Daved van Stralen, MD, FAAP, Sean D. McKay, Thomas A. Mercer, RAdm, USN (Retired)
Abstract
NICU preparation for a hurricane includes evacuating or sheltering neonates, agreements to transfer neonates, communication, and emergency transport systems to move neonates to safer ground. Under-represented are identifying the skills and capabilities to support a neonate for hours, if not days, in an austere and adverse environment. The successful operations that sheltered and evacuated 235 neonates with only two deaths and no adverse events recorded are under-recognized. Such accomplishments came about from the actions and improvisations of local Neonatologists and NICU staff who extended an ordinary workday into the consequences of major hurricanes.
Introduction
Hurricanes have a measurable intensity with a predicted path that winds of hurricanes cause severe damage, and the storm surge floods low-lying areas, damaging structures and disrupting road travel. Power is lost. It would seem prudent for us to evacuate the NICU early when transporting infants is safer. However, we do not. Hurricanes are extreme environmental forcing events that bring severe, abrupt change to the NICU and regional healthcare system. Disasters as external ‘’forcing functions’’ alter the qualitative nature of the dynamics of a system (1). At the same time, disasters expose deep weaknesses in the system and reveal latent, under-recognized resilience, adaptability, and strengths. These forcing functions destabilize the internal environment of the NICU and the regional healthcare system. Each everyday problem thus becomes a new problem.
We can more accurately describe hurricanes as developing from ambient, continuous stochastic noise. Hurricanes as entropic, stochastic forcing functions drive unpredictable external environmental influences into the organization. The resulting destabilization challenges the reliability and safety programs we have in place — even as profoundly embedded problems initiated by the hurricane begin to form. Problems become contextual, resolved more effectively through local actions and pragmatic solutions. During the hurricane responses described in this article, neonatal staff self-organized to engage and contain problems while ensuring care for their neonates.
Routine, adaptive operations can suffice for disaster responses. We do not need to make any special distinction between normal environmental variation and catastrophes; they are the same thing experienced at different scales (2, 3). Operators in dangerous contexts seek the necessary capabilities for likely threats, particularly capabilities they can generalize to unforeseen threats or that will extend operations into novel situations (4). Disaster response, like routine operations, is about accuracy and responsiveness rather than belief in concepts (5-8). We observed how operations segued without transition during the hurricane responses described in this article.
Context occurs within a topological space. The strength of connections derives from the strength of the relations between elements rather than physical proximity or externally developed rankings. Topological elements maintain their connectedness despite deformations (9). An administrative approach will more likely assume a Euclidean space comprised of metrics between elements that act as points, then builds from academic models based on logical categories, scientific theories, and compartmentalized knowledge (10, 11). Euclidean structure provides the necessary structure and operations for plans and planning. However, the resulting rigidity displays fragility within environmental forcing functions (2). The genius of these effective neonatal operators during hurricanes was their use of topological relations for adaptation to hurricane forcing functions.
The convergent problems solved, the different frames of reference used, and the points of view each person held that contributed to the decision are absent from public exposure. These contributors are unaware of the effects of thinking while acting, the topological nature of decision-making in context, and the influence of contextual thought and actions (6, 12, 13). When removed from the intimate context where these decisions are made, deciding whether to evacuate or shelter becomes an abstraction; we can discuss and evaluate such decision abstractions from a distance, using what ‘’we’’ personally would have done as our standard for judgment.
“During a crisis, there is no time to think about each specific bit of knowledge or experience that we depend on to make sense of imperfect information and ambiguity. But having those resources immediately accessible in our minds, we use them in a conceptual decision-making process to frame the decision. We essentially quickly come up with a paradigm of how to solve the problem. It is after the fact that we retrospectively begin to attribute specific reasons for the decisions that we made. “
Capt. Chesley “Sully” Sullenberger (personal communication)
The last sentence of Captain Sullenberger’s quote bears repeating, “It is after the fact that we retrospectively begin to attribute specific reasons for the decisions that we made. “
Rather than discuss the elements and processes of evacuation decisions versus sheltering decisions, the pros, and cons, or the risks and benefits, we have extracted the experiences and actions taken by operators during various hurricanes that have been published in the medical literature. We then collated the material, grouping experiences into the hurricane environment, initial emergency engagement, the sensory environment experienced by participants, rapidly improvised hurricane operations, neonatal care during the hurricane, the decision to evacuate and the evacuation itself staffing, and problems encountered.
We will interpret these behaviors and activities through the lens of High-Reliability Organizing, our discussions and interviews conducted over decades, diverse academic concepts, and personal experiences. Participants dealing with an emergency will not know the reason they acted how they did with accuracy or precision. They do know what they did and the results of their actions.
We reviewed published accounts containing first-person experiences (14-20). From these articles, we extracted and collated the actions and words of participants. Rather than listing models and tools that the participants stated they had used, we describe how they used the models and tools. This follows James P.Spradley’s description of culture – how people use social knowledge to interpret the world (21).
People use social knowledge to enact future states (22), critical processes for an event that abruptly collapses our sensemaking (23). An outsider looking at the actions described in this paper could easily arrive at an “I would not have done that” response. This is not hindsight but a thoughtful discourse to reach an effective conclusion. What that approach lacks, though, is one of the necessary High-Reliability Organizing (HRO) values identified by two of the authors (DvS, TAM) as necessary to make HRO operational (24). “That could be me. “
Despite their unpredictability, hurricanes present similar challenges as other disasters: the decision to evacuate or shelter, the evacuation itself, and providing medical care during and after the hurricane. As long as an obstetric patient remains in the hospital, the NICU cannot close and must retain staff for possible admission to the NICU.
Evacuation and Sheltering
Timing for evacuation currently rests on opinion. Not evacuating early enough has led to criticisms. However, there are no published accounts of a NICU evacuated before a hurricane and later receiving consequential structural damage to that empty NICU. Such an occurrence could help with a cost-benefit analysis of preventative evacuation. There are also no published reports of neonatal death during or after an evacuation. We have reports of two neonatal deaths in the NICU during a hurricane (14, 20). Hypothermia contributed to one death in a NICU that could not be evacuated. The other death cannot be attributed strictly to environmental effects or if the infant survived evacuation. We do not know if the paucity of NICU deaths due to a hurricane is from the capabilities of healthcare providers or the low number of such events. The timing of evacuation in a dangerous situation of continuous change is deeply contextually dependent. Consequently, the organization becomes exposed to criticism from spectators and outside reviewers.
Criticism, to some degree, addresses deviations from a norm or standard. As part of classification systems, standards reflect agreed-upon rules, serve more than one community, and are used to make things work together. We create classification systems by removing contextual characteristics from the situation. Such abstraction then allows comparisons and standardization (25). Slowly changing environments with slight variance provide stable contexts which make ‘’abstractionalization’’ possible (26). These stable contexts, through these abstractions, are then amenable to the creation of a proper conceptual order (26, 27) from which we create standards by which others must abide.
What makes these environments stable is the minimal effect of external forcing from stochastic environmental noise. ‘’Noise’’ in this context refers to random or stochastic variation in the environment (3, 28). In this sense, noise is graphed as the inverse of its frequency against the power of that frequency to form a power law (29).
- White noise environments, like the white noise used to cancel background sound, occur from an equal and independent representation of all noise frequencies. Events in white noise environments are purely random, without temporal correlation, because no frequency dominates (3, 28).
- Brown noise represents randomness, named after Brownian motion.
- Red noise, named after the low frequency, longer wave lengths of the visible spectrum, describes rare, low-frequency events. However, red events have a more significant influence on the system because they also have a greater spectral density (3).
- Pink noise is a particular frequency (1/f) that lies precisely midway between the predictability of ‘’organized’’ white noise and the randomness of brown noise. The variance of pink, or 1/f-noise, differs from other red-spectrum noises in that variance continues increasing regardless of the length of the measured time series. That is, pink noise events are sudden and extreme (3).
Fixed standardizations and classifications function most effectively in environments with limited variance, where increased information (data) will decrease the variance of the data and reduce uncertainty. Information in these environments acts to reduce model-parameter uncertainties, which are ‘’information sensitive’’ uncertainties from imperfections of the model (Bob Bea, Professor Emeritus, Civil Engineering, University of California, Berkeley, 8/8/2007, personal communication, (30)). Collecting more information reduces uncertainty and measured variance, much like creating pieces for a puzzle that can be completed (31). The characteristic of limited variance creates white noise environments that are stable over decades (2, 28).
Reddened or pink-noise environments are information insensitive. In fact, more information (or data) makes the data messier or reveals covert, unexpected influences. We operate more in a mystery, searching for and testing clues using a full spectrum analysis (31).
If viewed as powerful forcing functions in a ‘’pink noise’’ environment, hurricanes are abrupt, uncommon systems in flux – rapid, continuous change that we must make sense of (see below). This means abstracting continuous change into fixed, discontinuous concepts (26) that we can use for standardization and comparison. Nevertheless, continuous abstract change into fixed discontinuous concepts creates conflict between theory and practice, the concrete and abstract, imagination and reality, belief, and action (6, 26, 27, 32, 33).
Extracting environmental cues to fit our abstractions makes conflicting interpretations possible (26). Cues in a stochastic environment are ambiguous and in flux. We risk selecting evidence and interpretations for their plausibility, constructing a world that, while supported by evidence, is not true. This is the danger of ambiguity and abstractionism – later events show we were wrong (34).
Drawing out the extraction of cues to support action, often to be right or at minimum to not be wrong, moves individuals outside the details of the situation, transforming them into spectators (27). “When an abstraction is compounded in the direction of formalization, updating and reconstitution become secondary, and the system becomes vulnerable” (26). We have achieved logical classifications and created standards for the normative stance. We have lost context and the pragmatic stance, increasing vulnerability (6, 26, 27).
Forcing functions appear during routine operations. It is through routine operations that we first engage.
The Hurricane Environment
For those who do not live where hurricanes are common, an appendix explains hurricane terminology for the events and threats during a hurricane. Below is an abbreviated glossary.
Hurricanes, generically ‘’tropical cyclones,’’ are symmetrical, rotating weather systems with a warm core that gain energy from warm ocean waters. Hurricanes, typhoons, and cyclones are regional names for the same type of storm:
Hurricanes – North Atlantic; central and eastern North Pacific
Typhoons – western North Pacific
Cyclones – South Pacific and the Indian Ocean
Extratropical Cyclones develop when a warm-core, symmetrical hurricane moves to higher latitudes (lower latitudes in the southern hemisphere) and encounters a frontal weather system (air masses differentiated by temperature or pressure). The cold air mass surrounds and distorts the hurricane, altering its direction and dangerously increasing its variability.
Hurricane Damage
Storm damage. From the speed and intensity of the hurricane and the rising water level. For coastal margins, the primary threat is wind, waves, and swell; while away from the flood zones, the major threat is wind.
Water, rain, flooding. Water, not wind, is the biggest threat. Total Water Level = Storm Surge + Astronomical Tides (natural or lunar tides) + Waves + Freshwater Input.
Storm surge is the water level rise above the predicted astronomical tide level. Storm surge is caused by strong storm winds pushing water toward shore. The low pressure of the storm has minimal contribution to storm surge.
Storm tide is the water level rise due to the storm surge and the astronomical tide. While storm surge has no reference level, the astronomical tide does as the height above mean sea level.
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What Helped
Calmness, open-mindedness, tolerance, and improvisation are valuable traits (15).
The hospital command center kept staff informed about the status of preparations and then updated on the progress of the evacuation(44).
Thermoregulation. Several NICUs placed multiple neonates in the same incubator for warmth or to use the proximity for nursing care (16, 20). Solutions utilized included polyethylene bags, chemically activated warming or perineum pads, and skin-to-skin contact using kangaroo mother care if possible (14, 16, 20, 62).
The Process of Lessons Learned
A Lesson Learned process provides realistic, actionable recommendations that cause an organization to improve from the knowledge acquired after an adverse experience. It reduces or eliminates the potential for failures and mishaps or reinforces a positive result. Analytical processes discover what happened and why it happened. By identifying the root causes and remedial or corrective actions, experiences are transformed into best practices and lessons. Expert consultation from subject matter experts (SME) helps the organization understand the collected data to create informed recommendations (78).
A Lesson Learned must connect to a measurable change in behavior. The organization must take deliberate corrective actions from the Lesson Learned to enhance performance (78). Lessons Learned can prepare the organization for the next disaster or improve routine operations to support operations during the next disaster.
We recommend a formal Lessons Learned process with an analysis of the observations, consultation with SMEs, correctional actions, and identified operations of what should be reproduced through training and simulation.
The Lessons Learned
Below, we list Lessons Learned that connect a problem described in the article with a solution that can be acted upon by the Neonatologist.
Thermoregulation
- Supplies – polyethylene bags, chemically activated warming, or perineum pads (14, 16, 20, 62)
- Interventions – multiple neonates in the same incubator for warmth and proximity for nursing care (16, 20); skin-to-skin contact using kangaroo mother care if possible (14, 16, 20, 62)
- Better charting and education on thermoregulation of preterm infants during disaster management (20)
Transfer of neonates (44), a central authority or system to facilitate mass transfers of patients.
Food supplies (15), from experience, it is recommended that each person should bring necessary food and supplies for three days separate from the hospital supply.
Created an organizational structure for NICU-specific disaster management (44):
- Evacuation and surge plans incorporated into preparedness plan
- Coordinated with the New York City Pediatric Disaster Coalition
- Explicitly detailed our NICU Incident Command Structure, which includes the designation of our staff social worker as liaison to NICU families
- NICU-specific evacuation equipment stocked in an easily accessible location
- Disaster plan includes strategic placement of transport isolettes (ground floor)
- Evacuation and power outage checklists
- Simulation center for neonates and vertical evacuation
Conclusion
Deciding when to evacuate a NICU before an approaching hurricane is a judgment outside the authority of the Neonatologist. The Neonatologist can inform authorities regarding the infant’s physiological demands, the capabilities of staff to support those demands, and the adequacy of the physical space. Communicating across various infrastructures created problems common to NICUs. Problems emerged from the lack of understanding of local objectives and missions, and most solutions were local. Boundary objects, vague objects used for shared work by various domains and infrastructures, can become effective methods for communication.
Whether to evacuate or shelter, standard support for neonates was not possible. The published narratives describe Neonatologists and NICU staff focused on the same objectives as before the hurricane, but now the methods to reach those objectives were generated through improvisation.
We do not disagree with efforts to characterize better the risks of sheltering or evacuating, but such arguments may benefit from the inclusion of structural characteristics necessary for hurricanes. While narratives revealed gaps in staff’s mental and physical support and welfare, what must not be lost are the similar capabilities, judgment, and skill for improvisation exhibited around the world.
In nearly all the published hurricane experiences we reviewed, problem solving happened locally. One outside hospital directing evacuation efforts relied on a government agency’s report that all hospitals were empty. They were reached by a text message from a NICU following a circuitous route they learned of an entrapped NICU and hospital. Neonatologists and NICU staff may look to government agencies and emergency services for help, but they must rely on their capabilities and improvisations to save babies.
It is a testament to the care and the evacuation of over 235 infants with prolonged care lasting hours to days that only two infants died. Hurricane planning would be well-served to exploit the ingenuity and dedication demonstrated by the neonatology community for answers about preparing to shelter and evacuate.
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Conflict of Interest: The authors have indicated they have no potential conflict of interest relevant to this article to disclose.