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what if...
The ED floods, electricity gets cut and staff are stranded for days

True Story by James Aiken, MD:
On August 26, 2005, Hurricane Katrina came ashore on the Mississippi Louisiana border. The winds and water surge decimated poorly constructed metropolitan levees and pushed water into a city situated below sea level. Charity Hospital, a large two-hospital acute care public facility in New Orleans, weathered the actual hurricane only to fall victim to rising waters.

By the second day water was within inches of our first floor patient care area including the emergency department. The electrical systems were disabled, paralyzing patient care. Rising water prevented even high water trucks from accessing our hospitals. After the storm our communications were reduced to a few land line phones, text messaging, and ham radio. The hospital informatics system did not have back-up capability.

We knew from prior planning that hospitals would not be an immediate evacuation priority. We also knew that total evacuation, rather than Continuity of Operations, was the overriding objective. Throughout the week, providing care to our critically ill patients became more challenging. We were able to employ a neighboring hospital air evacuation operation to get our critically ill patients out within two days. Our separate incidents command systems became increasingly uncoordinated. Each hospital leveraged whatever evacuation assets they could independently. We did employ adequate incident command operational periods and incident action planning, but did not do an adequate job making our staff and employees aware of the extent of our efforts. While the command staff held regular hospital wide briefings, a sense of hopelessness and despair became pervasive. Thankfully, by the 5th day we were able to completely evacuate the hospitals and leave with few patient deaths. We ultimately evacuated 500 patients and 900 staff and families. However there was virtually no patient tracking in regards to patient evacuation destination and subsequent medical condition.

Lessons Learned:
1. Disaster plans needed to focus more on the loss of electrical systems and subsequent system gaps

2. Needed pre-storm evacuation options for critically ill

3. Need enhanced statewide ham radio networks and redundant informatics server capabilities.

4. Need enhanced patient tracking and communications with families

5. During crises the medical staff tends to neglect all of their personal needs. They should be mindful of the need for adequate down time

6. Prior personal relationships and trust, both internally and externally, tend to propel the positive momentum of a response to a crisis.

aftermath:
Charity Hospital remains closed. Many employees were ultimately furloughed months later, including heroes of this event. The acute care hospital services are now located in the sister hospital to Charity Hospital awaiting the construction of a new facility.


MORE ON FLOODS:
“About 12 years ago when I was in Cambridge, Ohio, we had severe storms and flooding over 3 days. We anticipated the county building and jail might be flooded – a local dam had broken – and set up mini aid stations across the county and moved the communications and safety services to a high building in town. The flooding came faster than expected. We ended up with the county separated into islands as even the interstate flooded. I went in for a night shift and there was no one able to relieve me the next day. One physician made it down to where a rescue boat was helping evacuate a local nursing home. They brought him across and he was relayed into the hospital where we alternated shifts until another physician was floated in.”
-Joe Bocka MD
 
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what if...
A psych patient shows up in your waiting room with a loaded gun

True Story: Robert Fisher was working the night shift in a community ED in Phoenix, Arizona. The hospital was located in a rough part of town and the small ED waiting room opened directly to the street. “We did not lock out the public at that time,” said Fisher. All of a sudden, a man showed up in the waiting room and brandished a fully-loaded Uzi. “It was very black and ominous looking,” recalls Fisher, who discovered later that the man, though mentally ill, had permits for more than 200 fully automatic machine guns.

Strategies for de-escalating a potentially violent situation
1. Decide what kind of situation you are dealing with. Is this person insane or are they trying to rob the hospital? Do they have an external goal you can identify?

2. Listen. Most people become violent because they want something, and they will usually tell you what they want outright. If external goals are not clear, the person may have internal goals, such as respect or pride, which you will have to try and identify.

3. Whether the goals are external or internal, a fundamental rule of de-escalation is this: You need to help that person get what he or she needs while at the same time getting what you need. If their goal cannot be reached, a compromise can be made.

4. Be ready to take physical action when the moment presents itself.
 
how it went down:
That night in Phoenix the potentially deadly situation was diffused by one brave security guard named Roy. He assessed the situation and then calmly, quietly, asked the man to hand him the gun. Which he did. “I don’t think I’ll ever forget how simply he solved the problem and likely saved everyone’s life that night,” said Fisher.

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what if...
A SWAT team descends on your ED while you are at lunch

TRUE STORY by John Frey, MD:
One day I went to lunch in the hospital cafeteria and emerged to find the hall lined with police officers, guns drawn. They were looking past me down the hallway. I chose to go in the direction that the officers were NOT looking. As I exited the back of the hospital, several black helicopters ominously circled overhead. No one knew where exactly the shooter was. Just then my supervising physician called me from inside the hospital and said, “get back to work.” I said, “where’s the shooter?” He didn’t know, so I said, “call me back when you find out”. It turned out several ER doctors were shot, including one in the head. The shooter, if I recall correctly, was upset that his friend, an outpatient, hadn’t received pain medicine.
 
LESSONS LEARNED
1. It’s better to prevent a ‘worst case scenario’ than to deal with it after the fact. Be courteous to everyone, all the time. (OK, 99.99% of the time).

2. Don’t talk down to people, or you just might wind up talking up to someone.

3. It is dangerous to work in a hospital with a culture that doesn’t respect patients (or each other) with basic human decency.

4. Don’t wait for others to tell you what to do. Do what you think is right.

5. Protect yourself even if – especially if – your supervisors won’t.

6. If you see the ‘guns drawn sign’, vote with your feet.

AFTERMATH
I noticed in the weeks and months that followed this incident that patients seemed to be treated more compassionately and with more respect. But that could have been my imagination.

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what if...
Two hurricanes hit within a month and you suddenly have to coordinate thousands of volunteers

TRUE STORY by Randy Pilgrim, MD:
Based in Lafayette, Louisiana, our group cares for patients in 37 emergency departments that are vulnerable to hurricanes. On August 29, 2005, Hurricane Katrina affected 18 of those departments. Twenty-six days later, Hurricane Rita ripped into 16 more.
As the nation watched these disasters unfold, our group received over a thousand calls offering assistance, from nearly every state. With federal and state centers overwhelmed, our group unexpectedly evolved into a conduit for communications, strategy, and physician deployment. All this happened as we were addressing the acute needs of our own EDs, new field operations and staff. To this day, we greatly appreciate the much-needed help. But we underestimated the quantity and complexity of coordinating thousands of volunteers in a disaster-ridden, communication-challenged environment.

LESSONS LEARNED
1. Have a communication plan in place. Within a week we had to establish a phone center, develop a database, enhance our web site, streamline communications, and staff a brand new department. We fielded calls, triaged volunteers, assessed evolving patient care needs, and coordinated air and land travel with complex schedules. Next time we’ll have systems ready ahead of time, and redundancies in place.

2. All dressed up and nowhere to go. Despite the humbling generosity of many, only a handful of physicians had proper state licenses, almost none had appropriate hospital privileges, and few had malpractice coverage for field operations. The Board of Medicine was literally underwater, unavailable, and without contingency plans. It became very clear that the acute phase of disaster recovery would last for months. We needed to find a solution promptly. So, on about day four, after returning from a quick run for food, I jotted down several thoughts and solutions on a yellow Wendy’s napkin. Forty-eight hours later, with the assistance of key colleagues, those thoughts became an Executive Order from the Governor allowing any health care professional with a state license in good standing to provide much-needed services for recovery efforts. Equally important, the Order provided malpractice coverage. Hospitals responded in kind, granting temporary privileges, and surge centers could put talented doctors to work. And we learned yet another lesson.

Now, we have guidelines, procedures, and standing relationships with decision-makers, along with contingency plans. In addition, our group established an identified team of disaster medicine physicians licensed in a number of states, who carry credentials with them into recovery zones. Their availability is coordinated with their own colleagues, and on-going training in disaster recovery and response is provided.

3. Everybody needs friends. We learned the significant value of meaningful relationships with elected officials, appointed leaders, and regulators. As professionals who focus on episodic care, emergency physicians often neglect this vital part of the health care system. Now, we have even better, current, and solution-making relationships, and are glad to see these folks as a necessary part of the health care team.

AFTERMATH
To this day, I think of the incredible outpouring of assistance during hurricanes Katrina and Rita. In my view, it’s one of the most encouraging and unifying experiences our specialty has ever had. We were humbled by the support and good will of emergency physicians nation-wide.

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what if...
The largest blackout in American history leaves your ED powerless for days on end

TRUE STORY by Jyoti Mahapatra, MD:
In August of my intern year, at approximately 4pm, everything went dark and very quiet in the emergency department. We quickly realized that this was no generator drill when nothing had come back on minutes later. Though it was five years post 9/11 our first thought still went to terrorism. We expected the worst, assuming our country was being overtaken piece by piece. It seemed like hours before we found out we were part of the largest power outage in North American history. From Michigan to New Jersey to Canada, approximately 50 million people lost power that day.

Our patient tracking system was computerized and gone. Patients on IV pumps stopped getting their medications, and all the telemetry alarms were silent. Being August in a windowless ED, we were soon removing white coats, rolling up scrub pants, and wiping foreheads. It was dark, eerily quiet, very hot, and we all looked ridiculous.

In addition to the typical ED patients, traumas started rolling in from traffic control accidents. Elderly patients too frail to withstand the August heat at home came next. And last but not least were the ventilated patients at facilities that could not support the power needs of their patients.

Staffing was at the mercy of transportation. You worked until you had a replacement, which depended on whether your relief had enough gasoline to make it to and from the hospital. It was complete chaos, but ironically a great demonstration of how emergency medicine can and should be practiced. A few lessons we learned along the way:

LESSONS LEARNED
1. You can take care of trauma patients without CAT scans. Subtle changes in mental status, vitals, and neurologic status can still make a diagnosis instead of the pan-scanning that seems to have become the standard of care.

2. Labwork doesn’t grow on trees. When labs take four times as long and a cardiac panel monopolizes a technician for a half hour, it is less likely to be ordered on a 22-year-old patient with chest pain for eleven minutes.

3. Turkey sandwiches and apple juice really do heal. In the ED, there will always be patients whose social ills are their main health problem. While it might seem like a waste of a bed that could be used for a ‘real’ patient, some days these will be your most satisfied patients. It is not glamorous, but sometimes taking the best care of our patients can be as simple as a warm blanket or cup of coffee.

4. Common sense is not always common. As a new resident it was shocking to be told to send away patients without so much as a blood draw or X-ray. However, it was then that I really appreciated the value of my attendings’ years of experience and clinical gestalt. We sent home everyone that looked stable and gave them strict instructions on when to return. It was refreshing and efficient, and I wish I could practice this way more often.

5. Nothing ever stays the same. The first few hours after the blackout were a total mess. But when I returned for my next shift the following evening, things were running as smooth as before, despite several adjustments in practice. As with most things in the ED, being flexible and expecting the unexpected are essential to your practice no matter the disaster of the day.
 
 

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