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When the Healer is Hurt: How Providers Cope with Being Victims of Disaster

By Emily Friedman. First published in Hospitals & Health Networks Daily on August 7, 2012

Health care leaders whose hospitals and health care systems have been damaged severely by natural disasters over the past two decades share many lessons learned.

Emily Friedman

On Aug. 24, we will mark the 20th anniversary of Hurricane Andrew making landfall in Florida; on Aug. 29, we will mark the seventh anniversary of Hurricane Katrina's landfall on the Gulf Coast and the subsequent failure of levees in New Orleans. Since then, hospitals and nursing homes in Illinois, Iowa, Missouri and elsewhere have been damaged severely by natural disasters. While most health care disaster plans focus on how providers can serve others affected by calamity, not all of them include adequate provision for situations when the facility itself is hit. Those health care leaders who have been through such trauma have many lessons to share.

Historically, health care providers have been leaders when it comes to emergency preparedness. They have to be. Not only is this mandated by governments, the Joint Commission and other entities, communities count on providers, especially hospitals, to be there even if there is calamity and confusion everywhere. So there is a moral mandate to be prepared as well.

For years, the classic plan envisioned the hospital's taking care of others: receiving evacuees, providing trauma care, arranging for evacuation, maybe even supplying food and water to those who need them. And, over the years, many hospitals have been heroic in fulfilling these needs.

Not all providers ever thought they might be the victims of disaster.

Katrina Changed the Equation

Then, on Aug. 29, 2005, came Katrina, the collapse of levees in New Orleans and the resulting severe crisis affecting many hospitals. The Touro Infirmary lost two patients; seven more died in the acute long-term care hospital on the campus. At Memorial Hospital, 41 patients were found dead, spawning a tale of impossible choices and probable euthanasia. At St. Rita's nursing home, which did not evacuate as other homes in the city had done, 34 residents drowned. More than 100 patients died in health care facilities.

Those events should have been a wake-up call as loud as an air raid siren. Yet on April 13 of this year, the inspector general of Health & Human Services issued a report on progress made by nursing homes since that agency had issued a warning in 2006 about lack of compliance with even minimal federal preparedness standards on the part of some providers. The new report found that, especially when it came to nursing homes, "many of the same gaps in preparedness and response" still were present six years later.

I clearly remember, in the aftermath of Hurricane Andrew, being told that the disaster plans of many nursing homes consisted of instructions to evacuate patients to the nearest hospital. The result was that hospitals trying to transport patients to safety through the front door found nursing home patients being dropped off at the back door.

Hospitals have done better than nursing homes in their planning, but that does not mean that they have fully prepared for being disaster victims themselves.

Many Hospitals Affected

In the past few years, hospitals have suffered repeated calamities. The University of Texas Medical Branch facility in Galveston was nearly hit by Hurricane Rita in 2005 and was evacuated; the storm missed it, but Hurricane Ike's storm surge flooded the hospital on Sept. 13, 2008.

In Fukushima Prefecture, Japan, a 9.2 earthquake hit on March 11, 2011, followed by a huge tsunami less than an hour later. The combined events destroyed five hospitals, whose patients had to be evacuated to Fukushima Medical University Hospital. A large nuclear power plant subsequently failed, and another hospital had to be evacuated because it was too close to the damaged reactors that were leaking radiation — and still are.

In a large area of the southern United States, a swarm of tornadoes hit on April 27, 2011. Although the five facilities in the Erlanger Health System, based in Chattanooga, Tenn., were not hit directly (one tornado circled all around the Erlanger North facility, but then moved on), the largest hospital campus faced severe challenges involving staff and keeping a trauma center and a neonatal intensive care unit open amid chaos and more tornadoes.

St. John's Regional Medical Center in Joplin, Mo., took a direct hit from an EF5 tornado on May 22, 2011, which essentially destroyed the hospital. Five ventilator-dependent ICU patients and one visitor died.

Hurricane Irene visited destruction up and down the East Coast, flooding the laboratory, some operating rooms, patient rooms, central supply and the chemotherapy unit at Dorchester General Hospital in Cambridge, Md., on Aug. 26, 2011.

This year, Harrisburg (Ill.) Medical Center was hit by a tornado on Feb. 29 and lost heating and air conditioning; it had been able to move its inpatients to safety and continued to treat those injured in the storm.

Greater Regional Medical Center in Creston, Iowa, was damaged by an EF2 tornado on April 14; fortunately, the hospital's basic structure survived and it was able to make repairs and resume full operation by July.

These are only a few of the events that make it imperative for providers, literally, to look to their own houses in their disaster planning.

Different Types of Damage

Hospitals, nursing homes and other providers are subject to a wide variety of damage. Fukushima Medical University Hospital in Japan did not suffer any serious damage from either the earthquake or the tsunami, but it lost its water supply. It also found itself screening, treating and decontaminating patients and power plant workers who had been exposed to radiation. Fortunately, Japan is generally considered to be the best-prepared nation in the world when it comes to earthquakes and radiation accidents.

UTMB in Galveston expected a major storm surge from Ike, and that's just what happened; the surge flooded the facility to a height of 8 feet and took out the campus elevators — all 132 of them.

The hospitals that were hit by tornadoes had little warning; those affected by hurricanes had more, but often were unaware of the severity of the events that were about to overtake them.

Planning for the Predictable — and the Unthinkable

Generally speaking, the first focus of planning should be events that most likely will happen. That is, Missouri providers are more likely to suffer tornadoes and floods than earthquakes (although several of the worst earthquakes in American history occurred in Missouri, in 1811-12); Alaskan providers are more vulnerable to earthquakes than heat emergencies. But that does not mean that any type of emergency should be ruled out.

Some of the changes sweeping health care and other sectors of society are making planning easier. For example, in a rare move, federal meteorologists warned the residents of Alabama, Georgia and Tennessee two days before the 2011 tornado outbreak that impending severe weather was likely to cause such an event. Debbie Shepherd, corporate preparedness officer and corporate safety officer for Erlanger Health System, reports that this allowed the system to put itself on an emergency footing. Granted, she says, the National Weather Service display screens at the Hamilton County Emergency Operations Center were tracking so many storm cells that the image looked like one big blob, but at least they were providing a picture of how bad the situation was.

Furthermore, the shift to electronic medical records, digitizing of images and e-prescribing means that even if there is a direct hit, information can be protected. Indeed, says Gary Pulsipher, president and CEO of St. John's in Joplin (the new hospital is known as Mercy Hospital Joplin), for a facility that took a direct hit from a tornado, St. John's was under a lucky star: "We had gone live with our electronic medical records system on May 1, and the tornado was on May 22. All those brand-new computers getting blown out the door ! But we were able to print out all relevant patient records that night and get them to where the patients were."

In the future, community health information databases may be able to protect the data for entire populations (as long as proper privacy and security are honored).

But planning only can go so far, especially for providers that didn't expect to be at the center of catastrophe. Joyce Richardson, M.D., a pediatrician at UTMB in Galveston who was the hospital's chief emergency preparedness officer at the time, reminds us that "You need a plan, but you also have to know full well that things can happen that you didn't plan for. So you need a Plan B, a Plan C and a Plan D, down to Plan Z when things happen that you didn't expect."

At UTMB, she says, "We had a wonderful plan for retaining emergency services [it is the only hospital on a large, low-lying island off the Texas coast, which has seen more than its share of calamities]. We have a great emergency service, which is on top of the parking facility, a good 30 feet above ground. We needed to stay open and provide emergency care to people who might get hurt or otherwise need help. Across the street was a boat storage facility. The winds from the hurricane blew down an electrical pole holding a huge transformer, and the transformer fell onto the boats and set them on fire. We had acrid black smoke, containing hazardous materials, blowing right into the ER, so we had to close it and move emergency services into one of our ICU units."

Also, some patients are particularly vulnerable, and special provisions must be made for them. Of those who died during these emergencies, the majority of them were ventilator-dependent; their deaths were often the result of power failures. In the case of Joplin, the ICU was so mangled that it was impossible to determine how the patients there died. It is difficult to evacuate obese patients, which proved to be a fatal problem in New Orleans. Also, diabetics, patients with hypertension and those on dialysis cannot go for long without medication and care. Targeted planning for these groups is necessary — including lists of names and locations that will be available even in the event of total loss of power.

It is also necessary to plan for the unthinkable. John Matessino, president and CEO of the Louisiana Hospital Association, says of Katrina, "The hospital buildings in New Orleans rode out the storm pretty well. It was just that the levees failed. Otherwise, the hospitals would have been back in operation the next day." Few providers could have foreseen such a widespread calamity in a major U.S. city.

Ryuku Kassai, M.D., professor of community health at Fukushima Medical University, told the International Forum on Quality and Safety in Healthcare in Amsterdam last year that the remaining hospitals in the prefecture could have handled the aftermath of the earthquake and tsunami, but "the third disaster" — the failure of the nuclear plant — was too much. Searchers could not enter the radiation zone, where elderly residents had refused to leave because it was difficult for them, especially if their families were elsewhere, so no one knew how many there were. There was also much uncertainty about the extent of the nuclear disaster (attributed by many to poor reporting and concealing of information by the power company), and patients and staff alike were concerned and often frightened.

Kassai says that children are particularly susceptible to radiation, but "high-quality, evidence-based information" is not available to guide clinicians treating them. And although Japan is the only nation ever to be attacked with atomic weapons (during World War II in the cities of Hiroshima and Nagasaki), there is still "a lot of misunderstanding" about radiation. And because the area has a high degree of farming and fishing activity, food safety will be a concern for a long, long time.

Shepherd of Erlanger Health System therefore advises, "Plan for the worst-case scenario."

Doing It Together

And providers should do their planning in sync with all relevant entities, whether competitors, government agencies or others. Pulsipher of the Joplin hospital admits, "We had done our planning pretty much in isolation. We had done some community desktop exercises, but we had not done much in partnership with our friends at Freeman [Health System, whose main hospital is across the street from what had been St. John's]. And they are, indeed, good friends of ours. We will always be competitors — but at first we were afraid that they were gone, too." Freeman was not hit by the tornado and offered every kind of aid to the facility across the street. Pulsipher recalls, "That first night, literally, we couldn't find a pad of paper, and distributing supplies was a big challenge. Freeman and many other facilities were as helpful as they could possibly be."

They will plan for emergencies together in the future.

On the other hand, Erlanger Health System had engaged in meticulous countywide planning with everyone from police and fire departments to other hospitals, a process in which the Tennessee Hospital Association was invaluable, Shepherd reports. The association had aided in creating standard emergency codes throughout the county, so "code black" [internal emergency] meant the same thing in all hospitals. Representatives of all these services meet monthly and quarterly, and there is a citywide drill in Chattanooga at least once a year. This may sound like overkill, but it came in handy when swarms of tornadoes were obliterating parts of a six-state area; the system has hospitals in three of those states.

Collaborative planning is also essential because, as Matessino of the LHA warns, sometimes a hospital or nursing home or clinic must shelter in place, with its patients, and bring assistance from outside.

However, many survivors of these events say that in the end, providers must be prepared for a high degree of self-reliance, because others may not be able to get to them.

Communications Are Essential

Unfortunately, one of the first things to go when a facility is hit by an emergency is communications, just when they are needed most. High winds blow down cell phone towers; earthquakes wiggle them out of position. Phone lines break, electricity fails, computer screens go blank. This can, as Kassai laments, "make it difficult to get a picture of what is going on." Indeed, Matessino reports that although everyone believed that all infants had been evacuated from New Orleans, 20 high-risk newborns were still at University Hospital. And lack of information about possible rescue contributed to the tragedy at Memorial.

At St. John's in Joplin, all internal communication had been lost, and Pulsipher reports that, therefore, triage became "a unit-by-unit operation." In the neonatal unit, the healthier mothers and infants were evacuated first. "In other units, staff had to decide what was best for the patients; they were on their own. We couldn't find any of our manuals, so they had to use their problem-solving skills." Those skills are now being incorporated into staff training.

Meetings of staff leaders are a must; the Fukushima hospital held them three times a day.

As for which communication technologies actually will work, almost everyone interviewed for this article cited ham radio operators, who are usually more than happy to help out. Erlanger has a memorandum of understanding with the local ham radio operators association. Also, cell phones that use towers outside the affected area will usually function — at least until the batteries go dead.

What else will work is somewhat surprising. Shepherd of Erlanger reports that staff members who had BlackBerrys took them home with them, and they became the only means of communication with people who may have been taking shelter in closets and crawl spaces. Matessino reports that in Slidell, La., one hospital employee's car had OnStar, and it worked just fine.

However it is achieved, Kassai says that getting communications up and running has to be an extremely high priority.

Supplies and Utilities

The move by many hospitals to just-in-time inventory has been a problem in some emergencies, although suppliers and vendors often go to extraordinary lengths to provide what is needed. Furthermore, warehouses and other points of supply storage can be damaged or destroyed along with everything else, which was the case in New Orleans. But even if you have supplies on-site, it is necessary to be able to get to them, which is not always possible if central supply is under water or 10 feet of rubble. Keeping caches of key supplies in strategic spots throughout the facility is advisable and can be a lifesaver.

Matessino of LHA recommends having enough critical supplies to last three to five days.

It is also important to consider the location of key services such as generators, IT servers, imaging and pharmacy. In many cases, they are on lower floors or in the basement, which is not such a hot location if the place floods. In Galveston, many supplies and pharmaceuticals had to be brought up to higher floors.

Loss of utilities is just as damaging as loss of supplies, if not more so. Leslie D. Hirsch, president and CEO of St. Clare's Health System in Denville, N.J., was president and CEO of Touro Infirmary during Katrina. He reports that one of many catastrophes was that it was the first time in anyone's memory that the entire city of New Orleans lost its water supply. He points out that beyond the obvious, neither air conditioning nor some generators will operate without water.

Hirsch also recommends that whatever it takes, generator power for at least five days should be available.

Some hospitals in the area, including Ochsner Medical Center, already had wells; many others have since dug them, although some cannot because the city lies so low and the saltwater table is too high.

Coordination of Effort

Trying to coordinate efforts of various entities in a time of chaos is difficult in the extreme, but it is necessary. Kassai reports that, largely due to lack of communications and a weak primary care network, people with primary care needs flooded into University Hospital after the quake and tsunami, making it more difficult to handle evacuees and radiation patients. Shigeatsu Hashimoto, M.D., chairman of the department of clinical quality management at the hospital, reports that his organization became the de facto coordinator of effort because of confusion on the part of many agencies as to who was responsible for what.

Someone has to be the decision-maker and must have the authority to see that those decisions are implemented. Speaking at the same meeting in Amsterdam last year, I offered the example of dozens of nongovernmental organizations showing up in disaster areas without coordination. Some of them are very skilled at helping out; others are good-hearted but are best kept away. And some can cause problems. After the horrendous 2010 earthquake in Haiti, inflatable hospitals were erected almost immediately by Israeli aid workers and Doctors Without Borders, and they were most welcome.

But a busload of pharmaceuticals was held up at the border with the Dominican Republic, possibly because of fears that the drugs were unsafe and possibly because the Haitian guards were demanding bribes; both stories have been told. (Unfortunately, pharmaceutical firms have been known to dump outdated products on nations suffering disasters.) A church group was detained after trying to take a busload of Haitian children out of the country. During Hurricane Andrew (and probably in other drastic situations), unlicensed physicians showed up, offering to help. Some were undoubtedly genuine but were not licensed in Florida; in other cases, they could have endangered patients.

In its superb document on disaster preparedness (see below), the Missouri Hospital Association also warns that citizens always show up, seeking to be of assistance, and how to handle them must be part of planning.

Indeed, hospital associations have played critically helpful roles in many of these emergencies, as well as at the time of Andrew and of Hurricane Iniki in Hawaii in 1992. They can be a lifeline by arranging for communications, provision of supplies and other desperately needed services when individual members are unable to do this themselves.

Nothing Is Mundane

When the world is caving in around you, counting noses may seem like a futile gesture, but it matters. Kassai reminds us that frail elderly, young children, pregnant women, the mentally ill and the chronically ill easily can be left behind in an evacuation because they simply cannot get to the gathering point. And often, their loved ones will stay behind with them; this happened all too often in New Orleans, and they drowned.

Richardson says that UTMB had to make a special provision for the safety of laboratory animals in its research facilities. And one of the lessons of Andrew is that people will not leave their pets behind, in many cases; a hospital association official warned of this as one of the lessons from that storm, and little attention was paid to her advice. People died in New Orleans because emergency services and shelters would not take their pets and their owners would not abandon them.

It is also important to remember that, although disaster-related injuries and the critically ill tend to absorb most of our attention, life among those who are not affected goes on. As I mentioned in my remarks in Amsterdam, every day, babies are born; people die; kids fracture limbs; someone gets an allergic reaction to something. These patients need help as well, even if their requirements seem mundane in the context of things. And as Hirsch advises after his experience at Touro, getting business operations — payroll, billing, supply — running as soon as possible is extremely important.

And sometimes it is necessary, in a gross calamity, to take care of patients and leave the paperwork for later. If a patient's house is now floating in the Gulf of Mexico or has been reduced to toothpicks, it is unlikely that he or she can produce proof of insurance or a birth certificate, or even an address.

Caring for Staff

Taking care of staff members also must be a priority, especially because, in most cases, they will keep working until they drop. In Joplin, New Orleans, Fukushima, Chattanooga and other places, both clinical and nonclinical staff were under enormous stress — many did not know if their families were alive or if they still had homes — but they stayed at their posts. Heroic might be too weak a term for these people, such as the 500 volunteers who stayed behind at UTMB in Galveston while it was evacuated, knowing that the island could go entirely under water with no way out. At Erlanger, 57 staff members lost their homes or suffered damage to them, yet they kept working.

In extreme situations, staff also can be scattered, and locating them can be a real challenge. In Fukushima, Kassai reports, it took five days just to find all the medical students and residents. In Joplin, says Pulsipher, "We put up electronic billboards to get in touch with staff members, and our direct patient staff were assigned to the convention center, one of the high schools, and the university campus, to provide care. It took us 10 days to find everyone; those who had lost everything had gone to stay with family, so it took a while to locate them."

After Katrina, of course, staff members were spread over half the country. Hirsch reports that Touro's leaders did the right thing under the circumstances: "With advice of counsel, we decided to provide extended pay to people, and didn't make any decisions, for eight or nine weeks; only when we thought that people weren't coming back, or couldn't come back, did we take them off the payroll."

Getting that money to them was extremely difficult, so a change was made, Hirsch says. "It may sound simple, but as we reconstituted ourselves, we decided that you couldn't work at Touro unless you had direct deposit for your pay. As it was, we had to put ads in the paper and direct people to an emergency website. We at least wanted to know what people's banking relationships were, so we could get their money to them. We also advanced funds to many employees."

Sensitivity to on-site staff also is needed. Many University Hospital employees in Fukushima were worried about exposure to radiation, so the hospital brought in Professor Shunichi Yamashita from Nagasaki University, an expert on radiation, to speak to staff and calm their fears. As the tornadoes barreled through the areas around Erlanger's hospitals, leaders discreetly asked security staff to bring back employees who had gone out to the parking lots to take photos of the funnel clouds.

Maintaining Security

Although patients must be the first priority, security of the facility — especially during and after evacuation — is "a huge issue," according to Matessino of the LHA. In New Orleans, he says, "many hospitals did not have enough security. There will be looters, addicts looking for drugs and other problems. Touro Infirmary had police officers staying at the facility to protect it. We asked the Bush administration for troops to assist with security, both at hospitals that were open and those that were closed."

Hirsch, then of Touro, recalls, "We kept security under control very well during the evacuation, and after that we had an armed perimeter around the hospital because of what was going on in the city. So many people were suffering to a terrible degree, and they were angry and behaved in ways in which they normally would not; the hardships that people endured should never be forgotten."

In Galveston, UTMB had made security a priority during the evacuation associated with Hurricane Rita, and that carried over to the situation with Ike. Richardson says, "We did not have security problems; we had planned for it, and our university police were part of the plan. Most of our entrances were locked down, and there were police in place to guard all areas. We also have agreements with other parts of the University of Texas system, so other police could come in and give our staff breaks." Because UTMB is a state facility, the government of Texas was very helpful in this and other ways, she says.

It can make a great difference if an evacuated hospital, and its stores and supplies, are in one piece when people return to reopen it.

A Need for Leadership

Although ideally, good planning provides staff with a clear picture of what they should do if the facility is struck by disaster, there is still a need for decisions to be made, plans changed and creative thinking employed. In other words, there is always a need for strong leadership. Hirsch's experience in New Orleans was as brutal a test of this as any hospital CEO is likely to encounter. "I had been on the job for seven days when Katrina hit," he remembers. "And although I had never thought about it before then, it was necessary to rise to the occasion. We tend to think in terms of delegation, but that is not always possible; it does take a team, but a leader is also needed. And leaders must be prepared for the unexpected, even if it's something that they have never experienced."

Hirsch had 30 years of experience working in hospitals in Colorado, Kansas and New Jersey, "but I had never gone through anything like Katrina. And although I was new, staff accepted my leadership. It was my moment of truth. I couldn't sit on the sidelines and say to them, 'You all have been through hurricanes before, and I haven't.' That wouldn't do. It was a team effort, but it wasn't time for me to sit on the sidelines; it was a time to exert visible leadership. Even though I had been there so briefly, it was time to lead. I was fortunate to be surrounded by people who were heroes in their own right. But had I not done that, I never would have been accepted as a leader at that facility."

He advises his peers to ask themselves, "Are you ready to lead in a time of the unexpected, in a situation that you have never been in? What would you do? What path would you pursue? In other words, are you ready?" If a health care leader does not like the answers, he says, "then do what you need to do to prepare. Because when it happens, you have to be able to lead."

Although his experience was extreme, in many of these situations, leadership has emerged among staff when it had to, as in Joplin, where managers isolated in their units had to make independent decisions about the order of patient evacuation. It can mean the difference between life and death.

Sometimes, No Good Choices

Unfortunately, even if there has been excellent planning and skilled leaders are present, sometimes there are no good choices. The owners of St. Rita's nursing home in New Orleans have said that they believed their patients were too sick to be moved, even though other facilities evacuated as Katrina closed in; critics claim that the owners, Salvador and Mabel Mangano, did not want to spend the money. The home also had little in the way of an evacuation plan; its nine-passenger van hardly would have been sufficient to transport dozens of patients. The Manganos eventually fled, leaving residents to their fate. They were later indicted on charges of negligent homicide, but were acquitted.

The story of the deaths at Memorial Medical Center is far more tangled and was chronicled by Sheri Fink in the New York Times magazine in 2009 (see reference list at end). There was an acute long-term care hospital within Memorial, whose patients were extremely ill, most of them bedridden and many ventilator-dependent. Although the majority of the general hospital's patients were evacuated fairly quickly, these patients were not. The hospital was cut off by floodwaters and had little communication with other entities, and staff did not know when — or if — help would arrive. Two days after the storm made landfall, the hospital's generators failed; battery backup soon followed, and staff had to hand-bag patients who needed oxygen. Some patients died at that time.

Three days into the crisis, the hospital had no power, water or food; exhausted staff had been working for 72 hours; toilets no longer functioned, and the heat and stench were overpowering. Although many patients in the acute long-term care unit had been evacuated by then, the rest would have to be carried down many flights of stairs; some were obese and were being hand-bagged, and it would have been profoundly difficult. And it was not known when help would arrive.

Under the leadership of surgeon Anna Pou, M.D., a rough sort of triage began, with patients who had DNR orders and others who were unlikely to survive evacuation receiving lower priority than those who were stronger or had not executed DNRs. Many who could leave were finally picked up by boat, but some remained.

What happened after that is a matter of debate, and always will be. Faced with the prospect of watching patients die of dehydration, heat exhaustion or suffocation, staff members made the decision, apparently advanced by Pou, to inject them with high doses of morphine and midazolam. It has been argued that the goal may have been to calm them, although witnesses suggest that the physicians and nurses involved knew this was a lethal act. The patients died, albeit peacefully. Some were already dying; others were comatose. At least one was still conscious and had been joking with his caregivers.

John Thiele, M.D., a pulmonologist who was involved in injecting patients, later said, "This was totally against every fiber in my body. We were abandoned by the government, we were abandoned by Tenet [the owner of Memorial] and clearly nobody was going to take care of these people in their dying moments. I did what I would have wanted done to me if the roles were reversed."

Of 41 bodies later recovered at Memorial, half tested positive for morphine and midazolam.

A year later, Pou was charged with multiple counts of homicide. The grand jury declined to indict her. She has since worked tirelessly for legal protection for clinicians caught in such gruesome circumstances.

Katrina, like Fukushima, was a crisis that was extreme beyond imagination. Across New Orleans and along the Gulf Coast, exhausted hospital staffers had to make decisions that may appear questionable to some of us, in hindsight. But we weren't there. Patients and clinicians alike were better protected in Fukushima, in no small measure because of Japan's history of being thoroughly prepared for earthquakes and tsunamis. It must be remembered that although 40,000 Japanese people died, in Indonesia, the 2004 quake and tsunami claimed a quarter of a million lives.

As Shepherd of Erlanger Health System says, plan for the unthinkable, because it could happen.

Even Katrina had a bit of a silver lining; many providers studied what had happened with that storm and adjusted their own preparedness thinking. Richardson of UTMB recalls, "One of the most important things in relation to our planning was what happened during Katrina; it provided us with a sense of reality that we did not have previously. We really tightened up our plan." She adds, "You must have a plan, you must practice that plan, and you must change your plan in learning from other disasters."

Furthermore, government also learned its lesson. Pulsipher of Joplin reports that "the tornado occurred after Katrina, so government pulled out all the stops to be of whatever help it could, but that wasn't during the first 24 or 48 hours; it was a longer-term thing."

After the Crisis

And the longer term must also be part of the planning equation. Hirsch recalls that many people at Touro did not expect him to return after he left New Orleans to see his family, who were still living in Colorado. "Of course I went back" to Touro to oversee recovery, he says. "I can't say I didn't give it a second thought because I never gave it a first thought. I had been back in Colorado only a few days before I bought a ticket back to New Orleans."

He adds that in some ways, "recovery was even more intense. Instead of worrying about evacuating or taking care of additional numbers of people, we had to ask, what if the facility closes? Can we make insurance claims? Do we know how to relocate our information technology? How would we reopen? How can we contact staff, who might be spread out all over the country? What if you lose all communications, and don't have Internet access? What do you do if you have to restart your business after it has been closed for weeks? These are huge learning curves that our staff had to figure out on the fly."

Touro also was faced with the fact that many staff had lost their homes and had nowhere to go. "At one point," Hirsch says, "we had 150 people or more living on campus, and about 70 or 80 FEMA trailers as well. I'm sure we easily had a total of 250 people living there."

With many staff permanently gone, Touro had to hire new people, some of whom had worked in hospitals now closed. "We had to forge a new culture, one that wasn't the old Touro culture, but that included the cultures of many other hospitals."

And in many instances where hospitals or nursing homes have been devastated, staff don't just forget about it and move on. Hirsch emphasizes that they "are dealing with trauma and the stress and strain of their personal lives" for a long time after the event. Many of those who live through these calamities are plagued by post-traumatic psychological problems; in 2008, Matessino reports, Hurricane Gustav hit Baton Rouge, "and people started suffering flashbacks." This can happen years later; Richardson explains, "During the crisis, everyone is hyped up on adrenaline, and when it's all over, they get depressed. And reactions usually don't occur for weeks — or longer. Recently, the power went out at our hospital and I had a flashback and had to keep telling myself that Ike was four years ago."

Most hospitals offer counseling to staff members who have been through these wars; not all of them take advantage of it. They should be encouraged to do so.

Speaking of which, there is something that others who want to help can do after the fact, in addition to making donations. When asked how others could be of assistance in Fukushima, Kassai replied, "Please provide encouragement. Being encouraged and knowing that others are thinking of us means a great deal. When my colleagues are working too hard and get messages of encouragement, they are re-energized."

As is often true when someone dies, the first few days are filled with activity: Visitors come and go, the casseroles pile up, cards are mailed, traditions are observed. The difficult time comes later, when the house is empty, the cards have stopped coming and the bereaved are left alone with their memories.

All health care folk should remember what many of their peers and colleagues went through, and offer support and encouragement after the reporters and news cameras are gone.

It Can Happen to You

The last lesson that veterans of catastrophe offer is perhaps the most important: As Matessino says, "A disaster can happen to any provider." Not everyone really believes that. Pulsipher of Joplin recalls, "Although every organization has one or two people who do take it very, very seriously, many others just check disaster planning off the list and move on. Emergency preparedness; check." He and his staff no longer think that way.

Shepherd of Erlanger also warns that previous history, or folk tales, are no substitute for planning. "Our whole community had been in denial; we sit between two mountains, so we believed we could never be hit by a tornado." They were wrong.

The Titanic was supposed to be incapable of sinking. Tidal waves 128 feet high aren't supposed to occur, even on the exposed Japanese coast. The twin towers were not expected to collapse on September 11. Downtown Nashville and Salt Lake City weren't supposed to be susceptible to tornadoes. But all these things happened. As Richardson says to providers everywhere, "It's not a matter of if it's going to happen to you; it's when."

Useful Resources

Fink, Sheri (2009). "Strained by Katrina, a hospital faced deadly choices." New York Times magazine, Aug. 30
The Joint Commission (2006). "Standing Together: An Emergency Planning Guide for America's Communities"
The Joint Commission (2006). "Surge Hospitals: Providing Safe Care in Emergencies"
(The Joint Commission also hosts a periodic conference on emergency preparedness.)
Missouri Hospital Association (2012). "Preparedness and Partnerships: Lessons Learned from the Missouri Disasters of 2011"
Office of the Inspector General, U.S. Department of Health & Human Services (2006). "Nursing Home Emergency Preparedness and Response During Recent Hurricanes," publication OEI-06-06-00020, August
Office of the Inspector General, U.S. Department of Health & Human Services (2012). "Supplementary Information Regarding the Centers for Medicare & Medicaid Services' Emergency Preparedness Checklist for Health Care Facilities," publication OEI-06-09-00271, April 13.

Copyright 2012 by Emily Friedman. All rights reserved.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.


First published in Hospitals & Health Networks Daily on August 7, 2012

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