Vol. 17 Issue 18
Providing home care services in an environment with a damaged infrastructure
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has placed a growing emphasis on patient safety. Living in South Florida, where hurricanes pose a threat annually from June 1 to Nov. 30, we can relate to JCAHO's concern with disaster preparedness.
On Oct. 24, 2005, Broward County and the city of Fort Lauderdale were hit by a storm called Wilma. It had been forecast to strike as a strong tropical storm from the "favorable" west side of the city. The forecasters were wrong.
Wilma hit as a strong category 2 storm that spawned tornadoes and crashed through a number of high-rise apartments on the beach. This article will look at the preparations beforehand and the challenges dealt with in the week after the storm.
Preparing for the Worst
As a PT who relocated to Fort Lauderdale from New York City, I had been in the area working with Holy Cross Hospital's Home Health Agency for less than one month when the storm hit. Luckily, I had just undergone a thorough two-week training, which included storm preparations. All the information was fresh in my mind.
Upon admission, Holy Cross Home Health clients are triaged into an acuity level one, two, or threewith "one" having the most needs and "three," the least. Case managers also gather information on whether clients live in an evacuation zone, what they would do if a storm was imminent, who outside the home would be the emergency contact and if they would consider a special needs shelter.
Clients are provided with information about emergency planning, evacuation possibilities, local phone numbers for assistance (e.g., American Red Cross, Hurricane Hotline) and a checklist of appropriate actions, supplies, foodstuffs, stocks of medicine, batteries, flashlights and anything else that one might need to survive independently for up to one week. When word of an approaching storm is received, acuity levels are verified and patients are contacted and reeducated about necessary preparations.
A Powerful Punch
For the week before Wilma, as the storm stalled over the coast of Mexico, the staff followed the appropriate protocols. I personally educated all of my patients on how to prepare and confirmed the emergency contact information and plans for when the storm would hit the area. One factor that the agency had no control over was hurricane "fatigue." South Florida has been threatened multiple times and was nearing the end of the storm season. Many people did not take the situation seriously. Many took few, if any, precautions.
The storm hit on the morning of Oct. 24. For about six hours, the winds raged over the city and tornadoes swept through the beach communities. At 6 p.m. I left my niece's house and returned to my condominium. I was not prepared for what I would see.
I had practiced in New York City at the time of Sept. 11. Although it was a devastating blow to the city, most of the city's services continued to function. There was phone service, power, water and transportation. While Wilma's death toll paled in comparison to that of Sept. 11, the effects of the storm were far-reaching. More than 3.2 million Floridians lost power, and the economic effects of the storm continue to be felt.
We've all seen the images from Louisiana after Hurricane Katrina. The city of New Orleans was so badly damaged, it was rendered uninhabitable. The primary goal was rescue and evacuation. In the case of Wilma, services had been stopped, but the situation didn't warrant evacuation of an entire city. The work of home health had to continue.
Driving home that day was a challenge as there was debris everywhere. Trees, roofs, power lines, signs, and various other remnants covered the roadways, making the two-mile trek a long obstacle course. There were no stoplights. They had blown off of their wires. Intersections were turned into four-way stops with seriously compromised visibility. When I returned to my condo, I found the roof that used to be on our building had destroyed cars in the parking lot. Our community pulled together to collect debris and we all collapsed that evening without lights, phones or water.
One Day at a Time
On Day One after the storm, the roads were not safe to travel because of debris. Holy Cross Home Health Associates had contact among ourselves as we all had been supplied cell phones with a common carrier. The clinical director informed us via a broadcast message that we should try to contact the patients we were case managing. I was able to contact half of my clients and they informed me that although uncomfortable, they were safe. The other half had phones that were out of service.
The remainder of the day was spent cleaning and removing storm shutters. When darkness fell, flashlights were necessary to negotiate darkened stairwells and apartments. I wondered what my clients who lived in houses with storm shutters in place, which didn't allow sunlight in, would do in perpetual darkness. Most would be unable to remove the shutters themselves.
On Day Two after the storm, our director again informed us that it was too dangerous to conduct regular business and to keep in contact with our clients as much as possible. The same people responded that they were alright, while the others were still without phone service.
I walked about my neighborhood to survey the damage and had a whole new appreciation for the Red Cross' instructions to check a scene first. Power lines lay hidden under uncleared debris. Tree limbs that had been hanging by a thread would crash down when struck by a breeze. Broken glass and sharp metal were everywhere. We remained without power, water or phone service.
On Day Three, we were cleared to see whichever clients we could reach. Driving continued to be a challenge as one had to dodge debris, conserve gas, negotiate checkpoints at closed neighborhoods (my hospital ID would grant me access), and figure out new routes as many roads were impassable. Not only were there no stoplights, but no street signs either. This was a particular challenge for someone who had only lived in the area less than a month.
My first two clients were at home with family and sufficient food and water. One even had power. My third client, however, was my biggest challenge in the storm's aftermath. I pulled up to the 20-story building on Pompano Beach to find a structure that appeared to have been attacked with missiles. Holes dotted the building.
I was grateful the building had a working generator for the elevator as my client lived on the 18th floor and I wasn't looking forward to climbing all the way up. This was a client I had not been able to reach by telephone so it was important that I confirm he was all right.
When I reached his floor, I was greeted by sunlight. This was odd as there were no windows on this floor. I found that the storm had completely blown out an apartment, knocking it through the hall and out the back of the building. Only empty space existed where once had been a two-bedroom home. My client lived next door to that apartment.
He answered the door, disheveled in his pajamas. He was agitated and confused. The apartment was soaking wet with water pouring in through the light fixtures and mold already growing up the walls. He had existed on three cans of Ensure for three days. I had to get him out of there.
Holy Cross Home Health had set up a command post at the hospital, where there were working phone lines and generator power. My clinical director and nurse supervisor worked with me to find a nursing facility that was intact and had a bed where we could place this gentleman. I had to convince the client that he had to leave his home. After helping him clean up and pack, I secured his apartment as well as possible and called a cab to take him to the nursing facility.
It took four hours of dropped calls, pleading, educating and coordinating to get this man on his way. The most difficult and time-consuming task was getting the taxi. Many cars had been destroyed and the transport services were extremely busy. Consequently, they had used up much of the available gasoline. Our executive director had to call the cab company and convince them to take the client.
I would not have been able to place this client if not for the teamwork of Holy Cross Home Health. I was able to see a total of five clients that day. It was getting dark by the time I got home and I didn't want to try driving on streets littered with debris and devoid of lights and traffic signals.
We were able to keep our cell phones charged with car adapters. Holy Cross Hospital was able to secure a manually operated gas tanker so that we had fuel to make house calls over the next few days. The average wait for fuel at public gas stations was five hours during the week after the storm.
Another challenge the agency faced after the storm was how to record clinical information. Except for trainees like myself, the entire agency is electronic and works off laptop computers. Copies were made of the paper versions of notes and the agency went hard copy for the week.
Eventually, the lights began to come back on, water flowed, phones rang and the streets became more easily traveled. However, many intersections were still without signals two weeks after the storm.
Our patients received the treatment they needed. Only one tripped in the dark of her shuttered home and sustained a minor abrasion. One caregiver even managed manual tube feeding of her spouse as she had been instructed prior to the storm. Of our active clientele, 94 percent were accounted for by the end of the first week and all patients we accounted for by the two-week point.
A major disaster can punch holes in the most well-planned systems. Patients who were clear on staying or going to one particular place had their plans changed by the severity of the storm. One client wound up on the west coast of the state as his refuge of first choice became unlivable. That was also the location of his emergency contact so we could reach neither of them. He returned home two weeks after the storm in relatively good shape.
I believe that Holy Cross Home Health and its patients successfully weathered the storm because of careful and consistent planning upfront, the existence of backup systems in case of primary system failure (cell phones with a common carrier, paper documentation to back up the electronic, voicemail systems to complement the cellular system) and most importantly, committed teamwork with the common goal of caring for our clients.
Two weeks after Wilma, I finally got my power back and was able to enjoy a hot shower for the first time. The positive outcomes of my clients helped me to keep my personal challenges in perspective and enabled me to persevere after the storm.
Dean Metz graduated cum laude from SUNY Downstate in 1992 and has been providing home care since 1993. He currently practices as a rehab consultant in New York City with Visiting Nurse Service of New York, Choice Program and continues to maintain homes in both New York City and Fort Lauderdale.