Hurricane Irma Poses Huge Test for Florida Hospitals

September 08, 2017

Rick Murray is trying to stay positive about the fate of Florida hospitals as Hurricane Irma roars toward an anticipated landfall in Southern Florida this weekend.

"Florida hospitals have hurricanes down pretty well," said Murray, director of emergency medical services (EMS) and disaster preparedness at the American College of Emergency Physicians (ACEP). "But Irma is a bigger storm than they've ever had."

"It's wider than Florida."

If Hurricane Irma's 150-mile-per-hour winds blow north as expected through the entire state, Murray told Medscape Medical News, so many hospitals will be stressed that the cumulative effect could overmatch their ability to cope. Too little diesel fuel to go around for emergency generators. Not enough ambulances and paramedics to evacuate ICU patients. The need to evacuate patients out of state and out of reach of Irma, even.

Evacuating sooner than later in the path of destruction is a good practice, according to Murray, and Florida's gotten off to a head start. As of Friday morning, 17 hospitals along with 117 assisted living facilities, 33 nursing homes, and 46 other facilities have transferred their patients elsewhere, according to the Florida Department of Health. These precautions parallel a mass civilian evacuation in Southern Florida, which is mandatory in much of Miami-Dade County, home to 2.7 million people.

"If you are in an evacuation zone, you need to go now," Florida Governor Rick Scott said in a news conference today. "This is a catastrophic storm like our state has never seen."

What Can Go Wrong

Rick Murray, a paramedic and former field supervisor in the emergency management agency of Texas, understands what happens when a hospital meets a hurricane. He led an ACEP task force that studied how Hurricane Sandy tested the healthcare infrastructure of 12 states and the District of Columbia in 2012. A survey of hospitals and other healthcare facilities and services revealed how Sandy disrupted patient care, and how big sister Irma might follow suit in Florida.

Power: Hurricane Sandy knocked out the power for 18% of hospitals surveyed by ACEP. Hospitals are required to have electric generators for backup. However, during Sandy, these generators frequently generated their own problems, according to ACEP. Some failed after overuse. Other generators didn't produce enough power for air-conditioning and refrigerators. Floodwaters ruined still others.

Fuel shortages: A handful of hospitals ran out of diesel fuel for their backup generators. At the same time, gasoline shortages grounded ambulances and hindered staffers from driving to work.

Flooding: Eight percent of hospitals were flooded during Hurricane Sandy, with water pouring into basements and first floors. Such inundations aren't crippling if hospitals keep their backup generators, electrical systems, food supplies, fuel supplies, and medical records well above flood-prone areas. Most coastal hospitals caught on to this after Hurricane Katrina devastated New Orleans in 2005, Murray told Medscape Medical News, but some hospitals hit by Sandy hadn't taken the necessary precautions to protect their generators and fuel supplies, for example.

Communication: Problems here were reported by 9% of hospitals. Loss of power was an underlying factor, as well as the lack of radio backup when phones went dead.

Staffing: Hospitals along the Atlantic Coast knew Hurricane Sandy was coming their way, giving physicians, nurses, and other staffers lead time to prepare for the storm and report to their stations. However, that was sometimes easier said than done, given transportation shutdowns and security checkpoints ("Nobody is allowed to cross this bridge"). And when hospital staff had to ride out the hurricane at the hospital — called sheltering in place — they couldn't take care of their families.

The Challenge of Patient Evacuations

Fourteen percent of surveyed hospitals evacuated some or all of their patients before and during Hurricane Sandy. For some hospitals, it was an easy and early decision, said Murray. "Their locations were at high risk for flooding and losing power." Other hospitals reckoned they could shelter in place, but were forced to transfer their patients when flooding turned out to be worse than expected, or when their emergency plans weren't up to snuff.

Some patient evacuations smacked of parochialism that didn't necessarily serve patients well. A hospital would send its patients to another hospital in its network even though it was in the same hurricane danger zone, instead of an unaffiliated hospital on a safer plot of ground. Murray said disaster planning authorities now are urging hospitals in a given community to work across ownership lines when it comes to transferring patients as well as sharing needed supplies during a hurricane.

Some patients are relatively easy to clear out of a hospital, such as those scheduled for elective procedures. They're typically the first to go, said Murray. More challenging are ICU patients hooked up to ventilators and infusion pumps, especially when they must be transported down stairwells because the elevators aren't working. The ACEP study found that hospital staff frequently weren't well trained on how to use patient sleds during Hurricane Sandy.

Transporting patients to other hospitals had its pitfalls, too. Sometimes ambulances would take patients to the wrong hospital, creating confusion all around. Out-of-town ambulances would get lost.

In any disaster that requires hospital evacuations, different types of patients require different kinds of ambulances and the right emergency personnel to staff them, Murray noted. ICU patients require critical care ambulances and nurses and paramedics who are qualified to administer a full range of drugs, read cardiac monitors, operate ventilators, and perform intubations.

Tracking evacuated patients from hospital to hospital can break down, Murray said. With power losses shutting down computer systems during Hurricane Sandy, hospitals exchanged hard-copy patient charts, with all their drawbacks. Some patients would arrive at a new hospital without any records.

Will Florida hospitals in the path of Hurricane Irma experience all the mishaps reported in the ACEP study of Hurricane Sandy? Murray told Medscape Medical News he's confident that Florida hospitals have done their homework to get ready for this weekend. However, the best-laid plans may crumble if Irma accosts hospitals from one end of Florida to another. In that case, every hospital would be scrambling for a limited set of resources, like critical care ambulances.

In a worst-case scenario he'd rather not think about, flooded highways and damaged bridges could force hospitals to evacuate patients by helicopter to out-of-state facilities. "Flying one or two out at a time would take forever," he said.

Murray has empathy for physicians, nurses, and others who will be holding down the fort this weekend at hospitals in Florida. He was trapped in New Orleans during Hurricane Katrina while attending an EMS conference.

"I know what it's like," he said, "when you don't have control over anything, when you don't know what's going to happen next."

Follow Robert Lowes on Twitter @LowesRobert

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