Published in the December 2012 issue of Today’s Hospitalist
PHYSICIANS WHO PRACTICE in New York’s five boroughs are no strangers to disaster. With blizzards, blackouts, last year’s Hurricane Irene and the 9/11 mobilization, doctors in New York not only do disaster drills and planning, but unfortunately they get some regular practice with the real thing.
But New York hospitalists talking about this October’s storm keep repeating one word: “unprecedented.” Hurricane winds and an unexpected 14-foot storm surge temporarily wiped out power to half of Manhattan, along with public transportation and outpatient health care for millions, and it destroyed homes and neighborhoods in several boroughs and New Jersey.
On top of so much misery, hospitals had to contend with thousands of nursing home beds being shut down, as well as the voluntary and forced evacuation of several Manhattan hospitals that included major academic centers. While much of the power had been restored in New York by mid-November, hospitalists throughout the city were still struggling with a new medical normal that includes the indefinite shuttering of thousands of inpatient beds, which may last several months.
“We did not expect many areas of Manhattan south of 20th Street to be under water,” says Vishwas Singh, MD, a hospitalist at Manhattan’s NewYork-Presbyterian/Weill Cornell Medical Center, which took in some evacuated patients and wrestled, like all the hospitals that stayed open, with surging volume after the storm. “How do you plan for something that’s never happened and is unimaginable?”
The Monday that the storm hit was quiet for Katherine Hochman, MD, who directs the hospitalist group at NYU Langone Medical Center on Manhattan’s East Side.
“We were taking the storm very, very seriously,” Dr. Hochman says. The day before, she’d brought in three or four extra hospitalists to work with additional social workers and care managers. “We were trying to expedite anyone waiting for placement or infusion,” she notes. “That Sunday, we discharged 27% of the medicine service.”
While Dr. Hochman left the hospital around 4 p.m. on Monday, NYU Langone officials decided to evacuate patients just hours later at the height of the storm. (Two other downtown hospitals, the VA New York Harbor Hospital and New York Downtown Hospital, had chosen to evacuate before the storm.) Some of the distribution circuits housed in the hospital basement that work with the back-up generators shut down for a portion of NYU Langone’s Tisch Hospital when they, along with the lower floors and elevator shafts, were swamped with water.
Dr. Hochman and several other hospitalists who live close by called to see if they were needed to help evacuate several hundred patients down flights of stairs. But they were told that the more than 750 people onsite ” physicians, nurses, medical students, firefighters, police and others “could finish the evacuation and transport patients out to several hospitals around the island.
When she arrived back at the hospital at 5 a.m. Tuesday, “I saw the tail end of the evacuation efforts.” She and two hospitalist colleagues went through the entire hospital, checking every room and bathroom to make sure no one
was left behind.
“Operating outside the system”
At Mount Sinai Medical Center, which borders Central Park uptown and was spared major damage and power outages, Andrew Dunn, MD, the chief of the hospital medicine division, had, like many other clinicians, brought in clothes to spend the night of the storm. He was watching
“Monday Night Football” when he heard that NYU Langone was evacuating
“Patients started arriving about 1 a.m.,” Dr. Dunn recalls. “Some went to psych, a lot were OB. In my area, we ended up taking care of a lot of critical care patients. First one or two patients came, then one or two more. Then 25 came all at once.”
To house those patients, Mount Sinai decided to open its post-anesthesia care units as a makeshift ICU.
“Most patients came with some paperwork and some orders,” says Dr. Dunn. “I’m not sure how NYU managed to pull that off in a blackout, but I give them a lot of credit for that.” Most of the evacuated critical care patients also came with NYU physicians and nurses, which he says “helped tremendously.”
“We helped orient the NYU staff, making sure they figured out our lab system and how to get the right ventilator settings,” says Dr. Dunn. Because the units being used were technically anesthesia areas, even the Mount Sinai physicians were handicapped in terms of keeping records.
“That’s not a place that uses our Epic EMR,” he notes, “so we were all operating outside the system.” The physicians broke out pharmacy order sheets, sending them physically through pneumatic tubes. “We really did make up a lot of this as we went.”
Innovation and ingenuity
At Lenox Hill Hospital, which also took in evacuated NYU patients, senior hospitalist Brad Flansbaum, DO, MPH, found himself and his colleagues “reverting to the analog world.” The hospital didn’t lose power but the computer system went down for a bit.
“Residents had never handwritten an order before,” Dr. Flansbaum says. “They didn’t know what to do.” Eventually, like at Mount Sinai, NYU Langone physicians and residents came to care for the evacuated patients. But until then, Dr. Flansbaum says he relied on his cellphone and his friendship with Dr. Hochman to connect Lenox Hill physicians with NYU Langone attendings.
“She was really instrumental in acting as a kind of gatekeeper,” he says, “giving us phone numbers for the hospitalists and allowing people to have direct conversations with the doctors caring for these folks at NYU.” Over the next day or two, the Lenox Hill clinicians also received temporary access to NYU Langone records.
At Mount Sinai, both that center’s physicians and the visiting staff from NYU rounded together the next morning and began distributing patients throughout the hospital. But then came news that the National Guard was going to help evacuate more than 700 patients from another East Side hospital “Bellevue Hospital “on Wednesday and Thursday.
It turned out, says Dr. Dunn, that Mount Sinai didn’t take any of Bellevue’s medical patients. But anticipating that it would, the hospital staff in a matter of hours converted a chemotherapy infusion center into a 15-bed skeleton medical ward, “getting it staffed with nurses and physicians and working out issues like oxygen and isolation,” he points out. “We did increase our capacity and filled the space to allow for increased volume to the ED.”
An ongoing crisis
At Beth Israel Medical Center on the lower East Side, Dahlia Rizk, DO, chief of the hospital medicine section, says the hospitalists have a lot of experience dealing with higher volumes. After St. Vincent’s Hospital closed in 2010, she says, Beth Israel had to open additional units and saw “at least a 30% increase in patient volume.”
But during and immediately after Sandy, the hospitalists had to deal with much higher spikes in volume. Because the hospital was powered during the storm by back-up generators, Dr. Rizk says the physicians worked with headlamps and intermittent computers while caring for their own patients and evacuees from nearby facilities. FEMA delivered extra back-up generators to make sure that power was sustained.
The doctors took an “all-hands-on-deck” approach, bringing in available hospitalists and outpatient physicians, as well as assigning surgeons to medical patients.
“We opened up two additional units and back-filled surgical beds with medical patients because nonemergent surgeries were being held,” she notes. “We were seeing at least 60 to 80 additional medical patients in the new units.”
But the surge from evacuations proved to be only the first stage in an ongoing crisis as outpatient services “pharmacies, doctors’ offices, dialysis centers and home health “were virtually wiped out for a week. “We were really absorbing and carrying most of lower Manhattan,” says Dr. Rizk. In the days immediately after the storm, the hospitalist census jumped from around 120 to more than 200.
The ED fielded twice as many ambulance visits per day. And although the hospital pharmacy normally doesn’t dispense drugs, “we were dispensing medications like insulin and nebulizers in short supply for patients who could go home,” she says. “Social workers were contacting building supervisors and visiting buildings in Manhattan to make sure buildings were safe enough to discharge patients home to.”
A week of triage
Because police were bringing in homeless patients even before the storm, Weill Cornell was running at capacity when evacuated patients arrived, says Dr. Singh. And in the first days after the storm, the hospital turned its atrium lobby into a holding area for hundreds of patients who needed non-emergency care.
“For people who needed to be admitted, we doubled up in many of our rooms,” he says. “People who came to the ED who were stable were triaged uptown to the Allen Pavillion at Columbia, an affiliate hospital, to help with volume.”
But a lack of records remained a problem for patients who, scheduled to receive treatments at one of the closed hospitals, arrived at Weill Cornell instead.
“Acute patients were being admitted, like cancer patients coming in with colitis, neutropenic fever or ascending cholangitis,” says Dr. Singh. “They couldn’t remember their medications, their history or what chemotherapy they’d received. We basically had to be flexible and just do our best.”
A population of displaced persons
At Staten Island University Hospital, which didn’t evacuate, personnel scrambled during the storm to get patients off low-lying floors to less vulnerable parts of the hospital campus. In the days immediately after, it became clear that homes and neighborhoods on Staten Island had sustained much more damage than had Manhattan.
“We saw an enormous range of maladies and conditions,” says Aaron Gottesman, MD, director of hospitalist services there. Dialysis was a major concern, and three-hour courses were shortened to two. “But dealing with dialysis patients still took up an inordinate amount of time.”
Hypothermic patients with multiple exposures ” “they were up to their chest and neck in cold water” “came in, as did patients who had waited on rooftops to be rescued. There were MIs, angina exacerbations, rhabdomyolysis, and “probably between 50 and 100 patients who had no power and could no longer use oxygen tanks, chronic ventilators or any durable medical equipment,” Dr. Gottesman says.
But the storm’s real legacy in the weeks after, he adds, was how to deal with social service issues, not acute medical problems. “We’ve been struggling with displaced individuals who don’t need a hospital but a roof over their heads,” he says. “The sheer lack of physical housing for these patients to return to was, I think, the most daunting task of all, and that caught everyone by surprise.”
The new normal
Within a week, many of the evacuated patients had been discharged. But estimates of damage at NYU Langone run as high as $750 million, and patient volume at the hospitals that remain open plateaued at much higher levels than before the storm.
“We are treating this as an ongoing situation,” says Dr. Rizk, who notes that Beth Israel continues to utilize additional hospitalist staffing, with debriefing with leadership meetings two or three times a day. “While we’re starting to see some kind of normalization, it is still a new, steady state of intensity.”
At Lenox Hill, floors have been turned over to NYU Langone patients, which Dr. Flansbaum refers to as “Occupy Lenox Hill.” Several NYU resident teams led by hospitalists continue to admit NYU patients to Lenox Hill, while other NYU residents are being distributed throughout hospitals in Manhattan and Brooklyn.
NYU’s Dr. Hochman says that she and her colleagues rounded on all the evacuated medical patients throughout the hospitals in Manhattan. At the same time, no longer having a home facility at least for a while is certainly a challenge for leadership.
But “I have a very cohesive group,” she notes, “and even though we’re not going to be physically together, the members of my team will support NYU Langone Medical Center in every way until we reopen.”
In the meantime, other hospitalist groups are adjusting to the new volume normal. Hospitalists at Staten Island University Hospital are still pulling extra shifts. Mount Sinai administrators approved one additional hospitalist per day going forward. And similar staffing discussions are taking place at Beth Israel and Weill Cornell.
“We’re deciding whether to make permanent extra teams for the next few months or play it week by week,” says Dr. Singh. “I anticipate that we’re going to create extra hospitalist teams to handle some of this extra volume.”
The medical community
For everyone concerned, the extraordinary efforts made by every level of hospital staff and personnel were a testament to exceptional community, dedication and sacrifice.
“The fact that we transferred whole hospitals full of patients in the middle of a hurricane “critically ill patients, newborns “safely without one incident and that other hospitals already at capacity accepted those patients without question says a lot about the medical staff in this city,” Dr. Singh says.
For Mount Sinai’s Dr. Dunn, that community is one lesson to take forward in disaster planning. “Don’t just think within your institution,” he says. “It makes a tremendous amount of sense to have hospitals linked. When a disaster happens to one, others will be able to accommodate.”
But for Dr. Gottesman on Staten Island, a borough that was devastated by the storm, the lesson learned is dealing with what you can’t plan for. He likens the experience that he and his colleagues have had to that of doctors in Joplin, Mo., in 2011, when a tornado destroyed not only their hospital but much of their town.
“If it’s just a loss of power, you can see light at the end of that tunnel,” Dr. Gottesman says. “But no one could anticipate what happened here in the broadest scope of planning. It’s been an enormous social and humanitarian challenge.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
ALL THE PROBLEMS that New York patients had to contend with “no power or transportation or, for many in outer boroughs, homes “were borne by hospital personnel as well.
At Manhattan’s NewYork-Presbyterian/Weill Cornell Medical Center, hospitalist Vishwas Singh, MD, says that some nurses came to work Monday when the storm hit and didn’t get home until Friday. “At one point,” he notes, “the hospital put up 1,000 employees in beds in the hospital” “and provided them all thousands of meals.
And because transportation was so limited, the hospital set up its own bus service to transport personnel home to other boroughs. But “our capacity was around 200 per borough per bus,” Dr. Singh says. “We saw twice that many waiting to get on each bus, and we didn’t have the capacity.”
Jack Percelay, MD, a pediatric hospitalist who divides his practice between Lenox Hill Hospital in Manhattan and Saint Barnabas Medical Center in Livingston, N.J., lives in New Jersey. While he says he was only minimally affected by the storm, given the area’s widespread devastation, he was hampered by the lack of both public transportation and gasoline.
According to Dr. Percelay, national armories in the state began offering free gas to doctors and nurses. But “I didn’t have enough gas in my car to get in line,” he says. To get to work the day after the storm when public transportation was suspended, “I paid $140 for a car service.”