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The Red Badge of Katrina


 

“If this old ninny-woman, Fate, cannot do better than this, she should be deprived of the management of men’s fortunes. She is an old hen who knows not her intention. If she has decided to drown me, why did she not do it in the beginning and save me all this trouble. The whole affair is absurd. … But, no, she cannot mean to drown me. She dare not drown me. She cannot drown me. Not after all this work.”

—Stephen Crane, The Open Boat

Stephen Crane, the famous 19th-century American author of such works as The Red Badge of Courage, also penned a short story entitled The Open Boat during his illustrious career. The tale is a fictionalized narrative of a traumatic experience in his life. A ship on which he was a passenger sank during a storm off the coast of Florida. He found himself one of four survivors drifting in a tiny open dinghy struggling to stay alive in a tumultuous sea and pounding surf.

Caution tape was still up outside Charity Hospital in New Orleans on Thurs., Oct. 6, 2005. Assessment and structural engineers advised that the hospital, which opened in 1939, be closed due to extensive damage from Hurricane Katrina flooding.

As Crane shows in his story, his characters’ salvations depend upon whether or not they will adapt to their surroundings and help their fellow human beings—not whether or not they can conquer nature.

I couldn’t help but think of Crane’s story and its inherent intimations after digesting firsthand accounts from medical staff on duty in ICUs during the recent traumatic experiences of Hurricane Katrina. The circumstances seem so unique and foreign in our modern age of delivering expeditious, accurate, and technologically supported medical care. I invite all physicians to bear witness to these incredulous stories and cleanse their own complacent perceptions, tabula rasa if you will, of functioning as a practitioner of 21st-century healthcare. These tales harken back to a not too distant time in medical practice.

Charity Hospital in New Orleans is one of the oldest continuously operating hospitals in the country. Along with University Hospital, another public facility just up Gravier Street in the Crescent City, Charity dispenses the lion’s share of all medical care in the city to one of the most uninsured populations in the country. Both hospitals are staffed and run jointly by Tulane and Louisiana State University (LSU), whose medical schools sit contiguously with Charity on opposite ends and lie unfavorably in one of the Big Easy’s topographical low points. Here are first-hand accounts from hospital staff who endured Hurricane Katrina from the confines of Charity and University hospitals.

Ben DeBoisblanc, MD, an LSU pulmonary attending physician, was assigned to Charity Hospital’s ICU. What follows is his chronicling of the events surrounding Hurricane Katrina.

“Prior to landfall it was obvious that Katrina had all the characteristics of the hurricane experts for decades had predicted would be the worst natural disaster in U.S. history: A category 5 storm hitting a city that is largely below sea level and completely surrounded by water. We were able to reduce our ICU patient load in Charity Hospital to about 50 prior to the storm hitting.

“After evacuating our own families, our emergency activation team set up to provide medical support for the remaining patients. During the storm windows blew out in the ICU, flooding it with about two inches of water. The power went out, but the emergency generators kicked on and all seemed well.

“But an hour later for some unknown reason we lost all power and began bagging our patients in total darkness. We were able to restart the backup generators late in the day on Monday, which allowed us to start cleaning up the mess in the ICU. Although the city was without power, we were high-fiving each other over a job well done. The day crew went to sleep late Monday, but was suddenly awakened at 3 a.m. on Tuesday to help bag patients when the emergency generators went out again. As dawn began to break we began to understand why: Water was pouring into downtown New Orleans from every direction and had flooded the generators that we located on the first floor.

I cried when I left Charity, perhaps for the last time ever. Some were tears of triumph, some were tears of profound sadness. Triumph for the miracle of human resolve that allowed a group of civilian doctors, nurses, and respiratory therapists to accomplish what the federal government could not. We got all of our patients out alive except two.

—Ben DeBoisblanc, MD

“Without power for our life support systems (suction, monitors, vents, dialysis, IV fluid pumps, radiology, laboratory, etc.) we realized that we needed to get our patients out ASAP. Subsequently, a sanitation crisis unfolded when we lost water pressure for toilets. We were not only caring for 300 patients in the hospital but we were also providing refuge for more than 1,000 support staff and their families. Before we lost communication with the outside world on Tuesday FEMA instructed us to prepare for evacuation later that day. Much to our surprise the governor’s office was telling news agencies that we had already been evacuated. Needless to say, no outside help came until Friday, despite FEMA’s instructions.

“It soon became clear that if we were going to get out, we would have to get ourselves out. Our hazmat team had acquired four small diesel generators for field use, but did not have diesel fuel on site to power them. Our ICU respiratory therapist used his ‘Mississippi credit card’ (a hammer and a screwdriver) and some oxygen tubing to siphon diesel from on ambulance flooded on the ED ramp. We were able to power up the ICU to run about six vents. For the others we used gas driven portable vents or continued to hand bag. The roof of Charity Hospital was the only cool place to get a few hours of restorative sleep each night, so we broke away from our 12-on, 12-off usual staffing plan to allow each shift to enjoy a few hours with the rats seeking higher ground.

“By Wednesday we were still without any FEMA presence, and a morale crisis erupted among the employees. Although many staff were incapacitated with fear, grief, and despair, others dug deep and rose to the challenge. We could not communicate with police, National Guard, or FEMA, but our ICU residents were able to text message and get live on-air transmissions to CNN.

“On Wednesday, Francesco Simeone, a colleague from Tulane got a call from private air ambulance services wanting to send in their own helicopters to start the evacuation. The only problem was that the only commercial heliport in the area was at the Superdome, which was in the midst of a security crisis.

“Joe Lasky, the chief of Tulane pulmonary services, paddled a canoe from Charity and found a National Guard five-ton truck with a driver that was not in communication with his command. This actually worked to our advantage because he could not be accused of disobeying an order by helping us.

“Wednesday night we put the first four of our patients in the back of the truck and drove them across the street to Tulane Hospital’s parking garage. One patient was 23-year-old kid with Goodpasture’s and acute renal failure who had not been dialyzed in four days and who being bagged with 100% O2 and a 12 cm PEEP valve. We had to emergently insert a chest tube in the back of the National Guard truck when he desaturated in the middle of riding through the floodwaters.

“We then used a ‘borrowed’ pick-up truck to ferry the patients to the rooftop of a parking lot adjacent to Charity Hospital, where we set up a mini-ICU for the next two days. After removing light poles helicopters were able to begin landing, but the sun set before we could get any ICU patients to the roof, leaving us with four patients and no exit strategy for getting them out of New Orleans. The commercial ambulance personnel were able to communicate with military helicopters and by 11 p.m. Wednesday the clap-clap thunder of a Black Hawk was heard overhead. The Black Hawks were configured only as troop carriers, which meant that we would have to provide patient support for all of the sorties.

“The first ride for me was surreal: a moonless night, unlit buildings and towers, pilots with night vision goggles. A triage landing site had been established on the edge of town on the interstate. Amazingly there were thousands of people waiting, ready to help, but no one had known of our plight. We dumped our patients with brief medical records taped to their forearms into waiting ambulances for dispersion all over the region. A day later I got a call that the 23-year-old patient was alive and doing well.

A helicopter drops a sandbag as repair work on the London Street levee continues Saturday, Sept. 10, 2005, in New Orleans.

“We continued the air evacuation all day Thursday, Thursday night, and Friday morning. Nurses cat-napped on the concrete roof by putting their heads on the legs of colleagues who bagged and comforted those waiting for the next helicopter. Not knowing the structural integrity of the rooftop, the Black Hawk pilots stayed powered up while we loaded our patients, docs, and O2 cylinders. After 48 hours of screaming commands over the roaring sound of the Black Hawks our entire ICU staff was both deaf and mute. By Friday afternoon we had completed our mission and walked the three blocks back to Charity in chest-deep sewage just in time to discover that FEMA had arrived to begin evacuating our hospital.

“I cried when I left Charity, perhaps for the last time ever. Some were tears of triumph, some were tears of profound sadness. Triumph for the miracle of human resolve that allowed a group of civilian doctors, nurses, and respiratory therapists to accomplish what the federal government could not. We got all of our patients out alive except two. One we expected to die; the other was an intubated elderly lady with COPD whose husband we were forced to leave behind at Charity.

“I remember how he sat day and night fanning his wife in the sweltering heat of the ICU. Fanning even as he seemed to slip into sleep. She died in the arms of her resident physician who could do no more on the rooftop than comfort her with the touch of a hand. I never saw her husband again because he was evacuated before I got back to the hospital. I don’t even know if he knows that she had died. Even if he does know, I somehow feel that he remains profoundly grateful.

“I feel sad because valuable time was lost both due to the anemic early response and because valuable resources were misused. I personally witnessed dozens and dozens of helicopters—many military—land and fly away with able-bodied citizens while patients died on the rooftop. And sadly, many of those able-bodied citizens were physicians.

“It was an experience that I will never forget. I left with one memento: a set of keys of a John Doe with an unknown medical condition that we loaded into a helicopter to be carried to an unknown place with an uncertain future. If you received a John Doe looking for his keys, let me know, I’d love to one day be able return them.”

Steve McPherson, MD, a third-year Tulane medicine resident was assigned to the ICU of University Hospital. Here is his story.

“I was on a typical every third call schedule for the ICU working that Friday night [August 26, 2005]. As far as I knew, Katrina was in the Gulf at a category 2 and headed for the Panhandle. Friday night as I answered four or five pages, I kept checking the weather channel. The reports kept looking worse. Katrina was growing in strength and had changed course to head right at New Orleans.

“Saturday morning I called my fiancée, informed her of the updated prediction of a direct hit category 4-5 hurricane and asked her to start packing to leave. That afternoon a ‘code gray’ [natural disaster] was called, and we were informed by e-mails and pages. This meant that both the Saturday and Sunday teams had to report on Sunday and would be on duty indefinitely.

“Sunday morning I reported to work under the code gray status. Katrina was bearing down on New Orleans, and it was evident from the media that there was going to be some major damage. [New Orleans] Mayor [Ray] Nagin issued a mandatory evacuation. Katrina was becoming a super-storm, and we were right in her path.

By Tuesday afternoon the order was given to evacuate University Hospital. The residents accompanied two patients each to Baton Rouge. One of my patients had West Nile virus and the other had dermatomyositis with ARDS in the fibroproliferative stage. The latter patient had been requiring 50%-75% FIO2. The ambulance I was in ran out of oxygen, and the O2 sats on my ARDS patient began dropping precipitously. We had to stop the ambulance so I could wave down a trailing ambulance and obtain supplemental oxygen. With a wide-open valve on one tank, I alternated between patients until I was able to drop them off at triage.

—Steve McPherson, MD

“Our attending rounded as usual that morning. Then he met with the upper echelon of hospital administration. At this meeting the house staff were informed that there was a real possibility that the first two floors of the hospital could be flooded. The administration asked all services to prioritize a list of ‘salvageable’ patients. Essentially this meant asking—assuming we lost power, generators, and elevators—who would be the most appropriate to carry manually up to higher floors. Further, assuming the necessity of economy in allocation of medical resources, who would stand the best chance of survival and would benefit from these resources.

“So, we put our heads together with the SICU teams and developed a triage list. The next step in hurricane preparation involved moving the patients away from vulnerable window areas in into an adjacent recovery area that was more internally located. The rest of Sunday afternoon was business as usual. There was, however, a palpable undercurrent of nervous anticipation. Sunday night we pitched a no-hitter. Of course, this was not due to luck but rather because the town was empty. Aside from zero admissions, the hospital that night from a functional standpoint was essentially normal.

“Monday morning Katrina struck. Despite being in a rather sturdy steel frame, brick-and-mortar public building, you could feel that the wind strength was impressive and the rain was pounding relentlessly like a banshee from hell. At 10 a.m., we lost primary power and generator power kicked in. The ICU was still functioning fairly normally. We were obtaining labs, running vents although we had no computer system, and had to retrieve lab results like an old-fashioned errand boy on the main floor.

“Outside, I could see about three feet of water had flooded Gravier Street. Surrounding houses were missing a few windows and shingles, but otherwise the damage seemed minimal, and it looked like initially we had dodged a bullet. I remember thinking that the levies had done their job. This notion became a pipe dream as the water level surrounding the hospital steadily began to rise sometime between the hours of 12 to 2 p.m. We had no idea about the now-infamous levy breaches, but the burgeoning deluge provided the information that the media or government was unable to give us at that time. The feculent water continued to rise slowly throughout the day. Pretty soon, I saw boats with outboard motors cruising by. I’m not sure if anyone in the hospital knew precisely that our predicament was becoming more precarious by the hour.

“Late Monday, a random boat pulled up to the ED ambulance ramp, which had become a makeshift dock. On board was the boat pilot, a New Orleans police officer, and two chronic ventilator/PEG nursing home residents. Our ED staff informed the cop that there was no way we were able to take these patients and care for them given the rising water levels and impending loss of even backup generator power.

“The cop insisted, stating, ‘This is not my problem.’ He laid the patients on the ED ramp and promptly departed. This incident caused quite a ruckus as no one really knew how to handle it.

“Hospital security quickly stepped in and barked, ‘Everybody inside. We’re locking down the building.’ I guess this was a desperate attempt to control a situation that was obviously way out of control by now and discourage any further ‘dumping’ of patients. All of the staff and residents quickly retreated inside the hospital in a knee-jerk reaction to the mandate. As we filed into the hospital like lemmings, Josh Willis, MD, one of our chiefs, suddenly realized the ethical mistake we were making by abandoning the cast-away patients lying on the ED ramp. ‘What kind of doctors are we anyway?’ I remember hearing him inquire rhetorically.

“This statement seemed to summon forth the quiescent words from the oath of Hippocrates when we had pledged to ‘ … apply dietetic measures for the benefit of the sick according to my ability and judgment … [and] … keep them from harm and injustice.’ We realized our mistake, turned around, and went back outside to bring the two patients into the hospital.

“Through early Monday evening, three to four similar trach/PEG patients were delivered from the same nursing home via watercraft. A piece of tape adhered to their threadbare gowns on which was written the name of the nursing home, the patient’s name, and their social security number. This was hardly a thorough past medical history or active problem list. We situated these patients with the other cast-offs inside the ED. It was apparent by initial observation that several of these patients were in dire medical straits at baseline, let alone having to deal with a natural disaster to boot.

“By early Tuesday morning, our backup generators went down. We had no labs, no chemistries, no ABGs. We were shooting from the hip, so to speak, in terms of treatment. Those nursing home patients brought in by boat remained not only in the ED, but also at the bottom of the ‘salvageable’ list.

“Besides just holding their hands, we could only give them supplemental oxygen. Meanwhile, on the roof of the hospital, a couple of smaller portable generators were running with lines powering three to four vents. Somehow it seemed that all the patients who really needed vents and who had made the salvageable list were getting them. By now, we already had to let one patient die … .

“By Tuesday afternoon the hospital had become—for all intents and purposes—entirely useless. The order was given to evacuate the entire hospital. The first order of business was to evacuate the most critically ill, salvageable patients. The house staff instructed the residents to accompany two patients each to Baton Rouge. One of my patients had West Nile virus and the other had dermatomyositis with ARDS in the fibroproliferative stage. The latter patient had been requiring 50%-75% FIO2. With only supplemental oxygen, trach tubes, and bags, we began our journey through the oppressive heat of late summer New Orleans.

“A boat took us to the Claiborne Avenue/I-10 ramp, which had also become a boat launch with awaiting ambulances. As we drove on the overpass past the drowning city, I could see hordes of wayward and destitute people lining the interstate and around the Superdome. The image was surreal. It looked like some third-world country in the throes of utter civil war chaos. The slings and arrows of outrageous fortune continued their incessant barrage as the ambulance I was riding in ran out of oxygen. The O2 sats on my ARDS patient began dropping precipitously into the low 80s. Before we could reach the safety of Maravich Center [now hospital] in Baton Rouge, we had to stop the ambulance so I could wave down a trailing ambulance and obtain more supplemental oxygen. With a wide-open valve on one tank, I alternated between patients until I was able to drop them off at triage. I called my fiancée who also happens to be an RN to pick me up, and we went to Bunkie, La., to await our next move. After two days, we traveled back to the Maravich Center to volunteer. We were told that our help wasn’t needed.

“It was frustrating to watch TV the next few days and see my colleagues still working at both Charity and University hospitals. I felt I should still be there with my teammates trying to sort through the medical maelstrom. In then end, I guess I took care of my patients and did what my attending ordered us to do. I was lucky because I got out on Tuesday. I’m sure it got ugly in there for everyone who didn’t get to leave until Friday.

“This has proven to be an experience that not many people go through and its lessons I will not soon forget. Leadership is a quality that too often gets overlooked when assessing the qualities of a good physician. When push comes to shove, we as physicians are ultimately responsible for running the patient-care ship. Without a doubt though, I do feel a closer bond with my program colleagues. Jeff Wiese, our program director, even sent out an e-mail stating that there would be no hard feelings if any resident wanted to find a new program. So far, there have been zero transfers.

“Based on the camaraderie being expressed among my fellow residents, I don’t anticipate that there will be any ultimately when all is said and done. This fellowship has truly been inspirational and renewed my own ethical ideals about being a physician.”

Conclusion

The harrowing presence of nature pervades Crane’s The Open Boat as it does the above accounts of two medicine residents during the tragedy of Katrina. But the most significant aspect of these struggles lies in human beings’ attempts to help one another survive despite their backgrounds, vocations, or social status. There is no fighting an angry sea or an incensed hurricane; neither can be conquered. But one can learn to survive the onslaught and to care for to the best of one’s ability those fellow human beings who are also caught in the grip of nature’s immense indifference whether they be castaways on the open ocean or deserted doctors in a drowning city.

“It would be difficult to describe the subtle brotherhood of men that was here established on the seas. No one said that it was so. No one mentioned it. But it dwelt in the boat, and each man felt it warm him. They were a captain, an oiler, a cook, and a correspondent, and they were friends, friends in a more curiously iron-bound degree than may be common.”—Stephen Crane, The Open Boat TH

Dr. Bucci is a psychiatric resident at the Mayo Clinic in Rochester, Minn., and a member of Tulane Medical School’s class of 2003.

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