Hurricane Andrew Remembered 20th Anniversary




            1.  The health care community ought to develop a warning system that augments the National Weather Service's standard "WATCH, WARNING notification.  The national standard allows, at most, 48 hours warning of an impending storm.  A schedule designed for the health community ought to allow for notification of "substantial risk" in enough time for the evacuation of special needs, elderly and at risk patients from the areas most likely to be in the path of the storm.


            Emergency agencies, relief agencies and health care agencies in South Florida, like those in most other hurricane-prone areas, do not begin formal preparations for a severe storm until they are notified that a Hurricane Watch has been posted. The Hurricane Watch is usually announced 48 hours before actual landfall. At this point most hospitals begin to initiate their Hurricane plans. Most other medical facilities go to alert and locate their key staff members. All of them begin to make contact with the Emergency Management offices in their area. But little else that involves extra staffing and additional expenditure is done until a Hurricane Warning is issued. Most of the time the warning is sounded about 24 hours before the first effects of the storm are expected to arrive. Because of liability issues, the EOCs do not order a mandatory evacuation of flood prone areas or the gathering of special needs individuals until the Hurricane Warning flags fly.

            Since hospitals and the rest of the health care delivery systems wait until an official Hurricane Watch is issued before they institute emergency plans and they wait until a Hurricane Warning to act, this means they can have no more than 24 hours to execute those plans. The reasons they wait this long have to do with logistics and justifying the cost of transporting patients, closing the facility, canceling procedures and installing shutters.  They want the crisis to be real before they act. But their desire to act only in response to a crisis becomes a self-fulfilling prophecy.  When they wait to the last minute, everything must be done at once and the potential for catastrophe increases exponentially.

            If the National Weather service provided EOCs and/or hospitals and nursing homes with warning information in percentages, then the organizations, corporations and political subdivisions could set a timetable of activity that begins when the risk hits a predetermined percentage. Facilities could and should begin evacuation of at-risk patients and preparations when the risk of danger exceeds 50 percent, for example, although the Hurricane Watch might not be posted for two more days or until the risk reaches 70 percent.




            2.  Hospitals and nursing homes ought to establish relationships among providers and facilities that are hundreds of miles apart. Make them contractual when possible. When possible, designate and exchange emergency teams of personnel in practice drills.


            Power companies and some units of the fire departments have established relationships with their counterparts at substantial distances so that they can receive back-up manpower and material immediately after a storm, in case the devastation is wide spread. Hospitals rely on the next hospital, figuratively just down the street, as if a powerful storm would spare one and take the other. Their plans are based on the false supposition that the hospital will survive without being victimized and will only have to cope with casualties from beyond the hospital community. The plans anticipate an extraordinary patient load and some logistical inconvenience for a few days after the storm. They do not contemplate a total lack of power, water, and staff reinforcements. They have not planned to be victims of a storm, only to care for the victims.

            Emergency Medical Technicians, the power companies and fire departments are quasi-paramilitary in their organization.  Their protocols and chains of command are relatively uniform and consistent wherever they operate.  Medical professionals are, almost by definition, resistant to uniformity, long term planning and the surrender of key decisions to a central authority.

            Nevertheless, each hospital that is not part of a system that extends across several counties, ought to be making arrangements with similar hospitals to swap trained staff who can become familiar with the plant during the down periods then come in to relieve the corresponding hospital staff immediately after a storm. The primary public hospitals, especially those with level 3 trauma centers should be compelled to plan for the exchange of staffs in preparation for the next storm cycle.

            In this remarkable era of mergers and collaborations, systems such as Columbia\HCA can and should play a major role in disaster preparation and organization. Columbia has the resources to grow a half dozen disaster teams among its member hospitals. It has such a far-flung network of acute care and psychiatric facilities that it should be factored into the evacuation plans of hospitals beyond its membership.  And there is no excuse for the for-profit system with their centralized organization to postpone developing an exchange program among hospitals in hurricane-prone areas.  


            3. Modify plans so as to divert volunteers to staging areas far away from a storm area. Assign them task numbers. Do not let volunteers into the disaster area without a task number.


             The story about the Winnebago full of Korean War Veteran physicians that was coming to South Dade hell bent for glory is both true and instructional. Immediately after a storm the needs of the affected community may be great, but they are also specific. The one thing that is needed above all else is order. And the one thing they don't need is extra people to feed, house, direct, protect and indemnify. This is one of those rare cases when it is better to need it and not have it than to have help and not need it.

            Any profession that requires licensing can make it a standard of their code of conduct that members are not permitted to enter an emergency area to practice their licensed skill unless they are first accredited by the agency in charge of accreditation in that area. On the other side, EOC's should set up remote accreditation far beyond the threshold of the affected area. Professionals would be admitted as volunteers only after they are accredited and receive a task number that tells everyone where they are to work, for whom and when.



            4. Plan to be without any food, water, power or human back up for at least 48 hours. Plan to be self sufficient for that long.


            This is self-evident. Even the latest revisions in the FEMA regulations allow for 24 hours before professional federal relief agents arrive, after the locals declare a need for assistance. As we have seen, it is difficult to imagine a serious emergency where it doesn't take the locals 24 hours to complete their assessment and begin to take remedial action. Where there is wide spread damage the 24 hours when the damage assessment is conducted is typically followed by 24 more hours to marshal the manpower and equipment to remedy the loss of basic services and provide emergency power and supplies.


            5.  Consider modifications in the hospital and health care facility's accreditation and licensing standards that include close scrutiny of evacuation plans and transportation arrangements for facilities that are built in evacuation areas.


            It is not sufficient for hospitals, nursing homes and congregate living facilities to pass health and safety inspections of their physical plants, alone, when they have been built in flood prone, evacuation areas.

            Licensing agencies and accreditation boards must look at facilities in the context of their location and the amount of effort that will be required to evacuate them when the time comes. They must make sure that the operators have secured contractual arrangements with shelters at appropriate distances and with transportation services that will make them a priority.

            This, of course, is accomplished with much greater need if medical facilities begin their emergency evacuations sooner than the rest of the population.


            6. Require the hardening of all facilities not in evacuation areas.


            It is easier in theory to harden facilities than to evacuate the people who the facilities are designed to serve each time a natural disaster threatens. In fact, instead of school buildings becoming default shelters, health care facilities could be built or modified to perform these functions, solving two problems at once. Tax incentives or some other compensation for the hardening of facilities would be in order.

            7. Restrict the construction of new health care beds in all evacuation areas unless the facility can prove it has the resources to evacuate all of its potential patients.

            This is a difficult suggestion. All of the populated areas of Monroe County are in mandatory evacuation zones, for example. This would mean that hospital and nursing home construction would be curtailed in Monroe unless extraordinary evacuation plans were documented. Local decision makers should decide if this is as it should be.

                        8. Develop a mental health component that begins with search and rescue that follows through for at least a year beyond the date of the storm. Make it neighborhood-based and integrated with the delivery of public assistance and emergency relief.

            The stress of enduring the force of a major storm is sufficient to trigger latent mental health problems in much of the population, where latent mental health problems exist. The statistics show us clearly that violence, substance abuse, psychosis and suicide increase dramatically in storm affected populations. In South Florida we learned also, that those who endured the storm well were often brought to the brink of mental health crises by the continuing sequence of frustrations attendant to seeking food, shelter, insurance settlements, contractors and a decent place to stay in the mean time.

            The South Florida team put a mental health specialist in with its social service workers who called on storm victims and made expedited social services a component of mental health, much to the satisfaction of everyone involved.  The State of Florida, however, ended the process prematurely and made little effort for follow through, plunging victims whose expectations had been raised, back into the morass of despair. The system for social services and mental health should be looked on as totally interconnected, community based and ongoing long after the storm episode is past.


            9. Consider that transportation is an essential component of the public health and mental health delivery system post-storm.


            For the indigent population it makes no difference how quickly storm aid arrives unless there is some system for access to the centralized locations where it is provided. Jitneys operated by multi-ethnic drivers worked extremely well in South Dade. The jitneys ran with no cost to the riders on a fairly regular schedule. They went the places the population needed to go. And, almost as importantly, the drivers became messengers of the system, warning of changes in locations and operations, spreading the word as things got worse, or better.  This was done ad hoc because Jamaicans, Haitians and Latins dominated the jitney business--both legal and unlicensed-- in South Florida. These people had no formal training as facilitators and no formal system was established for them to notify public health officials what they were seeing and hearing as they travel beyond the front lines of the relief effort.

            An opportunity to provide these people with base line skills and a system of communication with public health authorities is, I think, a worthwhile idea.

            10. Create four sets of emergency-era standardized documents: One that can be used at every venue to track the care provided to each individual entering the emergency health care net; one that can be used for procurement in the rescue phase; one that can be used to request FEMA funds and one that can be used for reimbursement for out of pocket expense at any time during the process.

            It doesn't have to be four sets. But the idea is that there needs to be a standardization of the paper work that recognizes that storm victims who really need help probably don't have much of the usual documentation available, nor will they be able to get it.

            Likewise, agencies that are afflicted by increased demand from a storm will have less time to prepare requests and grant applications that they might when there is no storm.

            11. Advancements in radio telephonics have opened a new set of wavelengths. While this system is in the development phase and before all frequencies are assigned, set up one standard frequency or set of frequencies for all emergency communications, nationwide.

            The most glaring deficiency in the South Florida experience after Hurricane Andrew was communications.  Southern Bell's wire system collapsed, overcrowding the wireless telephone system. Each emergency organization operated on a different wavelength, both figuratively and actually. Citizens' band transmissions were impossible because of the traffic jam. Only short wave communications worked well. But short wave operators are geared to speak long distances, not within a region. And they too need a power supply.

            But technology has made it possible to tune radio telephonic equipment with greater precision. And, with an infinite number of points on a line, there is a prospect that several of these points could be set aside solely for emergency communications. Then each and every organization needing to send or receive information could purchase communications gear attuned to these frequencies. Some could be set aside for broadcast only, others for two-way communications. Call it the information sidewalk.