How can we be prepared for emergencies?

I read with interest the article in the NY Times magazine about decision making at Memorial Hospital during Hurricane Katrina. See the link at the bottom to the article. It describes the long series of events that occurred after Hurricane Katrina that led to the deaths of a large number of patients, many of whom were not expected to die.

Who and what else is involved in the wrongful deaths? We might consider:
-prior administrators had decided not to pay for the cost of improving the electrical system so that flood waters would not cut power completely
-officials who allowed the circumstances that lead to the floods occurring in New Orleans (including our overall lack of foresight in building anything below sea level!).
-lack of coordination between the hospital and the LifeCare unit; why would this subunit in the hospital come second to the hospital at large? What was the coordinated disaster plan and evacuation plan for this unit of critically ill people? How had communication ensued that LifeCare could not independently evacuate their patients?
-A lack of knowledge or training related to principles that should be used to carefully allocate resources in the midst of an emergency that is long term. When should such principles be used? Are the most ill evacuated first or last? When would people not be evacuated? What is abandonment in a situation like this? How can workers in the midst of such a great crisis be expected to think logically and make the best decisions? Was this a group think situation, with individuals only seeing one way out of an extremely difficult situation?
-How were decisions made about who was a priority to rescue and evacuate? Why wasn’t more help available to move or transport patients when the hospital staff was exhausted? What was the rationale to send away the helicopters at that point? How could this be better planned for in the future?
There is also a more general consideration, for a different blog... How comfortable are we that every day lethal combinations of drugs are given to people who are at the end of life? Generally this is done to ‘comfort’ the seriously ill in their last moments. Comments by the physicians and nurses do indicate a knowledge that death is hastened in these circumstances. Does this comfort with hastening death make it easier to decide to hasten death in a person not otherwise expected to die immediately yet who is seriously ill?

There was a disaster plan...
-The person in charge, a nursing administrator knew that disaster plan… had authored it, managed work groups to develop it, and implemented that plan during the Hurricane. This is a good example of how difficult emergency planning is. Particularly for large entities. How can we envision every emergency that we would be faced with? How can we know exactly what our deficiencies in planning are, until we are faced with the reality? In this case it could be argued that it is easy to imagine the emergency and sequelae of a hurricane in New Orleans. This is true, but think of all the expected and random events that could occur in such a situation. Generally disaster planning is rather linear. You assume a particular situation and its parameters and decide upon how we can best be prepared for all aspects of that situation and its ramifications. Should the emergency plan have figured out details for evacuation if the streets were flooded? Should the plan have identified what to do if there was a ‘complete’ power failure (and for how many hours or days)?

A problem is that planning probably did not ever imagine the conditions that continued for days in this situation. In the midst of a crisis situation, best decisions cannot be made. Decisions are made based on the information and resources available. It seems to me that in the midst of this terrible, terrible situation, many of the caregivers experienced cognitive constriction. Cognitive constriction is the inability to imagine any other means out of or to resolve a situation. It is a common symptom experienced by those who are suicidal, and is described by Edwin Schneidman (1996) in his book, The Suicidal Mind. It sounds like elements of 'Group Think' are also present.

Now it is easy to see that in the midst of this incredible crisis, that there were many alternatives available. Unfortunately in crisis situations problem solving abilities may not be at their best. Which of course is the reason we plan for disasters.

The article does not tell us how communication or decision making were handled after the initial implementation of the plan. It appears that many were working based on limited or varied information. It is unclear what information offered by individuals involved and reported in the article is presented to protect the providers involved.

Should providers be called into question about decisions made during those long and terrible hours following the floods of Katrina? Absolutely.

Should there be protections for health care providers who do provide care? Absolutely.

I believe there is a middle ground here. Without questions we will never learn from a situation so that we might respond better the next time. We do need providers to feel able to respond without personal risk during a crisis. We also need to learn how to prevent a similar situation from occurring within a disaster.

A harder question is what we as a society expect in the midst of such a crisis or disaster? Most people expect that somehow normal functions of all kinds will resume quickly after a crisis.

What is reasonable in situations of 'chronic' disaster functioning like this?

Here is the link to the NYT Magazine story: http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=16&th&emc=th