it is a title and a way we can organize to sort of cut out a lot of the normal business processes, make quick decisions, move resources very quickly. Incident command sort of helps identify problems a little quicker and also provide resources without going through the normal chain of command and things like that. So it's able to respond a lot faster than normal operations.

Host Amber Smith: Have you learned anything about emergency planning on the job that you've brought back to your personal life?

Chris Dunham: Yeah, a lot of fundamental emergency preparedness stuff for me really comes down to, folks should have a plan. They should understand and watch the environment around them, whether it be weather or traffic closures or whatever. You know, you can't be prepared for everything. But communication is key, important to havefolks that you can call in an emergency to either let them know you're OK or if you need some things.

And also too, have a heightened awareness for what's going on. If your local fire department says, "Our residents need to do this," then you should do it. Realistically, folks watch the news or have information come in online. They should definitely follow or pay attention to their local county's emergency preparedness program. They're very good at putting out information, let's say in a winter storm or any sort of emergency. And they're a great source of information.

Host Amber Smith: Along those lines, how would you advise people maybe who are new to Central New York to prepare their homes so that they're ready for a disaster? Are there items that they should keep stocked?

Chris Dunham: I think some canned goods. Certainly, it depends on how far you really want to go. Have about three days' worth of food on hand. Make sure all your medications are refilled. You don't want to run out at the middle of a blizzard. You can also make sure you have enough winter clothing. And I say that ... you know, we've had a number of folks new to Upstate come from the Southern part of the country, and invariably they'll be like, "Hey, how bad is the winter here?" And when I explain it to them and kind of give them sort of the average numbers, you know, "Oh wow, I need to get a better vehicle, maybe, or at least get a better winter coat."

I mean, you know, as Central New Yorkers, we kind of wear the weather as a badge of pride of like, "Oh yeah, I've been through this." And that is OK. But sometimes there are people out there that sort of disregard things of, "Well, it's only 12 inches of snow. I can drive to the supermarket," and things like that. And yeah, and that speaks to getting to know your environment, getting to know the people who would be able to tell you, "Hey, now's not a great time to be on the road," or "Hey, you should be hunkered down" kind of thing. So that kind of gets back to the listening to the local emergency managers or the local police or fire or what have you.

Host Amber Smith: Are you one who advocates having a to-go bag packed?

Chris Dunham: Yeah, I think that's a good thing to have sometimes, depending on where you live. I think that the reasons for using a to-go bag during a mandatory evacuation, I think are pretty, blessedly, low in Central New York. In other words, the reasons that would happen would be pretty unique.

But having a to-go bag in terms of copies of important paperwork or, clothing, things like that, especially if you have children, might be an extra toy or two thrown in the bag to keep them occupied. I think it would be a good thing. People typically struggle with maybe an extra phone charger or things like that.

You can even get the, I say "old," but the transistor radios that are battery powered. They still sell those. Those could be quite useful in an emergency. Things like that. There are to-go bags for sale. You can buy one on any online retailer. It depends on how far you feel comfortable going with that. But having the bare minimums would be important.

Host Amber Smith: Well, this has been very informative, and I thank you for making time for this interview, Mr. Dunham.

Chris Dunham: Oh, thanks for having me.

Host Amber Smith: My guest has been Chris Dunham. He's Upstate's director of emergency management. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Krithika Ramachandran from Upstate Medical University. What makes pulmonary hypertension dangerous?

Krithika Ramachandran, MBBS: Pulmonary hypertension is dangerous because it causes you to have congestive heart failure, so the end result of untreated pulmonary hypertension, just like the end result of untreated systemic hypertension, is that you end up with these big dilated heart chambers, which are unable to push blood forward through the lungs anymore.

So now you have lack of blood flow forward, blood flow to the rest of the body, because the left side has inadequate blood to send forward. So you have low oxygen everywhere. Your brain is not getting perfused (properly supplied with blood), your kidneys are not getting perfused. So you can actually end up with congestive heart failure, and terminally with cardiogenic shock, which is when, essentially, all your organs are shutting down.

Anemia can worsen pulmonary hypertension because you have low blood counts, right? And there are fewer red blood cells to carry oxygen everywhere, but pulmonary hypertension and congestive heart failure, because of the chronic inflammation they set up, can cause anemia also. So, it's almost like this vicious cycle. In recent years, they've been screening patients for anemia and iron deficiency, and it's been shown that patients who are iron deficient actually have a higher chance of having bad outcomes from pulmonary hypertension or even from regular congestive heart failure.

So, we look to see if they are iron deficient, and we can actually supplement them, which improves their functional status, and it also helps improve their disease and their overall mortality.

The landscape for treating this disease has changed dramatically In the last, I would say, 10 to 15 years. Earlier, and by earlier I mean maybe back in the early '90s, late '90s, it was almost like a death sentence. If you were diagnosed with it, more than 50% of patients were dead before three years were out. But now, it can be one of those diseases that you kind of die with instead of die from.

So there are multiple medicines now which help dilate these blood vessels in the lungs and bring the pressure down so that the right side of the heart feels less stress while pumping blood through the lungs. So definitely there are multiple, multiple treatments now, as compared to a few years ago, which has changed the outlook of the disease.

Host Amber Smith: You've been listening to Dr. Krithika Ramachandran from critical care and pulmonology at Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate's Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

What's it like waiting for test results? Rich H. Kenny Jr. is an associate professor of social work in Chadron, Nebraska. His poem "Closer Looks" describes the passage of time for one patient.

Monday, the fifth

A stray dog ransacks a trashcan.

Dark skies linger like a taste of bad wine.

Wind-blown headlines tumbleweed across a yard.

The interstate becomes a parking lot.

Raucous birds fly overhead.

An obituary is clipped from a newspaper.

The guard tells a visitor not to touch the exhibit.

A man is tested for cancer.

Thursday, the eighth

Pals pose trailside in a decades-old photo.

A Horse with No Name plays in bumper-to-bumper traffic.

A man in his sixties feeds ducks at the lake.

Sidebars and box scores flutter against a neighbor's fence.

The abandoned puppy breakfasts from a shiny blue bowl.

Puckering rain clouds spritz wine cellar skies.

At shift change, the young girl discovers art with her fingers.

The man studies skin left too long in the sun.

Monday, the twelfth

Canadian geese, in perfect V-formation, splash down at the lake.

The tail-wagging beagle drops a tennis ball at my feet.

I tape and frame the tattered picture.

A student, blind since birth, tells me she wants to become a sculptor.

I crank up Mud Slide Slim in the rush-hour commute.

There's a hint of promise in robust, blackberry skies.

I unhook yellowed bylines and hang wind chimes from the breezeway.

Biopsy results will be ready tomorrow.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": how neuromodulators relieve pain. If you missed any of today's show or for more information on a variety of health science and medical topics, visit our website at healthhinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.