pediatrics
May 2006, VOLUME117 /ISSUE Supplement 4

Using International Practice Techniques in Texas: Hurricane Katrina Experiences: Receiving Patients in Longview, Texas, 350 Miles From Ground Zero

  1. O.W. “Skip” Brown, MD, FAAP
  1. Diagnostic Clinic of Longview, Longview, Texas
  • Hurricane Katrina
  • evacuees
  • disaster response

Longview, Texas, is located off Interstate 20, more than 350 miles from New Orleans, Louisiana, and 120 miles east of Dallas, Texas. It has been a wonderful place to practice pediatrics for the past 27 years. The onslaught of Hurricane Katrina would produce opportunities for many of us to volunteer our medical expertise to evacuees on a scale never before anticipated. Some providers with experience in developing nations would find, in the following days, many similarities to the styles of medical practice seen there. This observation was made independently by more than 1 practitioner.

AUGUST 27: 2 DAYS BEFORE LANDFALL

Our community was called on to provide medical services, social services, food, shelter, transportation, and clothing to as many as 500 evacuees (people who had left their homes in advance of the storm) in our community shelter. In addition, we provided the same services for an estimated 4000 to 6000 additional evacuees who were in the area and living with family or in campgrounds, motels, and churches.

Our medical community participates in disaster drills at our 2 local hospitals at least annually. The scenario usually entails a disaster at a large petrochemical plant or a massive accident on an interstate highway. The drill, which is very well scripted, is rather poorly attended. Katrina's evacuees had very different need sets in almost all situations when compared with the needs of victims of a petrochemical plant explosion in both intensity and, especially, duration of support needs.

The city and the Red Cross opened the convention center as an evacuation shelter just 2 days before Katrina hit the Gulf Coast. As the storm grew in intensity, it became obvious that a much larger number of people were seeking shelter here and in the surrounding area than was ever planned for, and more were coming.

SEPTEMBER 2: 4 DAYS AFTER LANDFALL

Relief workers delivered the first evacuees who had been trapped in New Orleans by the flood waters, mixing them with evacuees who had already arrived by their own means. Because of the total devastation and poor communications, there was a “rumor a minute.” It became apparent that some structure to this effort needed to develop quickly, or the quality of services might be degraded substantially. To the credit of the Red Cross, the county officials, both community hospitals, and the multitude of volunteer service agencies with their willing workers, things quickly shaped up; services were implemented with reasonable order.

On the medical front, many nurses, pharmacists, physicians, and pharmaceutical companies stepped up immediately, identifying and filling needs. An impromptu medical clinic and pharmacy were assembled during the day. People with previous experience with command and triage developed schedules that provided 24-hour coverage. Physicians recruited to staff the clinic varied from urologists to psychiatrists, and there was a heavy emphasis on pediatrics, internal medicine, and family practice. By afternoon, the clinic became operational with 2 pediatricians, 2 internists, and 2 family practice physicians. Many others would volunteer, including emergency medicine physicians, during their off time. They all took shifts of about 6 hours, which continued over the next several days. During the course of the time that the clinic was open (over 14 days), more than 50 physicians offered their services. In addition, pediatric nurse practitioners and physician assistants offered their time and were invaluable in filling in slots in the schedule. That evening was spent by many of us triaging unknown numbers of arriving evacuees with unknown conditions and ascertaining their expected needs.

Initially, all physicians cared for people of all ages. Too many problems needed solving to have the complete luxury of “limiting their practice.” We saw many people with chronic problems who were without their medications. I recall seeing patients with asthma, HIV, hypertension, gout, and a woman who was 6 months' pregnant with abdominal pain; off to the emergency department, stat! Unfortunately, a very large number of these patients had no idea of the names of their medications.

As I read their Red Cross medical encounter forms, I recognized the street names of where these people lived before the storm from my childhood and young-adult years. I was able to find a common thread and talk to them by some geographic reportage. Talking with someone who had knowledge of their home area seemed to help them, but it clearly brought me a great deal of satisfaction.

SEPTEMBER 3: 5 DAYS AFTER LANDFALL

After 24 hours, the physician work schedule became more structured, which allowed us to revert to our own specialties a little more consistently. However, this was never a guarantee, and we continued to see both children and adults when needed. Although this medical interchange made some physicians uncomfortable, help was available at all times for adults or children if we needed it. Overall, this fostered a great sense of camaraderie, which I enjoyed greatly. Longview has never seen an outpouring of volunteerism such as this event engendered. The consistently amazing daily event was that we always seemed to have more volunteers than needed, especially for the first 4 to 5 days.

When it became obvious that evacuees would not be going home soon, some long-term needs began to appear. We found ourselves filling prescriptions from emergency supplies or donated medications or writing prescriptions to be filled by 2 or 3 large national chain pharmacies that volunteered to do so for these evacuees. The challenge of this initial full day was similar to a sentinel memory I recall as a junior medical student in an internal medicine clinic at Charity Hospital in New Orleans. I remember a small, frail, wrinkled woman who called me “Doctor” (I was impressed even if no one else was). She then proceeded to pour a shoebox full of medicine bottles onto the cubicle desk and asked, “Doctor, which one of these do ah need to be takin'?”

Nevertheless, all of us worked in conjunction with the pharmacists to find the “pink pill for pressure,” the “white pill for fluid,” and the “red pill I take for my thinner.” I must admit that my personal digital assistant (also known as my peripheral brain) was not my savior, because it does not access medications by color—such disappointment.

We began to see more children with exacerbations of their asthma, lower respiratory infections, methicillin-resistant Staphylococcus aureus infections, otitis and pharyngitis, immersion wounds, rashes, and a very aggressive gastroenteritis. The gastroenteritis, which was reported initially the previous day in evacuees, began infecting volunteers by midafternoon. We were seeing equal numbers of symptomatic volunteers and evacuees. This problem continued over the next few days before finally tapering somewhat.

By that evening, a routine seemed to have established itself. This was good, but the routine was soon to be interrupted. Rumors started and spread about our receiving “8 busloads of people, some in really bad shape.” This generated unnecessary responses such as having ambulances position themselves, calling extra volunteers, and seeking backup from hospital emergency departments. Poor communication fostered this problem, which continued for at least the next 48 hours. Although we didn't get 8 busloads of evacuees from the New Orleans Superdome, we did get 2 busloads of people with more acute levels of need.

The pediatric nurse practitioner from our practice went to the small community on the border of Texas and Louisiana to help triage and communicate to help us appropriately prepare for arriving patients. She spent several hours dressing wounds and caring for those with dehydration before they left to their next destination.

Eventually, our 2 busloads of evacuees arrived. I recall watching the bus pull up into the covered driveway at the convention center and the opening of the glass doors to let the people out to be checked in to security. The majority of the volunteers were overwhelmed by the odor. Unfortunately, these exhausted, stressed, dirty, and bewildered people smelled so much like sewage that their arrival did not need any announcement. The magnitude of this disaster intensified in our minds as we cared for them. We realized that we would be going home to our loved ones, who were all accounted for and waiting to see us, and clean, warm beds; none of this would be possible for these people for a very great while, if ever again.

SEPTEMBER 4: 6 DAYS AFTER LANDFALL

The medical clinical triage structure and volunteer schedules set up by the Red Cross were working well, and the medical clinics were proceeding relatively smoothly. The day was busy, with about 40 patients seen on my shift.

Predictably, many of the evacuees who had been in the community for several days presented with a variety of stress-induced problems. I remember a very polite, subdued, quiet lady (she apologized for bothering me) who was wringing her hands while talking to me. She told me that she did not understand what was wrong. She insisted, “I am so upbeat and never let things get to me…. I don't know why I feel this way.” She was tearful and obviously distressed. I recall thinking to myself, “Gee, let's see; you just lost your home, your job, and your city, and you don't know where half of your family is. So what could be wrong with you?” We talked for a few minutes and found a little common ground. She lived in a part of the city close to an area in which much of my mother's family lived when I was a child. She was secretary for the dean of admissions at Louisiana State University Medical Center. I learned that she had really come up the hard way and had done well for herself…. We shared a few common experiences about New Orleans. I offered to arrange some counseling the next day or maybe something for sleep if she still felt badly the next day. She smiled a little and left saying that she would return if she had problems again. I hope that she really did feel a little better and that some sense of control was returned to her for a short time.

Obviously, many patients have situational anxiety or depression. I can report that, as time has passed, this has been a frequent problem with those who have remained in the area. I still follow 4 to 5 adolescent evacuees, and depression, anxiety, or posttraumatic stress disorder seems to be a common thread among them.

SEPTEMBER 5 (LABOR DAY): 7 DAYS AFTER LANDFALL

The sheer amount of work began to stabilize and actually diminish as the early part of the new week progressed. We continued a daily pediatric and general medical clinic for the next 2 weeks until most of the evacuees were placed in the community or returned to family closer to home.

LESSONS LEARNED

  1. The impact of a severe disaster on a region and the subsequent needs that are produced can be anticipated in part. A flexible response is very important to a successful response.

  2. Those in areas of support that are closest to ground zero should concern themselves with the most immediate needs, and those in less devastated areas should focus on support of longer-term needs such as housing, social services, and long-term medical care. We were in a much better position to provide care than those in many places in southern or even northern Louisiana by virtue of our distance from impact.

  3. Every state should coordinate medical care on the basis of levels of care that are available in each licensed hospital. We were asked to accept some patients who clearly were unable to receive adequate care in a community hospital. This coordinating should be updated annually and made available to a national medical database.

  4. Volunteerism for acute short-term needs is highly effective in providing a rapid response, but it should be structured before the need arises; “organization” is the key word.

  5. For longer-term support, some method of relieving volunteers is needed to avoid “burning out” the volunteer base.

  6. Medical volunteers by specialty should be recruited ahead of time to be called on for major disasters with local or regional effects. This information could be managed through the above-mentioned medical database.

COMMENTS

The reverberations from the impact of Hurricane Katrina will continue for years, if not generations. Most of these effects have been destructive and highly negative, but they have afforded many of us with a distinct learning opportunity that can be shared with our communities, states, and nation, as well as with our profession, to better be able to manage tragedies of a similar magnitude in the future. To not extract the critical lessons from this event would be an irresponsible loss of the only positive aspect of this catastrophe.

Footnotes

    • Accepted January 25, 2006.
  • Address correspondence to O.W. “Skip” Brown, MD, FAAP, Diagnostic Clinic of Longview, Department of Pediatrics, 707 Hollybrook, Longview, TX 75605. E-mail: sbrown778@hotmail.com
  • The author has indicated he has no financial relationships relevant to this article to disclose.