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Special Report: Hurricane-Proofing the ED

Scheck, Anne

doi: 10.1097/01.EEM.0000458996.43332.af
Special Report
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Yet another hurricane tore through New Orleans this year, destroying power and causing massive blackouts across the city, but only a small group of people even knew about it.

By the time summer rolled around, though, anyone who read the American Journal of Public Health had learned the details. A simulation model based on Medicare data was used to assess emergency preparedness after gale force winds and high floods caused a complete loss of electricity. Now, thanks to that research, there's tangible evidence that vulnerable medical populations in the city will fare better the next time around. (Am J Pub Health 2014;104[7]:1160.)

The emergency department at Veterans Administration Medical Center wasn't included in the drill, even though the facility is being built for state-of-the-art disaster protection. It hasn't opened its doors yet, but once it does and disaster strikes, the medical center will be able to get back online in about a minute. Inverse construction, often referred to as an “upside-down” design, has now placed offices on the first floor, where they can be shut down quickly if storm water invades. The ED, now on the floor above, is able to operate at full capacity for five days thanks to generators 20 feet above ground.

In fact, the ED and the VA Medical Center may be evidence of what some economists call the productivity effect. Simply put, the idea posits that large-scale advances with potentially far-ranging benefits can occur after a disastrous event. The flip side is that such scenarios, particularly those that are weather-related, can also create irrevocable harm, leading to poverty traps that persist. What makes the difference? The productivity effect appears to be tied to reconstruction that's carefully planned and executed, according to the research. (Ecol Econo 2009;68[3]:777.)

If anyone can describe this effect in an up-close and personal way, it is Michele Campisi, MD, an emergency physician at the VA. When she looks back on emergency care in the aftermath of Hurricane Katrina, she remembers a city that dwindled from nearly a half million people to about 20,000.

When residents returned, they did so with a gritty drive to reclaim their lives. They were so intent on rebuilding that they neglected their health, foregoing medications for chronic conditions and suffering severe stress while trying to repair homes damaged by muddy water and wind.

“We saw people who were injured after working eight hours at their jobs because then they went home to work there, using power tools to fix their houses,” Dr. Campisi said.

Like so many in the city, she considered the destruction a tragic setback but not a reason to leave. She became instead one of the Post-Katrina Pioneers, even though her position was in an ED that had closed.

As an emergency medicine resident, Dr. Campisi made periodic trips from the East Coast to New Orleans for medical conferences, courses, and workshops. Over time, the city began to feel more like home than a training destination. She'd lined up a job in New Orleans when Katrina took its terrible toll in 2005, heralding the worst U.S. hurricane season on record.

“I was dedicated to the idea of coming to New Orleans to practice,” she said. She had even selected a house in the Lakeview section of the city, but it was flooded, along with the neighborhood she'd already grown to love.

It was during these months that she learned the inspirational power of people at their best when life seems at its worst, she said. “It was a pleasure and a privilege to care for these people,” she said. “You saw the human spirit at its finest.”

Then, while renovating a home in the same area she'd originally chosen, she and her partner began to throw “blight fests,” a name whimsically bestowed on the potlucks and cookouts the pair threw along their street on vacant lots or remaining slabs. It drew people like themselves — neighbors determined to rebuild.

That's how Dr. Campisi met Elizabeth Failla, a supervisory project engineer for the VA and the chief of Project Legacy, the name given to the medical center reconstruction project. Now, they finish each other's sentences and share the same indomitable view of the new VA medical center: It won't simply provide top-notch care despite whatever nature unleashes; it will also impart a warm welcome for anyone entering with an information desk and a cafe at every entrance.

No corridors connect the ED, which has 12 acute-care beds and one complex treatment room. Instead, a pod for nurses and physicians is the center of the open floor plan. The radiology department and the pharmacy are right next door, not in a different part of the hospital or even down a long hall. In fact, there are no long hallways in the ED. A 12-bed observation unit can be converted for other care in a weather disaster, and a dock near the emergency-bay ramp allows access by boat when flooding prevents ambulances from making the trip, she said.

Plans for the new building took shape in veterans focus groups. Using this inclusive, diverse information-gathering strategy took a lot of time, but it also reduced the sense of loss in those who use the VA and produced some great ideas, said Ms. Failla. Research suggested that she is right about the restorative process, not just structures, being relevant to people. Vulnerability and resilience can be weakened or strengthened by such actions during the aftermath of a traumatic weather event. (Ecol Soc 2011;16[3]:1.)

The VA Medical Center will now be partnering with Louisiana State University and Tulane University, both of which helped meet a post-Katrina patient load that couldn't be served by the VA alone.

As the cityscape changes along with the skyline of the VA Medical Center, “it's like we all learned that we have good neighbors we can count on, even when they're in other parts of the country,” Ms. Failla said, adding that this was demonstrated by the bags of clothing handed over by complete strangers. It was not surprising then when Hurricane Sandy wreaked its havoc on the East Coast that the people of New Orleans, through churches, nonprofit organizations, and volunteerism, loaded two 18-wheel trucks with every necessity, from baby formula to clean shirts, and sent them to New York. (See sidebar.)

Time will tell whether Project Legacy set a system-wide template for post-disaster plans. But a study of post-Katrina neighborhoods showed that alliances created by such outreach seem to have long-lasting positive effects. (Sci Technol Human Values 2013;38[2]:224.) The city now has a renewed sense of itself, Ms. Failla observed. “New Orleans is going from being known for Bourbon Street to being known for its growth in bioscience, too,” she said.

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NYU Hospital Takes a Bath

If nature ever strikes again with Sandy-like strength at NYU Langone Medical Center, it will have to get past a 15-foot sea wall and an impermeable rubber-like layer of protection that's capable of sealing off everything around the medical center like a bathtub. That's how Lewis Goldfrank, MD, the chair of emergency medicine at NYU Langone, describes the improvements in storm-proofing at his institution.

The new flood wall surrounds and connects all current buildings. The sealing system is a set of Tiger Dams, which are temporary flood barriers designed to be rapidly activated should the campus be threatened with flooding that matches the magnitude experienced during Sandy. This Tiger Dam system takes three days to fully deploy, so set-up begins well in advance of a potentially significant storm. In addition, all areas considered vulnerable to flooding have been structurally reinforced.

NYU Langone reopened this past spring, but Dr. Goldfrank warned that the lessons learned in the new construction cannot be universally applied to other centers. “It's been called the ‘Florida-ization’ of New York,” but the term doesn't mean it's precisely the same weather challenges that are faced in the Sunshine State or anywhere else, he said.

That's why a universal approach to weather-related disaster planning won't work. Every area is different. Windows, for example, are generally considered no risk to patients at NYU Langone. But in the Midwest, the glass in them may need to be completely shatter-resistant or not installed at all in some rooms, such as the intensive care unit. “Tornadoes make this a bigger problem” in whirlwind-prone states like Kansas and Nebraska, he pointed out.

On the other hand, these fortified windows may one day be needed to hold up to the ravages of Atlantic cyclones that have the power of heartland twisters. Extreme precipitation in the Northeast and Midwest, as well as more intense hurricane activity in categories 4 and 5 is anticipated in the future, according to the U.S. Global Change Report Program.

Like Hurricane Katrina's destruction of the VA in New Orleans, Hurricane Sandy's ramming of NYU Langone in 2012 shuttered the ED for more than 18 months. Like the Legacy Project, the closure also provoked re-examination of how best to provide and preserve emergency services.

Now the ED has more than tripled in size, with back-up systems designed to maintain reliability under any energy outages. “I'd say we are ready for the next storm,” Dr. Goldfrank said, adding that there are no guarantees it won't be worse. In fact, experts predict that these fluctuating weather patterns may become the new normal for several regions of the country, including New York.

One of the biggest threats comes from severe heat waves, which federal forecasting shows will become more frequent in the West, but the East Coast is likely to be affected by soaring summer temperatures as well. The risk isn't just to patients who succumb under the unrelenting hot streak, but to hospital information-technology systems that fail when overheated. The New Orleans VA and NYU Langone have circulation systems that will cool continually, even during the hottest stretches. — Anne Scheck

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