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Tours of Duty


 

When a hospitalist steps outside during a seemingly unending shift, and a city is silent but for the bark of dogs, something is wrong. When he returns not to a scheduled shift, but to an undefined “tour of duty,” something is very wrong. Such has been the case for many hospitalists and healthcare providers along the Gulf Coast since Hurricane Katrina first devastated miles of the coast in August, and then Hurricane Rita hammered home our vulnerability to natural disasters in September. These sentinel experiences offer learning points for our nation’s healthcare system. “Challenges Hospitals Encountered During the 2005 Hurricane Seasons” (p. 8) lists some of the areas in which hospitals and healthcare providers were tested.

Karen Sexton, RN, PhD, UTMB's incident commander during Hurricane Rita, discusses evacuation options with her employees.

Karen Sexton, RN, PhD, UTMB’s incident commander during Hurricane Rita, discusses evacuation options with her employees.

Half the Battle: Getting There

Eniola Otuseso, MD, a hospitalist who works in locum tenens positions across the southeast, calls Atlanta home. Her native Nigeria does not have hurricanes—their natural disasters are dust storms and monsoons—so she had never experienced one. The day before Hurricane Katrina hit, Dr. Otuseso had departed for her next job at Cogent Healthcare’s program at St. Dominic-Jackson Memorial Hospital (Miss.). Unable to take the last flight of the day, she packed a rental car and she, her 22-month-old son, and her teenage niece set off on the 380-mile journey to Jackson, Miss. Her account of the ride gives new meaning to the term “Sunday drive.”

MapQuest directions in hand, Dr. Otuseso took I-20 west toward Mississippi. From the road she called the hotel where she had reservations, only to find them canceled due to overbooking. She proceeded with nervous jitters: She had to report to work at 10 a.m. So she found another hotel, spent the night, and set out again at 6 a.m. Monday.

Then she had another problem: Although she thought she was on I-20 west, she had accidentally taken route 59 south—directly into New Orleans and the brunt of the storm. She notified the hospital that she was on the way, and promptly lost phone service. “I realized I needed to turn around and got off at the next exit, but a tree had blocked the road,” says Dr. Otuseso. “No one was around.”

Challenges Hospitals Encountered During the 2005 Hurricane Seasons

  • Employee transportation problems;
  • The need for hospitals to be self-sufficient and patients to be evacuated for longer than expected;
  • Communication, power, and water systems failures;
  • Lack of medical records;
  • Difficulty locating patients and/or physicians who evacuated;
  • Constantly changing policy;
  • Security challenges;
  • Compassion fatigue;
  • Lack of privacy for patients;
  • Ample—but untrained—volunteers; and
  • Ample—but unsorted—tangible donations.

She took the one-way exit back as trees fell around her. Her nervous jitters escalated to panic.

When a tree fell in front of her car, her attempted circumvention landed the car in the mud, and she ran out of gas trying to dislodge it. Miraculously, she had phone service, but the appalled 9-1-1 operators couldn’t help. Finally, a motorist and his adult passenger stopped and offered a ride. Dr. Otuseso and her wards climbed into the good Samaritan’s vehicle, and they were off again. The frequent need to get out of the car to haul trees from the road slowed their journey.

Finally, the mud was too thick and they became stuck. She managed to reach a nearby house on foot, and the owner used his tractor to move the car. He also offered them respite in his home with his wife and baby. A drenched, discouraged Dr. Otuseso and her children accepted the offer and were ferried there by tractor; her previous companions slogged on.

Dr. Otuseso is a graduate of Medical College of Georgia (Augusta). The rural family that housed her was was uneducated in some of the basics of preventive healthcare. Although culturally and in terms of health beliefs Dr. Otuseso and the family that sheltered her could not have been more different, the host family offered remarkable hospitality by providing food and clothing.

“Tragedy brings different people together,” Dr. Otuseso told her niece. The next day, the hurricane had passed, and the host family transported her to Hattiesburg, Miss., a town a mere 100 miles north of New Orleans. She needed basics: shelter and transportation. Hattiesburg’s hotel lacked power and water, and gas was scarce. Eventually, Dr. Otuseso convinced a service station owner to help her retrieve her rental car and fill it with gas. She then set off for Jackson.

On arrival in Jackson, she checked into another hotel with no water or electricity, but eventually made it to work Tuesday. The hospital had electricity and an endless stream of patients. Dr. Otuseso says that her experience made her more empathetic to patients. She could understand the extent of their loss. And after a lifetime of giving to others, she learned to accept help, hospitality, and assistance from others.

Donna Weaver, MD, says the “organized disorganization” of a pharmacy stocked with samples, borrowed supplies and equipment, and no lab facilities created a situation in which physicians had to rely on medical clinical skills. People came with nothing, and medical records were unavailable. The medical history—just what the patient could tell them—was the cornerstone of treatment. “The low-tech physicians did well,” she says.

In New Orleans

Rob Minkes, MD, chief of pediatric surgery at Louisiana State University and Children’s Hospital (both of New Orleans) started a shift on Sunday, August 28 that became a four-day tour of duty. With him were more than 700 patients, families, and staff. Throughout the ordeal, they had Internet access and intermittent phone service. It was almost business-as-usual: All employees reported for work, and they even performed procedures in the surgical suite.

Once the storm passed, patients of all ages began to appear needing help. With them came strangers who threatened the hospital’s safety Employees could see looters from the windows. Some visitors who had no official purpose roamed the halls causing fear and despair among employees; although they were few and far between, they created chaos. Once the interlopers were escorted out, the hospital locked down. Lacking armed guards, they contacted local, state, and federal authorities for help, but none came.

“The situation became surreal, like a Stephen King novel,” explains Dr. Minkes. “There was just enough of what was normal, but the workplace and general life began to blend into some kind of limbo.”

He praises staff members who kept doing their jobs. The physicians made rounds, the nurses provided care, the housekeepers cleaned. “People can behave commendably in a crisis,” says Dr. Minkes, who noted that Children’s Hospital was well prepared and their disaster training was effective. The hospital was so prepared, in fact, that it was able to divert a fuel shipment that arrived Monday or Tuesday to a nearby facility that had a greater need.

On Wednesday morning, Children’s Hospital lost water pressure, so running water and air conditioning were history. Hospital leadership made the decision to evacuate patients and staff using any available means. Some neighboring hospitals sent helicopters. A convoy of ambulances and SUVs, staffed with care providers using hand-bag ventilators, set out for Baton Rouge. Those patients well enough were discharged. Hospital leadership received word that the National Guard had aircraft at the airport and could take remaining patients if they could be there by 7 p.m.

John Heaton, MD, chief anesthesiologist for Children’s Hospital, led a caravan of 40 cars, trucks, and SUVs to the interstate and onward to the airport. Staff members returned to the hospital despite worsening violence and health hazards in the city. Wednesday turned to the early hours of Thursday with only a few ICU patients remaining at Children’s.

At 4 a.m. a state trooper who came to support a chopper that was evacuating a patient recommended that staff prepare to evacuate at first light because of increasing danger due to flooding and looting in the city. Until then, Children’s had had very little contact with authorities, and basically made its decisions in isolation. One caravan of employees left with a police escort shortly thereafter. The remaining staff made their way unescorted when the last patient left for safety at 8 a.m., leaving a facility that had operated nobly despite Mother Nature’s wrath and security issues. When staff members left, Children’s Hospital had sustained only two broken windows.

Dr. Minkes praises the staff of every department, and indicates that leadership withstood this test. “The day after the hurricane, we were prepared to stay for two to six weeks,” he says.

When asked if he saw any skill used that surprised him in its utility, he hastens to say that they had power and water for most of the ordeal. He noted, however, that their chief of anesthesiology, an ardent fisher and hunter, calculated how high the waters would rise if the levies broke using a tool he retrieved from the Internet. He assured the staff that the water would not reach Children’s Hospital. It helped people’s spirits immensely.

After UTMB Galveston discharged and evacuated more than 425 patients in 12 hours as a category 4 Hurricane Rita was charging toward the island, Dr. Sexton called on the governor's office to provide C130 military cargo planes to evacuate employees. About 130 UTMB employees chose to leave Galveston and were evacuated to Fort Worth.

After UTMB Galveston discharged and evacuated more than 425 patients in 12 hours as a category 4 Hurricane Rita was charging toward the island, Dr. Sexton called on the governor’s office to provide C130 military cargo planes to evacuate employees. About 130 UTMB employees chose to leave Galveston and were evacuated to Fort Worth.

Back to Jackson

Meanwhile, Dr. Otuseso was seeing an influx of patients in Jackson. With her, Lancy Clark, a registered nurse and Cogent Healthcare Program manager who liaises between St.Dominic-Jackson Memorial Hospital’s hospitalists and community physicians, was frankly shocked. The St.Dominic-Jackson facility staff—150 miles from Gulfport—had not thought that the devastation would reach them. It did.

With no electricity or water, St. Dominic-Jackson’s internal and external communication was in a shambles. Their backup: using the telephone, personal cell phones, and overhead page system. Although the county’s priority was to restore power and water to hospitals, its employees were working in the dark. And county-wide gas shortages meant that staff had difficulty reporting to work. Fortunately, the county gave healthcare providers head-of-the-line privileges for fuel.

“I was amazed at how fast people bounced up and worked,” says Clark. “We were all counselors. We often cried with patients as they told us their stories. We used all the resources we could to help emotionally and financially.”

In all of this, the healthcare providers, too, were victims; many have strong roots and family in the devastated communities.

As the adrenaline rush subsided and things started to be a little more normal, care providers began to feel the effects of the strain. All Clark wanted to do was sit in a chair and sink deep into it. Some experts call this compassion fatigue. It is a unique type of burnout experienced by people in fields that provide care for people under extreme circumstances, or the stress of caring for people who are scared, in pain, and/or suffering. Critical incident stress management and debriefing exercises are two ways to alleviate compassion fatigue. Clark indicates that Cogent Healthcare has plans to hold debriefings so they can apply what they learned.

On Wednesday, Sept. 21, dozens of state-provided ambulances cycled through the main entrance of UTMB’s Galveston branch to transport patients to hospitals in Texas cities, including Austin, Tyler, and San Antonio. The patient evacuation was the first in the university’s 114-year history.

On Wednesday, Sept. 21, dozens of state-provided ambulances cycled through the main entrance of UTMB’s Galveston branch to transport patients to hospitals in Texas cities, including Austin, Tyler, and San Antonio. The patient evacuation was the first in the university’s 114-year history.

Westward Bound

Some Hurricane Katrina evacuees found their way to Galveston, Texas. Two physicians on the faculty of the University of Texas Medical Branch (UTMB) at Galveston, Janice Smith, MD, and Donna Weaver, MD, worked in a Red Cross clinic assembled in a Methodist church’s indoor racquetball court.

Like hundreds of others, Dr. Smith responded to the call for volunteers early in the process to help the 300 evacuees. She says that there were many bureaucracies, and their nurse-coordinator handled them all well. In terms of challenges, “Every few hours, policies and procedures would change,” says Dr. Smith. “There was no interclinic communication, and roles were unclear. Although it was emotionally difficult seeing patients who had lost everything, that was the easy part compared to dealing with constant change.”

Dr. Weaver, who is codirector for Center for Training in International Health and teaches the Practice of Medicine course at UTMB at Galveston, responded to a request to describe her previous experience in one word: “Nicaragua.”

She often volunteers in Nicaragua (as does Dr. Smith) and in rural U.S. communities they open clinics in people’s homes. Dr. Weaver says the “organized disorganization” of a pharmacy stocked with samples, borrowed supplies and equipment, and no lab facilities created a situation in which physicians had to rely on medical clinical skills. People came with nothing, and medical records were unavailable. The medical history—just what the patient could tell them—was the cornerstone of treatment.

“The low-tech physicians did well,” she says. Listening skills became key. Dr. Weaver intends to reinforce that lesson with her students.

Both physicians could identify gaps that would have been nice to fill. Dr. Smith said that having an on-site dentist would have helped the many people suffering from toothaches. She also appreciates geographic prescribing differences more now, and would have liked to have had a pharmacist there to tell them what certain drugs were or suggest therapeutic alternatives. Dr. Weaver said privacy was at a premium—a situation that was uncomfortable for providers and patients alike. As each day passed, more barriers and walls were rigged to try to improve privacy.

Lessons for Hospitalists from the 2005 Hurricane Season

  • Identify a reliable transportation system and early in the emergency ensure your loved ones are safe.
  • Anticipate evacuating hospitals early, transporting the sickest first—when seriously disrupting conditions are predicted. This means writing dozens of concise transfer summaries, and leading the team to identify what parts of the medical record must be copied, and what supplies, medication, and equipment must accompany the evacuee.
  • Encourage hospital leaders to create a plan to help employees after patients are evacuated.
  • Instruct community-based patients to bring ample medication (perhaps a month’s supply) and copies of medical records if possible.
  • Know your communication, water, or power failure work-around systems.
  • Acknowledge the “changing theater” of disasters and help other employees cope. Review how the Health Information Portability and Accountability (HIPAA) regulations address disaster. (A good overview is available at www.hhs.gov/ocr/hipaa/EnforcementStatement.pdf.)
  • Seek continuing education in disaster mental health counseling.
  • Develop polished listening skills so a patient’s verbal history and physical conditions can guide care if necessary.
  • Consider what security needs might be under extreme conditions.
  • Anticipate ample donations and an influx of volunteers and create policies to respond to them.

Desk Jockeys No More

Anthony Campbell, RPh, DO, an internist and a pharmacist, and Joseph Matthews, RS, a sanitarian, were deployed together as part of a United States Public Health Service (USPHS) team. They landed in Louisiana to find their accommodations sufficient: a cot in one of five tents at Camp Allen that housed around 125 responders each. Both of these USPHS-commissioned officers had prior hospital-based practices in one of Washington, D.C.’s poorest neighborhoods. It was perhaps this recent experience that made them prime candidates to be plucked from desk jobs and jettisoned back into a stressed clinical milieu. While experience prepared them for the issues of indigence and poverty, it did not temper their reactions to the devastation and exposure to elements.

Their reunion made the task less challenging but the work they did was grueling. Dr. Campbell and Matthews traveled through parishes conducting needs assessments at Red Cross shelters in Washington Parish during the first week. The days were long—sometimes beginning at 5 a.m. and ending after 11 p.m.—and impossibly hot.

Both were impressed with people’s positive attitudes. Many shelters were overcrowded and lacked bathing facilities. Members of the community welcomed displaced people into their homes to shower and took turns preparing copious quantities of food. In a significantly overcrowded shelter, the Federal Emergency Management Agency (FEMA) tried to move people to hotels; often, unrelated people who had been neighbors or who had weathered the storm together would refuse to go unless they could go together. A group of retirees from Maine who were visiting New Orleans, for example, insisted on staying together even if it was in the crowded shelter. This was an unanticipated dynamic.

Matthews talked about what he called, “the changing theater,” a military term that describes the need to change plans frequently when conditions of austerity dictate it. He indicates that many clinicians were unacquainted with the principle of gathering your assets and regrouping when plans take an about-face. That was the case throughout their deployment.

During the second week, Dr. Campbell moved closer to New Orleans, and Matthews went to the area’s largest animal shelter, a place with five huge barns, two filled with horses and three with smaller pets. In the chaos there, his main concern was not the lack of volunteers—they had plenty—but the frequent disregard for human health risks as they handled hungry pets that had been plucked from toxic floodwaters. The need to take universal precautions is not a universal belief. Just trying to get people to wear gloves was an ordeal. The volunteers were often unaware of their own cuts and bruises, and worked relentlessly.

Matthews laughed as he related a story of the volunteers’ compassion. It was late in the evening, and his transport had not arrived. Concerned, he called the base operation and learned that he’d been forgotten. He started to melt down with anger and fatigue. A group of volunteers quickly surrounded him with comfort and reassurance; they thought he was upset because he couldn’t find his pet! It restored his sense of humor and balance.

Meanwhile, Dr. Campbell was knocking on doors in a housing project, looking for people with health needs. Care was centrally located in Washington Parish, but lacking communication methods and transportation, many residents didn’t know about the help offered there. He relied on the project’s resident manager to help his team. The manager often knew who had been evacuated, how many children lived in units, and who was older and remained.

Dr. Campbell cites the heat and incredible stench as indelible memories. His deployment ended in New Orleans. Even in the French Quarter, which sits on higher ground, the air was thick with the smell of rotting food that had been removed from freezers to prevent it from ruining equipment. (Clark in Mississippi also mentioned the memorable foul odor of rotting food.) He understands now why police officers and forensics workers carry Vicks VapoRub to dab under their nose when they find a decomposed body.

Dr. Campbell indicates that the Red Cross shelters needed more trained medical personnel, although they had ample donations of medication from doctors’ offices in the form of samples, and from hospitals and pharmacies. They did not have a pharmacist, however, and he relied on his dual training to provide some of the services that Dr. Smith in Galveston also identified. He was saddened by the devastation. He visited the Superdome and indicates that the debris and human waste told a sad and shocking story.

Patient Satisfaction

Sixty-year-old patient Emelda Zar evacuated from LaFitte, La., before Hurricane Katrina. She landed in a crowded but hospitable shelter in Jackson, Miss. Some days later, her daughter called an ambulance as Zar’s health deteriorated. She was admitted to St. Dominic-Jackson Memorial Hospital and diagnosed with heart failure.

Recently discharged and about to relocate to an apartment and planning to remain in Jackson, she and her grandchildren have nothing but good things to say about the hospital and, in particular, the hospitalists who provided care.

She arrived with no medical records and a serious health problem. Her hospitalists listened and created a care plan. She left the hospital with not only a clear idea of what she needs to do, but with a scheduled follow-up appointment in the community. Like so many of the people we heard about from healthcare providers, she remains upbeat and optimistic.

Progress Notes

Shortly after Dr. Smith and Dr. Weaver were interviewed in Galveston, the news was full of a new threat: Rita. This time, the hurricane’s target was a few hundred miles west of Katrina’s path. Karen Sexton, RN, PhD, vice president and chief executive officer of Hospitals and Clinics for UTMB shared the story of how Katrina changed their response.

During routine monitoring they saw tropical depression #18 develop on Sunday to the point that it was named Rita on Monday, and began to look like trouble for Galveston. By Tuesday, the city mayor had declared a voluntary evacuation, applying one lesson from Katrina: Residents could take their pets in government evacuation vehicles. The university went on emergency status. UTMB looked at decreasing their activity and reducing the hospital census. They sent the students home.

Tuesday night, their hospitalist service and other key physicians wrote transfer summaries for all patients, beginning with those who were gravely ill. This was a change of policy based on their experience with Katrina. They chose to move critically ill patients while they had the greatest control. The pharmacy prepared medication for all patients, and parts of medical records deemed most important were copied.

Wednesday dawned, and it was clear: Rita was coming in as a level 4 or 5 hurricane. For the first time in 114 years of existence, UTMB evacuated under Dr. Sexton’s direction as the incident commander. Using resources sent in part by the governor, their team discharged and evacuated 427 patients in 12 hours.

“We were all a little teary eyed when the first patient left,” says Dr. Sexton. “We knew we had never evacuated before and we knew were making history.”

Key to the success of UTMB’s evacuation were checklists on the units and at two evacuation stations. This, too, was something they learned from Katrina: Track patient disposition and send as much information as possible. With the goal of improving patient safety, UTMB recently started training staff on an aviation model that mimics what the aviation industry does to ensure safety.

They tracked what went with the patient, where the patient went, and that family notifications were done. The staff’s increased awareness and use of checklists were key components for a successful evacuation. No patients were “lost.” As the last patient left, Dr. Sexton found herself with a hospital staffed to support 500 to 700 patients, no patients, and the realization that staff also needed to evacuate but might not be able to navigate the exodus traffic.

Another request to the Texas governor’s office put two C130 cargo planes at their disposal. Staff were given three options: Stay at the hospital, leave of their own accord, or take the C130 to shelter in Houston. One-hundred-thirty-one staff members chose the latter option and left Thursday; the same planes brought them back the following Monday.

During the storm, UTMB’s ED remained open and staffed. It was the only operating ED for miles. A burn victim and several firemen who were harmed fighting a tremendous blaze during the storm on Friday proved that remaining open was the right thing to do to for the community.

Although UTMB lost some equipment, blocks of air conditioning, and some power, administrators believe that they made good decisions and emerged almost unscathed.

“I never felt prouder of our staff,” says Dr. Sexton. “This will be a different place because we all did this together.”

Less than a week later, they continue to treat patients from the community, have started admitting patients, and have welcomed some of their critically ill neonates back.

Conclusion

Who believes weather analysts? Often, we look at unwelcome weather forecasts and dismiss them, thinking that it always sounds worse than it is. Hospitalists and healthcare providers who weathered Katrina and Rita, and who are still working with the aftermath are probably more apt to listen to future dire weather predictions. “Lessons for Hospitalists from the 2005 Hurricane Season” (left) summarizes some of the lessons learned from the 2005 hurricane season to date. Every hospital will have to look at disaster plans and make changes based on what we’ve learned. Self-sufficiency for 48 hours is probably a less-than-ambitious goal; we may need to think in terms of planning for a week or more. Certainly, hospitalists will need to take leadership roles. TH

Contributor Jeannette Wick, RPh, MBA, is a senior clinical research pharmacist at the NIH in Bethesda, Md. The opinions expressed herein are those of the author and not necessarily those of any government agency.

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