In Disaster Response, Physician Leaders Must Inspire and Empathize

By Susan Kreimer
February 13, 2018

It goes beyond planning for the worst and hoping for the best, experts say. It requires a “giver” who makes others look like heroes without seeking credit for themselves.

Before Hurricane Irma wreaked havoc on Florida in September 2017, André Hebra, MD, and his team prepared to rise to the occasion. His experience in shepherding hospital staff through tropical cyclones began in 1989, when Hurricane Hugo battered South Carolina, and it instilled the leadership skills necessary for navigating disasters.

hebra

André Hebra

“When you are confronted with these events, you always learn a lot,” says Hebra, chief medical officer and physician in chief at Nemours Children’s Hospital in Orlando.

Physician leaders such as Hebra are responsible for creating a disaster strategy, maintaining operations and supporting staff in any crisis — whether it is sudden or expected, wrought by nature, machine or human. However, true leadership extends beyond planning for the worst and hoping for the best, experts say. There are aptitudes inherent in every successful leader who must navigate any calamity.

The most difficult of these skills might be motivating those responsible for executing the plan. This involves giving value to employees by listening to their concerns, providing accurate and immediate information, and making decisions quickly when unforseen conditions arise — before, during and after the crisis.

Having the right “mindset lays the foundation for everything else,” says Dan Diamond, MD, a national disaster relief coach who directed the medical triage unit at the New Orleans Convention Center after Hurricane Katrina ravaged that Louisiana city in 2005.

In a high-pressure situation, a true leader becomes “an empowered giver” who takes responsibility without seeking credit for making a difference, Diamond says. This person is a thriver, “who believes he [or she] has the power to make a difference, and they put other people first.”

Diamond Katrina

Dr. Dan Diamond (center, standing) coordinates resources while directing the medical triage unit at the New Orleans Convention Center after Hurricane Katrina struck in 2005. In a high-pressure situation, a true leader becomes “an empowered giver” who takes responsibility without seeking credit, Diamond says. | Photo from Dan Diamond

He or she does whatever can be done to make other people look like heroes, “and they don’t care who gets the credit,” says Diamond, of Seattle, Washington. “It’s about serving the people who need to help. … I’ve encountered all types of leadership mindsets in disasters. When leaders put themselves first, it's horrible. The disaster becomes disastrous.

“My team is able to get things done in disaster settings, when the work matters and resources are scarce, because we stay engaged, put others first, and don't care who gets the credit.”

So how does a leader inspire such vigilance needed amid tragedy? It begins with a commitment to involving staff in the effort of creating response plans, then testing those plans through training to build confidence and agility, says Lynne Bergero, MHSA, project director in the Division of Healthcare Quality Evaluation at The Joint Commission, the nonprofit group that accredits U.S. health care organizations.

bergero

Lynne Bergero

“Leaders who value their staff know that their staff are on the lines of patient care, and can see better than anyone where there are risks to patient care and safety from potential emergencies,” Bergero says.

The ability to listen and ask great questions is paramount in leadership situations. Sometimes the issues are not what they seem. There could be underlying problems. And it’s important to "go a little bit deeper to understand what the real issues are,” Diamond says.

Bergero notes that leaders operate on both a functional and an emotional level during a disaster, so they must first recognize that they are only part of a leadership team. “Though they have specific accountabilities during disasters, they need to perform these functions in mutual support and consultation with others,” she says.

Leaders invest in the training, equipment and supplies for an effective response. And they help “build knowledgeable, nimble teams that have practiced together, established understanding and trust, and can coordinate and adapt as the situation, resources and timeline of the disaster evolve.”

Those employees expect leaders to be present during the response period, and to provide clear, accurate and timely information, Bergero says. “Employees do not want to see leaders unengaged or providing conflicting instructions or information about the status of the emergency, response or recovery activities,” she says.

EMPLOYEES’ PERSONAL NEEDS DURING CRISIS

Effective leaders accommodate team members’ psychosocial needs — particularly their own safety and well-being, as well as that of their families and their property — during a disaster, according to the United Nations’ Emergency Preparedness and Support Team.

“The care that helpers provide others can only be as good as the care they provide themselves,” the agency says, adding, “Your goal as a manager should be to reduce the risks of these occupational hazards and enhance the potential for yourself and your staff to feel useful and successful in your roles.”

Beaumont drill

Medical personnel outside Beaumont Hospital-Wayne in suburban Detroit, prepare to receive mock patients during a drill in 2014. Managing an anxious workforce during a tragedy is a formidable task that physician leaders can’t fully prepare for with training exercises. | Beaumont Health

In the Detroit, Michigan area, a 500-year flood in August 2014 delivered 6 inches of rain in two hours, overwhelming the sewers. That imperiled employee travel to Beaumont Hospital in suburban Dearborn, says Cristy Rankin, director of emergency management at what is now Beaumont Health, based in Southfield, northwest of Detroit.

With the hospital’s ground floor, including the emergency center, under 2 feet of water, it was Rankin’s responsibility to come in and help oversee the response. Earlier that evening, 47 emergency center patients had been evacuated in 17 minutes. Flooding and debris prevented Rankin from commuting in her own vehicle, but she caught a ride back into work with a public safety responder.

rankin

Effective leaders accommodate team members’ psychosocial needs during a disaster response. Cristy Rankin, director of emergency management at Beaumont Health in suburban Detroit, says employees would never be required to work during an emergency if the crisis is affecting their personal life. | Beaumont Health

Once there, she learned that a few employees were unable to do the same because of flooding at their homes. It was a small number, however, and didn’t affect staffing levels. “We would never require an employee to come in if they’re dealing with that crisis in their personal life,” Rankin says.

In Orlando, during Hurricane Matthew in 2016, some employees brought their immediate and extended families as well as pets — a dozen dogs, a couple of cats, even a rabbit or two, in total. Facility management staff created a temporary pet shelter in the basement and provided food and water.

Although the animals were monitored closely, it’s a situation Hebra wanted to avoid in the future. He emphasized the importance of allocating all the hospital’s resources toward meeting patients’ needs, so before Hurricane Irma struck, employees were instructed to evacuate loved ones and pets to safe havens.

“It’s really important to think of your family’s safety first,” says Hebra, a practicing pediatric surgeon who worked through both hurricanes. “Otherwise, they wouldn’t be able to function if they just feel like they abandoned their family.”

You can choose to say, ‘This will never happen’ and be minimally prepared, or not at all. You should say, ‘I’m a leader here. We should have a plan.’


Dr. Lenworth M. Jacobs Jr.; trauma surgeon, chair of Hartford Consensus

Managing an anxious workforce during a tragedy is a formidable task that physician leaders can’t fully prepare for with disaster drills. Leaders need to initiate conversations with the people on their team during a noncrisis time about confronting their fears in panic mode, says Ana Pujols McKee, MD, executive vice president and chief medical officer at The Joint Commission.

Leaders also must remember to arrange for mental health professionals — psychologists, grief counselors and hospice partners, faith-based providers and others — immediately after a tragedy, says Bergero, of The Joint Commission.  

This is for employees as well as themselves, who can experience the same risks and losses.

“Heroism saves lives, but it’s not a sustainable plan for ongoing disasters,” Bergero adds. “Some people will work until they drop, but that’s not what we want for hospital staff.”

MASS-CASUALTY EVENTS AND RAISING AWARENESS

Whether on the iconic Las Vegas strip or in a small Texas town, mass shootings are “a ubiquitous problem.” Gun violence can strike anywhere and at any time, says Lenworth M. Jacobs Jr., MD, MPH, a professor of surgery at the University of Connecticut School of Medicine.

HARTFORD CONSENSUS

Four conferences of trauma physicians and public safety experts (2013-16) helped develop policies for enhancing survivability from mass-casualty events. Here are some key findings.

  • THREAT: Acronym reflects needed response to improve victim outcomes through collaboration: Threat suppression, Hemorrhage control, Rapid extrication to safety, Assessment by medical providers and Transport to definitive care.
  • Continuum of care: Seamless integration of hemorrhage control from initial response to definitive care. Process starts with the actions of the uninjured public or minimally
  • Stop the bleeding: Medical training for hemorrhage control techniques is essential — not just for law enforcement and fire rescue, but also for the public.
  • Educating public: Build a national resilience by outlining strategies to educate public to become immediate responders.

CALLS TO ACTION

  • Public: Recognize that the initial response will be from bystanders and minimally injured victims. Design education programs and pre-position necessary equipment in appropriate locations. Education message should include concept of “Run, Hide, Fight.”
  • Law enforcement: Training for hemorrhage control is a core skill. Make appropriate equipment available. Ensure assessment and triage for immediate evacuation to trauma facility. Train to assist fire rescue in evacuations.
  • Fire rescue: No longer acceptable to stage and wait for casualties in perimeter. Response must be fully integrated. Training must include hemorrhage control, triage, and combat and tactical care.
  • Definitive trauma care: Design, implement, and practice plans to handle surge in patient care. Optimize existing trauma systems.

Source: American College of Surgeons

“You can choose to say, ‘This will never happen’ and be minimally prepared, or not at all,” says Jacobs, a trauma surgeon and vice president of academic affairs at Hartford Hospital in Connecticut.

Instead, he suggests, “You should say, ‘I’m a leader here. We should have a plan.’ ”

Under the guidance of Jacobs, the American College of Surgeons, government agencies and medical response groups convened the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events in April 2013. The committee established this protocol just a few months after the December 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut.

As chair of the Hartford Consensus, which advocates that “no one should die from uncontrolled bleeding,” Jacobs lectures physician audiences nationwide about undertaking leadership roles following mass casualty events through the Stop the Bleed campaign, which is promoted by the American College of Surgeons.      

While most mass-casualty events are unpredictable, the onus is on physician leaders to ensure their people are highly aware of the potential in today’s volatile times. In a hospital’s emergency department, where emotions often run high, personnel must be especially watchful for violence against health care workers and patients.

Community assaults potentially can find their way into local hospitals, says Debra Perina, MD, FACEP, FAEMS, a professor of emergency medicine and division director of prehospital care at the University of Virginia in Charlottesville, where a white nationalist rally turned deadly in August 2017.

Signs of looming danger might manifest in the form of clenching fists, loud speech or veiled threats. Physician leaders should do their part to ensure health care workers and security personnel know how to take appropriate action. For instance, observing an individual yelling loudly rather than asking the staff in a normal tone why the wait time is so long should heighten awareness, says Perina, who is a board member of the American College of Emergency Physicians.

“What’s important for all staff, not just physicians, but all team members,” Perina explains, is “to learn to de-escalate situations before they progress to a violent outburst, and part of that training is learning on the continuum where family members and patients are before they turn violent.”

 

AAPL senior editor Rick Mayer contributed to this report.

Susan Kreimer is a freelance health care journalist based in New York.

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