“Ochsner Clinic and Hospital: Hard Lessons from the Big Easy”, Imaging Economics, © Stephen Krcmar, 2/06

Having a disaster plan in place is critical, but Ochsner learned that ingenuity, flexibility, and having the right people on hand are what will keep an institution afloat.

On Thursday, August 25, 2005, Tropical Storm Katrina was upgraded to Hurricane Katrina, the fourth hurricane of 2005. By the end of the day, it had touched down in Florida and surprised forecasters when it changed direction and started paralleling the coastline in Miami. By Friday morning, the eye of the storm was located offshore of southwestern Florida and heading toward Louisiana where the governor promptly declared a state of emergency. As federal troops were deployed to Louisiana, the radiology department at Ochsner Clinic Foundation in New Orleans was putting their disaster plan into action.

"We knew that we needed to prepare ourselves to be in this for the long haul, that this was going to be very difficult for our employees, for our patients, and for this community. We were going to have lots of challenges to meet," says Suzanne Young, RT(R), CRA, the administrative director of radiology.

At 5 am on Saturday, the hurricane reached Category 3 intensity as it charged across the Gulf of Mexico. Ochsner could withstand a Category 3, according to Edward Bluth, MD, chairman of radiology. He thought that the structure could possibly withstand a Category 4 hurricane but was unsure about the effects a Category 5 would have. "If it was really a level 5, it might be a tremendous problem," Bluth recalls thinking.

At 7 am on Sunday, Katrina was upgraded to a Category 5 hurricane while it stormed over the Gulf. At Ochsner, the clinical personnel of "Team A" who were slated to cover the next 6 days at the hospital had just arrived. Daniel DeVun, MD, Dana Smetherman, MD, and John Eick, MD, were the three radiologists on duty who would work with three residents. The team of six reviewed emergency RIS and PACS protocols, making sure they had hard copies of documents that they might need but would not be accessible if the storm shut down computers. During this meeting, assignments were also reviewed as well as pager and wireless in-house phone numbers.

The team had been selected carefully to make sure that all modalities were covered and that there was redundancy, so the hospital would not be left in the lurch if something happened to a single specialist.

During the afternoon, the hurricane had strengthened to a strong Category 5 with 175 mph sustained winds and 216 mph gusts. By 7 pm on Sunday evening, the storm was less than 12 hours away from landfall: 17 members of the clinical support staff had arrived and were led by Young, who went over their duties for the 12-hour shifts. The group also discussed the equipment that was on backup power and where it was located.

Machines that were connected to emergency power were easy to identify. Unlike the traditional, off-white outlets, the outlets connected to emergency power are red and a lot more of these plugs had been added recently, just in case nursing home patients needed to be housed during a disaster. The CR units, portable x-ray units, and crash carts were also on these "red plugs" and placed strategically throughout the building. The redistribution of technology was done long before the storm hit because if the city power went down, so did the elevators.

"It's one thing to take patients and carry them up and down stairs. It's another thing to carry equipment," Young notes.

Downtime was also discussed during the morning meeting, nailing down a plan for sleeping arrangements and talking about food and water supplies. Every water cooler in the hospital had 5, five-gallon backups and 10 cases of gallon jug water were on hand in the radiology department.

Employees would sleep in one of two rooms the department had obtained at the Brent House, a hotel connected to the hospital. There was a room designated for men, the other was for women. The floors of both rooms were covered with air mattresses. Army cots were also strategically placed throughout the hospital. This still would not be enough: During the week, gurneys and the flat surfaces of various diagnostic imaging equipment would also be utilized for shut-eye.

Then they went to work: finding 55 gallon drums, filling them up with water, and placing them outside bathrooms so that there would be water to flush the toilets. They also gathered all 20 box fans designated for the department that would help circulate the air and fight rising humidity levels.

As they worked, the hospital was evacuating patients. Only the very sick who could not travel were left at the institution.

Bluth had spent many hours thinking about disaster preparedness in the past and had come to believe that these situations required an approach that looked at the hospital holistically.

"We had to think as an institution, not as a radiology department," Bluth says. And although preparation is incredibly important, Bluth emphasizes the importance of improvisation when it comes to the actual disaster. "There really is no organized preparation for the actual event, you have to play it by ear," says Bluth. "You have to be constantly vigilant."

THE PLAN

The extensive prehurricane plan had been refined over many years, and one of the primary focuses concerned essential personnel. As a plan, the umbrella of possible situations included a range of events like a plane crash, terrorist attack, or natural disaster. The radiology department's primary concern was ensuring that all modalities were covered while putting the fewest personnel in harm's way.

"You have to set up your team correctly. They have to be able to be freestanding and be able to exist independent of the rest of the world," says Bluth.

An autonomous and independent department means having multiple solutions for the same problem. If one machine was inoperable, having a backup plan is imperative.

Ochsner had multiple hurricane alerts in the past and adjusted the numbers of doctors and residents with each one. Lower numbers put fewer people at risk, but put more stress on the staff on duty. Larger numbers spread out the work more thinly but put more staff in harm's way.

"We knew that once a disaster took place, it wouldn't just be overnight," says Bluth. "We had to have an adequate number of people so they could rest."

Each of three teams was assigned to take the first watch for a different hurricane season. The team would work for 7 days before being relieved by the second team. The second team would be relieved by the third team after 7 days. After each event, there would be a post-analysis. In addition to changing the levels of staffing, they tried different policies concerning family.

"We realized that you had to limit family members, which is a big emotional problem for a lot of people, but that was a lesson learned," says Bluth. In the past, the department tried different things, forbidding family members at times and allowing many relatives at other times.

During Katrina, employees were encouraged to have relatives evacuate to safer areas. If the staff member was not comfortable sending their spouse away, common in couples that did not have children living with them, the spouse was welcome in the hospital. Many family members stayed in the lobby, where they pulled chairs together to create makeshift beds. Many of these spouses and relatives made the transition to volunteers. When a machine went down in the emergency department, it became necessary to run cassettes to the radiology department on the second floor, and it was volunteers who handled this 5-minute trip.

"I was very pleased," says Young speaking about the volunteers. "They stepped up and helped us every step of the way."

Single mothers also had a place for their children at Ochsner, which had day care on the premises, a necessity learned during previous hurricane alerts. Employees with kids in tow were incapable of carrying out their job duties.

Four-legged and flying loved ones were also taken into consideration. Initially, pets were not allowed. That decision caused a lot of consternation. So, Ochsner changed the policy during the early stages of the storm: try to make alternative arrangements, they instructed staff. But for those who could not and had to be at the hospital, their animals were welcome as long as they were caged.

Young was hoping she would not have to resort to bringing her boxer to work. She had planned for a friend to pick up the canine and take it to Alabama. But the storm rolled in so fast, that was not possible.

The dogs, cats, rabbits, and birds did not end up inside the hospital itself. The atrium of the parking garage was used for that. Staff members took turns walking, feeding, and giving water to the animals.

The hospital has about 20 full-time radiologists, 21 residents, one fellow, and a staff of about 350. During the week, staffing levels hover at roughly 250 employees and 14 radiologists. Weekend staffing is lower. During last year's disaster, the department operated with staff numbers that ranged between 10% and 17%, according to Young.

"I was very glad that we had technologists that could cross cover in other areas. But I can't say that we had too few people, nor can I say we had too many," says Young. "We had the right amount. We all had to pull together and do things like mop and help out in laundry and those kinds of things. We had the right amount of people to work our environment as well as care for our jobs."

There also were many portable restrooms on site. The team had learned that these units were important to have on hand when water was not available to flush toilets.

KATRINA HITS

As the storm rolled in, so did the phone calls. But the folks on the other end were not all searching for immediate medical help. They were from employees in dire situations: stuck on a roof with rising water or sitting in traffic with a dying cell phone battery and no place to go. For some situations, employees inside Ochsner could do little more than listen to those on the other end. In other situations, messages were passed on to administrators who worked to coordinate help. To make a tough situation more difficult, the communication infrastructure was starting to fracture.

Phone calls were not being routed to the correct lines, so the phone was ringing off the hook and almost all of the calls had to be rerouted. There were only two people on hand to deal with the calls and answer the diversity of questions. But employees who had multiple job duties handled this task. It took some callers as many as 2 days to get through and many were frantic.

"People were seeing all these horror stories on the news," says Young. "For us, we were just trying to mop and get air conditioning ... we were dealing with our own world. So having someone here who could give out basic information and take basic information and arrange so that when we needed someone, we would know how to contact them, is definitely something I would suggest."

Young herself fielded many of the calls on a wireless telephone.

In the days after the hurricane, the volume was low. Staffers ended up doing many things that were not in anyone's job description. Some radiologists ended up in other departments.

All in all, the 4 days that followed Katrina's touchdown included less than 130 examinations, a minimal number. Limited transportation in the city kept the numbers down. Getting specifics about particular days that immediately followed Katrina is difficult. Time ran together for people like Young, who estimates that she slept about 7 hours in the first week. (Bluth was not present during the first wave.)

Ochsner went into the storm with three generators that were expected to provide emergency power to the whole hospital. One had literally blown away early on, according to Young. The other generator promptly blew a circuit board. A technician was on hand, and he retrieved the single replacement board that was in storage only to find out that it was nonoperational.

More generators were ordered and the units were shipped immediately. When they got to city limits, the generators were turned back by the Federal Emergency Management Agency (FEMA). One of the lessons learned? "We probably need more stored generators so we don't rely on having to bring them in from the outside." Bluth says.

The circuit board was flown in a few days later.

Even though Bluth has been thinking about disaster preparedness for years, the severity of the power outage surprised him. "People expected the power to be off for a day, or two, or three—not weeks. So, I think the extent of this was well beyond most disasters," Bluth says.

HELP CAME FROM THE COMMUNITY

The surrounding and vendor community proved to be more helpful than FEMA or the Red Cross. After the hurricane, the airspace was described as resembling a war zone because of all the helicopter traffic. Employees could not understand how it was possible to get all of these whirlybirds up in the air, but it was impossible to get food and water.

Wanting to add to their stock of necessities, the purchasing director contacted a large box store and a smaller department store and worked out an agreement: the hospital would take what was needed, keep a record of all items they removed, and settle up later.

The department administrators hope to get some smaller individual generator units before next hurricane season. Their MRI experience taught them that. When they lost power, the MRI units were not on backup electricity. They did not realize that they needed power to get a helium level and a cryogen reading. So, they had to search the hospital for a portable generator to give the MRIs enough electricity for a reading. These generators had multiple uses during Katrina like powering portable air-conditioning units. For Ochsner, which offers numerous off-site clinics, these units have many nondisaster uses.

Why were the MRIs not on backup power? The units need fresh water, and the staff assumed that they would not be able to provide that so they were not hooked up to emergency power.

The lack of chilled water, the low cryogen levels, and the heat and humidity were dangerous conditions for the MRIs. A decision had to be made: to quench or not to quench. The three radiologists and Young got together, the radiology department's chain of command, to discuss the expensive and potentially dangerous procedure. When they discussed quenching, it was unanimous: it had to be done.

They all knew that if the machine malfunctions during quenching, a metal port could peel away from the MRI releasing oxygen-eliminating cryogens into the air. The resulting vacuum would likely asphyxiate anyone in the room. Two of the three MRI units had the quench switch located outside the actual room, so there was no danger in quenching those machines. One unit, however, was in a ballroom-sized space and the switch was as far from the door as possible. Young volunteered to quench it.

"Not that I wanted to lose myself, but I couldn't afford to lose one of the radiologists," says Young. "They were much more valuable to the hospital than me."

But DeVun would not let her go it alone. When she flipped the switch, the machine quenched itself just as it was supposed to. The manufacturer of the unit was quick to act when it discovered the hospital was without an MRI. It sent a mobile unit to Ochsner as a donation, and it arrived by the end of the first week.

The storm also ripped the roof off the 11-story hospital. Water channeled down an unpredictable path, finding both of Bluth's offices but fortunately not the technology. The radiology department covered up its high-tech equipment in a low-tech way—garbage bags and plastic sheeting.

The information services department controlled the server department on the third floor so radiology did not have to worry about waterproofing those. These systems were protected, but they were not immune to the heat. Without power for air conditioning, the temperature in the server room climbed steadily. When it hit 115 degrees, the decision was made to shut down the servers.

Radiology employees called their vendors and were given instructions on directly connecting all of the essential imaging equipment to two of the 27 workstations in two different reading rooms.

Being without power posed a difficult challenge for the radiology department. With the exception of mammography, the department is filmless. Using its single digital portable x-ray unit begged a single question: which floor should they put it on?

Since the elevators were not operating, the unit had to be committed to a single floor. It was placed in the ICU/CCU. This decision also had to be made for the 11 ultrasound units. Since the machines had wireless capabilities and were battery-operated, they required only a red plug.

"The portable digital x-ray unit has] greatly enhanced our productivity. We use a large percentage of portables with the types of care we provide here at Ochsner," says Bluth. "That's how we argue and get them. From a storm perspective, I would have loved to have four portable digital x-ray units. [They in fact had five analog portables and one digital portable.] They're very expensive, about $300,000 apiece, versus a normal unit, which is $37,000. It's hard to make that financial argument from a storm preparation perspective."

Young also sang the praises of the portable digital x-ray unit, from which they got tremendous productivity. It is also wireless and operates as long as the server is up. "I could have handled the entire workload with three digitals," she noted.

CONDENSATION EVERYWHERE

Once the air conditioning was back on, there was still plenty to worry about. The hot, heavy air had left a thin coat of condensation all over the hospital. The floors in the cafeteria were as slick as if they had just been mopped.

Radiology staff rounded up every dehumidifier as well as every nonelectrical dehumidifying product they could find to help remove the water from the air in the server room. They also utilized spot air conditioners that helped lower the temperature by removing humidity from the air. Circuit boards with a lot of condensation on them are more likely to blow.

It took about 24 hours to bring the temperature of the room down to the mid 80s, the temperature that most vendors specify for safe operations. All in all, the servers were down for more than 2 days.

Three days after the hurricane, one vendor's technicians arrived and set up a mobile command center and began repairing diagnostic imaging equipment as well as the process of bringing up the MRIs. The vendor also used Ochsner as a base so it could go help other institutions. (The vendor had shipped a generator that was also confiscated by FEMA.) Ochsner, now on city power, allowed the vendor to plug into its power.

Vendors not only helped with technological needs. They provided sustenance as well: one brought in a cooler of jambalaya and another delivered junk food and Gatorade. With employees that had just been through a disaster, the hospital became a surreal mix of the aftermath of a nightmare and a slumber party.

By day five, most of the employees were ready for a shift change. They were stressed and tired. The region's transportation infrastructure was not ready for the transition so the plan was altered and personnel who had sought shelter in Baton Rouge, Houston, and other locations that were relatively close were brought in.

Technicians across the country had their own struggles. Far from home, they were also far from work and the paycheck that accompanies it. Young was able to contact various hospitals and find temporary work for some of her displaced technologists.

By the time the third shift arrived, there were still transportation challenges. People could not come directly into New Orleans, but had to go to Baton Rouge and obtain a police escort.

Bluth tried getting back to the city early on, but was met with nothing but hurdles and bureaucratic responses from everyone he spoke with. There were no flights into New Orleans and Highway 110 was blocked from the east. Bluth finally got a flight into Baton Rouge and drove in from the west to lead the third team and relieve an exhausted Young.

THE AFTERMATH

Hurricane Katrina taught Ochsner employees the importance of communication and that the problem goes both ways: contacting people and being contacted. For the most part, cell phones did not work. The sources that power cell towers are on the ground, and they were underwater after the storm. Lacking electricity, very few mobile phones with a 504 area code worked and it was difficult for employees to reach the hospital or vice versa.

The e-mail at Ochsner worked intermittently. To fix that problem, additional Internet service providers were added and two-way communication was possible again. Unfortunately, not all employees knew about the new e-mail addresses that came with the additional sites. Now, Ochsner has more than one site that can accept e-mails and all employees are aware of it.

Bluth also plans on adding a staff member to the essential team who will be in charge of fielding phone calls. This new control room will allow people like Young to concentrate more on duties that fall within her job description.

The radiology department also faces unique challenges because it is not an autonomous unit but linked with other departments. Some of the equipment it has for emergency power is associated with the emergency department, which is on the first floor and therefore more susceptible to flood waters.

One of radiology's CT scanners was on the ground floor, and although the hospital did not flood, the department would have been in trouble if it had. To protect its valuable technology from leaks, which the hospital has experienced during heavy rain, Ochsner is in the process of fabricating a large ceiling pan that has a drain hole that redirects the water to a safe place. Young wants one in CT specifically because the air vents that control some of the heat in the gantry are on top. If water finds its way to those vents, the equipment will be ruined. The potential for flooding also helped the staff realize that they need emergency power for sections of the second floor.

"We've realized that we probably would need another large generator to add another grid. We wanted to add at least very minimal power to all three of our MRI scanners to be able to read cryogen levels," says Young. "We'd like to be able to pump our well water ... through our chilled water system so we could make one MRI a functional unit on total backup power."

When considering disaster preparedness, Young emphasizes the importance of thinking about the problem from multiple perspectives.

"Don't think about it just from the short term. A lot of times, most of us think about getting through an initial disaster and then we'll be back to normal. In this case, we're 4 months out and we're still very far from normal. Really thinking through your plan from a short, mid, and long-range perspective [regarding] what you're going to need and your staff's ability is crucial."

By early January, the hospital was running at 96% to 98% capacity. Its outpatient numbers were lower, because of the decreased population. The number of staff members also decreased. Pre-Katrina, the hospital had 6,700 employees. After the storm, 1,700 people didn't return to work; 600 new employees were hired.

Those who did return have been critical to poststorm recovery. "I would have to say, the staff was the number one asset. Having the right people there with the right attitude and the right skill mix, that's just essential. You're going to be dead in the water without that," says Young.