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Resiliency of Accomplished Critical Care Nurses in a Natural Disaster

2003; American Association of Critical-Care Nurses; Volume: 23; Issue: 5 Linguagem: Inglês

10.4037/ccn2003.23.5.24

1940-8250

Sherly V. Sebastian, Suzan L. Styron, Simone N. Reize, Susan M. Houston, Rosemary Luquire, Joanne V. Hickey,

Disaster Management and Resilience

This article provides snapshots of the events that occurred at St Luke’s Episcopal Hospital in Houston, Tex, a 954-bed acute care hospital, and the responses of nurses and other hospital personnel to their mission of caring and service during the disaster precipitated by the tropical storm Allison.Houston is accustomed to tropical storms and their accompanying rain. The city’s great bayou system (24 m [80 feet] deep at some points), intended to accumulate and disperse enormous quantities of runoff water, was thought to be adequate to handle even the most severe storm with only minor damage and inconvenience. But in early June 2001, a storm named Allison changed all that. Unprecedented devastation occurred due to flooding from the constant heavy rain over many days. Neither wind nor a great tidal surge occurred; only constant rain of biblical proportions (Figure 1).The Texas Medical Center comprises the largest complex of hospitals and associated medical buildings in the world; many of the hospitals are connected to one another by an interlacing underground tunnel system of 2 basement levels. One level houses generators, hospital laundry, caches of supplies and equipment, and food services. The second level includes major research laboratories that conduct animal and other basic research that has resulted in major medical breakthroughs. When the flood waters invaded these caverns, an event that was never supposed to happen, the devastation was unprecedented and shut down the vital services and resources that support patients’ care and the research community. Without generators to provide electricity, the lights, air conditioning, elevators, water pumps, and sanitary systems did not work. As a result, patients were at risk, and the staff responded to the emergency with the characteristic commitment to patients’ safety and care.This article provides snapshots of the events that occurred at St Luke’s Episcopal Hospital in Houston, Tex, a major hospital within the Texas Medical Center, and the responses of nurses and other hospital personnel to their mission of caring and service during the disaster precipitated by Allison. St Luke’s Episcopal Hospital is a 954-bed acute care hospital and has patient care units from the 2nd to the 26th floors of the main building. At the time of the flood, St. Luke’s was a newly ordained magnet hospital, the first magnet facility in Texas. The magnet designation, awarded by the American Nurses Credentialing Center, is recognition of nursing excellence. Nursing at St Luke’s Hospital is characterized by strong nursing leadership, a participative management style, and empowered nurses who practice with a high level of autonomy and the expectation to exercise independent judgment. In a culture of collegial nurse-physician relationships, high-quality care is the standard. These same characteristics sustained superb care during the emergency and facilitated rapid recovery in the aftermath of the flood. The response of the nurses and other hospital personnel was exemplary of a magnet hospital.In its initial assault on the Houston area, tropical storm Allison dropped approximately 6.3 cm (2.5 in) of rain. Isolated flooding occurred in southwest Houston, but it had no direct impact on Texas Medical Center or St Luke’s Hospital. During the June through November hurricane season, St Luke’s is routinely on a level 4 alert designation (Table 1). In accordance with its emergency plan (Table 2), St Luke’s established an emergency command center to begin monitoring weather conditions. On Wednesday, skies were clear and further precipitation from Allison seemed remote. However, on Thursday, forecasters suggested that the storm might “twirl around” and revisit Houston.On Friday, Allison, which had moved slowly in a north-northwest direction, returned to Houston with rain beginning in the afternoon. Between 5 pm on June 8 and 5 amon June 9, a total of 35.6 cm (14 in) of rain fell, exceeding the 100-year record for 24 hours of rainfall, which was 30.5 cm (12 in). A total of 20 cm (8 in) of rain fell between midnight and 2 am! The downpour clearly overwhelmed the bayous surrounding Houston and Texas Medical Center.By 6:30 pm, St Luke’s emergency preparation began, with the retention of the current staff while additional nursing staff was called to the hospital.At 9 pm, the senior vice president for patient care, Rosemary Luquire, arrived and assumed command of the emergency command center (Figure 2). The priorities were clear: patients’ safety; building occupants’ safety; and restoration of all life-support systems and building functions as quickly as possible. At 10 pm, the vice president for support services arrived, and the facility engineering department continued to install hospital flood logs and other flood prevention devices around the perimeter of the hospital. (At this time, little to no flooding was present around St Luke’s Hospital.)By midnight, the emergency preparedness level was upgraded to level 1. Patient care vice presidents and directors were called to the hospital to assist with emergency preparations; the Texas Medical Center rapidly became inaccessible. The hospital’s chief executive officer and the chief of medical staff were notified of flooding. By 2 am, the usual electrical supply was turned off by the supplier because of flooding in 1 or more of the other hospitals in the Texas Medical Center. At St Luke’s, a switch to emergency power occurred immediately, without any interruption. By 3 am, the tunnel system rapidly flooded. Although patients at St Luke’s Hospital were not in danger, the Medical Tower (the Tower), a St Luke’s building located across the street and connected by an enclosed skywalk, was evaluated for possible transport of critical care patients. The Tower is a 26-story building of physicians’ offices, clinics, diagnostic facilities, and ambulatory surgery facilities that has a secure electrical and cooling system and working elevators independent of the main hospital. These services were untouched by the storm.From 4 am to 5 am, the floodwaters continued to rise in the basement levels, threatening the emergency power sources located in this area. The emergency power was eventually lost, crippling the hospital. The remaining utility systems, with the exception of oxygen and telephone service, were lost in the main hospital. Concurrently, the critical care medical director and 2 intensivists arrived to provide physician oversight of critical care patients and triage. By 9 am, the evacuation of critical care patients to the Tower was complete.Recovery of essential services was swift and well coordinated to ensure overall safety of patients and hospital personnel. Other long-term preventive changes occurred over months. Table 3 provides a summary of the recovery process.The response of critical care nurses to the effects of tropical storm Allison is best told through the eyes of 6 critical care nurses who lived through the experience. The following vignettes describe their observations. For purposes of clarity, the nurses’ actual words were slightly modified, in some instances, to facilitate readers’ understanding.On Friday, June 8, my regularly scheduled shift in the neuroscience intensive care unit (ICU) was 7 am to 7 pm. I came to work with no inkling of what lay ahead. It began to rain, first, as a slow steady rain, then escalating into a driving rain. In the afternoon, my father called to say that our neighborhood was flooded; I would not be able to get home. Outside, things were rapidly deteriorating. Relief staff was unable to get to the hospital, so we stayed. It was 7 pm, 12 hours since I came on duty. I was asked to stay until 11 pm and take care of a new craniotomy patient. The evening progressed with a tired staff. The supervisor called to say that there were “sleep rooms” on the sixth floor. After 18 hours, I was tired. I told the staff to call me if they needed anything. The sixth floor sleep room consisted of stretchers; I didn’t sleep, probably because I was pumped up on adrenalin. It was also hot and humid; there was no air conditioning and it was 90°F [32°C] outside with 100% humidity.At 5:30 am Saturday morning, I received a call from the unit telling me that we were going to evacuate to the Medical Tower across the street. The Tower is accessible by a skywalk, a distance of 0.2 miles [0.32 km] after you make your way to its entrance (Figure 3). I immediately went to the unit, where we gathered supplies needed for each patient. Two attending physicians prioritized patients. Those on ventilators and on vasoactive drips would go first. By early afternoon a group of about 20 staff members descended on the unit to begin the evacuation. By now, the elevators were not working … ah, a change in plans. The 2 attending physicians determined that our unit would become a ventilator unit with other ventilator-dependent patients coming from other floors. Our stable patients were transferred to another unit on the seventh floor, thus making room for arriving ventilator-dependent patients from other units in the hospital. The ventilators had a 2-hour backup portable electrical source. We made sure that each patient had an ambu bag at the bedside. Two portable generators arrived in the unit. Where they came from, I don’t know, but they were a welcome sight. A hole was made in the wall to accommodate generator connections. We now had 9 ventilator-dependent patients. It took only 5 to 10 minutes to switch to the generators, during which time 3 or 4 patients were “bagged” with ambu bags. We affixed an identification label to each of the ventilator cords so we would know which cord went with which ventilator. We also developed a rotating schedule for recharging the intravenous pumps so our drips would flow automatically.Three basic needs were missing: electricity, flushing toilets, and water and food! Electricity is the juice for ICU monitoring equipment, intravenous pumps, ventilators, lights, and air conditioning (Figure 4). The most critical piece of equipment one could possess was a flashlight. We quickly put our names on our flashlights, threatening anyone who would dare to covet this survival tool. If a flashlight was inadvertently left unattended, it disappeared. Lanterns arrived and we each claimed one to carry with us. I felt like Florence Nightingale! It is amazing how much the light of a lantern expands one’s scope of the environment as compared to a flashlight.The hot and humid environment was hard for everyone. We removed extra bedding and clothing from patients to keep them as cool as possible. A few floor fans arrived. We placed them in the hallways for a shared effect.The toilets, which stopped working in the morning, were another matter. We emptied Foley drainage and bedpans into the nonflushing toilets. The odor was bad, made worse by the hot and humid environment. We did what we could to control odor such as putting covers over the toilet, but it helped little. Wearing a mask helped little. Staff drank little to avoid the need for a trip to the restroom. You could walk down to the third floor and use the facilities at an adjacent powered hospital, but that also required a descent and ascent of 4 double flights of stairs in a dark stairwell. Although patients were fed and there was water for all, the staff in our unit was the last to receive food. At one point, one of the staff nurses came to the hospital with a hamburger that was cut into 4 pieces to be shared by 4 people.Many weary nurses had been on duty for 24 hours. Because they were reluctant to leave the unit to take a break or to sleep, they needed urging by colleagues to do so. By 7 pm on Saturday, more nurses were able to come to work. Everyone was given a job, one that clearly defined boundaries of responsibility. This helped to keep the synergy and teamwork alive and well. In addition, a few staff members where dispatched to the unit where our stable patients were sent, because a few of our neuro patients were “sun-downing” [very active and disoriented at night, but sleeping during the day] and the staff wanted a neuro nurse to help manage these patients. It was rumored that the telephones were about to go down. We grabbed our cell phones and kept them near. It was strange to have your cell phone handy in a hospital where you are normally prohibited from using cell phones. The telephones were down for a short period. The command post kept in touch with our unit by way of my cell phone.Communication was critical for the flow of information, especially with patients’ families. Most family members were unable to get to the hospital to visit. We called each family and reassured them that their loved ones were doing well, were in no danger, and were being well cared for by competent staff. We also reassured those family members who were able to visit. The attending physician who was rounding on the patients reported that family members were very calm because the staff was calm. Family members reported no concerns regarding care or services within the hospital.I got drenched coming to work on Friday evening for the 7 pm to 7 am shift in the neuro ICU. It had been raining most of the week, so rain was nothing unusual. I caught glimpses of weather reports on the televisions at work, and my coworkers commented throughout the evening about how hard it was raining. About 1 AM, a supervisor came to the unit and pulled out the red folder (known as the Disaster Plan) and told us to read it to refresh our memories. We also checked the flashlights and made sure all equipment such as ventilators and pumps were plugged into the emergency outlets (red plugs). It had already rained 8 in [20 cm], and it was not letting up. The adrenaline was already pumping, and we felt like we were on high alert. We kept reassuring patients that we would be all right.Somewhere between 3 am and 4 am, administrators began to call and told us to prepare for evacuation of patients. We packed our patients and placed needed equipment such as ambu bags, charts, and supplies on each patient’s bed for the move. All patient monitoring was switched to portable or manual devices (Figure 5).Soon, an emergency room physician arrived and we triaged all the patients in the 10-bed unit. The plan was to move the patients to the Medical Tower (the Tower), which was located across the street and accessible via a second floor skywalk. The most stable patients would be moved first, leaving the more severely ill and unstable patients in the unit, rather than risking acute hemodynamic or respiratory deterioration during transfer. Half of our patients (5 patients) were moved to the Tower.Some of the ICUs are on the seventh floor and the remaining ones are on the second and sixth floors. Our neuro ICU is located on the seventh floor. At 4 am, we began to transfer ICU patients, beginning with those patients on the seventh floor, while the elevators were still working. About 20 staff members from the operating room helped us move. As we moved the patients, you could feel the sense of urgency, but composure and quiet assuredness was everywhere. Upon arrival at the Tower, we took another elevator to the ninth floor, which housed the outpatient operating room and recovery area room. This became the temporary home of the ICUs. In anticipation of our arrival, respiratory therapy and facilities engineering had already set up ventilators and other equipment. Decisions had already been made about which nurses would move to the Tower versus the hospital. Reporting to a fellow nurse, I returned to the hospital.At 7 am, we lost all power and were plunged into darkness. We quietly assured our patients that all would be well as the rain was dissipating. Of course, all staff was required to stay with patients since no one could come or go in the medical center. In retrospect, we were amazing. The confidence and solidarity were outstanding. As a nurse, I have never felt so proud of my profession. As a healthcare team, the teamwork was also amazing. More than 100 critical care patients had been triaged, and 55 patients were moved to the Tower, which never lost electricity. By 11 am, all of our hospital-based ICU patient equipment was connected to diesel generators. We had some power, but still no general electricity, water, or plumbing. We were facing another hot, sticky Western day.It was Saturday and my day off from work. I awoke and leisurely dressed and made breakfast for my family. It was raining. I told my husband that I was going to the gym. I headed out the door and looked down the street. There was some flooding, but nothing major. Returning to my house, I turned on the television. I was amazed to learn what was happening at the Texas Medical Center as a result of the storm. St Luke’s personnel were requested to come to work, if at all possible. I called the unit and talked to the nurses. I had no idea of what was happening on the unit! I said that I would try to get to the hospital. They asked me to bring food.My husband and daughters did not want me to go; I assured them that I would be safe. My husband and our 2 daughters (ages 6 and 8) drove me most of the way. I walked the last leg of the trip in the rain and rising water carrying food and supplies. As I approached the hospital, the darkness was so weird! Upon arrival, I did not recognize anyone on the first floor of the hospital (these must have been volunteers). I wanted to go to our unit, but was told not to go up alone in the dark stairwell without a guide. Someone took me to the unit. Everyone was glad to see me. One nurse who had been there since Friday needed to go home. She had not slept and she needed medication for a chronic health problem, and I sent her home. Another nurse also arrived. We were both fresh. It took us a little time to get a grip on the environment, and I took 2 patients. We had both neuro patients and other patients on ventilators, most with vasoactive drips. The physicians on the unit were mostly residents. We normally do not have neuro ICU residents. They were asking a lot of questions and giving directions, but they really did not know what to do, given the circumstances. The technology to which we had become dependent in the neuro ICU was not working. We had to do things the old-fashioned way, such as count drips manually and rely on our physical assessment skills, because there was no flow of physiological data on the monitors. We had a few portable EKG machines that we used to go from patient to patient. This was very reassuring. Some patients were sweaty. I gave them sponge baths with a little water. There was no water to wash my hands. It goes against everything you know and every instinct, not to wash your hands. I had a severe case of cognitive dissonance. We had bottled water, but I felt guilty using it to wash. I finally used some of this precious water to clean my hands. A resident said to me, What are you doing? That water is for drinking!To suction patients, we used the small portable suction units normally used for emergencies. We had 3 units to share. One patient had methicillin-resistant Staphylococcus aureus infection, and we designated one suction unit for her; we shared the other 2 units for the other patients. There was no place to discard secretions, so we had to use the isolation bagging technique.A patient on the 22nd floor was having some respiratory distress and needed to be transferred to our seventh floor ICU. I was dispatched with a big muscular resident and a patient care technician to get the patient. The elevator was not working, so we used the stairs. We collected the patient, who was a big man, carrying him in a double sheet. My job was to carry the lantern and guide them through the stairwell. We headed down the stairwell, stopping about every 2 floors to rest a moment and get water. It was steamy and hot. This patient, despite his respiratory distress, was not scared. He kept saying that he was so sorry that he had to be carried. “You are doing a great job, and we will get through this,” he said.As I reflect on this experience, I am so glad that I could help. Fortunately, I knew that my family and home were safe. In some ways this was the “best day” to see people working so hard together. What used to be done by machines now was being done manually. I remember how things were done before we had so much technology.Getting to the hospital was no easy feat. The streets were flooded, and traffic was flowing slowly due to abandoned cars and inoperable traffic lights. I arrived at the front doors at 1 pm to find the hospital completely dark; no lights in either lobby, except for the daylight that was making its way through the humidity-soaked windows. As I moved down the corridor, the light dimmed. I didn’t walk far before I met someone who lent me a flashlight. My first instinct was to head for the elevators that would take me to my patient care unit. Of course, without electricity, the elevators were not functioning. I headed to the central stairwell to climb stairs. As I rounded the corner close to the stairwell, I saw what would be termed an outpost in the military. People were collected around a smattering of supplies at the foot of the stairwell. It dawned on me that ice bags, gallons of water, and medical supplies were being transported up the stairwell to our patients (Figure 6). I stopped to chat with fellow colleagues and inquire about the state of affairs at the hospital. They confirmed the absence of water, electricity, and telephones—the basic human needs we take for granted in a hospital.I started to climb the stairs and was amazed at the work these people were accomplishing; many faces that I didn’t know were heaving supplies from one person to another. Some people were dripping wet from the heat and had obviously been here for hours. As I climbed the darkened stairwell, lit by flashlights and lanterns, I felt an air of camaraderie that was established. About every third or fourth step, an individual had staked out his or her territory and proudly chatted with the person above or below them, while constantly handing off supplies. The talk centered on the disaster, the need to adapt to meet the needs of patients, or delivering important communications up and down the stairwell. Everyone had a smile.I just couldn’t believe the number of people I encountered as I traveled the stairwell. Just fathoming how many people were here to make a “human chain” to service 26 floors was incomprehensible. But here it was, and I was witnessing it with my own eyes. I finally made it to my patient care unit. Surprisingly, many nursing colleagues had made it into work. Patients were being discharged, and I wasn’t needed at the moment. So, I decided to work the human chain. I simply stayed out in the hallway and asked where they needed someone or “at what level was the weakest link?” Shouts came down, directing me up to the 21st floor, and there I took up residence for the next 6 hours.The work required me to use muscles I haven’t used in quite a while. It certainly contributed to my endurance training (lifting, pushing, and pulling ice bags, lanterns, and boxes of food). I talked with the people around me; some were volunteers from the neighboring community who had walked in waist-deep water to help. Others were hospital employees who were able to make it in safely and wanted to volunteer their time. Our conversations centered on everything (work, family, friends, and the flood), but despite the small talk, we were focused on our work.We were all caught up in this magical feeling of commitment and determination. The air almost seemed to be laden with a drug that encouraged friendliness and a bond of respect. In all my years of nursing, I have never had the opportunity to experience such camaraderie and sincere commitment to a goal. Hopefully, this type of disaster will never happen again, so I am lucky to have experienced and participated in the human chain. I know I will always be able to recount how a group of people banded together to service the needs of our patients.I worked 11-7 (Saturday to Sunday). The environmental challenges were many. What do you do when the computer systems for charting and requesting lab work are not working? What do you do when the monitors and intravenous fluid pumps do not work? As a 12-year veteran of nursing and the hospital, I remembered how we cared for patients before the influx of technology. It was back to basics! You count drips; calculate rates by hand, using formulas that were embedded in your brain; take your own blood pressures manually; and look at your patient for subtle signs of change. Young residents and young nurses lacked this historical, “olden days” perspective. These survival skills were quickly taught to the young. You needed to look at your patient with new clinical eyes. Physicians who ordered laboratory studies and x-rays were informed that these services were not available. Laboratory data normally available on the computer were not an option. The large paper sheets previously discarded when computerized charting was introduced were resurrected from the storage room. These forms help you to visualize trends in physiological parameters such as vital signs. It certainly makes you realize that backup systems must be in place when the computer information systems are down.The night shift went well with our 9 ventilator-dependent patients. We developed a system of working together while keeping an eye on the generator backup system. I finished my shift at 7 am and left the hospital. Since my neighborhood was flooded, I went to my aunt’s house, but I could not sleep.Transfer of patients to the Medical Tower was smooth and well orchestrated by well-coordinated teams and support personnel. The team pushing the bed was led by a critical care attending physician. Nurses, respiratory therapist, and other staff members composed the transport team. Each patient was connected to portable monitoring equipment. Those who needed respiratory support were manually ventilated. Along the trek to the Tower, including the skywalk, personnel with crash carts and supplies were posted. Water and juice stations dotted the travel route to provide hydration for the transport teams. People with walkie-talkies were monitoring the progress of each patient and making the next spotter aware of the location of each team. “Patient number one has just crossed into the skywalk.” It was a trek just to make your way to the entrance of the skywalk. The entrance to the skywalk includes an incline of about 15°to 20° (Figure 7). To gain momentum to ascend the ramp, each team required a running start. At a designated point at the entrance, the attending physician gave the signal to begin to run, and the team broke into a run with the bed to make it to the top. The personnel at the crash carts and other stations along the way cheered us on with encouraging words of “you can do it” and “you are doing great.” This aerobic exercise and teamwork achieved the goal of moving us to the other side of the mountain. Everyone worked very hard and worked together well. You had to throw away the rule book and think out of the box to manage care. Nurses were waiting to receive our patients. The Tower was organized into discrete areas so each unit had its own defined space. We were again caring for our own patients, and this made everyone feel more comfortable.One unexpected problem was accessing equipment that was in clear sight. We used a system that stores patient care needs such as dressings and intravenous fluids in a locked cart. In order to unlock the cart, you must punch in the patient’s preprogrammed code. Unfortunately, the patients’ codes were not in the system in our new home (the Tower), so access was denied. The supervisor was able to assist us, but it was a barrier that I am sure will be addressed before we have another disaster situation. Otherwise, life in our temporary home was fine. Our patients were doing well.All nurses described how proud they were of the way that everyone worked together in a spirit of cooperation and selflessness. They expressed insights and personal responses to the disaster. “The team work was amazing … everyone worked hard … it made me proud. Nurses cared for patients before they cared for themselves. The “old timers’” knowledge and creative adaptation were very helpful when the usual ICU technology was inoperable. The disaster situation didn’t last long, thank goodness … I prayed that we didn’t have a code although we were well prepared to handle one. A few days later, the transfer was in reverse; we moved patients back to the hospital with the same care and organization that worked so well just a few days earlier.From the perspective of a staff nurse, the lessons learned were innumerable. A back-to-basics approach to patient care required heavy reliance on the 5 senses and nursing assessment skills, minus the technology. Sight, sound, and good communication skills reemerged as the fundamental components for providing excellent nursing care in the face of a disaster. Many support services were not available. Therefore, infection control strategies, complex psychosocial support services, and end-of-life care were the nurse’s responsibility. Collaborative teamwork was essential for the completion of daily activities. Relaying heavily on peers promoted a camaraderie that one feels only in the face of disaster.In preparation for future disasters, we have learned to stock additional flashlights, batteries, and lanterns. Fortunately, our hospital went the extra mile before the flood by purchasing the more expensive ventilators, intravenous pumps, and other equipment with backup batteries. During hurricane season (June to November), we now stock additional drugs frequently used in the critical care area. Also, backup paper supplies are now stocked in the event the electronic record is lost. It is better to be safe than sorry. We also have a backup system to enter the locked patient supply carts.St Luke’s Episcopal Hospital has taken steps to sustain basic services during future disasters. Elevators have been wired to function even with the loss of electricity. Storm (submarine) doors have been installed in the 2 basement levels along with a sump pump system for removal of water (Figure 8). Relocation of the electrical system out of the basement is also occurring. Evacuation chairs and lifts have been purchased as well as additional radio and satellite telephones. The disaster plan has been revised and quick reference guides are now visibly posted in every unit. Of course, one cannot live without disaster drills, which I think have increased 10-fold.From the perspective of the Texas Medical Center (which includes 14 major hospitals), a new collegiality and community has been forged among the hospitals. A “tunnel group” policy was developed that allows flood control measures to be activated, such as closing of the new submarine door, without prior approval. The Texas Medical Center now has a radio network to facilitate communications among hospitals when telephone lines are down. In addition, nursing staff may now float from one hospital to another hospital, which promotes staffing effectiveness and patients’ safety.The nurses at St Luke’s did an outstanding job during the flood disaster. No one believed that they were heroic; they were just doing the best job that they could do for their patients. However, everyone expressed a special pride about the extraordinary teamwork. This teamwork exemplifies the extraordinary nursing staff of the first designated magnet hospital in Texas. The nursing leadership, autonomy, and collaboration of an empowered nursing staff made the difference in getting through the disaster and ensuing rapid recovery (Figure 9).We thank Gus Salinas for the photographs shown in Figures 2 through 9.