By Tuesday evening Oct. 30, 2012, a few hours after Superstorm Sandy had flooded and blacked out swaths of New York City, heroic efforts made sure the hospital patients caught in harm's way were safe, but a precious commodity was still in danger.
Volunteers and health workers had already carried bed-ridden patients to ambulances down more than a dozen flights of darkened stairs at New York University Langone Medical Center's Tisch Hospital. Lights flickered out above flooded streets as stormwater crested over the banks of the East River and into basements along the water's edge.
With the infirm en route to medical care on higher ground, William Rom, a professor at the NYU School of Medicine and director of the Pulmonary Critical Care and Sleep Medicine division at Langone, turned his attention to saving lives in the future.
Rom was anxious to rescue more than 20,000 blood samples from the basements of Langone and nearby Bellevue Hospital Center, part of a study spanning more than a decade looking for cancer biomarkers in heavy smokers. The power outage, in addition to shutting down pumps, blowers and elevators, knocked out the freezers preserving the potentially lifesaving samples.
That started a desperate scavenger hunt. "The freezers became available Wednesday morning," Rom explained. The blood samples were brought out to a line of temporary freezers that had been plugged in on the sidewalk on First Avenue.
The research specimens eventually made their way to a more permanent facility on Long Island, but incidents like this starkly illustrated the city's vulnerability to extreme weather and the ad hoc responses forced on New York's medical infrastructure.
Across the Big Apple, five acute care hospitals and one psychiatric hospital shut down due to the storm, leading to evacuations of more than 2,000 patients. Three of these facilities -- Langone, Bellevue and Coney Island Hospital -- suffered power failures during Sandy, leading to evacuations in the darkness amid murky floodwaters.
The most stressful evacuations
Now, with the benefit of hindsight, hospital and city officials are piecing together what went wrong during the storm and are putting their hard-learned lessons to work, reimagining how the health care sector can anticipate and respond to future threats stemming from a changing climate.
For hospitals, one of the biggest issues is figuring out whether to stay or to go. "Evacuating a hospital, at any time, even in the best of conditions in perfect weather, is a difficult proposition," said Ian Michaels, a spokesman for the New York City Health and Hospitals Corp., which manages Bellevue and Coney Island hospitals.
Admitted patients are usually in poor health and depend on hardware like drug pumps, ventilators and monitors. Moving them around creates additional stress that could endanger lives.
The logistics behind an evacuation are also tremendously complicated, because patients need to move to an accepting facility while still receiving the same level of care. Doctors have to coordinate across different hospital administrations while maintaining consistent records, all while subways shut down and the city cowers under wind and rain.
Nonetheless, some hospitals, like the Manhattan campus of the Veterans Affairs New York Harbor Healthcare System, did clear out, anticipating that the risks of keeping patients at the hospital during Sandy would be far greater.
Martina Parauda, director at the VA New York Harbor Healthcare System, explained that the decision to move 105 patients from the Manhattan hospital to sites in Brooklyn came from experience. "We experienced a kind of dry run with Hurricane Irene in August 2011. I knew we couldn't sustain even a few inches of water in Manhattan."
A 'dry run' that probably saved lives
When the storm arrived, a 13-foot wave struck the building and inundated the basement with 5 feet of water, leaving the hospital without power, running water, steam or medical oxygen. However, all the patients were already safe in other parts of the city.
Though Parauda was keenly aware of the facility's vulnerabilities, other officials were also concerned that Sandy, like Irene, would overpromise and underdeliver when it came to storm damage.
"I truly believe Irene gave everyone a false sense of security," she said. "Even as I gave my staff the notice that we're going to evacuate, people were polite but were looking at me like, 'What are we doing?'"
This was apparent at Coney Island Hospital, which wasn't evacuated before Sandy made landfall in New York but had to be cleared once power went out. "I will point out that Coney Island Hospital did evacuate before Irene," Michaels said. "Prior experience did inform current experience."
Under extreme weather, the main concern is failures in electrical hardware, like backup generators, wiring and controllers. In a news conference before the storm, New York Mayor Michael Bloomberg said hospitals were taking extra precautions. "The teams from the City Health Department are at these facilities making sure that the emergency generators are working and that they have backup fuel supplies," he said.
These components are often located in basements or near ground level. "For years, we put generators in the basement," said George Mills, director of engineering at the Joint Commission, an agency that accredits and certifies hospitals. "From a practical point of view, basements make sense."
Generators and other building operations equipment are heavy and noisy, thus relegated to rumbling in the bowels of a building, which often happen to be the most secure in the event of disasters like fire, earthquakes or tornados.
The same goes for the machinery that runs elevators, which are critical to moving patients around in high-rise medical facilities. In hospitals, basements also house heavy medical equipment, like X-ray machines and MRI scanners, as well as servers storing patient records and freezers containing research samples. However, these locations are especially vulnerable to rising waters.
Did backup generators in the basement help?
Some of the afflicted hospitals did anticipate flood damage but were not able to react in time. "The ironic thing is we had built a new generator, but it was not yet commissioned," Parauda said, noting that engineers constructed the new dynamo on stilts and it survived the deluge.
At Coney Island Hospital, engineers shut down the backup generator to prevent damage after water poured in, leaving the facility pitch black for more than four hours. After the storm passed, hospital workers evacuated more than 200 remaining patients and spent five days pumping 10 million gallons of water out of basements.
Officials at Langone now say the hospital's backup generators were not behind the outages at Tisch Hospital. "NYU Langone Medical Center's Tisch Hospital's generators did not fail," Lisa Grenier, director of public relations at NYU Medical Center, said in an email.
"In fact, the generators continued to run and supply power to several hospital floors throughout the storm. Our investigation into the cause of the power outage is ongoing, and it is too early to speculate as to what caused certain floors within the hospital to experience the power outage."
City officials were critical. "The one thing we had not counted on, New York University's hospital backup power, in spite of them assuring us that it's been tested, stopped working, and we're working with them to help move people out," Bloomberg said in a news conference after the storm struck the city.
The storm damage lingered for months, leaving many facilities short of full functional capacity for doctors and for patients. "For our program, we had to spend four months sending fellows to other hospitals," said NYU's Rom. "We met with our program in restaurants and bars and had to conduct interviews in hotel cafeterias."
Now that the hospitals are back online, officials are preparing for the next big event along with gradual changes in the climate. In response to Sandy, the mayor's office commissioned a report in June titled "A Stronger, More Resilient New York." Among its provisions, the document highlights recommendations and regulations for hospitals to become more resilient to sea-level rise, high winds, rising temperatures and storm surges.
A $2B medical bill
Sandy cost New York City hospitals an estimated $1 billion in emergency response measures and will cost at least another $1 billion in repairs and mitigation, according to the report.
The plan calls for new hospitals to be built to withstand 500-year flood elevations, protecting their services by waterproofing electrical hardware, elevating equipment, sealing doors, and building redundancy into heating and air conditioning. Existing hospitals on the floodplain must also undergo retrofits to meet these standards by 2030. The city is offering some support for these upgrades through grants and loans.
"It's really an outstanding plan," Rom said of Bloomberg's proposal. "We're lucky to have it."
Hospitals are stepping up as well. At the Manhattan VA, Parauda said engineers are now looking to increase the height of a proposed sea wall, from 5 to 6 feet up to 10 to 12 feet high, while elevating critical hardware. Similarly, at Coney Island Hospital, officials are lifting the Emergency Department and moving equipment to higher levels. Bellevue Hospital is also investigating options for water barrier systems.
In an interview with Bloomberg Television, Langone Medical Center trustee Gary Cohn said the facility is in the midst of a $3 billion modernization effort that includes resiliency upgrades.
"I am very concerned; a hospital the size and importance of NYU is a mainstay of New York City," Cohn said. "When you are going through a natural disaster, obviously medical care is a crucial component."