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Charity Hospital and Disaster Preparedness

2005; Elsevier BV; Volume: 47; Issue: 1 Linguagem: Inglês

10.1016/j.annemergmed.2005.12.004

1097-6760

Ėric Berger,

Disaster Response and Management

IntroductionMichael L. Callaham, MD, Editor in ChiefIn this issue of Annals we introduce a new section, News and Perspective. The goal of this section is to explore topics that are relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. The approach will be inquisitive and open-minded, and the style narrative and journalistic rather than the usual formal structured scientific report. The goal is to provide unique new information or perspective not otherwise readily available, not simply to repeat the same facts and discussions presented elsewhere. Although we will try to ensure the information is topical and fresh, this section by its design will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. The goal of this section is not pragmatic instruction in how to practice better medicine, but instead to educate our readers about our profession and its interfaces with other aspects of contemporary society. The stories will be two to three thousand words in length, allowing thoughtful coverage and inquiry. Thus, the “perspective” in the title will be more important than the “news.” Story ideas will come from a variety of sources, including our readers, as well as our section editor, T.J. Milling (who had a career in journalism prior to becoming a physician). Professional scientific writers will investigate and write the stories, which will then be critiqued and edited by Dr. Milling, the senior editors of the journal, and myself. Thus, the peer review for this section will come from the members of our editorial board and not our peer reviewers. We realize we have set ourselves a lofty goal and that this section will evolve as we gain more experience with it. We hope it adds interest and value to your reading of Annals, and welcome your feedback on it.Charity Hospital's czar for disaster preparedness, Dr. Ed Halton, believed he had provisioned his facility for the worst as Katrina roared toward the Gulf coast. This proved no small feat considering the storm ranked as the third most intense Atlantic hurricane on record. But never did Halton expect his patients would fall under sniper attack. A reported rogue gunman on a nearby roof, taking potshots at Charity's patients and their would-be Special Forces rescuers, simply didn't fall within his preparedness calculus. And yet it happened, delaying the evacuation of his steamy, desperate hospital for more than half a day. “You try to figure out what is going through their minds,” said Halton, an emergency physician. “Who would do something like that?” As insanity engulfed New Orleans during Katrina's aftermath, Charity Hospital officials struggled to maintain order in the worst of circumstances. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines three levels of crisis: emergency, disaster and catastrophe. An emergency arises when a sudden rush of patients taxes a hospital's resources. A disaster happens when a hospital itself may be damaged, and its community isolated for a day, or perhaps longer. A catastrophe occurs when the hospital and community are completely overwhelmed, with little or no assistance for three or more days. Charity Hospital faced a true catastrophe. To Charity officials' credit, not one patient died as a result of the fetid floodwaters that poured into his hospital, despite the submersion of the main generator casting 400 patients and 1,200 staff members into darkness. “Get us the hell out of here,” pleaded one banner made from bed sheets as those trapped within awaited help. It took more than five days to evacuate Charity, the city's largest public hospital and a last refuge for the indigent. That Charity saw no flood casualties stands as a testament to Halton and other disaster officials, who drilled for this scenario with a prophetic model—a slow-moving, category-3 hurricane overwhelming New Orleans' levee system. The hospital had no cash to spare for such contingencies. “Administrators look at the bottom line,” Halton said. “They've got a lot of other things they can spend that money on, so disaster preparedness is kind of a back-burner issue.” This in mind, Halton and New Orleans officials were able to tap into federal money set aside for terrorism post 9/11. Their proposal noted that a small explosive charge set by terrorists could cripple the levees and bring floodwaters pouring in. “The luck was we didn't have to spend hospital money,” Halton said. The federal funds had allowed Halton to acquire 10 portable generators, several oxygen-powered ventilators and a stockpile of food. He spent $15,000 for a Ham radio system that would allow for internal and external communications when landlines, cell phones and pagers failed. A dozen hospital security officers were given additional training for catastrophic emergencies. The generators arrived a week before Katrina did. A day after Katrina struck, the city's levees breached. As water filled New Orleans, including Charity's emergency department, its four dozen patients were moved to the second floor auditorium. The hospital had to be evacuated. But with innumerable other priorities for public safety officials—residents stuck in attics or baking on roofs, unprepared nursing homes, and other local hospitals without Charity's foresight-not to mention the Superdome—it was unclear how long Charity would have to hold out. In the meantime, desperation reigned. Some doctors began carrying sidearms. Others hauled fuel and patients up dimly lit stairwells. By scrounging diesel, rationing food and keeping patients alive, however miserable the conditions, the staff and hospital finished the evacuation five days later, when the military helicopters and airboats ferried the last of them away. Charity wasn't the first level-1 trauma center to be evacuated. Houston's Hermann Memorial Hospital holds that distinction, having survived Allison, the nation's costliest tropical storm. In the Texas Medical Center alone, Allison wrought $2 billion in damage. “Quite simply, we were caught off guard by Tropical Storm Allison,” said Dr. Marc Boom, executive vice president of The Methodist Hospital, located in the Texas Medical Center. Just barely a tropical storm, Allison drifted over Houston in early June 2001, with virtually no winds. As such, it attracted minimal attention. Over the course of four days, as Allison meandered north and south across southeast Texas, it dropped moderate to heavy rains across the area. Such rain, however, was manageable for a city accustomed to heavy thunderstorms. Allison saved its strongest punch for the last night, June 8, when it dumped more than four inches of rain per hour in many parts of the city, including the Texas Medical Center. The torrential night flooded most of Houston's bayous, including Brays, which drains hospitals in the Medical Center. By early Saturday, June 9, much of the Medical Center campus had been drowned under five feet of water, swamping the basements of hospitals, where many stored their massive, diesel-powered emergency generators leaving facilities flooded, without power and, in some cases, running water. Memorial Hermann Hospital, one of the city's two level-1 trauma centers and its only burn unit, received the worst of it. The hospital lost electricity and its back-up power source. It had no running water, sewer services or reliable communications. Surrounding streets were flooded. By mid-morning Saturday, after the rain ended, hospital officials decided to evacuate 540 patients. “Any time you need to evacuate that many critically ill patients, it's always a difficult decision,” said Dan Wolterman, then chief operating officer of the Memorial Hermann System, and now its chief executive. “With our physical plant difficulties, there just was really no short-term hope. We used one criterion as our guidepost: patient safety and well-being. The risk of bringing our patients out was less than keeping them there.” Inside the hospital, conditions were frantic. Dr. Kim Connelly Smith, who assisted in the evacuation of 150 children, including eight from pediatric intensive care, recalls hand-ventilating patients and carrying them down 10 flights of stairs on backboards. Outdoors, in a park across the street, Blackhawk helicopters lifted patients to other hospitals in Houston, as well as other Texas cities. The hospital's LifeFlight fleet was of little use, as the choppers could only carry two patients at a time. “I wasn't prepared for that kind of situation, the drama and the trauma,” Smith said. “But I'm so proud of the hospital for making the decision to evacuate the hospital. Afterward, I don't think Hermann looked that great in the press, but I think they did a really great thing.” In September, when Hurricane Rita appeared for a time to be bearing down directly upon Houston, Hermann sought to apply the lessons of Allison to its preparations. Like the rest of the Texas Medical Center institutions, Hermann had installed floodgates to the underground tunnel system, designed to prevent its basements from flooding. It also moved its power generators to higher ground. Security was increased. In advance of Rita's landfall, the Memorial Health System also evacuated all 193 patients from its southeast hospital, even though the facility lay just outside the projected storm-surge area—more easily done before, Memorial officials reasoned, than after the worst had happened. The health care system's other hospitals were stocked with seven days of food, eight days of linens, and extra diesel for generators. Houston's hospitals learned something from Rita, even if the hurricane ultimately just grazed the metropolitan area. Methodist discovered that its sturdy walls would serve as more than a refuge for patients, said Boom, the hospital's executive vice president. Some 650 family members of staff sheltered at the hospital, and another 200 family members of physicians stayed in nearby professional buildings. “That's more than we expected,” Boom said. “It taught us something about the degree to which we need to be prepared for the social side of a major storm.” JCAHO Vice President Joseph Cappiello visited Houston after Allison, New York after the September 11 attacks, and recently, New Orleans, to better learn how hospitals manage emergencies. Before about 1998, JCAHO required hospitals to prepare only for “emergencies.” Then, shortly before Allison flooded Houston, and two planes struck New York skyscrapers a few months later, the commission began requiring hospitals to have evacuation plans and other means of coping with “disasters.” After those two events, Cappiello said, the joint commission again enhanced its standards, requiring hospitals to coordinate their disaster plans with their communities. “I really think we were a little naïve about the science of emergency preparedness and response seven years ago,” he said. “We've learned a lot in the last few years.” Katrina's assault on Charity and other hospitals in New Orleans only further highlights the need for a unified response by a community to deal with a disaster or catastrophe. At the disaster and catastrophe levels, Cappiello said, crises simply cannot be managed in isolation. Houston officials wholeheartedly agree with this approach. As Rita neared the coast, Dr. Jeff Kalina, the medical chairman of the Texas Medical Center's disaster response committee, called a brief meeting of the area's emergency department directors to coordinate storm plans, to ensure the doctors would continue to communicate between hospitals if disaster struck. If one hospital was in trouble, emergency officials knew they could turn to neighbors for help. “You have to be on the same page,” said Kalina, the associate director of emergency medicine at Methodist. “You have to know what your neighbor is doing.” Another Houston doctor agrees but acknowledges that cooperation between competitive, private hospitals and the local government can be touchy, especially when it comes to issuing and receiving orders. “In a disaster, you sometimes face a situation where a government might almost have to give orders,” said Dr. Richard Bradley, an associate professor of emergency medicine at the University of Texas Health Science Center at Houston, and medical director of the emergency center at Lyndon B. Johnson General Hospital. “The hospitals have to have a hand-in-glove relationship with local governments. The government absolutely depends on hospitals functioning in a time of crisis. So when the governments are making their plans, the hospitals must be sitting at the same table.” But a recent study published by the U.S. Centers for Disease Control and Prevention raises serious questions about how willingly hospitals fit into their communities' emergency plans. The research, published in Advance Data (Sept. 27, 2005; No. 364), found that about three-quarters of the 500 non-federal general and short-stay hospitals surveyed were integrated into their community-wide disaster plans. However, less than half, 46.1 percent, reported written memoranda of understanding with other hospitals in the community to accept inpatients during a declared disaster. Cappiello has other advice for hospital emergency planners, too, warning that they should heed New Orleans' wake-up call. Administrators should explore whether they can survive the loss of power, water, sewage and communications, all at once. Hospital officials should know what failures their facilities and staffs can endure, and have a clear line of demarcation at which they will unhesitatingly call for an evacuation. Then, to determine the effectiveness of these plans, drills, like the ones conducted by Charity, are essential. Cappiello says he commonly encounters shallow drills, which don't push people and facilities to their breaking point. “A good drill is when you drill to where you overwhelm the system,” he said. “That's when innovative thought begins to occur. You've got to find the flaws in your plan, so you can fix them.” Whether hospitals are willing to do so, with limited internal funding, remains unclear. In writing about this issue, Dr. Erik Auf der Heide, an emergency physician with the Agency for Toxic Substances and Disease Registry (ATSDR) of the U.S. Department of Health & Human Services and an expert on disaster medicine, describes it as the “apathy problem.” Hurricanes, earthquakes and other disasters are high-consequence, low-probability events, and the importance and effectiveness of planning for them is often not apparent unless it fails. Unfortunately, for many hospitals, planning for low-probability events must compete with the daily priorities of handling higher volumes of sicker patients in the face of decreasing budgetary resources. “Suppose you are the administrator of a hospital, and your institution is subject to the typical economic stresses of hospitals across the country—Medicaid cutbacks, higher proportions of uninsured or underinsured patients, unfunded mandates,” Dr. Auf der Heide noted. “By some quirk of fate, your facility becomes the beneficiary of a $100,000 budgetary windfall. Will you spend that money to prepare for a catastrophic event that may never occur, or on some needed new imaging equipment with which you can start saving lives tomorrow?” In “The Apathy Factor,” a chapter in his book, Disaster Response: Principles of Preparation and Coordination,” (available at no charge from http://orgmail2.coedmha.org/dr/index.htm) Dr. Auf der Heide states that motivating preparation may be more successful if it focuses on the problems faced in moderate-sized disasters rather than on the catastrophic disasters which occur only a few times a century. Many communities have not even addressed the basic response problems (such as the lack of intercommunity medical mutual aid coordination systems and two-way radio communications networks) necessary for any disaster response. The chapter states that preparing for moderate size disasters may be more cost effective and therefore more easily accepted by those in charge of the coffers, and this type of planning is less likely to fall victim to apathy as it has more frequent real-world applications. “This is not to say that planning for large disasters isn't valuable,” he writes. “However, planning is sometimes carried out for cataclysmic disasters to the exclusion of the more moderate and more likely ones. The advantage of a focus on moderate disasters is that the procedures involved are more likely to be used and, therefore, learned. They are also more likely to get funded. Furthermore, some of the skills, training, procedures, and supplies developed for moderate disasters are a logical step toward preparedness for larger events.” Dr. Auf der Heide also notes that historically a key problem in hospital preparedness has been the lack of sustainable, prospective funding mechanisms, though more recently, federal bioterrorism funding has begun to change this trend. He also observes that interest in disaster preparedness seems to be proportionate to the recency, magnitude, and proximity of the last disaster and declines rapidly thereafter. Therefore, the most successful time to seek funding is likely to be immediately after a disaster when public motivation is high. Often, the best preparation is preventing the need for evacuation itself. In Houston that means new submarine doors to prevent the hospitals from flooding, and moving generators from basements in case the doors fail. In New Orleans it will require a higher, more robust levee system, a task the hospitals cannot do themselves. And in places like California, Auf der Heide said, evacuation prevention means more rigid building codes for facilities to withstand all but the worst tremors. Yet as the sobering cataclysms in New Orleans and Houston demonstrate, hospitals simply cannot always plan for the disasters they might encounter. Whatever worst-case scenarios administrators and emergency personnel might devise, the reality is that still more terrible situations might arise. In such cases, hospitals must ultimately rely on their most valuable asset—people, said Dr. James “Red” Duke, chairman of the Southeast Texas Trauma Regional Advisory Council, which coordinates trauma centers in nine area counties. Duke oversaw the final evacuation of Hermann in 2001 and also bears responsibility for ensuring the Houston region is prepared for the next great disaster. “The thing that impressed me most is the absolute blind commitment by everyone to do anything they could,” Duke said. “During the crisis, it didn't make any difference if it was the chief of service or somebody working in maintenance. People who work in hospitals—and I think nurses are a classic example—love to take care of people. During a disaster these are the people who will save your patients and your hospital.”