by Dr. D

“Gee, this has never happened before.” My boss’s words hung in the air as the lights dimmed, flickered, and then went out altogether. It was 4:10 pm on Thursday, August 15, and we were in the middle of a chaotic shift change report in the psychiatric emergency room at Bellevue Hospital - also known as the CPEP, or Comprehensive Psychiatric Emergency Room. The night was to be my seventh overnight shift as the psychiatrist in charge. I finished my residency training at the end of June, and am still adjusting to the rhythms and responsibilities of life as an attending. As the power failed, the fifteen or so clinicians and trainees who were crowded into our small doctors’ station froze in the darkness, and then half the lights came back up. We realized we were on generator power, and that the room seemed so quiet because the air conditioning had stopped running. We finished our signout as others in the area tried to find out what had happened.

The evening was already shaping up to be chaotic - a number of new patients yet to be seen, including an angry, aggressive NYPD prisoner. Several trainees from the prior shift were still finishing cases that they would need supervision on. I divided up the new case assignments as news spread that cities all over the Northeast had lost power. Initially we heard the blackout was much larger - Montreal, Toronto, Ottawa, Boston, Baltimore, Cleveland, and Detroit were all bandied about.

“This can’t be an accident.” I said the thought aloud without meaning to, and heads whipped around. The interns’ eyes widened, and I realized I was starting to shake a little. “Okay, you’re in charge,” I reminded myself. “Be the grownup. Keep it cool. These folks need you, and so far, things are fine.” The director of the CPEP, remained in the area. Dr. G, the director of ER Services at Bellevue, an austere, fatherly man whom we all joked looked like Abraham Lincoln, came to inform us that the entire ER complex was on disaster alert. We were told to move as many patients out of our area as possible, either by discharging them if that seemed clinically reasonable, or admitting them to an upstairs inpatient psychiatry bed. Before patients could be admitted upwards, our normal protocol is to perform a complete medical clearance, including a battery of blood and urine labs, chest x-rays, EKG and a physical exam. The laboratories were not functioning in the outage, and we learned we’d have to do old fashioned medical exams, clearing patients based on histories and physicals.

The cramped clinicians’ station was overflowing with people from both shifts, all of them trying to ask me, as the doctor in charge, for direction. In addition, psychiatry residents from other parts of the hospital started to arrive, looking for colleagues, working phones, and ways to get home, or wondering if we needed more doctors. The scene was increasingly reminiscent of September 11. I began urging people to move out of the doctors’ station, or to go home altogether if they’d already signed out. I wanted to keep the frenetic vibe from getting any worse, and allow everyone, including me, room to get organized.

Once the initial fear and franticness passed, we settled into a routine of physical exams, paperwork, and completing our makeshift clearances on patients in groups of 4 or 5. There was one working freight elevator serving the entire hospital. Once we had a group of patients cleared, we assessed whether each would be able to tolerate a crowded elevator ride with other patients and staff. At one point we found we were out of wheelchairs to bring people upstairs. The resident and medical student went on a scavenger hunt, bringing back several of the antiquated, high backed wooden wheelchairs that are ubiquitous at Bellevue. We sent the patients up in groups with one-to-one staff escorts, and the number of patients in the ER dwindled as the hours ticked by.

Around 10:30 pm, as I was sitting at a computer trying to figure out if I could still enter orders, the lights began to flicker again. My hands paused over the keyboard as I watched the monitor go out, and we were plunged into darkness. This time, the lights didn’t come back up: our backup generator had failed. I could hear the voices of the staff in the other parts of the nurses’ station begin to rise anxiously. “Okay, everybody!” I shouted. “Nobody panic. We’re all right.”

Now what?! I’d been through four years of medical school, four years of residency, and a full 6 weeks of attending life, but nowhere could I recall being trained in what to do if you find yourself in charge of one of the busiest and most acute psychiatric emergency rooms in the world in the middle of a complete power failure. “Be the grownup,” said a voice in my head (perhaps parallel process setting in - was I overidentifying with the auditory hallucinations of our psychotic patients?). “Think safety. Are the patients safe?”

“We need staff with the patients. Let’s get flashlights and visualize all the patients in the area.” Fortunately, by that point in the evening, we had only eleven patients in the CPEP, a relatively small number, and usually an easily manageable workload. Somewhere in the dark I managed to find my signout list. Each shift, my list starts out as a neatly typed summary of clinical information, and devolves into a scribbled mess as the night wears on and new cases get added. Our wonderful nurses and technicians were already moving about the ER, locating patients and moving them into one area where we could easily communicate with everyone. I brought my list out and began taking attendance.

Half the crew was either asleep or lying calmly on gurneys. We had a mentally retarded fourteen year old boy with us, and the medical student went to his side, talking with him calmly. I heard the boy reporting that while he himself was not afraid of the dark, he did have a doll at home who was. Generally, the group was unfazed by the darkness, and seemed to need little reassurance from us. Nonetheless, I was a little nervous. We had some acutely psychotic patients in our care. What if someone became agitated in the darkness, and we had to coordinate a restraint procedure, or use injected medications?

As I continued down the list of names, one man approached me. “Is it time for my pill yet? I’m not feeling well.” When my flashlight shined on his hands, they were visibly tremulous. I checked my list against his name and found that he was being followed closely for alcohol withdrawal, and was due for Librium to prevent further symptoms.

“No Librium, doc,” Leo, the nurse in charge informed me. “We can’t get into the Omnicell.” I realized with a groan that all our oral medications were dispensed from an electronic cart. Without power they were inaccessible. We went to the medication refrigerator for IM Ativan, only to find that in a supremely ironic twist, the controlled substance lock was jammed. It stubbornly refused to budge despite the efforts of several nurses. We were a psychiatric ER without benzodiazepines! Fortunately, the medical ER was operating under full generator power down the hall. They were able to provide us with several vials of Ativan in short order. Withdrawal crisis averted.

We ran the CPEP on flashlight power for about 90 minutes, conserving batteries as much as possible in anticipation of a full night in the darkness. Fortunately, having to forage for benzo’s was our only major misadventure. The quiet, dim atmosphere probably served us well. There was minimal stimulation for the patients, and most of them slept. For once, we had virtually nothing to do. Around midnight, the backup generator kicked back in (I never did get an explanation for why it failed), and we went back to work.

As I watched our staff work together throughout the night, my sense of admiration grew. In the midst of a tense, stressful, terribly uncertain situation, the team, to a person, remained calm. Each of us found ourselves doing things well outside our job description. The clerks comforted patients, mental health techs wielded battery powered lanterns, residents scrounged for wheelchairs, and I served water and Cheerios (eventually our only available sustenance) to patients and staff alike. The good humor and creativity were contagious. As the hours wore on, everyone seemed to delight in coming up with new ways to solve the problems we faced. No one became upset or complained, even as the nurses’ double shifts rolled over into triples. Early the next morning, one of our psychology interns called in, very apologetic - she might be a little late for work, as she was walking from Brooklyn. Every one of our clinicians made it to work Friday morning, whether they had to walk for miles, or hitch rides from strangers.

I stepped out the back door of the ER hallway around 3am in hopes of some fresh air or a cool breeze, and gazed around. The road behind Bellevue is one of the least attractive parts of the hospital. The ambulance entrance lane is bordered by a creepy, weedy parking area, the 4-lane FDR Drive, and an empty lot filled with the construction detritus of prior Bellevue incarnations. But that night, the landscape was transformed. The nondescript high rise across the highway was almost cathedral-like, bathed from inside each apartment with the shimmering yellow glow of candles. I looked up at the sky and saw what I never thought I’d witness - hundreds of stars blinking over Manhattan. The blackout had deprived us of many necessities, but had brought some magic with it. I returned to the same spot a few hours later and watched the sun blaze into view over the East River. At last, light in New York City.