Lessons from Sandy--preparing health systems for future disasters.

network.” Since the Wi-Fi was still working, residents downloaded a telephony app onto their phones and used it to send urgent text messages. At one point, the system brought several residents together for a code in a dark room. By the glow of headlamps and bobbing flashlights, a resident began resuscitation while others prepared to place a central catheter. While Samad tried to sustain morale, dutyhour limits were no longer top priority — though the influx of outpatient providers helped residents get some rest. Like the boundaries defining a resident, a medicine ward attending, a housekeeper, a surgeon, and a social worker, the lines defining work shifts had blurred. Nagler recalls that when he first became Beth Israel’s president, he “got on the subway one morning and was thrust against the front of the subway car, pushed against the window by the crowd, and the view in front of me was pitch black except for the gleam of the tracks.” He remembers this image every time he faces the unexpected, hopeful he will find a path forward. When I visited the hospital 5 days after Sandy, the lights were back on, but in a sense Nagler still felt like he was on that subway, hurtling toward an uncertain destination. Many nearby hospitals remain closed, and high volumes continue. And even after this crisis ends, another unpredictable event is bound to occur, and whether it’s a hurricane, a terrorist attack, or an infectious disease outbreak, it will pose its own obstacles. As Manhattan works to repair itself, local clinicians find that part of their job is to evolve under duress, trying to provide good care under dynamic circumstances. One NYU hospitalist, lacking patients in her own hospital, visits evacuated patients at their new facilities, bridging gaps in the medical record. She is navigating a foreign landscape, but most health care professionals will encounter such unfamiliar terrain sometime during their careers. Nagler returns to his musing on meteorology. The weather and medicine are similar in many ways, he remarks, both full of complex variables that produce unpredictable outcomes. But the hospital managed to meet such outcomes with creative and rapid solutions. Nagler looks out the window onto 16th Street. The sun has emerged, briefly, over Manhattan, and somewhere nearby an ambulance siren wails.