Rae Woods (00:02):
From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae.

News clips (00:11):
The bigger concern, this fire near Castaic, still burning through dry brush. This is Bourbon Street in New Orleans, the city getting eight inches of snow, blizzard conditions near Lafayette, Louisiana. I'm from Florida originally, and I moved up to the mountains thinking, "Oh, I'm never going to be impacted by a hurricane here."

Rae Woods (00:33):
The clips you just heard represent the new reality for health leaders. Disaster preparedness is a top priority for healthcare leaders who must protect their patients, their staff, and their communities from unprecedented disasters. These disasters will only increase in severity and in frequency due to climate change. Every organization must prepare for climate-related incidents. Even if you're a hospital in a mountain town, hundreds of miles away from the ocean, you could experience the effect of a hurricane. That's the story of this week's episode.

(01:10):
On September 27th, 2024, Ballad Health was forced to evacuate Unicoi Hospital because of a freak flash flood caused by Hurricane Helene. Here to tell the story of that day, how it tested her leadership and resilience and what every healthcare leader can learn from this event, is Lisa Carter.

Lisa Carter (01:36):
I'm Lisa Carter, and my role at Ballad Health is Regional President, and so I oversee strategic and operational functions of 10 of our acute care hospitals that are located in Tennessee. Obviously, I have had some difficult days.

Rae Woods (01:59):
I've spoken to Lisa before on radio advisory about a lot of challenges, about working through a big merger, dealing with protesters after making some difficult decisions to close and consolidate, and of course being on the front lines of COVID-19. And yet-

Lisa Carter (02:15):
I can say without a doubt that the hardest day of my almost 30 years in healthcare happened on September 27th of 2024.

(02:28):
I'm ready to share that story of what we went through as a health system, what individuals went through, and what I personally went through as a leader on that day.

(02:39):
So let me tell you about Unicoi County Hospital. It is a ten-bed, one-story hospital. It opened in 2018 in the heart of Irwin, Tennessee. Irwin, Tennessee is a small town in northeast Tennessee. It sits within Unicoi County, and the city of Irwin and the town of Unicoi have an amazing heritage that's deeply connected with the railroad. And so when we built that facility, we wanted to do two things. We wanted to pay homage to the railroad and so much of the design and much of what was featured inside really was around the early beginnings of that town. The other thing that we wanted to do was we wanted to ensure that if you were a patient in any of the 10 beds, that you had a view of the mountains, so it literally sat in a valley around the Blue Ridge Mountains, and you had a 360 degree view of those mountains from any patient room within that facility.

(03:48):
The hospital today, it's basically a shell. It is a shell hospital. The entire area that surrounds the hospital looks almost like a post-apocalyptic movie and unfortunately, is just awaiting demolition.

Rae Woods (04:10):
Even hospitals that are as far inland as this do disaster planning for hurricanes, and Unicoi was no exception.

Lisa Carter (04:18):
One of the things that was different around this time was prior to the hurricane's arrival, we had seen significant rainfall, heavy, heavy rainfall that was a part of a different storm that had moved through the region. And so when Thursday came, we were already looking at some of the water levels in some of the rivers and streams that were present throughout the region, and we were thinking about, "What if the water continues to rise more? Are we going to need to look at relocating certain services, certain areas?" And so those thoughts were being had, but again, lots of conversations with many local agencies and knowing historically what hurricanes do once they come inland, we were planning, but it was planning out of an abundance of caution. We were planning for wind, we were planning for leaky roofs, we were planning for shingles being blown off. It wasn't really conversations anything related to what we saw then that happened on Friday morning.

(05:36):
We knew that there was a river behind the facility when we built it. And prior to the building of that facility, we worked with the Corps of Engineers to come in. And since that time I've learned a lot more about one hundred-year floods and two hundred-year floods, five hundred-year floods. And so really the facility was rated to be around a five hundred-year flood just because of the engineering work that had gone in to build burns around the facility, to guard against the rising river. And so while we knew a river was close by, the actual chances of a flood affecting and waters reaching the hospital would've happened in 1 in 500 year chance.

(06:25):
So I woke up as per usual on September the 27th and started my day. I knew that the rain was coming. I looked out my window, and I actually took a video because the trees were moving really, really violently, and I could tell there was a lot of heavy winds. And so they started about the way that it always does. I had a 9:00 AM regularly scheduled meeting with my boss, and so I had decided to do that at home instead of getting out in the wind and rain at that time. But just a few minutes later that my power went out.

(07:06):
About 15 minutes in, we finally got reconnected just through cellular, and I had gotten a call during that same time from my regional chief medical officer who said that he had been in contact with the Unicoi County Emergency Management Agency, and there was a concern from the emergency management director saying that the water within the Nolichucky didn't look right.

Rae Woods (07:36):
The Nolichucky River flows right alongside Unicoi Hospital, and the emergency management team are heavily involved in understanding how all of the rivers, streams, and lakes throughout the county are looking. And so when they told Lisa that the water didn't look right, that gave her pause.

Lisa Carter (07:58):
When the EMA director made the statement, "The water doesn't look right," our Ballad Health contacts that were communicating with him basically said, "If the water doesn't look right, do we need to make the call to evacuate the hospital?" And his words were, "Yes, we need to evacuate the hospital." So that happened at 9:38 AM, that morning the decision was made to evacuate the facility.

(08:30):
Usually decisions are made based on lots of different data points, based on a series of evaluations and conversations that then determine the most appropriate course of action. This was such a different feel from the people who were there on the ground that there was really no questioning of what the water was going to do or what we should do at that point because when you have someone with 20 plus years of experience around those rivers and streams, and he's concerned about water levels, we knew we needed to act immediately after that.

(09:21):
Incident command was set up immediately, and that was done under my boss, who is the executive vice president and chief operating officer of the system. He had called me back as I was trying to walk out of my door at home and said, "Hey, we're going to go ahead and set up incident command. Why don't you head over to the corporate office?" And so I shifted gears and started to head to the corporate office, and that's when I got the call from our chief medical officer who had been in contact with the emergency management director and said, "We need to evacuate the hospital." So immediately called my boss back and said, "We've got to evacuate."

Rae Woods (10:12):
The on-site team at Unicoi included the regular staff, physicians, nurses, the chief medical officer, and hospital administrator, and a quality coordinator was also deployed. Incident command was located 20 miles from Unicoi Hospital and included Lisa, several other high-level personnel, even the health system's EO and Board chairman.

Lisa Carter (10:36):
So the first thing that happened when the order was given to evacuate the hospital was our clinical command center immediately began working with local EMS and fire department to deploy resources to that facility in order to evacuate the patients. Unicoi County is a small county, and so we knew we had 10 in-patients there in that facility that day, and so they would need support and help from surrounding EMS agencies to pick up patients to transport them to other local hospitals. And so that was step one in the process, and that happened immediately when that evacuation order was given.

(11:17):
EMS and fire trucks began moving to that facility to be on-site to load patients and take them to other locations. Between the time that the evacuation order was given at 9:38 AM and the time that I walked into the incident command center at just a few minutes after 10:00 AM, our chief medical officer, who was on-site at the facility, was already on video phone with our chief communications officer and was concerned about the water.

(11:51):
When I came in, I took over from that communication standpoint, and he flipped his phone around to show me that the water had already overtaken the road where the ambulances had crossed to get to the facility. And he said, "I'm very concerned they're not going to be able to get back across through the water with the patients."

(12:25):
At that moment when we saw the water coming over the road, it still was almost surreal in thinking we had a very systematic plan to get patients out. It wasn't an emergency evacuation, it was a planned evacuation out of what we thought was an abundance of caution. And all of a sudden that mindset shifted to, "This is getting dangerous and is rapidly, rapidly changing."

(13:01):
When EMS arrived, we hadn't thought about a plan B. We assumed that the water would not rise as quickly as it did and that EMS would be able to move the patients as we had planned. Once we realized that the water had moved over the road, and it was unsafe for the ambulances to cross back over, we quickly recognized we needed to move to a next phase of evacuation, which included swift water rescue boats to come in on the scene, use the boats to get over to the facility and move people across the water.

Rae Woods (13:43):
The first responders inside of the fire trucks and ambulances, plan A, were now also stranded at Unicoi and would need to be evacuated along with the patients and the on-site staff. Plan B was a water rescue. Incident command worked with the Tennessee Emergency Medical Association to leverage state-level resources from neighboring cities and counties.

Lisa Carter (14:07):
In less than 30 minutes, the swift water teams arrived. They deployed the boats across the water to the facility. They began loading patients and moving patients into boats. The water had risen so rapidly that now coming down from the mountains was a considerable amount of debris. And when I say debris, I mean trees and vehicles and parts of houses.

(14:43):
Through the video call, we're continuing to see that the water is just rising. It's moving faster, and it's just continuing to rise. And the chief medical officer literally was walking around the building and holding his phone, so we could see the berms that had been built to withstand the rising water, and we saw one of the berms be overtaken by water, and we knew that it was only a matter of time that the facility was going to be breached with water.

(15:25):
As we've walked through so many pieces since then, one of the most profound moments that happened in our room was when that happened, they knew at that point they were not going to be able to get back across the rushing water in the boats, and there was a plea and a beg for life preservers to be delivered at the facility because they were trying to really think about being actually in the water and not being able to get out. And those words have echoed in our minds for so so long of the yells of, "Lisa, please, please get us life preservers."

(16:20):
And that was really hard, hearing that and knowing that was the request was a really hard thing, because the vice president of our supply chain literally got up out of his seat, and he said, "I'm going to go get some life preservers." And we all said, "We can't get them to them. And that was the problem." We could have had all of the life preservers in the world. There was literally no way to get them to them.

(16:50):
The hospital is now actively taking on water. There wasn't a plan C at the time, but plan C unfolded quickly because the water was inside of the building and was rising in the building, and the only plan that we had left was to evacuate to the roof. The issue about evacuating to the roof was that this is a one-story hospital. There's no roof access. And so what had to be solved for was an actual mechanism to get the patients and staff to that location. And we learned really quickly that it was a lot of grace that brought the fire trucks there in phase one because there was a ladder that was taken off of the fire truck and propped on the fire truck to the roof, and that was what was used to climb up to the roof.

(18:00):
We also learned really, really quickly that we were also very blessed to have had the second phase because we had patients who were physically unable to get to the roof, and that was a very difficult decision that had to be made because those patients had to be placed in those swift water boats that had come across and be tethered to the roof so that they could float with staff in those boats tied to the roof as the water continued to rise. Everyone is doing absolutely the best they can do to climb the ladder. Staff who really probably were not physically able to climb the ladder somehow developed the strength to move up the ladder. We had physicians and staff who literally put people on their backs and took them up the ladder to the roof.

Rae Woods (19:01):
Everyone made it to the roof. That includes patients who were floating in boats, tethered to the roof and the staff that were in the boats taking care of them the entire time. And remember, Unicoi is just one story. So these people are only 10, maybe 15 feet off the ground, and the water is rising.

Lisa Carter (19:23):
And what we were thinking was that we really, really needed something to give. We needed the water to stop. We needed the rain to stop. We needed the wind to stop. Since we had made the decision to evacuate to the roof, we had been in constant contact with the Virginia State Police and with the National Guard in the state of Tennessee, and we knew that helicopter rescue was the only thing that was left to get the people to safety. But unfortunately, because of the winds, the helicopters had not been able to take off. And so we were now waiting and waiting for something to break.

(20:08):
We were in contact with the people on the roof for a while, and the worst part of the day was the chief medical officer and the hospital administrator looked at us and said, "We're going to sign off now. Let us know when the helicopters are coming." And that felt like such a defeating moment because they knew there was nothing else that we could do, and we knew they had absolutely done everything they could in that moment.

(20:47):
And so I know now what they did on that roof. They were actually calling their families to tell them how much they love them, to tell them what was going on, to tell them bye. And they wanted to spend that time in conversation with their families.

(21:10):
The entire room at incident command felt 100% helpless because a room full of people who make things happen and who can overcome challenges and who can find resources and who can make phone calls, were literally watching the windows to see if there was going to be a break in Mother Nature to give us some sort of hope to get people off of the roof. We stopped, we prayed, and we waited.

(21:54):
We are very fortunate in that the hospital was new, so we were confident that the hospital itself structurally could withstand the water. The problem was we weren't confident that the hospital could withstand all of the other things that were happening around it. Things such as when the MRI quenched, and there was an explosion that came up through the roof related to that. They were also looking down again to see many, many more things floating in this rapidly moving water, things such as large industrial propane tanks, more houses, more trees, more things that were in the direct line and path of that facility that we were literally praying would not hit the hospital.

(22:53):
The other piece that we were actively evaluating was the ability for the hospital and the structure to withstand a helicopter on its roof. We knew we were preparing for a helicopter evacuation, but the hospital did not have a helipad on the roof. And so it was not built or graded for a helicopter to land there and so that was the first major concern that we had when we knew that helicopters were going to be deployed, would the facility be able to withstand a helicopter there?

(23:33):
So it was 12:27 that day when everyone finally made it to the roof or had been tethered in life boats to the roof. They were on the roof a little over three hours before the first helicopter was actually released to come. Virginia State Police were the first ones who were able to respond. They got the window of clear weather earliest, and so they made it to the hospital first. And these are true, true heroes that do amazing things in rescue.

(24:22):
The helicopter literally was able to barely touch the roof and people were able to then be lifted into the helicopter. Very, very planned, very systematically. Shortly thereafter, the National Guard from Tennessee was able to arrive. So between the Virginia State Police and the Tennessee National Guard, there was a continued circle of lifting people from the roof and dropping them off at the local high school.

(24:56):
They triaged patients first to get on the helicopter, and then they literally went by age of staff first. And as expected, my chief medical officer was one of the last people to board the helicopter and be rescued.

Rae Woods (25:21):
By 4:40 PM, a full seven hours after the evacuation decision was made and three hours since reaching the rooftop, all 70 people who were stranded at Unicoi Hospital were successfully airlifted and safely relocated several miles away.

Lisa Carter (25:40):
I can't say that I have ever felt joy like I felt when I started hearing just the stories that were coming out from when they landed and were reunited with family members and were able to know that they were safe, that it was one of the best feelings that I've ever had. Unfortunately, that was not a full sigh of relief for me or my teammates because we had also been notified that another river on the side of another one of our facilities was dangerously close to breaking its banks, and out of another abundance of caution, we began evacuating a second hospital. And so we weren't quite ready to celebrate yet because we were in the process of systematically evacuating the second hospital of the day.

Rae Woods (26:46):
Four of the 10 hospitals in the region ultimately had to be evacuated that day due to the effects of Hurricane Helene.

Lisa Carter (26:54):
Every single person from all four facilities was evacuated safely. I went to bed that night close to probably midnight. I don't know that I ever went to sleep that night. I just continued to hear phrases, to hear sounds, to second-guess things, to walk through things, to critically evaluate everything that had happened, to really not even be able to process yet, but just to still be so on edge and focused that you just can't quite relax yet.

(27:43):
Living through this and leading through this has changed me in so many ways. We know it fundamentally that things don't matter, buildings don't matter, cars don't matter. That truly, it's those people, the people in our lives and the human connections that we have, that really matter. But I also know that oftentimes we don't live that way. We take it for granted. We take for granted the people who are around us, and we find ourselves focusing more on other things. And that day served as an extremely up-close reminder that truly no one's car really mattered. The loss of the ambulances didn't matter, the loss of the facility didn't matter. We had one focus that day, and that was that every single life be saved, every single life be united with their family, and every single person get off that roof.

(28:47):
It was probably two days later, I was scrolling through LinkedIn, and I saw a story someone had posted about your boss is not your friend. Your coworkers are not your family. And that hit me so hard, and I disagreed so hard because these people are my friends. They're my neighbors. They're people that I have great relationships with, people that I truly, deeply love.

(29:14):
And when they're faced with life and death, then everyone in that room was willing to do whatever we needed to do to try our best to make sure they were safe. And so really fundamentally viewing the people that I work with very differently. It's not a job. That's one thing about healthcare that most people who get into it don't get into it because it's a job. You get into it to serve others, you get into it to care for others, to make a difference, and to make an impact in people's lives. And truly that day was really a personification of that from really that team that was there on the ground. They were willing to risk their lives for their patients that day, and that is such an amazing and beautiful thing.

Rae Woods (30:10):
Climate related events are becoming more frequent. So I asked Lisa what advice she has for our listeners and the leaders who may find themselves faced with a similar disaster.

Lisa Carter (30:23):
One of the biggest pieces of advice is to really not rely on the things that you counted as normal from the past. I stated earlier that we had had many hurricanes that had come inland in our area, and we assumed we were going to be facing some of the same challenges, but the things that were normal years ago are no longer normal today. And so we're thinking about planning differently, we're thinking about disasters differently, and we're really focusing on not only mitigating things that may normally happen, but also now in a more concerted effort, trying to anticipate some of those unknowns as well.

(31:19):
The future of Unicoi Hospital looks really, really amazing. We just found out earlier this week that FEMA has released an initial allotment of funding for a replacement hospital, so we are actively looking for a new spot, a new location, to rebuild Unicoi County Hospital. And so that's the work that we're doing right now. We continue to have an advanced urgent care service there in that community to serve people with basic healthcare needs and so we are hopeful that we can continue to work with FEMA to receive the maximum support for that facility so that we can rebuild that replacement hospital.

Rae Woods (32:12):
This is a story of resilience. It's a story of leadership, but it's also a story that really speaks to the spirit of rural health. The trust from that first decision to look at the water and get as early of a start as they could to evacuate. The dedication of the people who decided to stay back in boats, floating in the water, tethered to the roof, the decision to wait and be the last one to airlifted out of the hospital. That speaks to the dedication of healthcare, of health leaders like you, our listeners.

(32:49):
And remember, as always, we're here to help.

(32:54):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson, with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Special thanks to the team at Ballad Health, in particular, hospital administrator, Jennifer Harrah and CMO, Sean Ochsenbein. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week.