Nine Days at the Airport: The Medical Response

to Hurricane Katrina

Co-Director, Travel Clinic,

Clinical Assistant Professor

School of Medicine

University of Washington

November 1, 2005

Christopher Sanford, MD, MPH, DTM&H

Hurricane Katrina: Sunday, August 28, 2005

10:00 am: US National Weather Service predicts

catastrophic damage to New Orleans.

Over 10,000 people

enter the New Orleans

Superdome for the

night at the urging of

Mayor C. Ray Nagin.

Monday, August 29

5:20 am: New Orleans International Airport loses commercial electricity, and begins to utilize back-up generators, which provide sufficient electricity for minimal lighting, but no air conditioning. The temperature inside the airport quickly soars to 100º F (38 ºC).

5:35 am: Katrina, now a Category-4 hurricane, with winds reaching 140 miles per hour, makes landfall at the Louisiana-Mississippi border of the Gulf Coast. Accompanying the hurricane is a 29-foot surge of ocean water, the largest ever recorded.

Monday, August 29

8:00 am: Hurricane Katrina passes 20 miles to the

east of New Orleans.

11:00 am: Floodwall of the Industrial Canal breaks

open in two places, flooding the 9th Ward with

3-10 feet of water. Thousands of residents climb

to their rooftops.

Tuesday, August 30

1:30 am: 17th Street Canal barriers along two blocks fail, flooding 80% of New Orleans. The local pump station fails. A 300-foot section of the floodwall lining the London Avenue Canal fails, worsening the flood.

9:00 am: First helicopter arrives at New Orleans airport with evacuees from rooftops and hospitals.

Disaster Medical Assistance Team (DMAT)

Disaster Medical Assistance

Team

Established 1984 by United

States Public Health Service

61 DMATs in the US.

Approx. 27 are “Level I;”

deployable within 8 hours, are self-sufficient for

72 hours

Configured to manage 100-200 patients/day

Wednesday August 31

1:00 am: Initial 3 DMATs arrive at airport.

Over 25,000 evacuees are in the Superdome, which

is three-feet deep in floodwater. Water level

continues to rise.

Efforts to sandbag the failed 17th St. Canal barriers

begins.

DMAT Team Meeting

35 team members

4 physicians:

• Dr. Helen Miller: Team Commander ER and pediatrics

• Dr. Jon Jui: public health, infectious disease, critical care

• Dr. James “Judge” Hicks: anesthesiologist

• Dr. Chris Sanford: family practice, travel and tropical medicine, public health

Nurses, mid-level practitioners, pharmacists, EMTs, logistics, communications, ops

Thursday, September 1

DMAT OR-2 drove in convoy from Houston to

Baton Rouge (60 miles NW of New Orleans).

Radio contact with 3 DMATs at airport: no sleep

for two and a half days, running out of medical

supplies, food, and water.

Bizarrely, DMAT OR-2 told by NDMS (National

Disaster Medical System) to remain in Baton

Rouge.

The players:

Department of Homeland Security (DHS)

Disaster Medical Assistance Teams (DMATs)

Federal Emergency Management Agency (FEMA)

National disaster Medical System (NDMS)

Thursday, September 1

DMAT OR-2 drove

in convoy to New

Orleans Airport

despite instruction

from NDMS to

remain in Baton

Rouge.

Thursday, September 1

At the New Orleans International Airport: 23 of

26 New Orleans hospitals were flooded or

otherwise incapacitated by flooding. Virtually all of

these patients were transported to the airport.

Approx. 500 people on the floor: residents of

nursing homes, hospitals, evacuees.

Approx. 2,000 people waiting for triage.

Medical teams on-site exhausted.

Thursday, September 1

3:00 pm: DMAT OR-2 arrives at airport. (Three

days after Hurricane Katrina hit the Gulf

Coast).

First Impressions

No one—not Vietnam veterans, not those who

responded to 9/11, not those with international relief

work—had ever seen so dire and calamitous a scene.

“This is the worst I’ve ever seen.”

Triaging at airport

Holding area for shelter

Green Tent: ambulatory

patients

Yellow Tent: moderately

ill patients

Red Tent: critically ill

patients

Hospice: “expectant” care

only

Friday, September 2 - Saturday, September 3

Medical staffing at the airport

remains inadequate to address

even basic nursing care.

Primary task at hospital: triage

Rapid stabilization, then transport to either:

hospital

or

shelter

Most patients were not injured by the direct

effects of hurricane

Most were ill as a result of the abrupt withdrawal of

medical infrastructure, including medications.

• Diabetics without insulin for 5-7 days.

• Patients with chronic renal failure who had not

had dialysis for 5-7 days.

• Hypertensives off

antihypertensive

medications having

strokes and myocardial

infarctions.

Patients with skin damage from flooding

Abrupt withdrawal of medical services

Epileptics, asthmatics,

and schizophrenics

without medications.

Recent surgery, including

brain surgery and organ

transplant.

Jets, helicopters, and buses continued to bring evacuees and hospital patients to the airport.

In the peak hour, 160 helicopters landed and

took off in one hour.

Evacuee transport

Transporting patients

Crude mortality rate (CMR)

Usually expressed in deaths per 10,000 population

per day.

In developing nations, CMR is usually 0.4-

0.6/10,000/day.

A CMR of over 1 is

considered elevated,

and over 2 is

considered

critical.

CMR at airport impossible to calculate accurately

Exact logs of patients and evacuees were not kept.

However, as population at airport varied from

2,000-10,000, and approximately 36 deaths

occurred between August 31 and September 3, it

appears that the CMR was well in excess of the

generally accepted critical value.

Immediately prior

to being loaded

onto aircraft

Loading of wounded

2,700 patients were

evacuated from the

airport to hospitals; this

represents the largest air

evacuation in history.

Approximately

25,000 people were

transported from the

airport to shelters.

Mass evacuations

At Louis Armstrong New Orleans International

Airport:

"The hallways are filled, the floors are filled. A lot

more than eight to 10 people are dying a day. It's a

distribution problem. The doctors are doing a great

job, the nurses are doing a great job."

--Majority Leader Bill Frist, R-Tenn.

“…a distribution problem.”

Our bedroom: luggage carousels

Noisy!

• Overhead

announcements

• Barking dogs

• Passers-by

Incoming food and water

Sunday, September 4

Increasing staff and a lessened flow of incoming

patients allows transport of surviving occupants of

the hospice to hospitals.

Thereafter no patients

are designated to

receive hospice

care only.

Pets

Kudos to:

US military, including Army, Air

Force, and National Guard

• Transported patients

• Kept order

US Forest Service

• Provided hot meals, showers,

handwashing stations for staff

PRC Compassion

• Faith-based group. Cleaned,

performed nursing care

for patients

Kudos to: (cont.)

Health care providers who stayed at hospitals in New

Orleans.

Many remained and worked

without electricity until

patients rescued by boat.

Kudos to: (cont.)

DMAT leaders

• Kept calm, provided

team members with

daily briefings

DMAT members

• Worked extremely

long hours. Didn’t complain. Improvised.

• Converted airport bar into pharmacy.

Suggestions

Management Support Team (MST) should be

staffed not by DMAT commanders, but by their

own staff.

NDMS does not now

have control over its

logistical supply chain,

human resources,

communications, or

travel of staff. It needs to.

Suggestions (cont.)

Traditional doctrine of DMATs: they are to

reinforce local and state assets. At the New

Orleans Airport, we operated without those

assets, which were overwhelmed by the crisis.

Training should include

scenarios in which

DMATS are trained

to be free-standing

providers.

Suggestions (cont.)

Standardization is good.

At the airport, we used at least five different types

of models/brands of glucose monitors, each with

its own proprietary

strips, which were

not interexchangable.

Acknowledgements

Dr. Helen Miller, Dr. Jon Jui, and Joel McNamara,

for their DMAT OR-2 Hurricane Katrina After-

Action Report. www.odmt.org/Katrina AAR.pdf

Dr. Jon Jui for his analysis of command structure

issues.

References

FEMA website: http://teams.fema.gov/dmat/

Oregon Disaster Medical Team website: http://www.odmt.org/links.html

Medical Reserve Corps website: http://www.medicalreservecorps.gov/page.cfm?pageID=152

Briggs SM; Leong M: “Classical concepts in disaster medical response,”

in: Leaning, J; Briggs, SM, Chen, LC: Humanitarian Crises. Cambridge,

Harvard University Press, 1999, pp. 69-79.

Vankawala, Hemant reported to Josh Fischman, US News and World Report website: http://www.usnews.com/usnews/health/articles/050910/10emergency.

htm

References (cont.)

Thomas, Evan: The Lost City. Newsweek, Sept. 12, 2005, p. 44

VanRooyen MJ; Holliman CJ: Protecting yourself: traveling healthy. in

VanRooyen, M; Kirsch, T; Clem K; Holliman, CJ: Emergent Field

Medicine. New York, McGraw-Hill, 2002.

Childress, Sarah: Critical Condition. Newsweek, Sept. 12, 2005, p. 51.

Leaning, J; Briggs, SM, Chen, LC: Humanitarian Crises. Cambridge,

Harvard University Press, 1999, p. 25.

Giardet, ER: Somalia. Rwanda, and Beyond: The Role of International

Media in Wars and Humanitarian Crises. Dublin: Crosslines

Communications, 1995.

References (cont.)

Toole, MF; Walkman, RJ: The public health aspects of complex

emergencies and refugee situations. Annual Review of Public Health,

1996, 18.

Lowell, Jeffrey A. Medical Readiness Responsibilities and Capabilities: A

Strategy for Realigning and Strengthening the Federal Medical

Response. Department of Homeland Security internal document.

http://wid.ap.org/documents/dhsmedical.pdf

PRC Compassion website: http://www.prccompassion.org/

Miller H; McNamara J, Jui J: Hurricane Katrina: After-Action Report,

DMAT OR-2. ttp://www.odmt.org/Katrina_AAR.pdf

The shaming of America. The Economist, Sept. 10-16, 2005, p 11.

References (cont.)

Hurricane Katrina from the Airport’s Point of View.

http://www.flymsy.com/Katrinastory.htm

Thomas, Evan: The Lost City. Newsweek, Sept. 12, 2005, pp.

46B-C.

FEMA website:

http://teams.fema.gov/dmat/about/ndms.html#dmat

Hurricane Katrina

A public health official in

a Red Cross volunteer world

Cindy Smith, RN

Director, Hill County Health

Department, Havre, MT

Red Cross Response

Training 3 months prior with

certification for Disaster Health

Services. Why? To understand

Red Cross role and how Public

Health would work with Red

Cross in any disaster.

Aug 28 Call out

Aug 30 Flight

Hill County, MT

Red Cross Protocols

Red Cross disaster Health Services provides emergency and preventive health services to people affected by disaster and to Red Cross staff assigned to a disaster relief operation.

The primary responsibility for the general health of a community in a disaster rests with the local public health authorities and local medical, nursing, and health resources.

Disaster Health Services Protocols

Personnel Roster

Red Cross Report

Question

Have you had training as a red cross

volunteer?

A. Yes

B. No

Houston to Baton Rouge

Staging: Houston

Good

• Easy to find check-in site at airport

• Met and talked to many well qualified

volunteers from all over the US and the world

• Lots of H2O

Aug. 30 Houston: assignments into three

member team

Aug. 31 Rental Car from Houston to Baton

Rouge

Staging: Houston (cont.)

Needs improvement

• Organization of volunteers to travel to

Baton Rouge

• No clear time for the announcement of

assignments

• Tracking volunteers once sent to Baton

Rouge

Staging: Baton Rouge

Good

• Lots of computers

• Break down into command

structure e.g., logistics,

operations

• Volunteers eager to be deployed

• Some sections appeared to be organized

• Great city, very friendly people, many volunteering

their time and their homes

Aug 31 Baton Rouge – 12:00 pm Assignment

into the field? Where does the medical

staff check in? (Chaos and uncertainty)

Staging: Baton Rouge (cont.)

Needs improvement

• No one knew where to check in the health service volunteers

• Someone from DC assigned me to staff health without prior training

• Long waiting times for assignments while news reports showed Mayors etc., calling for help from Red Cross and FEMA

• Unorganized tracking of where they sent the Health Service volunteers

• No one used computers to make a central data base of shelters, volunteers assigned to the shelters, who needed help at existing shelters, identifying areas of need, etc.

• No forms made to take with us into the field

First Assignment

Good

• Physician and LPN triaged ill people

• Had lots of food and supplies e.g., clothes,

toiletries, diapers

• Many Red Cross Volunteers

3:15 pm Asked for assignment to Denham Springs Jr. High School in Denham Springs. Waited for car and supplies.

5:00 pm Left Baton Rouge

6:15 pm Arrived at Jr. High

First Assignment (cont.)

Needs improvement

• Little medical supplies

• No forms to fill out medical records on

• 100 degrees in gym and medical room

• Small area designated for ill

• Long distance to BR for elderly and disabled

• School to start in one week

Question

Does your local or state emergency

preparedness plans include the use of faith

institutions for shelters?

A. Yes

B. No

Ministerial Response

Good

• Great response from parishioners

• Vans for transportation

• Kitchens with prior sanitarian inspections

• Police protection support

• Showers and washer and dryers

• Ministerial association helped to provide

mental health

Aug 31 Revival Temple – Arrived 8:00 pm

Ministerial Response (cont.)

Needs improvement

• No medical supplies at the start

• No O2

• No local Public Health presence

• No Red Cross support from Baton Rouge

• Emergency numbers given were not helpful

First Response

Set up beds on church pews

Begin to interview, assess

and care for the displaced

Volunteer parishioners and

area churches come to the

rescue

Volunteer professionals

Donations

Emotions begin to swirl

Lockdown

Thankfulness

Anxiety

Fear and worry about displaced family members

Fear and worry about the future

Pain

Sorrow

Laughter

Happiness

Jealousy

Frustration

Settling In

Medical needs

• Physician visits

• Pharmacy

Searching web sites

Registering names into data base

FEMA arrives with family members

Disbursed all over the United States and some back home to face the next challenge

Church service

Next assignment

• Sent to staff shelter

• Great people in Baton Rouge

• 2 days with Staff Health (Just what is staff health?)

• Request for Health Services transfer

• Public Health Team assigned by National Red Cross to Baton Rouge met with resistance by existing Health Services staff

Sep 4 Left Revival Temple 2:00 pm. Return to

Baton Rouge for Staff Health

Assignment.

Baton Rouge to Monroe

Monroe

• Public Health Chart Reviews

• Where is local Public Health?

• Nursing assessments and referrals

to mobile clinics

Sep 6 4 1/2 hour drive. Check in and briefing

at local Red Cross Chapter 8:00 pm.

Sep 7 7:00 am to 7:00 pm at Monroe Civic

Center with 2500 displaced people.

Monroe (cont.)

Sep 8 7:00 am to 7:00 pm

• More chart reviews

• Where to find the people with

identified symptoms and or risk

factors?

Sep 9 Plan to move all 2500 to old State

Farm headquarter 300,000 square

foot building because of wrestling

match scheduled in civic center.

State Farm Residential Community

Good

• Badges made for all volunteers and

shelter residents

• Lots of space

• Medical wing existed in State Farm

organization

Needs Improvement

• 600-700 made the move

• No tracking of names of those who moved

• No on site cooking or meal preparation

• No showers

• No place for the pets

• So big with lights out at 10 pm

State Farm (cont.)

Needs Improvement

• Communication about events, plans, location

of services, etc did not filter from charge staff

to volunteers assigned to specific duties

• Need for cultural diversity training to volunteers

and local chapter

• All forms still not available

• Commissioned Public Health Officers made a

30 minute assessment

• Where do people put all their new belongings?

• How do they get all the things people send?

State Farm (cont.)

Lessons Learned: 1. Cross Training

Cross Training and continued discussions

with local, state and national volunteer

organizations

• Do they exist in our communities and

are they at our table or will we need to

seek them out?

• What can we learn from them?

• What can they learn from us?

Even if your community is not a direct hit of the

incident, you may be affected.

Think about having a city population that is twice your size all of a sudden moving to your area. In addition there may be volunteers in hundred counts coming right with them.

• Banks

• Food Service

• Traffic

• Security

• Grocery Stores

• Hardware and appliance

• Realty

• Churches

2. Indirect Impact

3. Mental Health

An overwhelming need to increase the training

to all responders. People needed to talk and

they needed to be acknowledged and heard.

Sure they were safe and in a shelter, but their

previous troubles along with new added trauma

became explosive.

• Pain management

• Alcohol and drug use

• Family dynamics

• Grieving

4. Local Capacity

In your local emergency plans do you have

• Ministerial Response Plans

• Oxygen supply companies

• Special needs children and adults identified with written evacuation or notification protocols in place and understood by those populations

Who are the special needs populations

• Elderly

• Poor

• Medical

• Disabled

5. Communication and documentation

If you don’t know anything what good are you?

What happened to all the forms? How many

forms do you have in your plan and how will

you get them to those who need to use them.

Just whose forms will we use?

6. More communication

How well will your local government work

together in an emergency? Do they know what

is in your plan? Are they trained? Do they have

the training as a priority on their list?

• Mayor

• Commissioners

How well will you work with your state

government in an emergency?

• Police chief

• Public Health

• Governor

• State Public Health