Disaster preparedness perspective from 90.05.32w, 29.57.18n.

A major disaster occurred in a major city in the USA. The aftermath produced significant difficulties in patient care. Failure of the communication system, lack of command and control, and incomplete planning were at the root of all of these difficulties.

Despite what the federal government would have you believe, disasters in the United States (and most of the rest of the world) will not, most likely, result from Biochemical Terrorism or Weapons of Mass Destruction (WMD). Can it happen...yes, but over the last 20 years or even since 9/11, disasters result from natural causes, blasts or structural collapse. Since this is the most common occurrence, it is this for which we must prepare. Keeping in mind that biochemical terrorism and WMD are possible but the same principles of patient care apply with variations. The principles apply to all. The preferences will vary according to etiology. The ole medical school axiom still applies A when you hear hoof beats, expect horses not zebras.

Most of the physicians in the US are not informed about disaster management, have only a very superficial knowledge of the preparations made by their individual hospitals or with in their community, and have not participated in local disaster drill There are several reasons for such lack of knowledge. These include: "it has never happened here, so I won't waste my time learning about it", "the nurses and administrators do all the planning and don't include me", "the drills are all about things like biochemical's which are not the common things that will happen so why should I play their silly games".

When the actual disaster does occur, the physicians are mentally unprepared for the constraints of the situation and do not understand the new paradigm for care of the patients. With such lack knowledge, they become part of the problem rather than part of the situation by refusing to follow the game plan, dropping out completely or try to force their own ideas that are not consistent with the disaster management. Another confounding factor is that the drills are seldom, if ever, practiced in real time to acquire knowledge that the peculiarities of the local conditions bring about.

The response to disasters can be divided into 3 phases: 1) Immediate (local), 2) external assistance, and 3) backfill (resupply). Patient care will be driven by the availability of people, supplies and equipments within these 3 phases (Fig 1).

There are two kinds of disasters that are significantly different in planning, management and outcome: with and without infrastructure failure. Katrina demonstrated both of these types. In New Orleans the disaster produced infrastructure loss. The same Hurricane produced a disaster in Houston but the infrastructure remained intact.

Immediate

For the first 2–6 days after the disaster, the response and medical care will come from local health care providers, using supplies that are on hand, equipment that is not damaged by the incident, and treating illness and injures that are: 1) present within the hospital prior to the incident; 2) the immediate result from the incident, or 3) patients with preexisting conditions. The first group of patients to be addressed is those that were in the hospital when the situation occurred. Their needs will be modified by loss of power, restrictions for food, water and medications. In Katrina, because of the isolation (the hospitals became islands without access from the outside or to the outside) there was no re-supply of the needed supplies, including diesel fuel for the backup electrical generators.

Preparation includes having on hand everything that will be required to care for patients: portable water, food, medical supplies including medication, oxygen, all things that one would consider critical and thing that do not pop to the immediate consciousness such as a weeks supply of diesel fuel or human waste disposal. A red human waste bag place over a toilet and a couple of scoops of kitty litter, significantly reduces the contamination and odor when the toilets fail because of loss water pressure and sewerage overflow.

When these items are in storage they must be periodically inspected to replace expired items, and security must be present to protect from pilferage by 2, 4, and 6-legged creatures.

As has been discussed following every disaster in the United States (and Katrina was no exception), communication failed. Cell phones worked sometimes.... too many people tying to make calls; too many towers blown down and without power the batteries cannot be recharged. Satellite phone did not work in the buildings and only approximately 50% of the time standing on the parking lot. Handheld push-to-talk phones and radios need to access repeater towers and also need to be recharged. Power outage impacts the hospital phone networks: paging, internal and external phone calls are lost.

The only phones that remained functional after Katrina were old-fashioned non-battery powered direct lines to Bell South. Phones that went through the hospital network and trunk lines failed when the power was lost. These phones were local lines. The only calls out of the city for help had to be charged on a credit card. Information exchange within the hospital was by runners.

Communication between Charity Hospital (CHNO) and University Hospitals (UH) and Tulane University Medical Center (TUMC) was wading through contaminated water, canoe, notes carried by boat drivers or on occasion bull horn to bull horn from the roof of the hospital. No direct voice-to-voice or other real time communication worked. Such information exchange produced lack of understanding, confusion, misinterpretation, out of context appraisal. All of which lead to poor exchange of information between individuals, hard feelings, lack of coordinated patient movement and, on occasion, poor or delayed patient care.

As a result of the communication breakdown, there was no citywide command and control. Every island was left to function on their own, setting their own rules, planning their own evacuation, security and re-supply

Evacuation of patients, health care workers, family and refugees was done by boat, large military trucks or helicopters. Boats worked for a while until one of the boats was 'boat-jacked' and the driver shot. The down side of the boats was that they carried people to the freeway where the lines for the busses were long, minimal patient care was available and no medical care provided en-route. Similar down side existed for the trucks. The only viable transportation for patients was via helicopter to another medical center or to an airport with ground medical transportation. With all of the local hospitals effected by Katrina, the transportation time and therefore return to pick up other patients was up to 1 2 to 2 hours. To evacuate the hospitals in a timely manner many helicopters were needed. For the entire evacuation process 250 landings and takeoffs occurred.

For a helipad, light poles were pulled from the top of the parking lot adjacent to the hospital to provide a landing zone (LZ). The initial design of the parking lot had included stress for a heavy helicopter. Both Blackhawk and Chinook helicopters landed without difficulty. To control for potential overload of the LZ due to weight of the larger helicopters and to make use of the aircrafts as efficient as possible, all patients, health care workers, and other personnel were loaded 'hot'(no engine shutdown and with rotors turning).

There will be additional unexpected patients and other personnel that arrive at a medical facility that must be cared for and evacuated. Such must be taken into consideration in developing plans for disaster management. Example. At the time that Katrina hit, TUMC had 110 patients, 800 medical personnel and about 200 other personnel. At the completion of the evacuation process, 254 patients and 1400 medical personnel, family members and others. (910 patients & others vs 1654 evacuees)

Regional/National Response

The regional/national response should be setup to achieve several goals 1) provide immediate assistance in the management of patients, 2) provide or assist with evacuation, 3) replenish supplies and 4) provide rest for weary personnel on a gradual replacement basis with overlap.

For Katrina, in two of the three hospitals, there was difficulty in achieving any of these goals. The author does not know the etiology of the failure at the time of this writing. It can only be speculated, therefore will not be addressed. At TUMC, requests for assistance in the first 3 categories were well achieved. Number 4 above was not needed since complete evacuation occurred

Throughout the region, however there were significant areas of failure. National/Regional assistance came late, was blocked by local authorities that perhaps did not understand the need and was inadequate to meet the needs. Failure of the communication system, lack of command and control, and incomplete planning were at the root of these problems

Backfill/resupply

Backfill and resupply are as the name implies. Additional personnel to replace those who were in the front lines for the first few days and now have become tired and spent. This is in the form of additional physician, nursing and maintenance personnel to staff the hospitals or insert new or portable hospitals, ambulance personnel and additional ambulance units to relieve the EMS folks who were initially present.

In Mississippi, the inflow of backfill personnel from both military and non-military sources seemed to work smoothly. Reports from volunteers who attempted to assist in Louisiana did not seem to work as well. The sources of the constraints are difficult to identify.

The USNS Comfort arrived in New Orleans and sailed out in less than 2 weeks. This occurred at a time that the trauma center and all of the major hospitals in the city of New Orleans were disabled or found by the owners to be beyond reasonable repair and condemned. Three hospitals in the neighboring parish (Jefferson) were pushed to capacity and were at the point of refusing patients (lack of nurses to open beds) when the USNS was ordered to sail. This left only a military Combat Support Hospital (CSH) unit and 2–3 emergency tent type units. The mission of the CSH hospital is to provide initial patient care and then transfer the patients to a full service hospital within 48 hours. Therefore area hospital had to agree to accept these patients in transfer. Many instances this was difficulty because lack of bed availability

This points out two major fallacies in the system. 1) Major hospitals cannot open beds because of lack of nurses. Volunteer nurses have difficulty in getting jobs in the hospitals (credentialing) and local nurses who work in the hospitals cannot find houses or apartments to live in. 2) The large mobile hospital (USNS Comfort) is ordered to leave on the upswing of patients. It did not stay to support the surge as residents were returning to the city and major construction was ongoing. CSH is set to leave in 3–4 weeks. At the time of the scheduled departure from New Orleans, no major hospitals will be full operational in the city.

Failure of the communication system, lack of command and control, and incomplete planning is again at the root of these problems

Summary

A major disaster occurred in a major city in the United States. The aftermath produced significant difficulties in patient care. Failure of the communication system, lack of command and control, and incomplete planning were at the root of all of these difficulties.