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.

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