College of American Pathologists
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  After Katrina, lessons from lab survivors


cap today

February 2006
Feature Story

Karen Titus

When laboratories in New Orleans began gearing up for Hurricane Katrina’s landfall late last August, no one was particularly worried. Hurricanes are nothing new to the region. As pathologist K. Barton Farris, MD, MPH, medical director at West Jefferson Medical Center, puts it, "We’ve done the hurricane drill almost on an annual basis for many, many years. We camp in our offices for a day or two, the storm passes, electricity and water are restored fairly quickly, and we go on about our business."

Adds Glenda Lee, MPH, MT (ASCP), laboratory administrative director at West Jefferson: "It’s always been more of a near-miss."

Katrina was a near-miss as well, at least in terms of hitting the city head-on. But when the levees broke and the waters began to rise, all bets were off.

Three hospitals remained open during the storm and its aftermath, saved, in one sense, by geography. All three—West Jefferson, East Jefferson General Hospital, and Ochsner Clinic Foundation—are in Jefferson Parish, a stone’s throw from Orleans Parish, where the city of New Orleans is located. Flooding in Jefferson Parish was minimal, in isolated pockets; the bulk of the damage was caused by wind.

But the hospitals and their laboratories were also aided by smart disaster preparedness, as well as an ability to adapt quickly when Katrina blew "normal" hurricane plans to bits.

West Jefferson got its first inkling this storm would be different the Sunday evening before Katrina hit. Sometime between 6 and 8PM , Dr. Farris recalls, the laboratory was told water would be shut off throughout the parish to avoid contamination of the water supply in the event of flooding. "That had never happened before." The laboratory’s main chemistry instruments required ionized water, which couldn’t be made without water pressure. "So before the storm hit we madly rushed around filling up as many containers as we possibly could," he says.

At 5:00 the following morning, the power died. It wouldn’t return for five days, well past the normal 24- to 48-hour outages of previous hurricanes. Though the hospital’s generators kick in during outages, they’re not sufficient to fully power the air conditioning, and temperatures in the laboratory soared to nearly 100 degrees.

Not that the laboratory was unprepared—as part of its disaster plan it had two portable air conditioners of its own "to keep the instruments from burning up," says Dr. Farris. However, the units were soon rerouted to the ORs, since the hospital had only two other portable AC units. With the loss of air conditioning, major instruments were doomed: Two hematology analyzers died, followed by the coagulation analyzers. With the chemistry analyzers, "Fairly early on we made the decision to restrict the menu, and we got down to offering only 10 chemistry tests," says Dr. Farris.

Renell Dore, MT(ASCP), supervisor of chemistry and hematology at West Jefferson, says she spent 10 hours one night on a vendor’s hotline, working with tech support to keep one instrument running. "We finally had to give up. I had never seen a machine die like that before," she says.

Over at Ochsner, the laboratory was starting to have problems of its own.

Ochsner, like West Jefferson, was more than reasonably prepared for a hurricane. "We’d been through the drill before. On every other occasion, it passes by, and the next day everything goes back to normal," says Bobby Rodwig Jr., MD, MPH, chairman, Department of Pathology and Laboratory Medicine.

Like other institutions, the laboratory had its hurricane disaster plan in place. Team A staff—those who would be at the hospital during the storm, typically for several days at most, at which time they would be replaced by team B—was on hand, and spent Sunday in last-minute preparations: checking the phone contact list of staff members, pulling fans out of storage, tracking down extra extension cords, and so on.

Late Monday morning, the hard rains and heavy winds arrived. Dr. Rodwig and his colleagues witnessed siding peeling off buildings, and small satellite dishes from the hospital roof crashed to the ground. Then the electricity went out.

Ochsner has three generators, located three feet off the ground. But one didn’t start; a second one started, then stopped after blowing "some kind of special fuse," says Dr. Rodwig. The third generator, however, was sufficient to power ventilators, critical IV drips, essential lab equipment, and the like. That, too, died at one point.

And then the levees broke.

News of the ensuing disaster reached the hospital slowly. Ochsner’s phone system worked, but since the phone system was failing area-wide, those in the hospital couldn’t reach anyone on the outside. Likewise, cell phones were out of commission. "It became a real problem, because everybody’s dependent on their cell phones," says Dr. Rodwig, noting that the lab’s contact list consisted of cell phone numbers. "We couldn’t connect to any cell phone for two weeks. People couldn’t talk to their families, and we couldn’t talk to employees." The hospital’s Intranet system was functioning, however, since the hospital was able to shift its server, which retained clinical information, to its major clinic, located 60 miles west of New Orleans in Baton Rouge. Spectralink phones also worked, but only within the Ochsner system, and only a handful of key people had them.

Ochsner could tune into one local cable TV station. "We thought we were doing OK. Then we realized water was filling up the city, and people started hearing reports of looting and unrest in the street," Dr. Rodwig says. "It became a completely different scenario for us at that time."

The lab had some 40 to 45 staffers on-site, which included both shifts of phlebotomists, technologists, supervisors, and managers. Alternating the day and night shifts is typically a one- or two-day affair after a hurricane. "But we realized we may be here for days and days. So, we quickly had to write out new schedules, and assign office spaces where people could sleep." Members of the relief team wouldn’t arrive for at least another week; in some cases, they didn’t arrive at all. For 12 days, Dr. Rodwig slept in his office.

The next wave of worries was the equipment. With the generators partially disabled, most of the air conditioning failed. As the week wore on, the laboratory became a sauna. "Lab equipment shuts down when it gets that hot, because it’s all computerized now," Dr. Rodwig says. "So the equipment would go into thermal overload."

The laboratory information system at Ochsner continued to work, although lab staff had to cover computers with tarps when water began leaking through the roof; the room storing the machines also became stifling, so again lab staff were forced to use fans to cool things down.

The city water system was no longer pumping water, either. Ochsner has its own well, which meant staff could flush toilets and take showers. "But it wasn’t water you could drink, and it certainly was not the kind of water you could pump into your chemistry analyzers."

The chemistry analyzer as well as other, smaller pieces of equipment eventually failed, despite every effort to keep them running. Staff opened equipment doors, stacked dry ice, and aimed fans at the machines to keep them cool, a solution that worked temporarily. They also moved lab equipment to the hallway, which they had lined with large fans. "We tried. We were doing everything we could," Dr. Rodwig says.

The heat also began taking its toll on lab workers, who were enduring temperatures close to 100 degrees, with 100 percent humidity. "We were getting less and less dressed every day," is how West Jefferson’s Lee puts it. "People were cutting off their scrubs and running around in shorts." When a donation of shorts arrived at her hospital and she wound up with a men’s pair, "I was never so glad to get a pair of shorts in my life," she says.

All three labs also lost touch with their outside blood banks, which had shut down in the flooding. Late in the week, West Jefferson’s laboratory found another blood source, in Shreveport, La., nearly 300 miles away, which made deliveries to Baton Rouge; the lab had to pick up the blood from there. "That really saved us," says Dr. Farris, noting that the hospital was starting to see trauma cases by this point.

With the phone systems down, the hospital staff at West Jefferson relied on the overhead page system for communication. For several days, says Lee, "We really didn’t know what was going on in the outside world." The parish president had established a command center within the hospital, but information was scattershot and word of mouth. "People were concerned and worried about their homes, about flooding. There was a curfew put in fairly quickly, so no one was able to leave and check on their homes," says Dr. Farris. "There were people who had no idea where their family members were. So there was an enormous amount of stress."

When one of the local radio stations finally re-established itself outside of town, news began trickling in. "Believe it or not, that made things worse," says Dr. Farris. The station was a call-in talk show, which trafficked in wild rumors and news of the unfolding chaos across the river, in New Orleans proper. "At one point, I heard on the radio that armed gangs had taken over our hospital, and were roaming through our halls, and that patients were dying and staff were being chased out."

In fact, the only armed presence was members of the National Guard, who arrived within 48 hours to reinforce the hospital security force. But those were the only outsiders to arrive for days. There were no lawless gangs—but no recovery teams, either. The backup staff would not be able to arrive for at least another week, so the staff at the hospital was split into two 12-hour shifts. "It was 90 miles an hour, 18 to 20 hours a day," says Lee. "You couldn’t sleep much, and you basically went from one crisis to another."

Hearing these stories, it’s somewhat jarring to realize that these are the tales of success. The area’s other 11 hospitals were forced to evacuate and shut down; only a handful had re-opened by late 2005, and some may never return.

None of the three labs found their disaster plans severely lacking. The labs knew equipment could overheat, and had fans and portable AC units to prevent that from happening. Supplies were stockpiled. It knew family members would be spending time at the hospital to wait out the storm, and food, water, and toiletries supplies were laid in. Phone lists were prepared.

Robert L’Hoste Jr., MD, co-director of the Pathology Department at East Jefferson General Hospital, says, "All in all, our laboratory did very well."

The hospitals also relied on lessons gleaned by other labs that had endured similar disasters. "A real relationship with somebody who’s been through it can be invaluable," Dr. Rodwig says.

To further refine their disaster preparedness plans, Ochsner’s executive team had previously visited a hospital in Houston, which experienced heavy flooding during severe rains several years ago. Similarly, Ochsner staff had developed a good relationship with a Pensacola, Fla., hospital hit hard by Hurricane Ivan in 2004. Ochsner assisted that institution post-Ivan, which in turn helped the New Orleans hospital further refine its plans. West Jefferson’s disaster planners had also visited colleagues in Florida, where they learned, among other things, how to improvise sanitation if water pressure was lost, using small plastic biohazard bags stretched across toilets and then placed in a large biohazard container. "That actually kept the facilities relatively clean," says Lee—no small feat given that 2,500 people were holed up in a facility with no water pressure.

What no one seemed to envision were the next stages of the disaster—not when plans failed, exactly, but when they were made obsolete by the unprecedented assault the storm made on New Orleans, its infrastructure, and the surrounding region. The surviving hospitals essentially had to function as isolated, not-so-tiny towns.

That’s why all three labs are reviewing and revamping their hurricane plans. "I think the first plan was designed to say the cavalry would arrive within 72 hours," says Lee. With disasters of this magnitude, however, "it’s not going to happen in 72 hours."

Looking to future disaster preparedness, the laboratories are drawing on lessons from the void, where the best-laid plans eventually made way for improvisation, luck, and sheer persistence.

Help slowly began to trickle in from outside, particularly vendors.

About three days after the storm hit, the administrative director of the Ochsner lab was told there was someone outside the hospital, in a truck, asking to see her. "It was one of our vendors, Biosite," Dr. Rodwig recalls. The sales rep and his wife had loaded an SUV with reagents and small cardiac analyzers, then driven from their home in Mississippi to deliver the supplies. "They drove through roadblocks and everything," says Dr. Rodwig, still sounding a little amazed. The laboratory was able to use the reagents, and it distributed the cardiac instruments to nearby MASH units set up in the days that followed.

Abbott deployed its Architour truck, which contains working chemistry analyzers. "They pulled it right up to the back of our hospital," Dr. Rodwig says. Another vendor, Sysmex, drove up with a truck filled with reagents, food and water, and clothes. "Everyone was wonderful, but the ones who risked themselves to drive here, they really stand out in your mind. Those are some of our best friends, as you can imagine."

Within a day or two of the hurricane, an Ortho rep had two chemistry analyzers sent to Ochsner’s Baton Rouge site. One stayed in Baton Rouge, where Dr. Rodwig’s lab sent some of its work, and the second—an analyzer that doesn’t require a water source—was shipped to New Orleans.

But, says Dr. Rodwig, within the laboratory, it was Abbott’s battery-operated i-Stat point-of-care devices that "saved us." When the lab’s own chemistry analyzer failed, the staff was able to use the handheld devices to obtain sodium potassium, chloride, ionized calcium, and glucose values. "They performed remarkably well," Dr. Rodwig says. These devices can also overheat, so staff kept them in the fan-lined hall or refrigerated when not being used. The lab’s CBC analyzer, made by Sysmex, withstood the high temperatures. The coagulation instrumentation, on the other hand, worked only intermittently.

Given the hit-or-miss performance of much of their equipment, Dr. Rodwig says his colleagues will look closely at devices that are portable and will function under horrible environmental conditions. "Every piece of equipment we buy, from now on we’ll ask, What happens if it loses power, or it’s 100 degrees in the room? That could make us choose one vendor over another."

At the West Jefferson lab, the Beckman Access and LX 20 systems kept running. The lab performed spun hematocrits and offered a limited test menu for three days. And when their two Cell-Dyn 4000 analyzers failed, Abbott arrived, literally, with another solution: Its service reps braved the barricades and curfew to bring two Cell-Dyn 1800s, enabling the lab to do CBCs. The reps showed up about 2:00 in the afternoon, and by 4:30 had uncrated and installed the equipment, performed linearities, and trained Dore before the curfew fell. By 6:30, Dore had written a procedure manual and trained her staff. "Those two little machines worked like crazy, and they did a good job," she says. The reps, she adds, "were the first here, and the bravest."

Preliminary discussions at West Jefferson are focusing on whether to have a set of backup instruments, limited in their scope, that could be used in an emergency. While it sounds like a good idea, maintaining linearities, correlations, and the like on such machines may outweigh the benefits, Dore says.

Vendors did right by the labs, certainly, though revised emergency plans are calling for more communication in advance of the next disaster. "We are planning, in a little more detail, to make sure we can contact all of our vendors and get extra supplies on short notice," says Dr. L’Hoste.

Dr. Rodwig says that in a disaster, labs must "be prepared to decide which reagents you can waste, and the ones you make every effort to keep." Some of his lab refrigerators worked fine but others failed because of the environmental heat, which meant staff had to constantly shift reagents from one refrigerator to another. "We had to make decisions: We’re no longer going to have this; we can’t do this test; we have no chance of doing that test; those reagents will have to be pulled." Reagent supplies were sufficient—with the evacuation of nearly half the patient population and loss of equipment, testing volumes plummeted. "But we want to evaluate which reagents have the shortest half-life, and which ones need specific refrigeration. We need to do that beforehand, and not in a crisis." Backup freezer and refrigerator plans are now in the works. Labs should also know which instruments may shut down, as well as how to move them to cooler areas. His lab intends to purchase additional portable air cooling units. "We need to have those on-site."

Some changes fall into the "things we wish we had done better" category, Dr. Rodwig says. "Keep detailed records of your communications with your employees," he advises. While the lab needed to half staff in the weeks after the storm—the patient population in the city had virtually disappeared—some lab employees contended they were told they could return to work full time. "It’s a human resources issue," he says. "So someone needs to keep detailed records of what you tell everybody, and perhaps track it on a spreadsheet."

Naturally, all three labs are now planning to provide for the long haul, in case they’re again cut off from support staff and supplies. That means having enough toiletries, clothes, food, and water on hand. "You have to be prepared for extremes in weather," says Dr. Rodwig. It also means bringing in extra air mattresses and pillows—Ochsner, for one, did not have enough to go around. Remember, he says, the lab may need to accommodate family members of staff. "We had mothers, we had kids, we had pets." After several days, however, employees had to make arrangements for non-staff to leave the hospital—yet another unforeseen event. "We’re not a shelter. Our responsibility is patient care, and the care of our employees," Dr. Rodwig says. The lab is also trying to figure out how to stage its support team closer to the hospital, so staff can be swapped out sooner. Dr. L’Hoste couldn’t make it back to East Jefferson for a week, though he had planned to return as part of the recovery team within a day or two.

Though Ochsner was able to flush its toilets, the hospital is taking a closer look at backup plans. "So now we want to fill five-gallon containers with water and store them, so we can flush toilets even if our well fails," Dr. Rodwig says.

West Jefferson faced a potential shortage of potable water. When the manager of a local Wal-Mart store, who had evacuated before the storm, heard of the hospital’s difficulties, he returned to New Orleans and "basically gave us all the bottled water they had in the store," says Dr. Farris. "So now we’ll be stocking a different mix of supplies, including distilled water, at least until our well is drilled."

Ochsner is looking at supplying staff with portable lights that can be hung around the neck, which would help light dark areas, keep employees visible, and free up their hands. Such lights would have come in handy, Dr. Rodwig notes, for lab staff—including himself—when they were hand-delivering test results throughout the hospital in relative darkness. Along those same lines, the facility is also identifying key stairwells and fitting doors with master keys.

As this disaster made clear, the laboratory’s fortunes are closely tied with the rest of the hospital. At West Jefferson, the hospital is building a new physical plant. (Originally set to be completed last October, the project was pushed back by the storm, and it’s now scheduled to open in April, still well ahead of next hurricane season.) The generators should be big enough to power the air conditioning, reports Dr. Farris. Likewise, the hospital now intends to drill its own well, to be used strictly for emergency purposes. Another expansion project is now in redesign—post-storm, planners realized it makes sense to move essential services, including the laboratory, radiology, the emergency room, and pharmacy, to the second floor. And the hospital will develop an evacuation plan for staff as well as patients.

Such matters are essentially out of the laboratory’s hands. But at West Jefferson, the hospital’s medical staff is also looking to revamp the mix of physicians who remain in the hospital during a disaster, a matter that involves the lab a little more directly. "Part of that is having the medical staff say ahead of time what tests they think are essential, so if we do have to limit the test menu next time, it can be done in a way other than me being a dictator, which is essentially what happened this time," says Dr. Farris.

Communication, low tech and high tech, has also come under scrutiny. Knowing that cell phones were useless, "We need to get landline information for everyone—well before disaster hits," says Dr. Rodwig.

At West Jefferson, the hospital will now be supplied with satellite phones. And the host for the Web site will be moved off-site, possibly out of state. "That was another problem—people on the recovery team had no way to find out what the situation was here, and what they were supposed to do," says Dr. Farris.

Dr. L’Hoste said being unable to communicate with his colleagues on-site "was the most frustrating thing for me." In the future, the hospital plans to set up a command post outside of the New Orleans area, which can take calls and relay them to the hospital. Another option may be 800-megahertz radios.

Dr. Rodwig says honest communication with employees was one of the keys to maintaining staff morale. He and his managers met regularly with the hospital’s executive teams, who drew high marks from Dr. Rodwig. "Every single person was here—CEO, CFO, treasurer, all the vice presidents, all working in shorts and T-shirts. We met every day, and they said, ’You have got to get this message back to your people: There is nobody outside with guns. We have plenty of water, and we’re trying to get another shipment in.’ Because the rumors were spreading like wildfire," says Dr. Rodwig. "We were hearing that they’re killing people in the street, that women were being raped, that there’s no food, that we’re going to starve, that people on ventilators are being killed. You have to squelch rumors."

He and his managers also had to reassure staff who were experiencing personal losses. "I worked alongside people who couldn’t find their kids or their husband, who knew that their neighborhood was under 12 to 14 feet of water. You have to put on a brave face," he says. "You have to give positive messages, and you have to give a shoulder to cry on." Nor should the lab overlook the importance of morale-lifting activities. "We set up a little room with a portable DVD player, so people had something to distract them when they weren’t working." Indeed, on the many, many pages compiled by the hospital and the lab listing "lessons learned," one item says "entertainment provided by staff." Ochsner has a piano in its atrium, which "some of us went down and played with our little groups," Dr. Rodwig says.

Managers also need to establish routines within the lab. Without environmental services, staff was responsible for keeping the lab clean, removing trash, and so on.

No disaster plan could have taken into account the long-term realities of the post-Katrina world.

Ochsner, which lost $31 million in September and another $8 million in October, is just starting to turn the corner financially, Dr. Rodwig says. It’s back to 100 percent of its business, and was helped by its business interruption insurance, but, like the other hospitals, faces a dramatically different landscape. All are seeing more indigent patients, who formerly were served by hospitals that remain closed and may never reopen.

"We’ve also taken on a tremendous amount of lab services for the community, because so many patients no longer have a hospital or doctor to go to," Dr. Rodwig says. For Ochsner, that now means working with nursing homes and small surgical hospitals that lost their lab providers, as well as patients requiring outpatient blood draws.

Blood centers in the city were also devastated, so Ochsner has partnered with suppliers in western Louisiana and Texas to receive and distribute blood to the remaining hospitals in the city.

East Jefferson had to devise contingency plans for its histology samples. Expecting a fairly quick return to normal, the lab limited its capabilities for the storm—it could perform frozen sections, but not routine cases. "There was a backlog of cases from the week before the storm," Dr. L’Hoste says. A week or two after the storm, patients began calling for their diagnosis or for their slides to be sent elsewhere so they could begin treatment. The lab brought its blocks for cutting to Ochsner, where a histotechnologist remained on-site. It was also several weeks before the lab could resume sending out its esoteric tests, since mail and other delivery services had disappeared.

All three hospitals are experiencing staffing shortages. Ochsner’s lab lost 30 to 40 employees—about 10 to 15 percent of its workforce. The biggest holes were left by low-wage employees, many of whose homes were destroyed by floodwaters. "They don’t have the money to come back, and they have nothing to come back to," says Dr. Rodwig. "We lost 80 percent of our phlebotomists." Although the lab is fully staffed with techs and managers, "We are struggling. We have managers and even physicians drawing blood."

The closing of other hospitals means there’s a large local pool of qualified lab workers seeking employment, and Dr. Rodwig has been quick to replace much of the staff he lost. "But there’s very few people looking for a phlebotomy job," he says. "There’s so much competition for the lower skilled, lower paid employees. They can make $20 an hour in a construction job, or earn a $6,000 signing bonus at Burger King." Dr. Rodwig lost his morgue attendant, who landed a $15/hour job cleaning refrigerators. "We’re going to struggle with staffing. Everyone is. The restaurants don’t have people to wash dishes, so they’re offering paper plates at fine restaurants in New Orleans."

With the major trauma centers shut down, the burden fell to Ochsner and East and West Jefferson, which alternated duties in the months after the storm. And there’s also concern about the medical residency programs in the city, since the two medical schools and their hospitals were severely affected. Ochsner is looking at the possibility of becoming the primary pathology resident training site for the area. "That’s kind of exciting for us," says Dr. Rodwig, "but it’s another big change. We’re just trying to roll with it."

As the labs continue to adjust to change, they can’t help but keep an eye on one more thing: future storms. "We’ve lived through this once, and we did a good job. And we’ll spend this spring improving our plans," says Dr. Rodwig.

"But I’m not looking forward to next hurricane season."

Karen Titus is CAP TODAY contributing editor and co-managing editor.