By Charles Ornstein, Propublica

Long after power is restored from Sandy, the effect of another more-precarious outage is still taking shape: Some of the largest hospitals in lower Manhattan remain shuttered. Other hospitals are scrambling to fill the gap, and concern is rising that the patchwork system can't last for long.

NYU Langone Medical Center and Bellevue Hospital, the flagship of the city's public hospital system, were forced to evacuate due to loss of electricity and damage from Sandy. The Manhattan Veterans Affairs Medical Center evacuated patients before the storm and has not reopened.

There is no firm timetable on the hospitals' return. A spokesman for the city agency that runs Bellevue said that the hospital will likely be out for at least several weeks. NYU's outpatient clinics have reopened but the hospital itself remains closed.

"This is not a tenable situation," said Bellevue's director of emergency medicine, Dr. Lewis Goldfrank, who holds a similar title at NYU. "There's just too many people. You can't dump this level of patients out on the open market."

Bellevue's emergency room treated more than 100,000 patients last year, and its physicians and outpatient clinics handled more than a half million patient visits, according to state Department of Health data. It is also a large provider of psychiatric services and a hub for treating patients in police custody.

Beyond the huge daily patient load it handles, Bellevue is also a key piece of the city's crisis response system as the only high-level trauma center near the lower section of Manhattan. Trauma centers handle the most serious cases, including victims of gunshots, stabbings, auto accidents, falls and terrorist attacks.

Now, the nearest Level One trauma centers for residents of lower Manhattan aren't all that close: New York Presbyterian/Weill Cornell Medical Center is on the Upper East Side at East 68th Street and St. Luke's/Roosevelt Hospital is on the Upper West Side.

Officials say there's no reason to think that, for now, trauma victims in lower Manhattan will be any worse off than those in other parts of the city. The response speed is still acceptable, they say. And if a trauma victim is in an immediately life-threatening situation, such as a traumatic cardiac arrest, ambulances bring them to the closest hospital, regardless of whether it's a trauma center.

But the fear is that there won't be enough surge capacity at other hospitals if there is a major disaster, or that overworked staff at other hospitals will grow fatigued under the load and patient care could suffer.

"All systems can work at above capacity for some time without significant detriment," wrote Dr. Ronald Simon, director of trauma at Bellevue, in an email to ProPublica.

"But, with time, people will tire, over-worked systems will fail, and patients will suffer," wrote Simon, who is also chairman of the state health department's regional trauma advisory committee. "No question in my mind that the current status of care in Manhattan is not sustainable for any length of time."

The longer Bellevue and the others are closed, the more worrisome it becomes.

It "leaves a whole blank spot in the lower part of Manhattan," said Dr. Amesh Adalja, an associate of the Center for Biosecurity of the University of Pittsburgh Medical Center.

Adalja studied the 2010 closure of downtown Manhattan's St. Vincent's Hospital when doctors feared that the system wouldn't be able to absorb the patients. Four hospitals—Bellevue, NYU, Beth Israel and New York Downtown Hospital—stepped in and expanded their services.

Two of those four are now out of service.

Bellevue's staff has been shifted to other public hospitals and clinics, which are coordinating to minimize the impact, said Goldfrank, the hospital's emergency medicine director. Goldfrank said he is particularly concerned about what will happen to patients with chronic conditions, such as heart disease and diabetes, who depend on regular care to keep them out of the hospital.

Beth Israel Medical Center, located in lower Manhattan at 1st Avenue and 16th Street, has seen its ambulance traffic increase by 70 percent since before the storm. It currently receives about 135 patients a day by ambulance, compared to an average of 84 before the storm, said Dr. Gregg Husk, chairman of emergency medicine there.

"For us, this is Guinness Book of Records territory," Husk said, noting that his ER had its highest-ever days in terms of overall volume, ambulance volume and admissions from the ER to the hospital.

The hospital has increased its staffing so wait times have not been affected, Husk said.

Other hospitals around the city have stepped in. Mt. Sinai Hospital on the Upper East Side accepted patients evacuated from NYU and Bellevue last week. Wayne E. Keathley, the hospital's president, said the hospital is prepared to do even more. "We're very much now in the moment-by-moment planning phase."

Ian Michaels, a spokesman for New York's Health and Hospitals Corporation, which runs the city's public hospitals including Bellevue, said the agency is still trying to figure out how quickly the hospital can get back online. "The assessment is ongoing," he said late Tuesday. "We'll know more soon."

Michaels disputed a report on the New York Times website Tuesday that said Bellevue was in lock-down mode "because of possible structural damage from the storm."

"We don't suspect that there are any structural issues," Michaels said.

In addition to Bellevue, Coney Island Hospital in Brooklyn was also evacuated and is not back in service. That leaves nine functioning public acute-care hospitals, Michaels said, "operating very near capacity. There are very few beds available within the HHC system right now."

A spokesman for the New York State Department of Health, Bill Schwarz, said in an e-mail that "the handling of trauma calls in Lower Manhattan has run smoothly."

"Patients are being transported to appropriate facilities based on their medical needs and services required," Schwarz wrote. "Response times for life-threatening emergencies in Manhattan are meeting FDNY Bureau of EMS goals. Turnaround times at Emergency Departments at Manhattan hospitals have remained steady, with no noticeable increases as a result of the storm impact."

An FDNY spokesman said response times for ambulances to get to patients in life-threatening situations "have been under our targeted goal of 7 minutes since the storm. No delays have been reported."

For the moment, doctors said, trauma calls have been way down since the storm.

"With the hurricane and with the bad weather, a lot of people are staying off the streets," said Simon, Bellevue's trauma director. "It's not uncommon after natural disasters for trauma in the immediate wake of it to go down."

Simon said he believes the existing trauma centers can probably pick up the added load and have "surge capacity" in the event of another disaster or a mass-casualty event. "If something did happen, all of the hospitals would still be able to take the additional patients that that would provide. Would they all have to travel a little farther? Yes. Would that mean anything as far as life and limb is concerned? Probably not."

Jennifer LaFleur contributed to this report.

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Donations of blood platelets are even more in demand than whole blood in the aftermath of superstorm Sandy, officials said.

It’s a request as common as clean-up crews after a storm: Please give blood.

And, indeed, disaster officials have been urging potential donors to step up to replenish East Coast supplies disrupted by superstorm Sandy.

“Patients will still need blood despite the weather,” said Dr. Richard Benjamin, chief medical officer of the American Red Cross. “It is critical that those in unaffected areas make an appointment to donate blood as soon as possible.”

Sandy's aftermath: How you can help

But what’s also true is that certain blood donors are more sought-after than others, particularly the relatively tiny group of people who donate the most perishable of blood components, the platelets.

 “Red blood cells? We’re in good shape. Platelet donors? Call your local facility,” said Dr. Louis Katz, executive vice president of America’s Blood Centers.

Katz and officials with the Red Cross say the highest demand in the days after the giant storm that struck the Eastern seaboard will be for platelets, the tiny, colorless cell fragments involved in blood clotting. At least 300 blood drives have been canceled in 14 states in Sandy's wake, resulting in a shortfall so far of some 10,700 units of blood and platelets, agency officials said.

Platelets are critical for cancer patients and others who require bone marrow and stem cell transplants, Katz said. Those patients need regular treatments, storm or no storm.

Stored at room temperature, platelets have a shelf life of just five days, compared with the 42 days of refrigerated red blood cells.

So far, supplies of whole blood and platelets have held steady in hard-hit New York, New Jersey and Connecticut, thanks in part to the distribution system that shuttles blood efficiently from one part of the nation to the other.

“The networks that move blood are well-coordinated and well-practiced,” Katz said.

Already, supplies of platelets have been shipped to Sandy-stricken hospitals and blood centers from as far away as the West Coast, said Stephanie Millian, a Red Cross spokeswoman.

But more donations are needed now, officials said. Platelet donors make up only about 3 percent of total donors, said Millian. The AABB, the American blood bank association, says that nearly 11 million volunteers give about 17 million units of blood and blood components each year.

There’s not a shortage of platelets in the storm-stricken region, but there is a need, particularly for rare type AB donors. They make up only 4 percent of the US population, but their plasma, for instance, can be used in anyone.

Donating platelets takes longer than donating whole blood, 2 hours compared with 45 minutes, Katz estimated. But it's just as painless and one platelet donation can provide enough for a full therapeutic dose for a patient in need, the Red Cross says. By contrast, it can take four to six whole blood donations to produce one dose of platelets.

Platelet donors usually know who they are. Because they can give 24 times a year, compared with the six times a year for whole blood, they’re often popular at blood centers, especially after disasters.

“Anybody can volunteer to be a platelet donor,” said Millian. Those interested should call the closest blood center to inquire.

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• How hurricanes kill -- it's not always what you think

Hurricane Sandy is already stressing millions of people living on the eastern seaboard, but it’s not likely to kill anywhere near the number of people who would have died in such a storm 100 years ago. That’s because weather and emergency officials can get people out of the worst flood zones in time.

So what are the most likely 21^st century causes of death? Carbon monoxide poisoning often leads the list, as people turn to grills and gas stoves in power outages. Flash flooding and storm surges are also big killers.

Each hurricane is different and while a large percentage of deaths are from drowning, it’s not necessarily always the main cause. Heart attacks can also kill people, especially the elderly.

Katrina, which hit the Gulf Coast in 2005, was the deadliest hurricane this century. Officials tried to evacuate residents in low-lying areas, but several hundred people died in Louisiana when levees failed and floodwaters poured in, quickly and silently, as people slept.

Louisiana’s chief health official, Dr. Raoult Ratard, and colleagues counted 971 deaths in Louisiana alone that could be directly blamed on Katrina. Forty percent had drowned, 25 percent of people died from injuries including carbon monoxide poisoning and 11 percent died from heart conditions, which may have been exacerbated by stress or lack of access to medical care. Nearly, half, 49 percent, of the victims were aged 75 or older – showing how the frail are often most at risk.

Carbon monoxide poisoning – usually listed under injuries – killed 10 people in Alabama and Texas after Katrina and a second hurricane, Rita, hit and power went out, often for weeks.

“Few homes had functioning carbon monoxide detectors,” Centers for Disease Control and Prevention and state health officials wrote in a report published afterwards. “CDC continues to recommend that generators be placed far from homes, away from window air conditioners,  and that carbon monoxide detectors be used by all households operating gasoline-powered appliances (e.g., generators and gas furnaces), with batteries replaced yearly.”

Watch now: Multiple live video streams of Sandy coverage

Carbon monoxide is an odorless gas generated when natural gas, gasoline, coal and other fuels are burned. Victims usually don’t notice they are being affected and they can die in their sleep. The first symptom is often sleepiness or nausea, as well as headache.

It can be a problem any time of year but especially during power outages as people turn to other sources to cook and to heat or cool their homes. “Don't run a car or truck inside a garage attached to your house, even if you leave the door open. Don't heat your house with a gas oven,” CDC cautions.

In 2008, Hurricane Ike hit the Texas coast near Galveston, killing 74 people in Texas and Louisiana. The largest percentage were people who died from carbon monoxide poisoning after the storm had passed and left 2.3 million people without power – 13 people died this way, state health offiicials reported. Eight people drowned and 12 died of heart attacks, strokes and other heart-related causes.

Anthony Arguez and James Elsner of Florida State University analyzed hurricane deaths and found that, even though more people live along the coasts, they are far less likely to die in hurricanes than in the days before highways and warning systems made it easy to escape the most dangerous areas.

In the past 100 years or so, they found, hurricanes have killed about 15,000 people – about half of them in 1900 when Galveston, Texas was destroyed by a hurricane. The storm surge – created when winds blow seawater up onto coastal areas -- was the biggest killer. Storm surges have been among Sandy's first effects on New York, New Jersey and Delaware.

“At least 1,500 persons lost their lives during Katrina and many of those deaths occurred directly, or indirectly, as a result of storm surge,” the National Hurricane Center says on its website.

Flash floods can also be a risk – not so much to people in homes, but to those out and about on foot and in cars. Even six inches of fast-moving water and pull a person down if they’re wading in it, and cars can be pulled into rivers or streams.

Live blog: Updates on Hurricane Sandy

When Hurricane Floyd hit North Carolina in 1999, dropping 20 inches of rain, most of those who died drowned when they were trapped in cars trying to navigate floodwaters, state health officials reported. Of the 52 people who died during and directly after Floyd, 24 died in cars, and seven, including five rescue workers, died trying to escape floodwaters by boat.

While people may worry about infectious diseases after hurricanes cause floods, they haven't historically been a major cause of death or illness. Health officials also issue detailed warnings about food poisoning -- a danger when power outages knock out refrigerators. But statistics don't indicate many deaths from foodborne illness after U.S. hurricanes.

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