All-hazards preparedness

All-hazards preparedness means anticipating how different emergencies can overlap and disrupt the systems people depend on, rather than preparing for each hazard in isolation. During Hurricane Katrina, Memorial Medical Center had an incident command structure and a large collection of written plans, yet the combination of floodwater, failing power, and blocked evacuation routes exposed gaps between documented readiness and practical capacity. The book treats that failure alongside the unequal ability of patients and residents to reach safety, and contrasts Memorial’s experience with preparations and staff practices at Charity Hospital.

From accreditation to emergency planning

The Joint Commission’s emergency-management standards emerged amid growing concern about attacks and mass-casualty emergencies. During the 1990s, disaster experts warned that hospitals needed stronger preparation as incidents including the Oklahoma City bombing, the sarin attacks in Tokyo, and bombings of American facilities overseas sharpened fears of further attacks. Emergency preparedness had previously received little attention in hospital accreditation standards. Hospital executives protested proposed new requirements as costly and unfunded, but the standards took effect in January 2001, before the September 11 attacks.

The standards called for hospitals to establish incident command systems and coordinate emergency plans with the wider community. That coordination mattered because a hospital could not manage a flood separately from citywide failures of power and water. But the standards offered broad requirements rather than a rigorous test of whether a hospital could carry out its own plans. Surveyors did not generally establish whether institutions possessed the resources their plans assumed they would have. Memorial’s May accreditation survey found other matters for improvement but did not identify an emergency-planning deficiency; emergency plans, the account notes, were difficult to assess fully until they were needed.

After the September 11 attacks and anthrax mailings, federal preparedness funding focused heavily on bioterrorism. By 2005, more than a billion dollars had been made available to the nation’s hospitals for that purpose. Memorial’s bioterrorism plan, written after the attacks, ran 101 pages, compared with 11 pages devoted to hurricanes. The disparity does not mean the hospital had no hurricane plan. It shows how preparedness could become shaped by the emergencies that attracted attention and resources, rather than by the full range of conditions a hospital might face.

Memorial’s plans and the risks they missed

Each year, Susan Mulderick convened Memorial’s emergency-preparedness committee to assess roughly 47 hazards on a three-page form, from volcanic eruptions to malfunctioning fire alarms and an undefined VIP situation. The committee used a free template, without hiring an outside consultant, and rated each hazard for probability, risk, and preparedness. The resulting matrix contained multiplication errors. Even so, members rated the hospital’s readiness for floods, power outages, and generator failure as good, the highest category. In retrospect, committee members said they had tended to consider emergencies that had happened before rather than the worst events that could happen.

The hospital’s 273 pages of emergency documentation were divided among 20 separate plans. They did not combine into a workable response to the crisis that arrived. The hurricane plan assumed that generators would function for at least 72 hours, though they had never been tested for that long. The plans offered no direction for a complete power failure or for evacuating patients when surrounding streets were flooded, and made no provision for helicopter evacuation or an arrangement to supply helicopters. Memorial did have an incident command system, but command alone could not supply the missing transport, power, or operational guidance.

The vulnerability was not unknowable. After Hurricane Ivan nearly struck in September 2004, plant operations director Eric Yancovich studied government storm-surge models with the Army Corps of Engineers. Memorial sat three feet below sea level; a major storm and flooding could bring 12 to 15 feet of water around it. On lined paper, Yancovich mapped hospital entrances and outdoor equipment against Magnolia Street. His calculations indicated that less than four feet of street flooding could send water over the loading dock and into the hospital. Although the generators themselves were on the second floor, parts of the emergency power distribution system were at or below ground level. Yancovich warned that limited flooding could disable much of the medical center and predicted that patients might need to move to the newer Clara Wing.

Some protective work was undertaken, including floodgates and a raised vent for underground diesel tanks, but broader improvements were deferred. Yancovich recommended raising emergency-power transfer switches and pumps supplying medical air and vacuum suction, which patients with respiratory problems needed. An electrical-work bid exceeded a quarter of a million dollars; his memo cited lack of capital and left the work for future consideration. The emergency generators could not protect the hospital if the switches and distribution equipment that connected them to clinical areas were vulnerable to water.

A forecast crisis becomes a systems failure

When water news prompted an emergency meeting, Memorial’s plans did not fit the circumstances. The hurricane plan did not anticipate flooding, the flood plan did not anticipate evacuation, and the evacuation plan did not anticipate loss of power or communications. The committee had ranked hurricanes, floods, and power outages among its top concerns, but treated them as separate hazards. The book’s central point is not simply that a particular plan was missing: the plans failed to join up the dependencies that made each problem worse.

That weakness became concrete as the generators failed. The three large generators had been running for two days, although they were designed and tested for much shorter periods of backup service. Memorial’s staff were not generator mechanics. When one engine stopped, workers used water to address overheating and restart it; later they tried fresh diesel and attempted to shift electrical loads. To reach equipment in the electrical building, workers waded into basement water. Roughly a third of the automatic transfer switches were located at a low level and appeared likely to be submerged. Attempts to connect loads from a failed generator to a working one produced signs of excessive current, while the staff also worried that a fire could spread with sprinkler pumps underwater. With no spare parts for another failed generator, repair attempts did not succeed. At about 2 a.m. on August 31, nearly 48 hours after Katrina made landfall near New Orleans, the last backup generator surged and stopped.

This cascade illustrates why preparedness depends on the whole system, not merely the presence of backup generators or a written promise that they will run. Fuel, switches, distribution panels, medical-air and suction pumps, water protection, staff expertise, and the routes by which patients could leave were interdependent. A weakness at one point could undermine the equipment intended to compensate for another failure. Yancovich’s earlier calculations had identified parts of that chain, but recommendations and plans did not produce a sufficiently robust system before the flood.

The city beyond the hospital

Preparedness also depended on resources outside Memorial. When the mayor ordered New Orleans evacuated, many residents had no car or other way to leave, and officials knew the transport plan lacked enough drivers. People who could drive were already caught in traffic. The Superdome was designated a shelter of last resort, and residents with medical conditions were directed there, but the mayor did not specify what assistance they could expect. Acadian dispatchers faced calls to move patients from hospitals, nursing homes, and homes; many of the roughly two dozen available ambulances were stuck on the interstate, and some began taking patients to the Superdome rather than out of town.

A FEMA representative had asked which hospitals in flood-prone areas had placed both generators and electrical switching gear above ground level. Around New Orleans, only two of roughly 18 hospitals had done so; Memorial was not among them. A Centers for Disease Control and Prevention emergency-response leader later reported that about 2,500 hospital patients remained in the city as Katrina approached. That number was consistent with the scenario considered in the Hurricane Pam emergency exercise held earlier that week, which assumed more than 2,000 patients would need protection during a catastrophic hurricane. Yet no workable means had been settled for moving that many people through a flood, and federal health officials had not taken part in the latest planning sessions.

These circumstances reveal how risk accumulated unevenly. A patient reliant on dialysis, oxygen, or other treatment could not necessarily use the same means of evacuation as a healthy person with a car. The traffic jam, shortage of drivers, limited ambulances, and dependence on hospitals made individual escape contingent on systems that had not been adequately coordinated. Later, an outpatient reached Memorial through the floodwater for a scheduled chemotherapy appointment, unaware that the hospital could not provide it. A neighborhood resident who had missed dialysis also made his way there. The hospital had become a destination for people seeking care even as its own ability to provide care and arrange evacuation was under pressure.

Contrasts and consequences

The book sets Memorial’s difficulties against Charity Hospital, which also faced severe conditions: flooding, loss of power and functioning plumbing, failed communications, no helipad, and a large patient population. Charity took until Friday afternoon, September 2, to transfer all its patients, a day after Memorial’s evacuation was completed. Despite having approximately twice as many patients across its two campuses and a lower staff-to-patient ratio, fewer than ten patients died there. Staff continued care in patient rooms, held meetings every four hours, and used a flashlight-lit talent show and other activities to sustain morale. The hospital had drilled for a Category Three hurricane and levee failure and had used federal preparedness funds to acquire portable generators, oxygen-powered ventilators, and a ham-radio system.

The contrast does not establish that preparedness alone explains the difference between hospitals. The account also points to differences in experience, resources, and working culture: Charity staff were accustomed to improvising amid the constraints of a public inner-city hospital. It does show that similar threats could meet different combinations of planning, equipment, coordination, and staff adaptation. Preparedness was not a document or a rating; it was the capacity to sustain care and adjust when assumptions failed.

After Katrina, reviews of the disaster identified failures at many levels, including delayed evacuation, insufficient buses and drivers, uncoordinated rescue efforts, communication problems, and hospitals and nursing homes that had not evacuated before the storm or invested in robust backup power and water. The later scrutiny of Memorial’s plans sharpened the distinction between meeting accreditation requirements on paper and preparing across hazards in practice. All-hazards preparedness, as the book presents it, is therefore both a technical and institutional problem: it requires realistic attention to connected infrastructure and transport, coordination beyond a single facility, and plans tested against the conditions people will actually face.