Hurricane Ian is a reminder that preparation and management plans are key in weathering the storm.
Having lived in Florida for over 30 years, I’m no stranger to hurricanes. This past week we had historic Hurricane Ian, devastating Fort Myers. It is estimated that the hurricane caused $65 billion in damages.
But that’s not the real cost, is it?
At least 104 are known to be dead so far. That compares with 65 dead in Hurricane Andrew in 1992. There were 1,800 who died from Hurricane Katrina in New Orleans in 2005. The worst hurricane is said to be Galveston in 1900 with 6,000 to 12,000 fatalities.
I moved to Florida in 1991 and spent my first Florida hurricane in the hospital as the director of the emergency department in a new hospital a year later. It was 30 years ago but I remember Hurricane Andrew as if it were yesterday.
Prior to the hospital’s opening, I had to approve all the documents that support the ED’s practice. No matter how thoroughly you may try to anticipate the consequences of a disaster, there are inevitably issues that could not have been predicted.
We had our pre-hurricane and post-hurricane staffing plans. Doctors signed up for one or the other, either coming to the hospital before the hurricane or relieving that team after the “all clear.”
Several of my colleagues and I arrived well before the storm. During the storm, of course, we were in lockdown. There are no emergency vehicles or services during the hurricane — and then there was the first power outage.
The emergency generator didn’t go on immediately and we realized all the ventilator patients needed to be manually ventilated. We all ran upstairs to the units and did that until the emergency generator kicked in. We did this many times that night. I was in the hospital for three days: before, during and after the storm.
Once the “all clear” was given, the transports began.
There were patients who had CVAs and MIs during the storm and others who were dependent upon electrically powered medical equipment. Hurricane Andrew destroyed areas south of us and devastated Homestead. Hospitals south of us began transferring as many patients as we could take.
And then the endless line of walking wounded commenced. Small injuries for some: nail punctures, lacerations and fractures with more significant injuries for others: falls, blunt trauma sustained during the storm and clean up.
No matter the injuries, each patient had a story to tell.
I remember the poignant tale of one patient. As I sutured his laceration, he told me about his experience. He tied his wife and three children to himself, and they hid under mattresses in their bathtub while their house literally blew away from them. “I thought we were all going to die.”
They turned out to be among the luckier ones — if you can find luck in any of this — because they survived.
The physical injuries could usually be repaired, but the emotional injuries would endure for so many.
I’ll never forget how the doctors behaved. Call lists were useless. Phone lines and towers were not working. We couldn’t call for help. Doctors “on call” for the hospital could not be reached.
Yet, the heroes showed up saying, “how can I help?” They even went to work in the emergency department helping with the overwhelming volumes of patients.
I recently watched a dramatization of Hurricane Katrina, surely one of the worst hurricanes in history. “Five Days at Memorial,” is a thought-provoking mini-series based on the well-researched book of the same title by Sheri Fink.
The hospital was damaged, windows were broken. The emergency generators were disabled by the flooding. They ran out of fresh water, food and medications. Toilets didn’t work, sewage backed up. The ambient temperature was over 100 degrees. The smell was noxious.
The hospital needed to evacuate the patients. Local, state and federal agencies were unprepared and in absentia. There were no organized rescue attempts to move the patients and there was very little communication available. No leadership existed on the outside.
On the fifth day, doctors faced an ethical dilemma when they were told that “everyone must be out by 5 p.m.”
At that point they were in triage mode with red, yellow, green and black bracelets on the remaining patients. It was clear to the doctors that not all patients could be evacuated by the deadline. There was not enough time, even with boats and helicopters.
Evacuating patients meant several people physically carrying them down several floors of staircases and carrying them up the rickety stairs to the helipad.
Ethical Dilemma: Doctors were mandated to abandon patients with DNRs and others who would not be evacuated. The likelihood was high that, denied food, water, medications and care, these patients would suffer and eventually die.
One doctor and two nurses were later arrested and charged with homicide.
What would you have done?
My surgeon friend, Dr. Vicki Rackner, emailed me: “How do we make sure that doctors in a major metropolitan area in the US are not put in this situation in the first place? I think the wrong people were on trial, and the movie does not really address the problem. This is a systems failure. Should FEMA have been on trial?”
Eventually, Dr. Anna Pou was not indicted, and her criminal arrest record was expunged. Louisiana legislation was subsequently written to protect physicians and nurses from criminal prosecution for actions taken to care for patients during a natural disaster.
AMA Journal of Ethics, Illuminating the Art of Medicine, Health Law 2010 article states in part:
“It is not speculation to state that Dr. Pou and the Memorial staff put their own health and safety at risk in the atrocious post-Katrina environment and successfully evacuated the majority of Memorial’s patients despite life-threatening conditions. The AMA has commended Dr. Pou for her efforts, and the chair of its board of trustees, Edward L. Langston, MD, stated, ‘We believe these physicians served as bright lights during New Orleans’ darkest hour.’ [1]
Now, in the aftermath of Hurricane Ian, newscasters are criticizing response management. They are saying the advance warnings were too late. Part of that problem is that the hurricane landfall was more south than anticipated — hurricanes will do that.
Hurricane Ian was expected to make landfall in Tampa. Tampa General surrounded the hospital with an “AquaFence” to protect against flooding and storm surges. They have a new power plant 33 feet above sea level.
But the landfall was in Fort Myers,126 miles south of Tampa. Lee Health in Fort Myers evacuated 22 newborns from the NICU, the most critical by helicopters, others by ambulance. News headlines today inform that they are transferring 400 patients and planning on transferring another 400 patients. They are at 96% capacity and have lost water pressure as well as having power outages.
The magnitude of challenges presented by natural disasters can never be fully defined.
We must learn from each disaster.
After Hurricane Sandy, ACEP undertook a research project to define how the healthcare system was negatively affected. “This information will be used to develop action steps to better prepare healthcare professionals, medical facilities, and public health for future mass casualty events.” (2)
“Many of the issues that are identified were expected areas of improvement for a storm of this magnitude. Some of the issues can be attributed to the persistence of silos. We identified the ‘silo effect’ on several different levels such as hospitals to EMS, hospital to hospital (particularly network to network), EMS to emergency management, and hospital to emergency management. Efforts within many of the facilities visited and groups interviewed is ongoing with the identification of gaps to reduce or alleviate some of the domino effect and to improve overall response and recovery.” (2)
Emergency physicians should scrutinize their disaster manuals and then look beyond them at what is not in there but should be. Consideration should be given to the catastrophic, unimagined situations that we now know could occur.
I humbly suggest our legal advocates ensure our protection from being punished for being dedicated, ethical physicians who must struggle with the impossible. The well-considered decisions of the leaders on the front line should be accepted as valid at the time.
No one can presume to walk in our shoes if they haven’t been there.
REFERENCES:
(1) The Case of Dr. Anna Pou: Physician Liability in Emergency Situations | Journal of Ethics | American Medical Association (ama-assn.org)
(2) Lessons Learned from Hurricane Sandy and Recommendations for Improved Healthcare and Public Health Response and Recovery for Future Catastrophic Events (acep.org)
1 Comment
What a great and informative article!
Looks we still have so much more to learn.
Criminally liable during a disaster situation?
How draconian.