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The resilience of hospitals is especially vital for areas that only have one major medical center. On the islands of Nantucket and Miami Beach, the latter of which may be affected by the storm this weekend, these central hospitals don’t just have to keep the lights on during a storm—they also serve as the center of the entire island’s emergency management during natural disasters. “You have to think of these medical centers as mini-cities that can sustain themselves,” says Natalie Petzoldt, a principal at CannonDesign who led the design of a new surgery center and emergency department for Mt. Sinai in Miami Beach. “They bring their own staff, and staff stay on site 24 hours a day during these storms.” Typically, large medical centers will evacuate everyone who is able to be moved, while protecting anyone who is too vulnerable to leave and must ride out the storm with the hospital. Hospitals also will invite some at-risk people to come stay out the storm, including heavily pregnant mothers or elderly people in nursing homes who rely on oxygen tanks or other kinds of assisted living. Hospitals haven’t always been well-equipped to deal with storms: The horrifying impact of 2005’s Hurricane Katrina on New Orleans’s Memorial Medical Center is a cautionary tale. With no power or running water, temperatures inside the hospital reached 100 degrees. The situation was so desperate that doctors and nurses decided to inject some patients with lethal drug doses. More storms, hotter temperatures, and higher floods The importance of protecting patients during a storm is critical on Nantucket Island, where CannonDesign recently renovated the existing hospital so that it would be able to withstand a Category 4 hurricane. “When you’re 30 miles out to sea, you only have one option,” says Dennis Patnaude, the facilities director at Nantucket Cottage Hospital. “Whatever your health conditions are and whatever Mother Nature throws at you, you have one place to go.” To ensure that all these people will be safe, hospitals have to be designed to ride out whatever a storm might throw at them—literally. The design of these ultra-durable buildings is becoming increasingly important as storms get stronger and more frequent. As climate change accelerates, global temperatures inch higher and sea levels rise. Critical pieces of infrastructure like hospitals have to plan for extremes, because what was once considered a storm that might happen once in 100 years is happening far more frequently—as often as once every few years.

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One concern for the designers of the Mt. Sinai extension in Miami Beach was ensuring that none of the windows would break due to flying debris. According to Michael Zensen, project architect at CannonDesign, the windows of the Mt. Sinai surgical tower have layers of tempered glass that will shatter to absorb the impact of a flying object. Then, there’s also a plane of strong plastic that’s laminated on the inside of the glass to provide extra support. The walls themselves are built of precast concrete that’s welded into a steel frame—which Zensen says is one of the most durable ways to build a wall. It’s a solid eight inches thick. “There’s no way anything is getting through,” he says. On the island of Nantucket, the glass windows have another purpose. They’re made of hurricane-resistant glass from the glass company Andersen, and they’re also designed in a residential style to allow people to open them—unusual in a medical setting. While the choice to use operable windows had aesthetic benefits, helping the hospital blend in with the island’s historic character, it had a practical logic as well: “You put in operable windows so if there was a need for summer, you’d be able to open the windows and provide cooling and ventilation” if the power does go out, says Brett Farbstein, the resiliency lead at CannonDesign who worked on the project. Designing a self-sustaining small city But more than wind, the biggest threat to hospitals comes from water. The island of Miami Beach is partially composed of in-filled land, and the hospital sits along a seawall built over the decades by the Army Corps of Engineers on the bay side of the island. Miami Beach and the rest of southern Florida is already suffering from flooding due to rising tides, even when there’s no major storm. A 2016 study in Nature showed that Florida residents are most at risk from climate change compared to any other U.S. state, mostly due to sea level rise and flooding. To curb its woes, the city of Miami Beach is spending $400 million on high-tech pumps and an initiative to raise streets to a higher elevation. Due to fears over flooding, CannonDesign decided to exceed the local building code requirement of buildings being seven feet above sea level by a full three feet. “I don’t think anyone can predict the future,” says Jim Gordon, the CannonDesign project manager for the Mt. Sinai project. “It seems like a responsible way to do better than what’s required.” The most important thing when it comes to potential flooding is making sure that water won’t take out a building’s power supply—something that devastated multiple hospitals during 2012’s Hurricane Sandy in New York City. Both Mt. Sinai Miami Beach and Nantucket Cottage Hospital have been designed so that all this vital equipment is either on the second floor of the hospital or higher.

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In Miami Beach, the mechanical gear is on the third level—at great expense, the hospital’s president and CEO Steve Sonenreich says (likely due to special infrastructure needed to support it). The hospital’s new emergency department and surgery center also have all their operating rooms on the second floor or higher. “Along with a power plant that is designed to withstand 180-plus-mile-per-hour sustained winds, when the generators are elevated 40 feet above the flood plane and we can power up and run our operations for nine days, we’ve created facilities that are as hurricane-proof as I think is possible,” Sonenreich says. In Nantucket, the generators and HVAC system are on the roof, and the hospital was designed so that all the mechanical systems have some level of redundancy. Because the island is so far from the mainland, the team also invested in enough fuel for the generator so that it can last for 96 hours—a full day longer than the 72 hours required by code. The “worst case scenario” is getting worse Along with redesigning their buildings to keep key mechanical equipment away from water and ensuring there are backups if something fails, both Nantucket Cottage and Mt. Sinai Miami Beach have built dedicated spaces for their city emergency departments to camp out. At Mt. Sinai, this “situation room,” as Sonenreich called it, is completely controlled by the city and can serve as a staging area for any kind of disaster or emergency. “We worked very closely with police and fire for the city of Miami Beach and we had the thought, since they do embed with us during a storm, of providing for them an emergency command center,” Sonenreich says, “We like having them here.” In Nantucket, it’s a similar situation. “This is designed to be the last building standing,” says Patnaude. “This design and the thought behind this one would be that in the worst-case scenario, this is where the island’s command center would be.” The Cottage Hospital’s layout also lends itself to act as a community hub in a disaster. A large lobby space on the first floor opens directly into the cafeteria. “If something were to happen, you’d have a large gathering space proximal to food . . . that isn’t affecting the patient care of the hospital,” says Brian McKenna, who leads Cannon’s health practice in the company’s Boston office. Hospitals have always been designed for the worst-case scenario—but what’s considered the worst case is changing. For Farbstein, the resiliency expert, hospital admins have to think about investing in even more extreme measures to protect themselves against an uncertain future. Take HVAC equipment. Hospitals might be used to assuming that there would be five or six days a year above 90 degrees. But 20 years from now, that might be 17 or 18 days a year.

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“Because we’re beyond historic data, we’re into predictive forecasting,” he says. “How can you make sure your building is adaptable to what’s going to happen in the future?”