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Hurricane Katrina: 10 years later


December 1, 2015

Hurricane Katrina: 10 years later

Hospital officials from storm-ravaged areas share the lessons they learned from the killer storm

It's hard to believe it, but it's been 10 years since the Gulf Coast was ravaged by one of the worst hurricanes the U.S. has seen, and emergency management officials got the major wake-up call they needed to prepare for future storms.

Hurricane Katrina hit the New Orleans area on August 29, 2005 as a Category 3 storm, which may not have been a big problem for the city's medical facilities in normal circumstances; hospitals in prone areas already train their staff and practice their emergency plans extensively to stay open and able to treat patients in the worst of weather.

It's what came next that hospitals weren't ready for. When 53 of the city's protective system of levees failed, the result left almost 80% of New Orleans under water, with citizens scrambling to the roofs of their houses to escape the floodwaters. What's more, the federal government was very slow to respond to the crisis, and hospitals found themselves on their own without electricity, communications, and crucial resupply lines to stay open.

"Every facility is aware of the risks they face; if you're on the West Coast, you know earthquakes are possible," says Lee Hamm, MD, senior vice president and dean of the School of Medicine at Tulane University Medical Center in New Orleans. "Everyone goes through exercises thinking they are prepared, but reality is the things you didn't anticipate are the biggest problems. We couldn't have expected the entire city to be under water and not be able to get things in and out."

In 2005, Hamm was chair of one of the largest departments at Tulane, and remained on-site throughout the entire disaster, he says. He was one of the last people to leave by helicopter evacuation after five days without power or water.

"The priority was getting patients out," he says. "We were getting patients out as early as we could, but some didn't leave until day four. It was very much primitive medicine without power or water."

Unfortunately, many patients died, because hospitals had to make painful decisions about triage, and without power, crucial lifesaving equipment such as ventilators didn't work. In perhaps the most heart-wrenching story to come out of Katrina, doctors and nurses at the now-closed Memorial Medical Center, faced with temperatures reaching 100 degrees and the cruel reality of trying to keep alive and evacuate critically ill patients, decided to administer lethal doses of drugs rather than let the patients suffer. According to an article in the New York Times, when the floodwaters receded, 45 corpses were removed from Memorial, more than any other hospital in the stricken area.

"Despite the fact that there were hundreds of people that died, it maybe was not as many as some may have anticipated given the circumstances," Hamm says.


What's changed?

The experiences of Hurricane Katrina ripped the proverbial rug out from underneath hospitals, which in theory should be fortresses that remain open with the lights on, ready to help patients that need them. No one expects these facilities?especially those in large, modern cities?to be completely isolated and unable to take care of patients under their care, let alone take on new ones walking through the door.

"The city has really pulled through to create a more organized approach to preparedness and availability of resources if necessary," says Susan Thomas, MHA, MBA, administrative director of Shriners Hospitals for Children in Houston, Texas, a city that found itself under the gun almost exactly a month after Katrina by Hurricane Rita, considered one of the strongest hurricanes ever recorded in the Gulf of Mexico. "We are a part of a very large medical center, so it's nice that we are all working together as a team to help each other out with bed space or needed vaccines, meds, etc."

Things have changed since the hurricanes of 2005, especially when it comes to emergency planning. Hospitals are now required by regulators to plan for emergencies with an "all-hazards" approach, drilling their emergency plans extensively and having evacuation, triage, and resupply contingencies laid out for scrutiny from The Joint Commission and CMS. Officials who rode out the storms on the Gulf Coast say a lot has changed since then. Here's a primer on some of the lessons learned.

Communications. It's a law of emergency management that if you can't communicate with the outside world, you are on your own, and that's exactly what happened to many hospitals after Katrina struck. Hamm says that when the power went out and phone service was cut, staff members tried to use cell phones, but downed towers from the wind and overcrowded circuits rendered cell phones useless. There were a few satellite phones available, but to use the phones, staff had to go to the roof of the hospital to search for a signal.

"They weren't adequately tested and there weren't any reliable antennas," he says.

How things have changed: Things are much different today?cell networks are much more reliable and cell phones are a much more dependable technology. Also, regulators now require hospitals to test their communications systems often, and have multiple backup systems available in the event of a crisis. Emergency planning experts recommend that hospital staff train to communicate with each other and outside emergency responders using primitive means if necessary, even if that means using pen and paper or two-way radios in the event of a power outage.

Cooperation. Prior to Hurricane Katrina, hospitals in New Orleans didn't have "memorandums of understanding" with other hospitals that let other hospitals accept their patients should the need arise. In many ways, this could have helped hospitals isolated in the most heavily hit areas of the city.

How things have changed: Hospitals routinely train to not only sustain themselves in an emergency, but with other facilities to be ready to help out with supplies or patient care, should a sister hospital become incapacitated. This type of agreement proved helpful during the 2011 tornado in Joplin, Missouri, when an EF-5 twister wiped out St. John's Hospital. Predetermined agreements went right into effect, allowing patients to be transferred (in many cases, by any means possible) to other hospitals to be treated.

"We have an electronic system now where we can indicate or request available bed space and resources in real time," says Thomas.

Resupply lines. Gone are the days when hospitals felt like they could rely completely on government resources to resupply them in the event of an incapacitating event. In 2005, FEMA was unable to get supplies into New Orleans because of a failure to properly position and mobilize resources. As a result, citizens?and hospitals?largely found themselves on their own without ways to resupply food, water, fuel, and medical supplies until National Guard troops were able to move into the city.

How things have changed: While the government has itself learned some lessons, many emergency planning experts still say the best way to plan is to expect to be isolated without help for several days in the event of a major disaster, hence the reason that CMS and the Joint Commission both require hospitals to prove they can be self-reliant and operational for 96 hours. In addition, fuel and other backup supplies may be hard to find in a crisis, and some hospitals?as was the case during Hurricane Sandy in the New York City area?are going as far as having tanker trucks standing by, or agreements to take over gas stations if needed for emergency fuel supplies.

"People did not anticipate [the] length of time they would not get fuel trucks to refill the emergency tanks to run the emergency generators," Hamm says.

Evacuation plans. One of the biggest problems experienced during Hurricane Katrina was the decision to evacuate that was made much too late. Whether it was the government, which waited much too long to issue an effective evacuation order for the city, or hospitals that waited too long to decide it was time to evacuate their patients and staff, those crucial decisions made the difference between being able to get ambulances and buses in to help evacuate critical patients and waiting until helicopters were available to assist in evacuations when floodwaters overtook the city.

How things have changed: No longer do hospitals take a "last one standing" approach to the difficult decision to evacuate. All emergency plans are written and practiced with the contingency that at some point, someone may have to decide to evacuate. The idea, Hamm says, is to know ahead of time who will stay and who will go, and at what threshold it is time to make that decision. If weather conditions are deteriorating rapidly, or transportation arrangements can't be guaranteed, or resupply lines might be compromised, the decisions need to be made earlier. In addition, staff are being more extensively trained in evacuating patients in many different conditions so that the actual situation does not come as a surprise. Hospitals in the New York City area had ambulance companies on standby long before the hurricane ever hit, just in case they were needed, and in some cases the most critical were moved early to inland hospitals as a precaution.

Speaking of staff, many hospitals were left short-staffed when employees either would not or could not report to work. Contingencies are in place to make sure employees' needs and the needs of their families are in emergency operations plans.

"We have planning sheets and checklists that we now have employees fill out annually to let them know if they have been designated as essential or non-essential, and what to plan for if a disaster hits?things like pet care, elderly care, childcare, transportation needs, etc.," says Thomas.

Utilities. Older facilities in New Orleans?and in New York City during Sandy?were crippled when backup generators stored in the basements and first floors of hospitals were flooded. Floodwaters contaminated emergency fuel supplies and left pumps unable to get the fuel flowing.

How things have changed: Gone are the days of hospitals being designed with fuel tanks and generators underground, as most new construction is being designed with utilities above ground and some in the roof structures of the new buildings. In flood-prone areas, hospitals are being built on "stilts," with the capability to remain operational even if the first floors are inundated by floodwaters.

Drills. Hospitals in Katrina found themselves crippled by a lack of preparation, with emergency and evacuation drills that had not been practiced in years. Because of this, staff had to improvise evacuations of the most critical patients?many of whom died when power outages caused ventilators to fail?to rooftop parking areas to await helicopters.

How things have changed: Emergency plans now include extremely detailed contingency plans?or at least they should. The Joint Commission and CMS require that these plans be rehearsed at least twice per year in the form of emergency exercises, and at least one of them must test the hospital's ability to handle a crisis that floods their facility with a patient surge. The idea, of course, is to make sure that staff are ready for any situation under all types of stressful conditions.

"If you feel confident, you may well be overconfident," says Hamm. "You don't know what you haven't thought about. Do be prepared, go through your mock drills, and make sure you understand every aspect of your plan. Redundancies are a big thing. Make certain you have secure backups."

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