Radiology in the Eye of the Storm: Lessons from Hurricane Helene and Beyond

Radiology as a profession has weathered countless storms in recent memory. The many unprecedented challenges of the COVID-19 years; seemingly endless CMS cuts and declining reimbursement in the face of soaring imaging volumes and workforce shortages; dangerous scope of practice expansion by unqualified individuals, and the increasingly prevalent corporate practice of medicine. My own practice, Tulsa Radiology Associates (TRA), spent several miserable months dealing with the fallout of a nationwide cyberattack affecting our entire hospital system, nearly resulting in the dissolution of our over 50-year-old physician owned private practice (that actually occurred a few months later, but that’s a story for another day). And for radiologists in Asheville, North Carolina? A town located several hundred miles inland from the Atlantic Ocean? They experienced one of the deadliest hurricanes to strike the United States (U.S.) mainland in the last half century.

Hurricane Helene made landfall in Florida as a Category 4 in September 2024, subsequently wreaking a 500-mile swath of destruction across the southeastern U.S. Catastrophic flooding, high winds and mudslides destroyed entire communities and resulted in numerous fatalities. The French Broad and Swannanoa Rivers reached heights of approximately 25 and 26 ft respectively, as reported by the New York Times, higher than previous records set by the Flood of 1916. In western North Carolina, it is estimated that it will cost at least $53 billion in damages and recovery needs.

Through all this chaos, patients continue to require medical care.

As usual, physicians rose to meet the challenge. There are countless stories of physicians who camped out in the hospital, leaving their own families and homes to run emergency departments and operating rooms, keeping patients alive and hospitals running.

Also as usual, radiologists quietly got to work.

Virtually all service lines run through radiology. In the current healthcare climate, there are few patients who enter a hospital and leave without some interaction with the radiology department. As such we could very well be considered the roots, the anchor, the glue, whatever metaphor you’d prefer – we radiologists are integral to the practice of modern medicine and the daily operations of any hospital. Yet rarely, if ever, does the spotlight shine on radiology.

Well, grab your sunnies, because it is long past time that it should – if only for the fact that there is so much we can all learn from one another! This is one of the many ways in which social media can have a positive impact. With widespread power outages and cellphone towers nonfunctional, for three long days I lost all contact with my elderly parents in Asheville.  With multiple highways submerged or washed away, my brother and his family could not get back into the city or return to their home for over a week. During that time, I spent quite a while scouring multiple platforms for any useful information – and was beyond thankful for our extensive online physician presence as well as our innate empathy and strong desire to help one another.

It was incredibly comforting to hear about fellow radiologists Drs. Marianne Ballisty and Emilie Ralston, and the efforts of their private practice to care for their community. When I had the pleasure of finally meeting Drs. Ballisty and Ralston nearly two months after the hurricane, we swapped tales from the trenches. They are both partners of Asheville Radiology Associates (ARA), a physician owned and operated private practice in North Carolina, which earlier this year merged with Hendersonville Radiology.

When Hurricane Helene hit on Thursday, September 26, Asheville experienced heavy rainfall. People in the know, like Dr. Ballisty’s meteorologist spouse, grew increasingly concerned. That day it was business as usual in the radiology department. However, Friday afternoon things took a sharp turn for the worse; multiple hospital systems went into catastrophic downtime. The hospital became reliant on generators. PACS and EMR were down.

A Louisiana native, group president Dr. Ballisty is no stranger to dealing with hurricanes. As a fourth-year medical student on rotation in NOLA during Katrina, she recounts, “I needed to be helpful….so I went and I volunteered.” This time was no different. She packed a bag, told her family she was heading into the hospital and wasn’t sure when she would be back. Utilizing hospital Wi-Fi, a few radiologists like Dr. Ralston with intermittent cell service and located close enough to safely gain access to the hospital were contacted and a modified weekend schedule was utilized until they were able to reach others and further coordinate efforts. For the next 48 hours, radiologists were physically stationed at each of the three CT scanners in the ED. Preliminary reports were written on two sheets of paper, one for the ER and another for eventual addition to PACS. Similar proceedings were utilized for portable machines in ER. She recounts, "Being in the ER, having the trauma team come by and interact – because you’re usually so removed – I think it went really well. ER staff was incredibly thankful."

ARA’s visionary Operations Committee had several contingency plans in place for catastrophic system failures. However, the citywide loss of power and cell phone service made execution problematic. In fact, some regional hospitals were completely cut off – not just communication/power, but direct physical access – as many roads were impassable or even washed away. Mission hospital sent radiologists there via helicopter to also read directly from scanners; the radiologist in question was out there for three straight days (pro tip – take a backpack of food and supplies).

While always critically important, strong leadership during a crisis can be transformational. Adapting to a constantly evolving situation to address issues in the short term, as well as making plans for once the dust settles. As Dr. Ballisty expressed, this requires constantly reassessing “What is happening, what do I need to try and staff for because at some point when PACS comes back, all of that work that had been prelim’d needs to be read.” Perhaps even more important? Leading with compassion and empathy, taking care of one another. During our talk Dr. Ralston mentioned, “I’m really glad Marianne was there. It was useful to have someone who was willing to take charge….and be REALLY nice about it. One good example of her leadership – I showed up for my shift but my car was on empty and we really had enough manpower so I asked, can I go get gas? She said 100%, go! And she made me feel ok about it.”

Preparation, adaptability, and interdepartmental collaboration were just a few of the things working in ARA’s favor. Most of the nightshift radiologists made it into the hospital early on; given that most PACS ‘upgrades’ happen at 3am, they were best equipped to deal with downtime issues. All the breast imagers also read general diagnostic imaging; this increased the pool of people who could aid with the immediate crisis, and proved beneficial in the weeks that followed as ambulatory/outpatient services were deferred. It may have been fortuitous this occurred on a weekend; there always seems to be less red tape when administrators are not around.

There are any number of lessons we can all learn from ARA Health Specialists and Helene, TRA and the Ascension cyberattack, and honestly any other radiology practice that has had to formulate a crisis response. Yet one thing is clear – any truly effective response to maintain a functioning radiology department will require radiologist input, involvement, and mediation. Much like at my own hospital during the aftermath of the cyberattack, it was a fellow radiologist in my practice who wrote a program to populate patient data into dummy powerscribe reports for eventual PACS upload; it was radiologists who figured out how to place a virtual ‘sticky note’ with preliminary impressions on examinations, it was radiologists who went above and beyond to bridge all the unforeseen gaps. Expect the unexpected and be ready to adapt and pivot; there will be daily monkey wrenches. Utilize the many and varied talents of your team, who will gladly rise to the challenge, because like their group website says, “At ARA Health, care is more than a service we provide. It's who we are.”