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The following is from David Oshinsky’s Bellevue.
In the realm of “emergency preparedness” at American hospitals, there really are two eras: Before Katrina and After Katrina. Until that point, attention had focused on treating mass casualties arising from a terrorist attack, a gas explosion, a highway pileup—what one expert called “disasters outside their walls.” While there were a handful of previous wake-up calls—the massive Northridge, California, earthquake that buckled several local hospitals in 1994; the immense damage done to Houston’s downtown medical complexes following Tropical Storm Allison in 2001—the danger to patients “inside their walls” seemed rather remote.
Katrina challenged that thinking. When the levees protecting New Orleans gave way in the summer of 2006, flooding the downtown hospitals, patients became casualties. In 2011, New York City faced its own mini-Katrina when Hurricane Irene roared up the East Coast. Fearing severe flooding, Mayor Michael Bloomberg closed the subway system and ordered the evacuation of all hospitals in Zone A, a low-lying area in lower Manhattan bordering the East River. NYU’s Langone Medical Center, which includes Tisch Hospital, shut down, as did the Veterans Administration Hospital a few blocks away. But Bellevue, located just between these two hospitals, remained open to serve any emergencies that might arise.
Irene struck New York City a glancing blow, doing its real damage farther upstate. The dire warnings had proved false, leaving New Yorkers weary of preparing for violent storms that rarely seemed to materialize. From a hospital’s perspective, an evacuation not only cost money, it also put the patients at risk by removing them from a secure medical environment. Weighed against the frightening but slim chance of a direct hit from a monster storm like Katrina, repeated evacuations seemed a heavy price to pay. New York City wasn’t New Orleans—or so it appeared.
Bellevue did make one key improvement, however. Because its emergency generators were located on the thirteenth floor, while the fuel pumps that supplied them sat in the basement, the hospital’s backup power system wasn’t fully secure. Though it would take a massive storm surge from the East River even to reach the basement, the hospital, to be safe, encased the fuel pumps behind “submarine doors” of steel and rubber to withstand water damage from a future event.
In October 2012, a late-season storm named Sandy made landfall on the New Jersey coast. This time there was no glancing blow. Sandy would be the largest storm ever recorded in the Atlantic Ocean, with a diameter approaching one thousand miles. And it hit New York City full on, arriving at high tide on the night of a full moon. The damage from South Jersey to the eastern tip of Long Island was catastrophic, but the densely populated parts of lower Manhattan fared even worse. The storm surge of a major hurricane adds four to six feet to the East River; this one measured fourteen feet in Zone A, an unfathomable event.
On Sunday, October 28, with Sandy approaching, Mayor Bloomberg again shut down public transportation and strongly advised residents in low-lying areas to evacuate. But for reasons not entirely clear, the two major Zone A hospitals abutting the East River, Tisch and Bellevue, stayed open, a decision that remains controversial. (The neighboring VA hospital, under federal supervision, did evacuate.) Predictions of Sandy’s storm surge varied widely, with city officials banking on the lower estimates. Dr. Thomas Farley, New York’s widely respected health commissioner—and someone who had worked in New Orleans during Katrina—appeared confident that the rivers surrounding Manhattan would rise no more than six feet at high tide. It’s also likely that the decision to “shelter in place” was colored by the false alarm of Irene: moving out patients prematurely might be more dangerous than keeping them in a well-stocked hospital with a secure backup power system. It certainly was more expensive.
Dr. Doug Bails, Bellevue’s chief of medical service, arrived early on October 29 from his home in New Jersey. Knowing that the subways and commuter rail lines would shut down that morning, he packed a change of clothing and some extra food, expecting to spend the night on his office couch as Sandy passed through. The day began mildly, but by mid-afternoon the winds had reached tropical storm force, with severe damage reported along the Jersey Shore. At 5:45 p.m., Mayor Bloomberg held a press conference to deliver some very bad news. Sandy could well be “the worst storm of the century,” he warned, and the time to evacuate had passed. Bails looked out his office window. It was raining hard, and the FDR Drive, a major north–south artery along the East River, had started to flood.
Just before 9 p.m., Bellevue went dark. “We were told it would take ten seconds for the backup system to kick in, so I began a silent count,” Bails recalled. At nine, the lights came back on and the elevators started to move. An explosion at a flooded Con Edison substation several blocks away had left the southern part of Manhattan in full blackout. For the moment, Bellevue’s backup power system was doing its job.
There was a problem, though. The hospital was taking in water—not in small puddles or isolated corners, but as one astonished worker put it, “like Niagara Falls.” Millions of gallons had breached Bellevue’s ancient retaining wall and flooded the 182,000-square-foot basement, much of it pouring in through the loading docks facing the East River. While the emergency generators were thirteen floors up, and therefore not in danger, the fuel pumps that supplied them sat directly in harm’s way. If the floodwaters pierced the new doors protecting these pumps, the generators would soon run dry.
Unlike neighboring Tisch Hospital two blocks north, where patients were successfully evacuated despite a full power loss, Bellevue faced a tougher set of problems. Larger than Tisch, it housed a more diverse population. In addition to its regular medical and surgical patients, there were prisoners in lockup, alcoholics and drug addicts, hundreds of psychiatric patients, and people detained under court order with highly infectious tuberculosis. Evacuating these groups would not be easy. Bellevue’s best option, it appeared, was to ride out Sandy until the floodwaters receded.
This was nothing new. Bellevue had always “sheltered in place” during major storms. The drill was second nature—all hands on deck for staffers while shedding those patients who were able to leave. But Bellevue had an additional concern: an unusually large group depended on electric-powered ventilators, dialysis machines, intravenous drips, and aortic pumps to survive. “In the event of total power loss,” recalled Dr. Laura Evans, director of critical care, “our limited resources would have to be allocated to the patients most likely to benefit from them.” Presently there were fifty-six people in her intensive care units, who had to be ranked according to need. Evans knew the protocol; she’d compiled a similar list during Hurricane Irene.
On Monday evening, Evans formed a committee of ICU doctors and nurses plus a medical ethicist to review the patient charts. One of the key lessons of Katrina was that the main public hospital in New Orleans (Charity) had suffered far fewer deaths than Memorial, despite having many more patients, because, among other things, “the sickest were taken out first instead of last.” At Bellevue, the committee looked at “severity of illness, need for life sustaining equipment, and likelihood of recovery.” It was an eerie setting, Evans recalled, with cases being evaluated as the lights flickered on and off in the background.
At 10:30 p.m.—high tide—the storm surge overwhelmed the submarine doors protecting the basement fuel pumps. Barring a miracle, Bellevue’s backup power would be gone in three hours, when the emergency generators exhausted the last drops of gasoline in their tanks. To make matters worse, the basement also housed the pumps that supplied wall oxygen to patient rooms and fresh water to the four fifty-thousand-gallon rooftop towers. Virtually everything needed to keep the hospital running was now disabled—or about to be. That meant no air-conditioning, no refrigeration, no flushing toilets, no laundry service, no wall oxygen, no blood work or laboratory results. Vacuum power was gone, forcing patients to be suctioned by syringe. All thirty-two elevators were out of service because the basement shafts resembled swimming pools.
Just after midnight came a reprieve. National Guard troops arrived, followed by a police tanker truck with 2,600 gallons of fuel. A call went out for volunteers to gather at the stairwell landings, and a bucket brigade quickly formed—guardsmen, doctors, nurses, medical students, technicians, secretaries—to pass five-gallon containers of gasoline hand to hand from the tanker to the backup generators on the thirteenth floor. “There was no division of labor, no complaints or hesitation, and no signs of stopping,” a volunteer remembered. “No one said it, but the pressure was obvious. . . . If [we] stopped moving, patients’ lives could end tonight. . . . This went on for hours, pushing . . . to dawn.”
The bucket brigade staved off disaster. The backup generators provided just enough power to run selected outlets in the wards and keep the hospital from falling into complete darkness. Meanwhile, interns were dispatched with oxygen tanks to the bed of every ventilated patient in case the electricity failed and mechanical IVs were converted to “subcutaneous injection.” In the pharmacy, prescriptions filled by flashlight were handed to medical student runners for delivery to the various floors.
At the hospital’s command center on 17 West, a whiteboard took the place of computers. Emergency phone numbers were scribbled in Magic Marker, along with breakfast and dinner orders. “This being Manhattan,” a staffer recalled, “deliveries of pizza and Chinese takeout food never flagged.” Perhaps the oddest whiteboard notation read: “19 S East Stairwell (knock three times)”—the new code for entering the prison wards on 19 South.
On Tuesday morning, October 30, a mini-evacuation began. Infants were transferred out, along with ICU patients and those on ventilators and dialysis. The threat of a full power loss, compounded by fears of bacterial contamination, sealed the decision. It had become too dangerous to treat vulnerable and compromised patients in conditions like these. “I am caught behind a team from the Neonatal ICU,” a social worker wrote in her diary of a stairwell trek. “One nurse who manages to seem stern, nervous, and commanding all at the same time, counts the steps. ‘Step One . . . Step Two . . . Step Three.’ She holds one of the babies . . . and five other nurses and doctors follow behind. They march in step . . . like soldiers down 16 flights of stairs.”
By Tuesday afternoon, Bellevue seemed a hospital on the brink. Garbage was piling up, toilets were clogged, the stink was nauseating, the air insufferably still and warm. The staff had been on duty for two days and nights, and exhaustion was setting in. The hospitals on both sides—Tisch and the VA—were empty. What was taking so long? “I have to pee, but I really don’t want to,” a worker confessed. “With no running water, the bathroom situation has become intolerable.” Hearing of a toilet with only urine in the bowl, she rushed over to use it. “Despite the many walks up and down the stairs,” she added, “we attempt to drink as little as possible.”
On Wednesday morning, October 31, the hospital was ordered to close. With lower Manhattan still blacked out, the danger of sheltering the remaining patients now outweighed the risks of moving them out. What followed was a “vertical evacuation” of unprecedented scope. Maneuvering hundreds of physically fragile and mentally ill patients through a maze of barely lit stairwells wasn’t in anyone’s playbook—Katrina notwithstanding. “All hospitals are required to do disaster planning,” an official admitted, “but we’ve never had [a drill] where we carried patients downstairs.”
It took a full day and most of that evening to complete the job. Working in teams, soldiers and staffers evacuated patients at the torturous rate of twenty-five per hour—some hand-carried, others on stretchers and sleds. Dr. Elizabeth Ford’s unit was among the last to leave. “It’s Bellevue, we’re used to crisis, but this was different,” Ford said of her criminal psychiatric ward on 19 South. “I don’t think I ever panicked in my life, but I was starting to worry that we wouldn’t get out.” Some of her sixty-one patients, hearing of the flood, concocted fantasies of being drowned. Wearing orange jumpsuits, they were taken down in groups of six, chained together at the ankles and surrounded by a phalanx of police.
By Friday morning, only two patients remained. One was a 550-pound woman who couldn’t fit into the sled to guide her down the stairs; the other was an elderly man with a ventricular assist device for a serious heart condition. Both had to wait until an elevator could be rigged to get them out.
More than seven hundred patients were in Bellevue when the storm hit and the power failed. All got out safely. Those transferred to other hospitals by ambulance were given handwritten discharge summaries, a list of their medications, and a doggy bag with a five-day supply. The rest—mainly homeless—were sent to local shelters. While the nearby hospitals were quite accepting of these transfers, the “patient handoff” could be trying, as Mount Sinai learned upon admitting a dozen Chinese psychiatric patients who spoke no English. Secure isolation rooms had to be found for the court-detained tuberculosis cases, and not all of the convicts were well enough to return to Rikers Island. Most of the evacuees wound up somewhere in the public hospital system. On Monday, November 5, 2012, Bellevue closed its doors for the first time in its history.
The travails of Sandy showed the hospital at its finest—its staff performing nobly in unimaginable conditions. Lives were saved because doctors and nurses, medical students and hospital workers, bonded together to protect their patients, and each other. And backing them at every turn was the National Guard—“our cavalry,” said an admiring Doug Bails. A Bellevue resident put it this way: “I can recall the patient monitor going black from the power failure; the smell of gasoline in a stairwell, where people had spontaneously formed a brigade to fuel a backup generator on the 13th floor; and the physical exhaustion of safely carrying a patient down the staircase. I describe that night as the most rewarding experience of my career. . . . The visceral feeling of ‘This is why I went into medicine’ is my most powerful sentiment left behind from the storm.”
Many shared his perception. But others couldn’t help asking how it came to this. What had made Bellevue so vulnerable? Was it a freakish act of nature or a failure to shore up the hospital’s primary defenses? And why did it take so long to evacuate, given the lessons of Katrina? With much of its infrastructure in ruins, its patients scattered to the winds, Bellevue faced an uncertain future. A disaster preparation expert put it well. “The amount of heroism that arises in situations like this one cannot be overstated,” he said. But one has “to wonder why we needed so much heroism.”
From Bellevue. Used with permission of Doubleday. Copyright © 2016 by David Oshinsky.