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Wednesday, September 6, 2017

72 Hours and a Category 3 Hurricane: As Harvey Hit, Houston Neurologists Stood Firm

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DR. AMROU SARRAJ wades through the murky waters of Harvey​.

BY GINA SHAW

When Kyan Younes, MD, a fourth-year neurology resident at the McGovern Medical School at UTHealth in Houston, arrived for his scheduled call at Memorial Hermann-Texas Medical Center on Saturday, August 26, it was cloudy and raining, but nothing seemed particularly foreboding. Dr. Younes and his colleagues knew that things were about to get much worse, however, as Hurricane Harvey bore down on the Gulf Coast of Texas. 

"Everything was fine until about 7 pm or so, when it began raining really heavily. My shift ended at midnight, and I tried to drive home, but when I got near my apartment complex, the flooding was getting higher and higher," he recalled in an interview with Neurology Today. Dr. Younes had left the hospital with just one neurology intern on duty and no attendings in the hospital overnight, and he realized that no one would likely be able to make it in and take over in the morning, so he turned around and went back to the hospital, and slept in the call room. Simply getting back was life-threatening: "The streets were unbelievable, with flash floods everywhere and a layer of water wherever you were driving."

Louise McCullough, MD, PhD, chair of the McGovern Medical School department of neurology, had made plans for the storm, closing clinics, arranging staffing, and planning discharges for any inpatients who could be safely sent home.

"We had emptied out the hospital as much as we could because there was enough warning," said James C. Grotta, MD, FAAN, director of Stroke Research at UTHealth's main affiliate, Memorial Hermann hospital in the Texas Medical Center.

The hospital itself was not in danger of flooding. In 2001, Tropical Storm Allison had dumped three feet of rain on Houston, doing over $2.5 billion in combined damage to UTHealth and the Baylor College of Medicine, across the street, and requiring the evacuation of hundreds of patients from both centers. After that disaster, Houston-area medical centers had dedicated major resources to flood abatement plans, including fortifications like submarine doors to protect foundations that had flooded catastrophically during Allison.

(The efforts weren't sufficient everywhere: Texas Medical Center's Ben Taub Hospital, the city's largest Level 1 Trauma Center, was cut off by flood waters, and St. Luke's Hospital had to be evacuated on Monday, August 28, as waters continued to rise.)

But this time, the problem wasn't flooding in the hospitals — it was getting people there. "Paramedics couldn't get people to the hospitals, because all of the access roads were flooded," said Dr. Grotta. "I couldn't get out of my high-rise apartment building — there were 20-foot-high waters all around the building, the entrances, and the highways. It was only on Wednesday, four days after the storm, that cars began to become visible on the freeway going past my house. Fortunately, because we had done all those advance discharges, on Sunday when staffing was at its worst, our census was at its least."

The neurology department at McGovern Medical School has four primary services: stroke, in-patient general neurology, general neurology consultations, and an epilepsy service. When Dr. Younes woke up on the morning of Sunday, August 27, he and the PGY-1 intern, Mahsa Khayatkhoei, MD, were the only doctors available to staff all four services. Dr. McCullough, who had been at the hospital most of the day Saturday, couldn't get past the flooding in her neighborhood to come back. So Dr. Younes sent Dr. Khayatkhoei to sleep and did rounds on the eight neurology inpatients who had not been able to be discharged prior to the storm. The stroke services were also covered by fellows Adriana Rosero, MD, and Bader Alenzi, MD (who remained in house all weekend), and Amrou Sarraj, MD, who walked the mile from his flooded complex to help.

"They were mostly those with multiple neurological diseases — really complex patients with significant medical needs," he recalled. "We also had more than ten consults, including four that were new and had not yet been staffed by attendings."

Fortunately, Dr. McCullough's advance planning had included an assessment of which staff were located within walking distance of the hospital. "You can walk or take a dinghy if you're within a mile, but you can't do that if you're ten miles away," she said. "The most dangerous thing in floods like these is being in your car. People drive into deep water and don't know how to get out and end up dying there, and that's not something I'm willing to have my residents risk."

So the embattled doctors were finally joined, on Sunday morning, by three physicians who had also walked to the hospital through raging flood waters infested with snakes, alligators, and fire ants. Second-year resident David Rosenbaum, MD, assigned to the stroke service, spent more than an hour wading through chest-deep water to the medical center. He was met by attending William Lindsay, MD, a multiple sclerosis expert, and Gary Spiegel, MD, an interventional physician who treats stroke and vascular patients, who had narrowly avoided disaster when he nearly fell into an open manhole whose cover had been dislodged by the flood.

Dr. Sarraj and Dr. Younes rounded on the inpatients and the consults. Then they were alerted to an inpatient stroke code. Dr. Younes, joined by stroke director Sean I. Savitz, MD, who had made his own way on foot to the hospital by this time, rushed to the patient's bedside. "We did a CT scan and gave him tPA, but we weren't able to get a CT angiogram because his creatinine was too high," Dr. Younes said. "So the interventional endovascular team, led by Dr. Spiegel, who had all walked to the hospital through the flooding, performed a thrombectomy. That was really amazing, that we were able to provide this kind of highly specialized care in the midst of such a catastrophe."

For 36 hours, Memorial Hermann's neurology service was staffed entirely by Dr. Younes, Dr. Rosenbaum, Dr. Lindsay, and Dr. Khayatkhoei, operating on virtually no sleep. But they weren't entirely alone: a WhatsApp group for all neurology residents stayed active throughout the storm, with the team communicating and making plans A, B, and C for who could cover the department's needs as Harvey and its aftermath raged on.

Saviour Achilike, MD, MPH, a third-year resident, stuck in his gated community by flooding, took consults from home for his pediatric neurology rotation. "I had the pager with me, and I was regularly calling pretty much every single team, and calling my patients' parents, since I couldn't check on them in person."

And Dr. McCullough stayed in constant communication with all the residents as well. "She was phenomenal," said Dr. Younes. "She was regularly emailing all the residents, gearing us toward a very focused approach, making sure that all the essential things that needed to be done were done. She even gave us her credit cards for whatever we needed in the hospital."

Around 5 pm on Sunday afternoon, a neurology resident assigned to night float managed to walk to the hospital during a brief window when the flooding abated, and Dr. Younes was finally able to go home. "The walk was okay for about three-quarters of the way, but when I turned on the road up to my apartment complex in the Bracewood Bayou, it was flooded, and I was soaked in dirty water up to my neck," he said.

By Thursday, August 31, the department of neurology was back up to full staff again. It was time to focus on recovery. "We're making plans to ensure our patients are safely discharged," Dr. McCullough said. "We now need bed availability as trauma patients are coming in, but a lot of patients don't have anywhere to go to, as homes and assisted living centers and nursing homes are flooded. I could not be prouder of the way our residents, fellows, staff and faculty stepped up during this crisis to ensure the safety of our patients. We have a great team."

Patients aren't the only ones with nowhere to go; many staff at McGovern Medical School and Memorial Hermann have lost their homes as well. "One of our stroke fellows was on his roof with his young daughter and his mother-in-law. They were airlifted out, but there wasn't enough room for him, and he sat on the roof for another day waiting to be rescued," said Dr. McCullough.

"People have to get their lives back together before they're going to be able to come back and work full time and concentrate on that," said Dr. Grotta, who noted that the UTHealth mobile stroke unit was temporarily taken off duty and returned to work after Labor Day. "The hospital will keep working on its normal activities, clinics will reopen, but there will be nurses and paramedics and CT techs and other people who won't be able to get into work for a while because they don't have a house and they have to get their families taken care of."