Prerna Mona Khanna, MD, MPH, FACP, certainly had strong qualifications to moderate a session on disaster relief at Internal Medicine Meeting 2016. Over the past 18 years, she participated in the response to 5 hurricanes, 4 earthquakes, 2 tsunamis, 1 plane crash, 1 typhoon, 1 flood, 1 disease outbreak, and 1 terrorist attack.
Her session, “Sustainable Health Care after a Disaster,” was one of 2 during the meeting that focused on disaster medicine. More specifically, both sessions delved into recent hurricanes that hit hospitals—Hurricane Katrina in 2005 and Hurricane Sandy in 2012, among other subjects.
Hospital physicians who survived those disasters offered advice for colleagues on how to prepare themselves and their facilities for similar events. “Let's talk about what we learned, so that you guys can maybe not make some of the same mistakes,” said Richard Deichmann, MD, FACP, a panelist at Dr. Khanna's session who was chief of medicine at Memorial Medical Center in New Orleans, now Ochsner Baptist Medical Center, during Hurricane Katrina.
“It's all in the prep work,” advised John Maese, MD, MACP, at his session, “Disaster Response and Preparedness: Lessons from the Field.” Dr. Maese was chief medical officer of Coney Island Hospital in Brooklyn, N.Y, when it was hit by Hurricane Sandy.
What it was like
Both Dr. Deichmann and Dr. Maese and their hospitals had prior experience with hurricanes. Coney Island Hospital had been evacuated by government order prior to Hurricane Irene in 2011. “We had an orderly closure of services, and by doing that, we had services up and running a few days after the event,” said Dr. Maese.
As Hurricane Sandy approached, there was no order to evacuate, but hospital leaders did take some preparatory actions, in case they lost power. “We partially evacuated the hospital and consolidated patients into a relatively new building. We took the patients who were power-dependent and either transferred them or moved them into the newer tower building,” Dr. Maese said.
Memorial Medical Center was actually taking on occupants as Katrina approached. “People from all over the community would come and shelter there for storms. It was common for staff to bring in their family and loved ones, even pets,” said Dr. Deichmann. There were about 2,000 people there when the storm hit, about 200 of whom were patients.
Immediately after the storms ended, both hospitals appeared to have gotten through relatively unscathed. In New York, high tide passed and the hospital was still above water. “The problem was that we didn't calculate that we were a mile from the water,” so the floodwaters were still on the way, said Dr. Maese, who showed video of water later pouring into the hospital.
Dr. Deichmann left his hospital and started to drive home with his family after Katrina. Their way was blocked by downed trees and they had to turn back, but they assumed things would be cleaned up by the next morning. “The next day, it's clear that the levees have broken and New Orleans is going to be in for massive destruction,” he said.
At both hospitals, the decision was made to evacuate as floodwaters closed in. At Coney Island, that meant shutting down an active emergency department. “Needless to say, it was a little harrowing,” said Dr. Maese. “From a patient point of view, it was much safer to pre-evacuate.”
Harrowing might be an understatement for the evacuation at Memorial. “This hospital had never been evacuated before; no hospital in New Orleans had ever been evacuated,” said Dr. Deichmann. “Only 2 trucks were able to make it through the water before it got so high that we couldn't evacuate anybody by land anymore.”
Twenty-five of the highest-risk patients—ventilated, pregnant, or newborn—were taken out by helicopter. That left 1,500 people at the hospital, with others trying to join them. “As the water kept rising, we would have more and more people coming up to our hospital, seeking shelter and help, and we felt awful having to turn these people away,” Dr. Deichmann said.
Memorial was finally fully evacuated 2 days later and didn't reopen until the next year. At Coney Island Hospital, “It took us months to restore services,” Dr. Maese said.
Based on their experiences, both physicians had numerous tips for colleagues, starting with having enough staff. “In any disaster, you're going to have less staff,” said Dr. Maese. “There's a shutdown of mass transit—people can't get there. Schools close—people want to be with their children.”
The rate at which health care workers will show up for work during a disaster was actually quantified in a 2005 study in the Journal of Urban Health, Dr. Deichmann noted. “About 70% said that they would be able to show up in a SARS-type epidemic, but less than 50% said they'd be willing to show up,” he said. During Katrina, clinicians who were employed by the hospital seemed to be more likely to come to work than those who were just affiliated, Dr. Deichmann added.
His hospital now requires clinicians who volunteer to work during a disaster to provide evidence that they won't be sidetracked by personal responsibilities. “You have to submit a written protocol and plan about what you're going to do with your loved ones,” Dr. Deichmann said. “If it doesn't quite make sense, like you're a single mom and don't have anybody to help take care of your kids...that'll be declined.”
Staffing the hospital is only the beginning of the challenges. “Then you have to figure out what to do with the staff you have—where are they going to sleep, shower, eat, etc.,” said Dr. Maese. Based on this concern, Dr. Deichmann's hospital has set up tighter policies since Katrina, no longer welcoming relatives and pets to shelter there. “You're not going to be able to allow everybody to be coming into your hospital, trying to feed 2,000 people when you really only have the supplies to feed maybe a couple of hundred for several days,” he said.
Resource limitations should also guide admissions in the days and hours prior to a predicted natural disaster, the physicians said. “The art of rapid discharge is a really important skill,” said Dr. Maese. “You should close nonessential services early.”
Dr. Deichmann described the consequences of not following that advice. “One of our oncologists did a bone-marrow transplant on a patient about 2 days before the hurricane hit, and then he didn't even stay for the thing. We had this phenomenally neutropenic patient. It was extremely difficult to get her evacuated.”
For such situations, it's helpful to know a little about neighboring hospitals. “If you have a neurosurgery patient, you've got to make sure you're sending the patient to a neurosurgery hospital,” Dr. Maese said. He added additional reasons: “We deployed our hospitalists with the [evacuated] patients, so there would be staff. So it's important for hospitalists to be familiar with neighboring facilities because you never know when you'll need to go there.”
Hospitalists should also be prepared to use telehealth technology to provide or receive assistance during a disaster. “You may need expertise for the patients you have or you may need to supply expertise for patients in the field,” Dr. Maese said.
On the other hand, also be prepared for technology to go down. “Don't forget old technology. Ham radios really work well in a disaster, and we need to train more doctors on how to use them. It's really simple,” Dr. Maese said.
Physicians should also know how to deal with the loss of their electronic medical records. “In a disaster, you need to be able to do things by paper,” said Dr. Maese. Another old-fashioned technology that he recommends is a headlamp. “Keeping your hands free in a disaster, being able to move and take care of patients, is very important.”
Calm, clear communication
One of the most important things, according to both physicians, is communicating effectively and confidently with patients and staff. “Everybody's frightened. You can either dissipate that tension or you can increase that tension, but it's all how you communicate,” said Dr. Maese.
“People's behavior really changes a lot when they feel like their life is on the line,” said Dr. Deichmann. “One of the ways you can try to help control this is to communicate very, very well. Let them know everything that you know is going on. Try to keep them as calm as possible.”
After a disaster, hospital staff may need counseling, according to Dr. Maese. The people of New Orleans had high rates of post-traumatic stress disorder after Katrina, including 5 physician suicides, Dr. Deichmann reported. “There are things you can do to help blunt this effect,” he said, noting that nurturing, ensuring good social supports, and returning to normal activity quickly were all found to help.
Practicing hospital response with drills should provide better outcomes during and after disasters, according to Dr. Maese. “Drills are really important to test readiness,” he said. “You want to involve as many stakeholders as possible. You have to do a debriefing after, and lessons learned must be shared.”
Both physicians hoped that the sharing of their lessons would help others. “Disasters are becoming more costly and more frequent, so certainly prepare for the disaster that is going to hit your community, because there will be one that will hit your community or a neighboring one,” said Dr. Deichmann.
Proving the point, the first speaker during his session's Q&A was a physician from Fort McMurray, Alberta, which had just been evacuated due to a massive wildfire. “I'm currently stranded,” he said. “I wonder if you have advice on how to plan for reintegration. The idea of just going back to normal practice doesn't quite seem to jibe.”
Dr. Deichmann offered his sympathy, before warning that reintegration can be very piecemeal. Although primary care physicians returned to New Orleans relatively soon after Katrina, there were shortages of other types of clinicians, including neurosurgeons, orthopedists, and psychiatrists, for at least a year, and the restarting economy created unusual dynamics. “Some of our nurses were leaving to go work at McDonald's. It was a really, really strange dynamic for the longest time,” he said.
“Reintegration is one of the most difficult aspects to manage,” said Dr. Khanna, who noted the particular challenges caused when clinicians and their families have either died or fled disaster-devastated areas and fewer health practitioners remain to assume a greater burden of care. For the questioner, and anyone else interested in the subject, she recommended the 2015 Institute of Medicine publication “Healthy, Resilient, and Sustainable Communities After Disasters.”