Two Category 4 Atlantic storms made landfall in the mainland U.S. in the same two-week period of late summer 2017, making Hurricane Harvey and Hurricane Irma back-to-back disasters that challenged surgeons’ preparedness and capacity to provide adequate patient care.1,2
Hurricane Harvey hit southeastern Texas August 25, 2017, resulting in more than 75 deaths.3 Hurricane Irma made landfall September 10, 2017, on Florida’s western coast, resulting in 75 deaths, including 14 storm-related deaths in the Florida Keys and 11 seniors who perished in a Hollywood, FL, nursing home.4 Estimates for damages resulting from Hurricane Harvey range from $65 billion to $190 billion, while Hurricane Irma damage could end up costing between $50 billion to $100 billion.5
On September 18, 2017, Hurricane Maria made landfall in Puerto Rico (see related story in this issue). In all, the three storms resulted in more than 260 deaths and an estimated $300 billion in damages—making the 2017 Atlantic hurricane season the costliest on record.6 According to CNN, “each hurricane posed different threats and caused different problems. Harvey brought massive flooding, Irma deadly storm surges, and Maria catastrophic high winds.”7
This article describes how surgeons and their institutions prepared for the storms, surgeons’ efforts to serve patients during the storms, the value of disaster preparedness, and lessons learned from working in the trenches during Hurricanes Harvey and Irma.
Hospital preparation
“All of the hospitals in Houston learned a lot from their experience with Tropical Storm Allison,” said Barbara L. Bass, MD, FACS, FRCS(Hon), President, American College of Surgeons (ACS), referring to the tropical storm that devastated southeast Texas in June 2001 due to a record amount of flooding. “Hospitals realized that every facility needs to have its own preparation plan in place well before one of these events happens. At our institution, we have a well-developed plan that includes a ride-out team that designates, well in advance, who is going to be at the hospital at the time of the incident,” said Dr. Bass, the John F. and Carolyn Bookout Presidential Endowed Chair, and chair, department of surgery, Houston Methodist Hospital, TX. “This planning is done as a routine part of living in this area, which is not infrequently hit with hurricanes and flooding due to tropical storms with exceptionally heavy rain.”
“Once we knew it was in the Gulf and that there was a possibility that Houston would be impacted, we didn’t wait for landfall,” said SreyRam Kuy, MD, MHS, FACS, associate chief of staff, Michael E. DeBakey Veterans Affairs (VA) Medical Center. “Figuring out the logistics is a huge part of disaster preparation. I think, as surgeons, we sometimes forget all the other stuff that happens outside of the operating room (OR). We think the OR is the coolest part and the most fun part, but so much happens elsewhere, everything from waste management to food services to the electricity and plumbing.”
When Harvey transformed from a tropical storm to a Category 4 hurricane, it became apparent that hospital staffing needs could reach critical levels.
“We knew that if we let people go home, there was a risk that they wouldn’t be able to get back in—and that’s exactly what happened,” Dr. Kuy said. “Holcombe Boulevard, which runs through the Texas Medical Center, became a river, and all the streets were flooded. People who had left the hospital couldn’t physically drive through.” To reach the hospital, “they swam or waded through the water, which many of our staff, residents, and students did.”
According to Dr. Kuy, nearly 700 staff members remained at the DeBakey VA Medical Center in preparation for Harvey, some sleeping on office floors, with many others sleeping on cots in the facility’s auditorium.
Even as an estimated 60 inches of rain fell from Hurricane Harvey in Texas, upending previous U.S. storm records, many hospitals in the area, such as Texas Children’s Hospital, remained self-reliant in terms of staffing.8
“We basically had all our people in place,” said Mary L. Brandt, MD, FACS, an attending surgeon, pediatric surgery service, Texas Children’s Hospital, pointing to the hospital’s ride-out system as the reason physicians were on hand throughout the storm. “If you’re on the ride-out team, you know that you’re there until it’s over.”
Leading by example: Do as I do
Staff, including physicians, adopted new roles during Harvey in an effort to keep hospital operations up and running.
“The nurses and physicians worked together to figure out what needed to be done,” Dr. Brandt said. “There were physicians doing tasks they don’t usually do. There was no question everybody was just chipping in wherever they could to help make things as easy as possible for everybody else. As a result, there was an extraordinary camaraderie.”
“We had staff who were here five or six days without ever going home—and that was the same for leadership,” added Dr. Kuy. “We’d been in the hospital for the same amount of time, sleeping in the same gross, disgusting scrubs and the same pair of socks. I think the fact that the staff saw us going through the same situation had a huge impact on them. You have to show people that you are in it with them.”
Surgeons who led by example included not only those individuals willing to work in the trenches and take on new tasks, but also those health care professionals who demonstrated a commitment to caring for patients under extraordinary circumstances.
“On Sunday morning, it became really clear that [Houston Methodist Hospital] was an island and that people were having a really hard time getting to and from the medical center,” said Dr. Bass. “One of our surgeons, Robert Ochoa, Jr., MD, FACS, who lives nearby, actually walked in, almost swam in through deep water to work.”
“On Saturday, it started raining, and by Sunday morning, I was following through with the intensive care unit (ICU) to make sure we had people there,” said Dr. Ochoa, the surgical director of the surgical and liver ICU. “By early morning, we realized how bad it was and that our staff wasn’t going to be able to get in. We had two interns and a second-year resident, a nurse practitioner (NP), and 28 sick ICU patients,” Dr. Ochoa said. “I live about three miles away [from the hospital]. I drove about a mile, which was as close as I could get to the hospital, and I waded in through waist-deep water the rest of the way—about a mile and a half. The three residents who made it all had to basically do what I did to make it in. One of them walked about a mile or so with water up to his chest at some points to get in. And one of them had his car stall out on the way in, and he left it there and continued to walk about another three-quarters of a mile to get in.”
To make matters more dire, many of the staff who were working at the hospital during the storm had to leave family and loved ones at home to face the hurricane alone, including Dr. Ochoa, who has a wife and three children.
“Leaving my house, I was a little bit anxiety-ridden because I wasn’t quite sure if I would be able to get home if something were to happen, but I also knew that I had a couple of residents and an NP [at the hospital] and the patients, and somebody had to take care of them. So, that’s why I decided to find a way to get here—to guide my residents and to give them support. And to support the nurses who also were here, and really just make sure that our patients were going to be safe,” Dr. Ochoa said.
Another surgeon undeterred by the flooding was Stephen Kimmel, MD, FACS, a pediatric surgeon who traveled by canoe to Clear Lake Regional Medical Center, Webster, TX, to operate on a 16-year-old suffering from testicular torsion.9
“I got the call to go take care of this boy and I drove my car about a mile from my house but the water was getting pretty deep, so I thought I would get stuck,” Dr. Kimmel said. “I turned around and went back to the house and called my chief medical officer [CMO] and said, ‘I can do the surgery, but I can’t get there. I need your help.’” Dr. Kimmel’s CMO made some phone calls and eventually was able to connect Dr. Kimmel with the Dickinson Volunteer Fire Department.
Firemen showed up at Dr. Kimmel’s house at approximately 1:30 am. “At my door were two 19-year-old guys soaked to the skin in firefighter baseball caps. They said, ‘Okay, doc, we’re going to run for a while,’” Dr. Kimmel said. “We ran about a half a mile down my street, and it was dark and windy and pouring rain. We got out to one of the main roads and ran a little bit further to the fire station, and that’s where they had stashed the canoe because the water between the station and the interstate was pretty deep. The three of us paddled about half a mile to the Interstate 45 overpass in Dickinson.”
One of the volunteer firefighters had parked an F30 truck under the overpass. They loaded the canoe into the truck and were able to get through the feeder ramp and onto the highway, which had flooding but was passable, according to Dr. Kimmel. At another feeder road, the three men faced a flooded road that was not passable, so they parked the truck, jumped back into the canoe, and paddled up the feeder, passing people who were standing on top of their cars waiting for help.
Dr. Kimmel said the deepest water he encountered that day was located directly in front of the hospital. “It was probably five feet deep. The hospital is located a little bit higher, so we were able to climb up onto the embankment and make our way to the OR,” he said.
“I really had no idea how bad it was going to be. I’d been in the hospital earlier that day and done rounds and done surgery and came home, and I was pretty confident that if I had to go back anytime, it would be no problem,” said Dr. Kimmel.
When Dr. Kimmel entered the hospital for the second time that day, he found the OR staff fully prepped to begin the procedure. The hour-long operation was a success, and the patient was discharged within 48 hours.
Some patients displayed as much grit as the medical teams who cared for them. A former U.S. Army Ranger swam through flood waters to the DeBakey VA Medical Center, where he was treated for a burst appendix. According to Dr. Kuy, when the patient couldn’t get anyone to take him to a hospital, he printed out a map to the VA, which he enclosed in a clear plastic garbage bag to waterproof it, and he walked to the hospital, even as the water rose past his knees and then up to his chest.
“This Army Ranger swam through two miles of sewage-contaminated flood waters to get to the hospital,” said Dr. Kuy. “I asked him, ‘How did you know it was contaminated with sewage?’ He said, ‘It smelled like a latrine. You never forget the smell of a latrine.’”
The patient was confident that if he was able to make it to DeBakey, he would receive proper care. He said, ‘I knew that if I could get to the VA, they would take care of me. I knew that I could call on the VA,’” Dr. Kuy said. “It’s humbling. We don’t give our patients enough credit. It takes so much courage and resilience to do that. When a patient says, ‘I know I can count on you. As long as I can get there, I know you will take care of me,’ that is something we cannot take lightly. That is a huge responsibility for us to live up to that expectation. I’m so proud of all my staff at the Michael E. DeBakey VA Hospital because they lived up to that. The surgeon who performed his surgery was at a flooded apartment. We were able to get a high-water vehicle to bring her in so that she could do the surgery,” said Dr. Kuy.
Patient care: Chronic medical conditions and pediatric patients in need of dialysis
As Harvey continued to swirl through the Gulf of Mexico toward the Texas coastline, surgeons and hospital systems, particularly in the southeastern part of the state, put their ride-out teams and other disaster plans into motion.
“We anticipated as many discharges as possible in order to get everybody out of the house that we could possibly get out of house,” Dr. Bass said. “We, of course, shut down anything but emergency surgery, but we did have a few emergency cases that needed to be done, including abdominal emergencies and things like perforated bowel with peritonitis. The kind of medical emergencies that began to evolve over the next three to four days were primarily the medical patients who had chronic conditions, such as people who needed help with their diabetes or others with heart failure.”
Managing chronic conditions was a top priority at Texas Children’s Hospital as well.
The chief of pediatric nephrology, Michael Braun, MD, realized that dozens of children had gone several days without dialysis, according to Dr. Brandt. “He called a colleague, Rita Swinford, MD, who is the medical director of the pediatric unit at Children’s Memorial Hermann Hospital located a few blocks away, and the two of them worked with the U. S. Coast Guard to help find these children—33 in all,” said Dr. Brandt, noting that these two hospitals cared for virtually every child on dialysis in southeast Texas.10 “There were Black Hawk helicopters delivering these children to dialysis centers—including our center—efforts that saved these young patients’ lives,” Dr. Brandt said.
Hurricane Irma
Less than two weeks after Hurricane Harvey made landfall, Hurricane Irma trounced South Florida, Georgia, and the Caribbean. After hitting the Florida Keys as a Category 4 hurricane, the storm was eventually downgraded to a Category 1 as it pushed inland and moved up through the middle of the state, bringing heavy rain and strong winds to areas of Florida that were not initially expecting these conditions.11,12
Enrique Ginzburg, MD, FACS, trauma medical director and vice-chair of surgery, Jackson South Medical Center and Chair, Florida Board of Medicine, said his experiences overcoming the challenges of the catastrophic earthquake that struck Haiti in 2010 prepared him for Irma.13
Jackson South Medical Center is one of two safety- net hospitals for Dade County, Dr. Ginzburg said. “We ended up being the front line to the Florida Keys, so we received the most significant number of patients right after the hurricane passed through,” he said.
Preparing for Irma
“We knew what to expect mostly due to Katrina and previous hurricanes. We knew that there would be virtually nothing going on during the hurricane itself, but we wanted to have a significant number of staff ready after the hurricane passed,” Dr. Ginzburg said. As a result, Jackson South Medical Center organized staff into teams. The Alpha team would be present during the hurricane, and the Bravo team would be available after Irma passed.
Part of Jackson South Medical Center’s natural disaster planning also took into account staff morale. “Our administrators are excellent. They basically allowed immediate family members to come in with the physicians with organized places for them to stay. And, although family members were asked to bring in their own provisions, the hospital actually provided food for everyone,” he said. In fact, significant changes in designated evacuation zones meant more individuals came into the center than originally anticipated. Jackson South Medical Center provided 6,500 meals within a period of two days.
Sheev Dattani, MD, a Resident Member of the ACS who is affiliated with Florida Hospital, Tampa, said his facility prepared four OR teams and a fully staffed ER to provide care to victims of the storm. However, the downgraded storm didn’t result in a noticeable bump in trauma patients, according to Dr. Dattani.
“Fortunately, it was different for us in Tampa because the hurricane missed us, although we had initially thought we were going to get a direct hit,” Dr. Dattani said.
Originally from Saskatoon, Saskatchewan, the tropical hurricane was the young surgeon’s first experience with how a hospital engages in hurricane prep. In a report to CBC News, a Canadian news outlet, Dr. Dattani said, “I’m grateful for my medical training and I’m grateful for being able to support whoever I can here.”14 Dr. Dattani is Advanced Trauma Life Support® (ATLS®)-certified and an ATLS instructor. “I have found this training useful, specifically regarding how to quickly triage multiple trauma patients, so I felt ready to help in any situation that we would potentially see.”
Lessons learned
While physicians who cared for patients during both Hurricane Harvey and Hurricane Irma credit their individual institutions’ disaster preparedness as key to meeting the challenges of these storms, many highlighted areas for possible improvement.
“We ran out of food,” said Dr. Kuy. “How are you going to run a hospital if you can’t even provide food? The VA system usually requires lots of contracts and a lot of processes to make things happen. We reached out to Secretary David J. Shulkin [U.S. Veterans Affairs office], who was amazing—he made it happen. By midnight on Monday, we had a convoy of high-water trucks that brought in food for us. That had a huge impact because it showed that the national leadership really cared deeply about staff and patient well-being.”
Another area for improvement is waste management. “We don’t actually have a system for taking care of the waste ourselves. We had about three days’ worth of space for waste even after emptying it out,” Dr. Kuy said. “Clearly, we were flooded for at least three days. We need to think proactively about how we can prepare for this and how we can deal with waste management on our own.” Despite these challenges, Dr. Kuy said strong leadership enabled hospital staff to provide quality patient care.
Dr. Ginzburg said a valuable lesson learned at Jackson South Medical Center was to have both the Bravo team—the recovery team intended to provide services after the storm had passed—already in-house along with the Alpha team. Physicians—many of whom were victims themselves suffering the loss of property due to Irma—worked tirelessly over multiple days to treat patients and to keep their institutions up and running. Even with adequate staffing and ride-out plans in place, health care professionals fought through physical and emotional exhaustion.
“With Irma, some people worked for two-and-one-half days at the hospital without relief,” Dr. Ginzburg noted.
No matter how prepared hospitals are to meet the challenges of natural disasters, it’s the enduring spirit of the health care providers—through coordinated teamwork, open communication, and a willingness to take on new tasks—that results in the provision of care to patients in need.
“It’s interesting—when you are aware that you are involved in a real emergency, people actually rally,” Dr. Bass said. “They take on a sense of a special mission. Situations like these actually become a memorable event, a bonding event for those people that are thrown into a crisis together.”
Acknowledgments
The photos accompanying this article were supplied by the interviewees.
References
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- Samenow J. 60 inches of rain fell from Hurricane Harvey in Texas, shattering U.S. storm record. Washington Post. September 29, 2017. Available at: www.washingtonpost.com/news/capital-weather-gang/wp/2017/08/29/harvey-marks-the-most-extreme-rain-event-in-u-s-history/?utm_term=.88dc0b02b78b. Accessed November 3, 2017.
- University of Houston. Houston physician canoes to hospital to perform surgery. Houston Public Media. Press release. August 29, 2017. Available at: www.houstonpublicmedia.org/articles/news/2017/08/29/233769/houston-physician-canoes-to-hospital-to-perform-surgery/. Accessed November 3, 2017.
- Jeltsen M, Campbell A. Inside the ‘impossible’ mission to rescue 33 kids desperate for dialysis during Harvey. Huffington Post. September 1, 2017. Available at: www.huffingtonpost.com/entry/inside-the-rescue-mission-of-33-children-in-need-of-dialysis-during-harvey_us_59a8e389e4b0b5e530fd8beb. Accessed November 3, 2017.
- Storm’s winds begin battering Tampa Bay area. New York Times. September 10, 2017. Available at: www.nytimes.com/2017/09/10/us/hurricane-irma-florida.html?_r=0. Accessed November 3, 2017.
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