Lessons in collaboration: New York surgeons look back at Superstorm Sandy

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Flood waters inside the Bellevue Hospital basement.

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Bucket brigade passing fuel at Bellevue Hospital.

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Flood waters outside Metropolitan Hospital.

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Flood waters in the Metropolitan Hospital kitchen.

The damage that Superstorm Sandy inflicted on lower Manhattan, NY, in late October 2012 resulted in an unusual merger by necessity of two of the city’s hospitals: Bellevue Hospital Center and Metropolitan Hospital Center. Guided by lessons learned from the September 11, 2001, attacks and the response of the now-defunct St. Vincent’s Hospital in Manhattan, surgeons and surgical residents at Bellevue and Metropolitan led a synchronized effort to ensure adequate care for patients in both hospitals. Bellevue—located at the south end of Manhattan and founded in 1736—is the oldest continuously operating hospital in the U.S. and one of the premier public medical centers in the world. Metropolitan, founded in 1857, is its smaller counterpart to the north. To mark the second anniversary of the storm, this article recounts the events that took place at each hospital, as well as their collaborative efforts to provide safe care to their patients in a disaster situation.

Sandy hits

Superstorm Sandy began as a tropical wave in the North Atlantic on October 19, 2012. On October 24, Sandy became a Category 1 hurricane in the waters just south of Jamaica. After its sustained winds increased to more than 90 mph that night, National Hurricane Center officials reclassified the storm as a Category 2 hurricane. Shortly after midnight on October 25, Sandy’s winds rose to 110 mph, and by dawn, the eye had passed over the eastern parts of Jamaica and Cuba.

Between October 25 and October 28, Sandy continued northward but declined in intensity and was reclassified as a Category 1 hurricane, then later as a tropical storm. But after passing over the Bahamas and traveling parallel to the coastline of the southern U.S., the storm had again grown, now into a Category 3 hurricane. On October 29, the storm curved westward toward the Mid-Atlantic states and by 8:00 pm made landfall near Atlantic City, NJ, with maximum sustained winds of 100 mph.

Winds circulating around the low-pressure centers of a cold air mass and of Hurricane Sandy began to mix. This interaction pulled part of the cold air mass to the south of the hurricane and turned the jet stream, separating the two systems westward and subsequently drawing Sandy sharply toward the New Jersey coast. After the cold air had wrapped around and mixed with the warm air of the hurricane, both systems merged and effectively transformed the hurricane into a sprawling post-tropical storm.*

Lights out at Bellevue

On October 29, all of southern Manhattan lost power by 9:00 pm, due to a Con Edison power substation explosion. This incident caused the lights in Bellevue to flicker, but its power was quickly restored by a backup generator. As a result, the overhead lights and red outlets worked in the intensive care unit (ICU), recovery room, operating room (OR), and hallways, but the patient rooms and emergency department (ED) went dark and all the elevators were out of service.

Outside, Superstorm Sandy’s wind and rain continued to rage, and the storm surge, which arrived at high tide, rose to an unprecedented 14 feet in New York City. Within an hour, Bellevue’s basement and sub-basement were filled with water from Manhattan’s East River, located just east of the hospital. The retaining wall was quickly overwhelmed. The generator was running on fuel reserves, and the transfer pump was completely inundated with saltwater. Once the cement barriers were breached, the fuel pumps ceased to function, leaving the generator to rely only on its existing fuel stores.

Just before these events, at approximately 11:00 pm, the Bellevue ICU staff met to discuss the situation—Bellevue had just hours of fuel left to power its generators. Physicians and nurses were asked to make lists of critical patients, define the organ systems that were failing them, and itemize the resources they needed. Once flashlights were distributed, critical patients were moved into adjacent ICU rooms where power was still being maintained. Intravenous drips were set to manual and charts were made of their dilutions and rate. Collectively, hospital staff braced for the worst. Communication systems were marginal, with intermittent cell phone service and the in-house phone system working only to call other Bellevue numbers. Communication within Bellevue and between other hospitals, including Metropolitan, became problematic.

At 3:00 am the morning of October 30, the City of New York delivered a diesel fuel tanker to Bellevue. Because the basement and sub-basement were flooded, there were no operational pumps to move the fuel to the 13th floor generator room. Social workers, nurses, medical students, radiology technicians, physicians, and secretaries passed open buckets of diesel fuel up a packed and sweltering stairwell in a human assembly line to keep the generators working.

A Bellevue hospital administrator was able to initiate a 9-1-1 call to request fuel delivery and patient assistance. The call was routed to the closest fire station. The individual who took the call, in turn, passed it on to a fireman who was on active duty in the U.S. Army National Guard, which responded quickly and arrived with a small team to take over the vital task of moving fuel up to the auxiliary generators.

As Sandy finally passed, the sun rose and the flood waters receded, revealing the devastating damage to Bellevue. With no power, running water, or a fresh supply of oxygen, it became clear that Bellevue needed to evacuate the 736 inpatients in the 21-story hospital. As Metropolitan had sustained less damage from the storm, it was well-positioned to help.

On October 30, the critically ill inpatients, ED patients, and dialysis-dependent patients left first, carried downstairs on backboards by medical students and residents. Handwritten discharge summaries and lists of medications were paper-clipped to patients’ gowns as they were carried away by ambulance. At the bottom of the stairwell, triage attendants in red jackets with clipboards took down the names of the patients and the receiving hospitals.

With no “official” evacuation order in place yet, the process of discharging patients that first day was slow. The policy of a “shelter in place” remained in effect while administrators focused on keeping the hospital open and restoring services. Because Bellevue was in its network—the New York City Health and Hospital Corporation (HHC)—Metropolitan Hospital Center issued an “open-door policy” for all Bellevue patients even before the formal evacuation was announced. In fact, it was clear that the administrative process had not caught up to the disaster, which would become a lesson learned for future events.

On October 31, 539 patients were still awaiting triage, including hundreds of psychiatric patients and 80 prisoners. The medical teams were told to triage and discharge any patients remotely ready to leave. As a result, 224 patients were sent home or to shelters without medication because the hospital pharmacy was closed and all clinics were closed to follow-up visits. The remaining patients could not be safely discharged and required transfer to other hospitals. Each medical and surgical team created a list of patients with diagnoses, specific inpatient requirements, bed type, and priority status. These lists were submitted to the hospital incident command center—now a guarded, fortified room bustling with activity. With the Manhattan VA NY Hospital and New York University Hospital already evacuated, Bellevue was the last hospital open in the Zone A flood territory.

More than 36 hours after the power went out, a large-scale evacuation began at Bellevue to move the remaining patients in one dramatic, chaotic day. A vertical hospital evacuation of this magnitude had never been attempted; its success was uncertain.

Metropolitan’s experience

Although northern Manhattan was likely to be less affected than the area along the East River, the Metropolitan administration alerted all staff in advance of Sandy’s landfall and activated the incident command center in anticipation of what was to come. All elective surgeries were cancelled and patients were notified and appropriately rescheduled. Patients who were not critically ill were discharged, and those inpatients who needed care were informed of the impending disaster. By 8:00 pm on October 29, it was fairly certain that upper Manhattan would be hit. All units were placed on alert, and in preparation for the impending storm, all data were backed up, orders and lists were printed, and flashlights and other battery-powered equipment, including cell phones, were charged.

At approximately 9:00 pm on the night of the storm, a partial power outage occurred due to flooding of some of the generators near the East River, although some portions of the hospital were spared. Because no patients were on ventilator support, a quick check of the surgical ICU (SICU) rooms provided assurance that all was quiet and stable. Fortunately, the power outage spared some elevators and the post-anesthesia care unit (PACU), which was located a floor above the SICU. In contrast to the situation in the SICU, across the hall in the medical ICU (MICU), five patients were on ventilator support and in critical condition. The ventilator batteries had kicked in and their respiratory status was stable. Oxygen cylinders were quickly switched with backup at the patients’ bedside. It was imperative that these patients be transported to another unit with enough power to keep the respirators working. The PACU had power, so it was the obvious choice. Two residents from the surgical service who were most familiar with PACU and the nurses quickly rallied both medical and surgical residents and ICU nurses and identified the four MICU patients who needed to be moved first.

Surprisingly, the initial chaos faded as staff began the job of moving patients. Two teams were created—one that would ready patients for transfer and another that would physically move the patients. Each team had a medical and surgical resident, a nurse for intravenous administration, and a respiratory therapist to manage airways. A portable ventilator was used during transfer, with all settings documented before transport. This information was relayed to the PACU team on patient arrival. The PACU team consisted of a nurse and a medical resident. Five patients on ventilator support were transported to the PACU, along with two non-critical adult patients and one pediatric patient. Once in the PACU, these patients’ primary teams took charge of their care. As the elevators were all being used to transfer patients, simultaneous transport of ICU beds, drips, and personnel was challenging, but teamwork made it happen.

In compliance with the disaster preparedness plan, orders and medication lists had already been printed before the temporary outage, and handwritten paper orders were initiated because the electronic health record (EHR) system was unavailable even on the floors that had power. All of this activity occurred as the storm hit Manhattan and as Bellevue was on the threshold of losing power throughout the facility. Metropolitan staff knew that if the hospital maintained power, then they would be receiving many of the Bellevue patients.

As the East River flooding progressed through the night on October 29, the surge inundated First Avenue at 96th and 97th streets and flooded a residence hall and a parking lot filled with vehicles belonging to nurses, residents, and faculty. Metropolitan staff became concerned that the hospital’s generators would be flooded. Fortunately, work performed by Metropolitan’s engineering department and Con Edison protected the hospital’s power supply against this flooding, and the power was back to full capacity as the storm subsided overnight.

Even though the area east of Metropolitan Hospital was flooded, the ED—which is on the ground floor—was unaffected. It is located approximately 50 feet above sea level, which kept that area of the hospital out of harm’s way, and all the patients who arrived before Sandy were accommodated in the ED overnight.

At approximately 4:00 am on October 30, the storm and the floodwaters started to recede. The worst was over, but we now had to face the storm’s aftermath. The parts of Metropolitan affected by the outage slowly regained power, allowing the hospital to return to somewhat normal function within hours.

Metropolitan started preparing for the arrival of Bellevue patients at 6:00 am. Even during the worst parts of the storm, we were in limited communication with our Bellevue counterparts and knew that, if we remained functioning, we would be responsible for many of their patients. The following day, the ambulance bay next to the ED was converted into a triage center and clinic run by medicine and surgery residents, along with medical students, to help the ED decant all of the additional Bellevue outpatients seeking continuity of care. This triage bay was constructed over a period of 24 hours after the storm and served at least 600 patients, allowing the ER to deal with more urgent and critically ill patients.

Evacuation and transfer

Meanwhile, plans were being developed at Bellevue for its evacuation. Patient handoffs were accomplished over the phone between the residents at both institutions, with the chiefs of surgery providing oversight. As a result of ongoing phone calls between the chiefs, select Metropolitan surgeons were granted temporary access to the Bellevue EHR system while hospital employees, especially physicians and nurses, were getting credentialed to work at Metropolitan. Records were transferred to Metropolitan and printed, and it was agreed that 24 of the sickest surgical patients would be transferred to Metropolitan on October 31.

The National Guard provided support for carrying out the evacuation plan. What ensued on October 31 was an organized pandemonium of telephone calls, ambulances, and emergency medical technicians (EMTs), evacuation sleds by the dozens, and approximately 250 men and women in uniform joining medical students, residents, and faculty in an effort to carry patients down as many as 20 flights of stairs. Complicating the process was the simultaneous evacuation of several other HHC facilities, including Coney Island Hospital and Coler-Goldwater Specialty Hospital and Nursing Facility, which decreased the number of available beds. However, Metropolitan had prepared for this possibility.

The command centers at Bellevue, HHC Central Office, and Metropolitan were in constant contact by telephone as these transfers became reality. Conference calls at 8:00 am and 5:00 pm were equivalent to physician rounds and ensured continuity of care and that all facilities were effectively communicating their needs and what they could offer. Despite the chaos and confusion, this process worked, and patients were transferred vertically without any real disruption in care. Throughout this entire process, the chiefs of surgery at Bellevue and Metropolitan were in contact at least three or four times at all hours, and even managed neurosurgery, otolaryngology, and urology services.

It is important to note that EMTs and ambulances arrived from across the East Coast to help move patients, and this extra transportation helped in getting patients evacuated expeditiously.

As the storm subsided, the prisoners at Bellevue were triaged back to Riker’s Island or transferred to the HHC hospitals with an additional temporary male prison unit that was set up at Harlem Hospital. A total of 38 pediatric patients were transferred, the youngest just two days old. Those pediatric patients who did not require hospital care were sent home, while those who did require care were sent to Kings County Hospital Center in Brooklyn. Another 38 patients were triaged from inpatient rehabilitation. The psychiatry department transferred the most patients, a total of 331, who were sent to several HHC hospitals, although most were sent to Metropolitan. The influx of patients to Metropolitan increased the demands on staff. It became clear that staff from Bellevue would need to be deployed to meet this need. Bellevue surgeons and residents were immediately credentialed. Whereas none of the Bellevue surgeons had clinical and operative privileges at Metropolitan, their credentialing paperwork was expedited by the Metropolitan administration. This process usually takes many weeks, and instead was accomplished in hours. This emergency credentialing process had never occurred before in New York City.

Over a 24-hour period on Halloween Day, patients left Bellevue Hospital, an average of one every 3.4 minutes. New York City had not seen this type of medical and surgical challenge since September 11, 2001.

As patients were transferred to Metropolitan, the entire clinical staff of the hospital, under the direction on the chief executive officer and the chiefs of medicine, surgery, emergency medicine, and psychiatry, orchestrated efforts to ensure continuity of care for all of the patients coming from Bellevue while maintaining the same level of care for the patients already housed in the hospital. Medical students, residents, and faculty reviewed transfer notes, and ordered labs and radiologic studies as needed.

During this catastrophe, Bellevue staff attempted to call patient families to alert them to the transfer, but without working computers, reliable phone service, or a functional interpreter system, the task of giving appropriate information regarding transferred patients was impossible and was ultimately given to the medical director’s office to be completed when power returned.

By the evening of November 1, with a Nor’easter blowing in, only two patients remained at Bellevue and neither could be moved safely down the stairs. One had a ventricular assist device and was too critical to move, and the other was morbidly obese. As a result, the decision was made to wait for the Bellevue basement to be pumped out and for restoration of elevator power and service, so that both patients could be moved three days later. These two patients were given extra staff to maintain their safety.

The aftermath

Metropolitan’s admitting department was informed of the transfers, and the patients were admitted to either the SICU or to the eighth floor of the main hospital. The eighth floor at Metropolitan had three inpatient units—A, B, and C. Preceding Sandy, 8B was the only open and active unit, and 8C was used only for respiratory isolation cases. The 8A unit was opened within 12 hours of Sandy to receive all surgical patients from Bellevue. The Metropolitan staff worked day and night to prepare the floors and the rooms, ensure EHR access, and stock supplies in 8A. Many of the patients had critical surgery at Bellevue and were in postoperative recovery in surgical wards but required transfer because they were not ready for discharge. Additional inpatient wards were reopened and Metropolitan’s operating census was close to 100 percent of capacity.

Some of the other patients were nonoperative under the care of the surgery team. The most complicated of these cases included a patient with a partial colectomy and a concomitant liver resection, a patient with duodenal perforation secondary to a motor vehicle accident, and a patient who had a reversal of an ileostomy secondary to treatment of inflammatory bowel disease. These patients were at various stages of recovery at Bellevue, which made the handoffs to Metropolitan extremely important.

With the sudden increase in patient volume, resources were bolstered by the integration of evacuated physicians, nurses, and technicians—especially those health care professionals with operating room experience. Many urgent cases had already been booked by Bellevue surgeons, and these patients were rescheduled and underwent their operations at Metropolitan in the immediate aftermath of the storm. When the famous Bellevue ED reopened, several months before the rest of the hospital, patients seen in the Bellevue ER who required immediate surgery were transferred to Metropolitan and operated on by Bellevue and Metropolitan surgeons.

The remainder of the week was spent assessing Bellevue’s infrastructure, patient care, and resident education needs. In the coming months, Bellevue’s electrical systems were rebuilt, plumbing lines were flushed, and all mechanical devices located in the basements were replaced. The basement and the sub-basement were emptied of infested river waters, the generators were reconfigured, and the entire infrastructure thoroughly cleaned. HHC President Alan Aviles stated that a total of $810 million would be needed to repair the damage to the city’s public hospital facilities, most of which was to be spent at Bellevue—the hospital most affected by the storm.

Over the next few days, many of the patients transferred were discharged with disposition plans because this handoff system was successful. Moreover, several patients who needed surgery underwent their operations as Metropolitan added two ORs for teams of Bellevue surgeons, with the two chiefs of surgery and the two departments of anesthesia organizing the effort.

Within two weeks, Bellevue’s operating teams were using assigned block times in the Metropolitan OR and in the outpatient clinics at Metropolitan. General surgeons and subspecialists from surgical oncology, plastic surgery, urology, neurosurgery, vascular surgery, and otolaryngology were quickly credentialed and performed procedures in two to three operating rooms, five days per week, specifically dedicated to Bellevue patients and entirely staffed by their own surgery, anesthesiology, and nursing teams. Within 10 days of Superstorm Sandy, two separate surgical teams—one from Bellevue and one from Metropolitan—worked in tandem within the expanded Metropolitan perioperative service and departments of surgery. This type of cooperation has never been reported secondary to an emergency event in New York City.

Grand reopening

The Bellevue ER was fully functional within four weeks, and other areas of the facility reopened on February 7, 2013—99 days after it was evacuated. There were balloons, banners, press releases, and smiles all around. Six months after Superstorm Sandy, the hospital had returned to its centuries-old tradition of caring for New York City’s injured and disenfranchised. Now fully operational, the hospital continues to address what went right and what went wrong regarding the preparation, evacuation, and recovery efforts in the wake of Superstorm Sandy.

Since its founding in 1736, Bellevue had never been without patients until Sandy shuttered her doors on November 3, 2012. Against overwhelming odds, the largest-ever vertical evacuation of a hospital was successfully accomplished because two hospitals came together to accomplish what was necessary in order to provide continuous care to patients.

Even in dire circumstances, the staffs of both institutions were resourceful, adaptable, and persistent, working in tandem toward a common goal. Cited by some as a “once in a hundred years” event, Sandy has proven that there is no such thing as over-preparation. The time to ready for the next storm event is now, as we repair, rebuild, and upgrade our infrastructure. More importantly, these lessons have resulted in improvements in HHC hospitals, especially Bellevue, to protect vital hospital infrastructure and be better equipped to treat patients when disaster strikes again.

*National Weather Service: Hurricane Sandy. Accessed August 26, 2014.

Blake ES, Kimberlain TB, Berg RJ, Cangialosi JP, Beven JL II. Tropical Cyclone Report: Hurricane Sandy (AL182012), 22–29 October 2012. National Hurricane Center, 12 February 2013. Accessed August 29, 2014.

New York City Health and Hospitals Corporation, Office of Communications and Marketing. Press release. January 8, 2013. Accessed September 8, 2014.

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