Fronting up to a civil emergency: maintaining services and caring for patients during the devastating floods in the Manawatu in February tested the expertise and resilience of the district nursing team to its limits.

In February this year, the lower North Is land suffered a period of very heavy rain fall, resulting in severe and extensive flooding. This civil emergency continued to worsen over four days, leaving townships flooded, people evacuated from their homes and limited power, water, sewerage and communication. The worst hit areas remained without services for weeks, and now months later, there are people whose lives and incomes are still severely affected.

MidCentral District Health Board's (DHB) district nursing service covers a wide area, operating 24 hours a day. We have six bases covering the Horowhenua, Manawatu, Feilding and Tararua regions, all of which were severely affected by February's extreme weather and subsequent flooding. This is a story of the experience of maintaining services and caring for patients during the developing civil emergency.

Oroua River breaches its banks

It had been raining all weekend. I had hardly been outside, marooned in the house by unrelenting curtains of rain. By Sunday night I was thinking that things might be getting serious, so when I woke to the 6.30am news on Monday February 16 to hear that the Oroua River had breached its banks, I wasn't that surprised. But I was worried and my thoughts were racing. How extensive was the flooding? What areas were affected? Would we be able to see our patients? Did the night nurse get home safety? My rather bemused family watched me rush out the door to be at work by 7.30am. I arrived at our Palmerston North Hospital base to find that the night nurse was running late. She had been to visit a patient near Sanson, and had to take a long detour home as a bridge had been washed out. She and her driver were safe but very tired. It had been a long night, with travel to Dannevirke earlier in the night also disrupted by the heavy rain, requiring detours.

Staff were phoning in to say they were unable to get to work. Some nurses were able to travel to other bases and help out there. My first act was to check the civil emergency policy. It began with the words: "The team leader will ..." My team leader Cushla Roache was trapped in feilding and I was going to have to "get on with it" myself. During such large-scale events, the hospital establishes a central communication centre to co-ordinate information and services in the hospital and wider community. I rang the number provided--there was no dial tone. Oh well, I reasoned, it was only 8am; they would barely be at work yet! I contacted the risk management officer and explained I would need accurate information regarding road closures and alternative routes, as we had approximately 750 patients scattered across both urban and rural locations, some of whom had to be seen within four hours. He sounded rather shocked by the numbers, but I reassured him we wouldn't need to see them all at once! Cushla rang to say that she and one of the Feilding nurses had been able to get to the base--with the help of the police--and were contacting as many of the local patients as they could. Water was lapping at the steps of the building and much of the town was already underwater. They had identified the patients urgently needing attention, one of whom would need to be brought over to Palmerston North to ensure her intravenous (IV) therapy could be continued and her condition monitored. Many of these patients were being evacuated and locating them was a challenge over the next 24 hours. The team leader also gave some much needed moral support and advice. It was great having her "on the spot", as transport in and out of the area was impossible.

Having checked in with all the bases, it was clear Feilding was the worst affected. Access in and out of Palmerston North was limited but all other areas were accessible locally. The nurses were trying to contact their patients to give them practical advice and reassurance that we would make our calls as soon as the roads were cleared.

Identifying the most urgent patient needs

By 9am I had assessed the immediate situation, identifying where the most urgent needs were. Information was finally coming through from the now established communication centre. Accurate information regarding road closures and alternative routes enabled me to re-deploy nurses within their local areas. For example, a nurse living in Shannon couldn't get to her usual workplace at Foxton, but she was able to help in Levin. A number of nurses were unable to leave their homes at all and found it incredibly frustrating not being able to use their skills to help others. There was a real sense of the team pulling together to make the best of the situation and thinking creatively about how to reach patients. I kept in touch with as many of our nurses as I could, to see where they would be of most value, many staying in their local areas and working with Civil Defence. Once our own patients were accounted for and contacted, nurses' wealth of expertise was much needed.

I stayed in regular contact with the only nurse who was able to reach the Pahiatua Base, Marie Taplin. She had been able to see all her patients, except a man an hour away on a metal road. This man had phoned to say the road was passable, but after driving for 30 minutes and negotiating several, small, slips, she turned back, feelling very insecure in her small, light-weight vehicle. Marie told me she felt guilty that she had been unable to see the patient, but I reassured her that her safety was paramount and, if necessary, we could use emergency services to get to the patient.

Hospital-in-the-home patients moved into town

As the day wore on and the weather was showing no sign of letting up, we arranged for five of our acute hospital-in-the-home patients to be brought in from outlying areas and put up in motels in Palmerston North. These patients were all receiving IV therapy and needed close monitoring. This proved to be a wise move, as the following day the situation became even worse. More roads were closed, and the coastal towns were now underwater and being evacuated. Phone contact was down in these areas and I was preparing to have two patients evacuated to Palmerston North. Fortunately this was not necessary, but it was reassuring to have the co-ordination of emergency services. The team in the communication centre was a huge help. I only had to explain our requirements and they were able to co-ordinate all the outside help.

Because of road closures, one of the Dannevirke district nurses Sarah Wadley came back to work at 11pm for several nights to administer IV therapy to one of our patients.

The emergency continued for one further day in the Palmerston North region, but by Wednesday afternoon we were able to return our motel patients to their own homes. One young man had come to support his brother. The pair thoroughly enjoyed the motel amenities and seemed a bit disappointed when we were able to get them home! While many roads were still closed, we were able to get to most of our patients by this stage, albeit with long detours, greatly increasing travel, time. This was particularly difficult for our night nurse and her care assistant, who were seeing patients across the wider region during the course of the night. By Thursday, all but the worst hit areas were able to get back to business as usual.

The following weeks were somewhat surreal. In Palmerston North all was normal, but within a 20 minutes' drive, there were people without homes, and the basic necessities of clean water and power. Food supplies were disrupted and a huge clean up was underway. Many of our nurses were torn between helping their families and friends, and coming to work to care for patients.

I spoke with our referral nurse Ros Meads with whom I share an office. While I knew that Ros had to make big detours to get to work, and that her farm had suffered much damage, it wasn't until I sat and really listened that I began to understand what it meant to be a working nurse, wife, mother, friend and member of a ravaged community, all at the same time. Coming to work was not just a physical. effort, but fulfilling all the other roles to support family and friends was creating dilemmas and stresses. Ros described the daily journey to work as eerie, like leaving another planet where farms were devastated and families were experiencing water and power outages, to arrive in Palmerston North where everything was back to normal.

Coping with after effects of the flood

By the end of the following week the huge outpouring of energy and adrenalin needed to cope with the emergency had drained away, and staff and patients were left tired and irritable. The nurses who were still coping with the after effects of flood damage and limited power and water supplies themselves were especially vulnerable, working with colleagues for whom it was business as usual.

One nurse told me of some of her patients' experiences: "Two elderly patients were still living in a hotel four months later because their flat wouldn't be ready until early July. Another woman's leg ulcer had deteriorated badly because she was unable to be seen for 48 hours because of the flooding. One gentleman was writing to his landlord to apologise for not giving sufficient notice of leaving his flat. He had been evacuated by emergency services at 2am!"

In the aftermath were the personal, and professional reviews. I took part in the DHB-wide formal debrief, where I was able to present the district nursing perspective to the wider group. Within the service I arranged for nurses to have the opportunity to share stories and review the emergency procedure documents at team meetings. It was really valuable for me to hear these experiences and to add them to my own perspective. I was really humbled by the ways our team had putted together, supporting each other and going the extra mile to continue to provide the best care possible for our patients. MidCentral's district nursing service--all 75 of us--are a great team!

Julie Vickery, RN, BN, PGCert, is charge nurse of MidCentral District Health Board's district nursing service.