Tia Powell, director of the Montefiore-Einstein Center for Bioethics in New York and also an author of the JAMA commentary, notes that Sandy called attention, too, to the dilemma of evacuation – when to stay, when to go and how to decide. There's no national policy or established wisdom, she says.
For example, what to do about obese patients? "Even big, strong men will have difficulty moving a 500-pound person down 10 flights of stairs, and the majority of health care workers are women," Powell says. Some vulnerable patients might be better off sheltering in place, their rooms powered perhaps by a dedicated generator. "Evacuation is risky for patients, really complicated and hideously expensive," she notes.
Expense is a big obstacle to fillingthe gaps in emergency preparedness that remain. Funds dedicated to the government's Hospital Preparedness Program, which supports readiness efforts, have declined from an annual peak of about $500 million in fiscal 2003 and 2004 as the economy slowed and the issue faded from the top of consciousness; grants in fiscal 2013 totaled $332 million. And "so many hospitals are on the financial brink all the time," says Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. "Preparedness efforts are low-hanging fruit when budget cuts are demanded."
The state and local public health situation is even worse, says Hanfling. An annual preparedness report from the Trust for America's Health released in December found that 35 states and Washington, D.C., achieved six or fewer of 10 key public health preparedness indicators such as having enough lab capacity to work 12-hour days, five days a week, for six to eight weeks, as might be required by a pandemic flu. "By and large, there's not a lot of terribly expensive stuff we need to buy," says Lurie. "But there's an ongoing need for training and exercises and knitting together the parts of the health care community."
Back in Joplin, construction is proceeding on a new and more heavily fortified hospital. And if another disaster should befall the community, Manley says, staffers will be even more prepared. The readiness plan has been revised to reflect the experience of those who worked through the tornado. Next time, patients moved into the hallway will have their shoes with them, in case the need again arises to maneuver through rubble and glass on the way to safety.