Nine Days at the Airport: The Medical Response to Hurricane Katrina

1
Nine Days at the Airport The Medical Response
to Hurricane Katrina
Christopher Sanford, MD, MPH, DTMH

• Co-Director, Travel Clinic, Clinical Assistant
  Professor
• School of Medicine
• University of Washington
• November 1, 2005

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Hurricane Katrina Sunday, August 28, 2005

• 1000 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.
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Monday, August 29

• 520 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).
• 535 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.

4
Monday, August 29

• 800 am Hurricane Katrina passes 20 miles to the
  east of New Orleans.
• 1100 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.

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Tuesday, August 30

• 130 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.
• 900 am First helicopter arrives at New Orleans
  airport with evacuees from rooftops and
  hospitals.

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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
  Ideployable within 8 hours, are
  self-sufficient for 72 hours
• Configured to manage 100-200 patients/day

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Wednesday August 31

• 100 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.
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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

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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.

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The players

• Department of Homeland Security (DHS)

Federal Emergency Management Agency (FEMA)
National disaster Medical System (NDMS)
Disaster Medical Assistance Teams (DMATs)
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Thursday, September 1

• DMAT OR-2 drove in convoy to New Orleans
  Airport despite instruction from NDMS to
  remain in Baton Rouge.

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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.

13
Thursday, September 1

• 300 pm DMAT OR-2 arrives at airport. (Three
  days after Hurricane Katrina hit the Gulf Coast).
  

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First Impressions
15

This is the worst Ive ever seen.

• No onenot Vietnam veterans, not those who
  responded to 9/11, not those with international
  relief workhad ever seen so dire and calamitous
  a scene.

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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

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Friday, September 2 - Saturday, September 3

• Medical staffing at the airport remains
  inadequate to address even basic nursing care.

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Primary task at hospital triage

• Rapid stabilization, then transport to either
• hospital
• or
• shelter

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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.

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Patients with skin damage from flooding
21
Abrupt withdrawal of medical services

• Epileptics, asthmatics, and schizophrenics
  without medications.
• Recent surgery, including brain surgery and
  organ transplant.

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Evacuee transport

• 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.

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Transporting patients
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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.

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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.

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Loading of wounded
Immediately prior to being loaded onto aircraft
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Mass evacuations

• 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.

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a distribution problem.

• 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.

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Our bedroom luggage carousels

• Noisy!
• Overhead announcements
• Barking dogs
• Passers-by

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Incoming food and water
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Sunday, September 4

• Increasing staff and a lessened flow of incoming
  patients allows transport of surviving occupants
  of the hospice to hospitals.
• Thereafter no patientsare designated to receive
  hospice care only.

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Pets
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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

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Kudos to (cont.)

• Health care providers who stayed at hospitals in
  New Orleans.
• Many remained and worked without electricity
  until patients rescued by boat.

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Kudos to (cont.)

• DMAT leaders
• Kept calm, provided team members with daily
  briefings
• DMAT members
• Worked extremely long hours. Didnt complain.
  Improvised.
• Converted airport bar into pharmacy.

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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.

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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.

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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.

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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.

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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.medicalr
  eservecorps.gov/page.cfm?pageID152
• 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.c
  om/usnews/health/articles/050910/10emergency.htm

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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.

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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/dhs
  medical.pdf
• PRC Compassion website http//www.prccompassion.o
  rg/
• 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.

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References (cont.)

• Hurricane Katrina from the Airports 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/ndm
  s.htmldmat