NFPA Journal

IN 2012, AS SUPERSTORM SANDY RAGED over New York City, Sheri Fink hunkered down with doctors and administrators in the command center of North Shore – LIJ Health System, a group that includes 16 hospitals and several hundred physicians’ practices in the New York and Long Island areas. An executive burst into a meeting with the news that New York University’s Langone Medical Center was on the phone; flooding threatened the hospital’s backup power systems, and NYU was in desperate need of ambulances to transport four critically ill babies from its neonatal intensive care unit before the hospital lost power. As North Shore – LIJ figured out how to get the ambulances to NYU, Fink looked on, dismayed — it was all too familiar, a story that repeated itself as health care facilities across the country struggled to cope with one disaster after another, from hurricanes to wildfires to tornadoes.

Fink’s primary point of reference was New Orleans in August of 2005, and the impact of Hurricane Katrina on the city’s Memorial Medical Center. Forty-five patients died at Memorial during and immediately after Katrina, and forensic experts determined that 23 of them had elevated levels of morphine and other drugs in their systems. Twenty patients were deemed victims of homicide — that they had in effect been killed by their caregivers as the flood waters rose, as the hospital’s primary and backup power failed, as the hope of rescue became increasingly remote, and as reports circulated of an immobilized city descending rapidly into anarchy and violence.

Fink was trained as a physician and scientist — she holds an M.D./Ph.D. in neuroscience from Stanford — and later became a journalist. In 2007, she began investigating the story of what happened at Memorial, and in 2009, The New York Times Magazine and ProPublica published her article "The Deadly Choices at Memorial," which won a Pulitzer Prize for investigative reporting. She followed that in September with her book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, a greatly expanded account of not just what occurred at the hospital, but why and how. Six years in the making, informed in part by more than 500 interviews with hospital personnel, patients, emergency responders, law enforcement representatives, and many more, Five Days is a monumental up-close account of a tragedy that defies easy explanation, just as the moral complexities faced by Memorial’s medical staff defy black-and-white categorization.

Precarious Rescues Clockwise from above: A patient sorts through her medication while waiting to be airlifted from a badly damaged Memorial Medical Center in New Orleans on September 2, 2005. A Memorial Medical Center nurse fans patients in the hospital's parking garage as they await helicopter transport. Helicopters hired by the hospital's parent company, Tenet Healthcare Corporation, did not arrive until two days after the streets around Memorial had flooded. A nurse gives a patient water as hospital staffers carry patients up three flights of stairs from the parking garage to the helipad. A patient is carried to a waiting helicopter. Some Memorial staffers wondered if the hospital's decrepit helipad would even be able to support the weight of landing aircraft. A doctor checks a critically ill patient loaded aboard a helicopter for evacuation. Photographs: Brad Looper / Dallas Morning News/Corbis.

It’s understandable why Fink had a sinking feeling as she watched the Superstorm Sandy drama play out around her. "[North Shore–LIJ] had a highly organized, local command center and was offering proactive and robust assistance not only to its own hospitals but also others in the region," she writes. "Yet, incredibly, just as in the lead-up to Katrina, some staff members said they had never pondered or planned for what they would do in case of a failure of the backup plan to the backup plan — a complete loss of power. This was true not just there, but also in many places where I have reported since Katrina. Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond — our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses."

Five Days directly addresses health care codes and standards in only a few instances, but it should be required reading for the industry nevertheless. Fink tells the story of Memorial through a large cast of characters, and in gripping narrative detail; scenes are painstakingly reconstructed to place the reader squarely in the center of the unfolding action. It’s in those details, and in the how and why of the manner in which things went wrong, where it’s easy to see the codes at work, or where they may need to be strengthened to better match the calamity they were designed to mitigate. Ultimately, Five Days is precisely about the effectiveness of the tools we deploy — codes and standards, emergency procedures, testing and training, and more — to prepare for and manage our response to disaster.

To Fink, the prognosis is not good, especially when it comes to electricity, the lifeblood of the health care industry. "I think we have a remarkably vulnerable health care infrastructure in this country," she told NFPA Journal in a recent interview. "In hospitals, for instance, backup generator systems do not have to keep HVAC systems going, which has been a real problem in a number of circumstances I’ve seen, including Memorial. Also, many backup power systems are still geared to short outage events rather than prolonged outages, and this can be an issue for all kinds of health care facilities."

There were a number of possible reasons why Memorial’s backup generators failed, Fink says. That failure was a point of contention in a civil suit brought by patients, relatives, and others against the hospital and its parent company, Tenet Healthcare Corporation, and the precise cause of the failure varied depending on who was asked. Among the possible contributing factors, Fink says, is that the generators weren’t very robust to begin with, and that testing requirements did not push the generators enough to reveal the kinds of problems that could arise during a prolonged outage.

NFPA codes and standards address these issues through a variety of provisions. NFPA 99, Health Care Facilities, for example, requires a Type 1 or Type 2 essential electrical system [EES] for most health care facilities, including hospitals and nursing homes, according to Jonathan Hart, a fire protection engineer at NFPA. The EES encompasses the entire electrical system, from the generator set to the transfer switches to the system’s various branches. NFPA 99 requires these systems to be Class "X" emergency power supplies, where the number "X" defines the minimum time in hours for which an emergency power supply system is designed to operate at its rated load without being refueled or recharged. "There are specific numbers of hours that can be assigned, but NFPA 99 allows for facilities to make that decision themselves," says Hart.

That decision should be made in conjunction with the facility’s emergency management plan [EMP]. The EMP does not require the emergency power supply to be a Class 96, Hart says; instead, it instructs facilities to identify possible resource shortfalls after 96 hours, including fuel, and to plan for ways to mitigate those shortfalls if they are necessary and feasible. In some states, the EMP includes a list of resources such as available bed space at surrounding facilities, the status of fuel deliveries, and the availability of contractors to perform emergency on-site repairs to generators, HVAC equipment, and other systems.

Fink also finds reasons for cautious optimism. She sees more of a national engagement taking place with the concept of crisis standards of care, which addresses questions of how scarce resources can be allocated and managed in a disaster and how we can avoid those kinds of scarcities to begin with. She offers an example from Memorial: Who should be given priority for spots on a rescue helicopter? "There’s no one way to decide who gets a life-saving resource," she says. "There are a lot of different ways to approach that question."

Despite increased engagement with such issues, gaps persist. "Very few of the doctors I speak to know about the work going on in this area," Fink told Journal. "But in order for these protocols to work, there needs to be more awareness, and a more inclusive input in the creation of these protocols, as well as more research on them."

Building a larger sense of awareness, especially around some of health care’s core vulnerabilities, is also necessary if we want to prompt change, Fink says. "I think there can be a desire to diminish the public’s perception that we are vulnerable, and that’s really unfortunate," she says. "It’s only when the public knows what these vulnerabilities are that it will support the kinds of critical investments necessary to fix them — it’s why the places that tend to act, that do make those investments, are the ones that have gone through a disaster and know what the stakes are for failing to prepare. Organizations like NFPA can perform a great public service by engaging the public with these issues."

One of the heartbreaking aspects of reading Five Days at Memorial is realizing that the hospital’s fate, especially the fate of its intensive-care and long-term acute-care patients, was far from inevitable: what happened did not have to happen. Instead, an accretion of circumstances, events, and decisions—the moments Fink captures with such nuance and clarity — gradually eliminated the hospital staff’s options for what to do with its most vulnerable patients.

Codes and standards, Fink says, can offer a strong defense against the circumstances and forces that hobbled Memorial and made it a worst-case cautionary tale. "Ultimately, the mission of health care standards is to protect us when we are most in need," she says. "We should be proud of the standards we have, but we also need to recognize our vulnerabilities. We don’t want to be a country where hospitals collapse in earthquakes. We need to acknowledge the gaps in our emergency preparedness and make the investments necessary to balance fiscal concerns with a commitment to assist the people who need help the most. We need to look at these problems and ask ourselves what we want to be as a country."

Scott Sutherland is executive editor of NFPA Journal.