Evacuate or ‘hunker down?’ ED experts ponder options as Katrina wreaks havoc
Evacuate or hunker down?’ ED experts ponder options as Katrina wreaks havoc
Hurricane veterans say the decision is not as easy as it may appear
Hurricane Katrina, clearly, was a health care disaster of unimaginable proportions. In the wake of the storm, Gulf Coast hospital emergency generators were rendered inoperable by rising floodwaters. In many facilities, there was no plumbing or potable water; buckets were used for latrines. In New Orleans, helicopters sent to evacuate critically ill patients were fired upon.
"This is bigger than anything anyone else has ever seen," says William (Kip) Schumacher, MD, CEO and founder of The Schumacher Group, a Lafayette, LA-based practice management firm that provides emergency medicine, staffing, and practice management services to 104 facilities, including 30 in Louisiana.
"Many of these hospitals were turned into armed camps; there were nurses and doctors walking around with shotguns slung over their shoulders, and no one questioned it," he points out.
No one would seek to minimize the scope of this disaster, and clearly no one questions the dedication and courage of the thousands of emergency medicine professionals who provided whatever help they could under such dire conditions. But those conditions all arose after Katrina hit, and there are those who wonder whether some of the stricken EDs and hospitals — or at least some of their patients — should have been evacuated ahead of time.
There are facilities with such plans in place, and some of these plans have been put into action when disaster seemed imminent; but conversations with a number of ED managers and experts in hurricane-prone areas reveal that to do so would involve a number of key decisions — most of which are never cut and dried.
Not everyone leaves
Even when a pre-evacuation is undertaken, that action does not necessarily mean the facility is entirely deserted, explains Obed Cruz, RN, the ED manager at Mercy Hospital in Miami. Mercy has done partial evacuations.
"There is always a remainder that stays behind, because there are always some patients who can’t be evacuated," he says. "Our ED faces the [Biscayne] Bay — so the nearer the storm gets, you literally close it, because the entire site becomes an evacuation area."
This partial evacuation was done last year in preparation for Hurricane Ivan, he recalls. "Anyone who needs to be admitted [from the ED] quickly goes upstairs, where beds are available because some other patients have been moved," he says. Any visitor stuck in the ED "becomes part of the family till it’s over," adds Cruz, as hurricane shutters in front of the ED are closed.
At St. Joseph’s/Candler Health System in Savannah, GA, the facility is considered a community resource in times of disaster, "so [total evacuation] is not a consideration," says Judy Peterman, RN, MSN, director of critical care and emergency services.
"We would discharge all the patients we could and send them elsewhere or manage them in a crisis if need be." With a Category 3 hurricane or higher, they have relationships established with outlying facilities, should they need to transfer ED patients.
When you are hired, you are assigned randomly to Team A or Team B, says Anne Byerly, RN, assistant ED nurse manager for St. Joseph’s/Candler. "In the event of a hurricane, Team A stays," she explains. "Team B leaves the city."
Texas Children’s Hospital in Houston would evacuate ahead of time. "We know what the ramifications of a Category 4 or 5 would be to Houston," says Mary Frost, RN, trauma coordinator.
"We have a Level 1 center in Galveston that evacuated ahead of time in 1983 for [Hurricane] Alicia, which was a Category 4," she notes.
When do you decide?
The criteria for evacuation and the decision itself should occur well in advance of the anticipated landfall, Cruz notes. "You can’t wait until it’s almost going to hit," he emphasizes.
The second you are in a hurricane watch, the plans need to already be in place, Cruz advises. "Usually, as soon as a watch has been issued in your area and you are in the path, the handwriting is on the wall and it has to happen pretty quickly."
The most dangerous part in all of this is the dangers on the road, he says.
These dangers can include downed power lines or massive trees falling on vehicles which, according to a Mercy spokesperson, was the cause of death in the first three Katrina-related fatalities in Florida.
At Mercy, the decision to evacuate is made by the safety officer and hospital administration, Cruz says. What storm category does he believe that warrants evacuation? "If it gets to a 3 or 4, you are definitely looking at something that will be pretty devastating," he says.
In New Orleans, however, conditions shifted so rapidly that such advanced evacuations may not have been possibly, counters Randy Pilgrim, MD, president and chief medical officer of The Schumacher Group.
"We opened our command center well in advance, but during a 48-hour period, the storm ranged from a 3 to an extremely strong 5, resulting in the fact that all the backup plans and emergency preparedness we had crafted on Saturday had to be completely revisited and re-crafted on Sunday," he says.
On Monday, after the levees in New Orleans broke, the plan had to be so substantially redone that it was unrecognizable, Pilgrim notes. "The point is, when you think about evacuating or closing a hospital, it’s extremely difficult to be sufficiently preparatory but not overreactive."
You may not have assurances that evacuating patients won’t place their lives at risk, he says.
If evacuation has to occur by helicopter, there is a tremendous risk of helicopter transport itself, including crashing, Pilgrim explains. Under circumstances of wind, rain, and adverse weather conditions, it is even more risky, he says.
"A patient in a room with electricity, oxygen, and all life support is in a very stable environment; if you move them to a vehicle, [intravenous lines] can come out, [endotracheal] tubes can become dislodged from airways," Pilgrim adds. "In the best of hands, in a controlled situation, it generally goes smoothly; but the risks are all that much greater under storm conditions or conditions of relative chaos."
In Cruz’ facility, there are several levels of response, and the ED is well prepared to keep operating during the toughest of times.
"We have an option called the sheltering in place’ plan, where we just weather the storm in the hospital," he explains.
"In the ED, if we have to move to the second floor, everything is wireless, so we could move the entire ED and our computers all the way to the second floor and be able to operate in a matter of two to three hours. If we were hard-wired, there would be a lot of disadvantages," he adds.
Cruz describes the decision to evacuate New Orleans as a tough call. "You’re not talking about 100 or 200 patients, but thousands. It’s hard to come up with scenarios to manage that kind of disaster, and it’s easy to point a finger if you’re not in charge."
Sources
For information on hurricane preparedness, contact:
- Anne Byerly, RN, Assistant ED Nurse Manager, St. Joseph’s/Candler Health System, 5353 Reynolds St., Savannah, GA 31405. Phone: (912) 819-4300.
- Obed Cruz, RN, ED Manager, Mercy Hospital, 3663 S. Miami Ave., Miami, FL 33133. Phone: (305) 854-4400.
- Mary Frost, RN, Trauma Coordinator, Texas Children’s Hospital, 6621 Fannin St., Houston, TX 77030. Phone: (832) 824-1000.
- Judy Peterman, RN, MSN, Director of Critical Care and Emergency Services, St. Joseph’s/Candler Health System, 5353 Reynolds St., Savannah, GA 31405. Phone: (912) 819-4300.
- Randy Pilgrim, MD, President and Chief Medical Officer, The Schumacher Group, 200 Corporate Blvd., Suite 201, Lafayette, LA 70508. Phone: (800) 893-9698.
- William (Kip) Schumacher, MD, CEO, The Schumacher Group, 200 Corporate Blvd., Suite 201, Lafayette, LA 70508. Phone: (800) 893-9698.
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