What’s the Verdict on Shelter in Place?

By Jack Cumming

You know the drill. A shrill alarm sounds. It’s deafening, except that those who are really deaf can’t hear it. The alarm goes on and on until the right person arrives with the authority to shut it off.

It’s a Test

It’s not a real alarm. It’s only a test. Until it’s not. How do residents know whether it’s the real thing? They don’t. Sometimes, they’re told in advance that there’ll be a test, but sometimes, it’s just a harmless trigger that gets it going. It’s almost never the real thing.

What are residents to do, even in the unlikely event that it might actually be the real thing? They are told to shelter in place. What’s that mean? That means that regardless of the threat, residents are to do nothing. What do residents learn to do from these incessant drill tests? They learn to do nothing. They learn to disregard all warnings.

What’s Overlooked

Then, there’s the fine print. Residents are told to shelter in place until they are told to do something else. The message “shelter in place” is what is seared into their consciousness. The “until” part is quickly forgotten, especially since that “until” is never rehearsed until it’s the real thing.

If you think that this is a recipe for potential disaster, you’re right. How that works out in practice is documented in a compelling book that everyone who works or lives in senior housing should read. The book is Inflamed, by investigative journalists Anne E. Belden and Paul Gullixson, with Lauren A. Spates. It recounts what really happened when wildfire overwhelmed Oakmont Senior Living in Santa Rosa, CA. Get a copy and read it. It’s an unsettling experience.

One quick takeaway is that “shelter in place” is not only contrary to common sense, but it’s also detrimental to the rescue of those most vulnerable to disaster. How did the “shelter in place” standard of practice for senior housing come into being? The answer seems to lie in an academic social scientific approach. Two “papers” about old age homes come to the fore. Click here for one, and click here for the other (PDFs).

Back to Atomic Fears

Actually, the term and concept originated earlier. In the early days of the atomic era, there was considerable fear of radioactive fallout and dust. The concern was that if someone went outside, they might inhale the dust into their lungs. The logical conclusion was to suggest that people stay indoors with the windows tightly shut, i.e., shelter in place.

The impetus to bring it to senior housing is different. The conclusion there was that evacuation drills can be traumatic, particularly for cognitively impaired residents whose condition is exacerbated by the upset of the drill and for frail elders for whom the drill process may be dangerous. That led to “shelter in place.”

The actual conclusion from the most recent social scientific paper just cited, which focused on Hurricane Katrina, is:

While it is important that facilities, public health and emergency management officials evacuate homes likely to flood during a hurricane, in light of the significant increase in mortality and morbidity associated with evacuation, the policy of universal evacuation of facilities requires careful reconsideration.

Today’s interpretation of shelter in place is far more conclusive than this call for “reconsideration.”

A State of Readiness

What makes more sense than shelter in place? The word “readiness” comes to mind. Still, that’s only half the story since those deafening alarms, woven into laws in many jurisdictions, are a big part of why there’s a lack of readiness. It’s the proverbial “boy who cries wolf” and then is disregarded when the threat is real. This is legislated madness. Why aren’t the wires to those alarms reconfigured to allow public announcements? Answer: That would be against the law.

Incidentally, the book Inflamed, mentioned above, details the post-incident deliberations that might have led to safer senior housing. It’s a testament to how our legislative and regulatory processes have become corrupted to put private interests before considerations of resident safety. It would be desirable to apply common sense and discerning deliberation to the practices that impact the lives of frail and hapless elders.

The Alternative

Here are some thoughts as to what a “readiness” approach might include to replace the passivity of the shelter-in-place dictum with a proactive standard of alertness.

1. Readiness Drills for Residents

A big challenge at Oakmont was older people with diminished cognition, who took the “shelter in place” instruction too literally and so were resistant to moving to a safer location. A safe drill would be to mimic someone arriving at their room and preparing them to evacuate. They might be moved just outside the door of their living unit, since in a real emergency staff, volunteers, and authorities could take them from there to safety. Still, they would accept more than staying put in place.

Periodic “readiness” drills might give residents the assurance of knowing what to do while they “cower” in fear “in place.” “Cower” may be too strong since residents just ignore those alarms. Still, fear is what distinguishes the real thing from the normal-times response to the shelter-in-place instruction. Since “shelter in place” means “do nothing,” residents learn to ignore alerts rather than rising to a heightened state of readiness.

There will be times when people are not available for scheduled drills. Residents leave the community at their own discretion and on their own responsibility. It’s the absent resident’s responsibility to get up to speed upon their return.

That differs for those residents who are unable to fend for themselves and who might be absent, say, for a hospitalization when the readiness drill occurs. For those few residents, staff could carry out an individual readiness exercise upon their return, so that they are prepared and not resistant in the unlikely event that there is ever a real reason to evacuate.

2. Communication With Families

Residents must be the primary focus for immediate threats of disaster. Informing families and others not immediately impacted is a secondary concern, i.e., desirable but not essential. If family members show up as a disaster unfolds, that is something that first responders — staff or authorities — will have to cope with. Some family members may be helpful, as was true at Oakmont, while others may have to be told not to interfere.

Staff Response

The staff response is critical and can be tough. That is the lesson to be learned from the on-the-ground practicalities at Oakmont. Some staff members are very courageous. Others are less so. Having been schooled in successful response tactics is probably the best boost to courage that we can give to staff and others.

If staff know what they should be doing and what their priorities should be, they are more likely to follow that practiced course than to react irrationally or to become bewildered and helpless. Much of readiness is preparing people so they know what their duty is and how to carry it out.

Takeaways

Navy SEALs are taught: “When you’re under pressure, you don’t rise to the occasion. You sink to the level of your training.” That’s what happened at Oakmont. The training was insufficient, and responsible staff were overwhelmed. It was different and more successful at the nearby Brookdale community, with which a comparison is made in the book.

It’s time to think of disaster preparedness from a pragmatic approach beyond the academics of social scientific analyses. It’s one thing to write a paper in pursuit of tenure. It’s quite another to have the overall responsibility for the lives and well-being of residents, many of whom may no longer be able to fend for themselves.

Common sense suggests that a proactive training program best prepares for what may happen. Even though an actual disaster will present unique challenges, training and understanding of responsibilities can pay off in lives saved and family and resident trust affirmed.