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November 1, 2013 Volume 77, Number 11
The Night of the Storm Jerome Lax, M.D.


I drove into work on October 29, 2012, faced with the following dilemma: Where to park my car in case the upcoming storm (later to be named Superstorm Sandy) was going to be “the real thing.” I pulled up to the parking lot across the street from NYU Langone Medical Center, and the attendant assured me that it was safe to park in the lot, even on the lower level, since the lot had “never had any flooding.” Little did we all know that the word “never” was not going to mean much after the next 24 hours. I opted to park a block away from the medical center, further west from the East River.

 

Throughout the day, my colleague and I followed the course of the storm. We noted its landfall and estimated the time it would reach the New York metropolitan area. Periodically, we glanced out the window at the East River. We tried to imagine whether the river, predictably contained within its usual confines below the FDR Drive, could somehow spread its tentacles to reach us, where we were securely nestled in our climate-controlled building.

 

For me, the first sign of trouble came at about half past 6 in the evening. A nurse reporting to the hospital for her shift told me that she had to take off the knee-high boots she was wearing because her socks were soaked. When I inquired as to how that happened, she showed me a picture of what was going on outside on 1st Avenue – it had been virtually transformed into a river.

 

I have been involved for several years in team training and simulation drills for crisis management on the obstetrics floor. The chief of the OB service, the nurse manager and I have focused on optimizing the group dynamic so that crisis management steps are carried out effectively. Fidelity of communication, leadership skills, and speaking up and raising objections when indicated have been the subject of much of our joint teaching. As fate would have it, the three of us were on duty the night of Sandy, a night when we were given the opportunity to put into practice the principles, skills and techniques that we had spent so much time teaching through simulation.

 

At 8 p.m., it was time for our bi-daily team report and we were on very limited power. The backup generator had failed and we were on the backup to the backup generator. Several flashlights had been procured from around the hospital, but there were not enough to go around; glow-sticks were used for less essential activities. Based on team reports, we ascertained that despite the constant threat that things could take a turn for the worse, the situation on the OB floor was presently stable. The patient of most concern, one with a placenta previa, was not actively bleeding.

 

What happened next, from an anesthesiologist’s point of view, was to prove to be the biggest dilemma of the night. Two patients had recently been admitted in active labor and were requesting epidurals. The role of neuraxial analgesia in labor has long been an area of controversy. There are staunch advocates on either side of the argument. Some consider an epidural an artificial intervention that serves as a disruption to a natural process that should be utilized only if absolutely necessary. It is a luxury of the late 20th and now 21st centuries – an “extra” – that certainly in times of crisis, such as a full-blown storm and power outage, would have no place. Questions came up such as “what if we need to evacuate? It will complicate the transfer of these patients to another location.” Then there are those who consider it only humane to provide state-of-the-art pain relief to any patient in pain regardless of whether the underlying cause is one of disease or a natural process.

 

Different sentiments began to be expressed by various staff members and I found myself facing quite a dilemma. Ultimately, I decided to turn to the patients themselves for guidance, as it is the individual herself who can best assess the degree to which she is suffering. I felt that by improvising, I could place an epidural catheter and monitor a patient under labor analgesia safely. I initiated a discussion with one of the patients in this way: “How are you doing? Do you think that you can hold out a bit longer until we have clearer direction as to how this night is going to play out?” The reply was clear and unequivocal: “No! I am already at wit’s end. Give me an epidural now!” That settled it for me. I outlined to the patient what the procedure would entail and how I planned to get around the challenge of working in the absence of virtually any power. We would procure battery-powered transport monitors to monitor vital signs, and use high-powered flashlights to visualize the epidural insertion site and tray. The epidural would be dosed conservatively to avoid a sudden drop in blood pressure.

 

With informed consent obtained, we sat the patient up and positioned her for epidural placement. As I was about to reenter the patient’s room to place the epidural catheter, I was approached by the nurse manager of the floor who expressed continued concern among the nursing staff about proceeding with the epidural placement. They raised legitimate issues, such as how we were going to monitor the fetal heart rate. At that point, the OB chief of service, nurse manager and I huddled to discuss the issues. We formulated a plan. We would dig up a manual fetoscope, a large metal stethoscope, which in years past had been utilized to auscultate the fetal heart rate through the mother’s abdomen, and the obstetrician would continuously monitor the baby as I placed and dosed the epidural. Through open communication and mutual respect, a consensus was reached. A plan in place, I proceeded to uneventfully place the epidural.

 

Meanwhile, the decision to evacuate the medical center had been made by hospital administration. Our patient list was triaged to prioritize patients for transfer out of the facility. The patient with placenta previa was the most tenuous on the floor, and she was assigned the highest priority. With the elevators out of commission, transport down the eight flights of stairs would be by emergency evacuation device, a flexible piece of plexiglass with straps that forms a portable stretcher for transfer down the stairs.

My patient who had the epidural placement by flashlight was one of the last patients to be ev

acuated from what was now an empty and desolate labor floor. As I turned to go down the stairwell with my patient and her husband, I took one last glimpse at the dark and barren floor. This active labor floor, which, for my many years at NYU Medical Center, had been a place where patient care was delivered 24/7, had come to a grinding halt. The toll that Sandy had taken on our facility was a microcosm of the havoc being wreaked outside.

 

Next, we made our way down the dark stairwell. The way was literally illuminated by volunteers who were standing at various corners of the stairwell in order to accomplish one goal – to provide the lighting necessary to facilitate the transfer of hundreds of patients. I was moved by the dedication of these individuals. Many were NYU undergrads who took upon themselves the unglamorous, but critical, task of helping in this way.

 

With safe evacuation of L&D complete, I next went up to the postpartum floor to assist with the evacuation of that area. On the way up the stairs, I sensed for the first time the ferocity of the storm. When I used an outdoor landing to gain reentry to a hospital floor, the wind was blowing with such force that it took all my strength to open the door to access the hospital. As I reentered the hospital floor, I caught a glimpse of a shattered window in one of the patient rooms. It was eerie to see the curtain flung outward into the dark void, the raging wind drawing it out into the chaos.

 

I saw more heroics: a group of nine men carrying an intubated, approximately 130 kg ICU patient down the stairs on their shoulders. The patient was too medically fragile to be slid down the steps on a sled. And there were nurses holding little newborns in their arms, keeping them out of harm’s way.

 

Hours passed and the evacuation was finally complete, so we headed to our call room to grab some sleep before preparing to leave the medical center in the morning. With the arrival of dawn, our dark and now frigid call room, without any functional plumbing, came into clear view. There were no more patients in the hospital, so I turned my attention to making my way home (where I knew that power had already gone out the night before). With some trepidation, I left the hospital to find my car and see how it had fared in the storm. I found it exactly as I had left it, completely unscathed. It is amazing that the distance of one city block spelled the difference between calm and utter destruction.

 

Some of the more important life lessons from the storm awaited us in the following weeks and months. When the medical center got its bearings, we moved into salvage mode. The closing of the main hospital campus forced staff to be rerouted to the different campuses of our institution. I ended up at the Hospital for Joint Diseases, a satellite hospital within our health care system, in foreign surroundings. An operating room suite built to accommodate X patients and staff, was being operated at 3X capacity, mainly by expanding work hours. At our site, we alternated staff and worked on a two day on/two day off schedule, including weekends, not leaving until the evening when the work was done. Call schedules were printed and revised frequently, only to be abandoned entirely. “Please disregard any other prior instructions” became the mantra of e-mail communications.

 

After almost two months, we made our way back to the main medical center campus. The resumption of patient services was a staged process, with outpatient services reopening first, followed by some, and then all, inpatient services. A full reopening of the emergency department still awaits, with an urgent care unit substituting in the interim.

 

As we settled back into the main campus, the universal sentiment was appreciation for just getting back to “normal.” As we move forward, the challenge is to maintain that sense of gratitude.



Jerome Lax M.D. is Assistant Professor of Clinical Anesthesiology, Associate Director of Obstetric Anesthesia, New York University Langone Medical Center, New York, New York.



 

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