New disaster response plans build on past lessons
From the June ACP Observer, copyright © 2006 by the American College of Physicians.
By Janet Colwell
PHILADELPHIA—Ruth E. Berggren, ACP Member, was working in the infectious diseases unit on the ninth floor of New Orleans' famed Charity Hospital when Hurricane Katrina hit. Thirteen of the 18 patients on that ward had infections related to HIV and AIDS, four had active tuberculosis, and one was a gunshot-wound victim that had been transferred from surgery. A prisoner from nearby Orleans Parish Prison, who had infectious disease and mental health issues, was shackled to his bed and flanked by two armed guards.
Fred A. Lopez, FACP, was also on duty at Charity Hospital on Monday, Aug. 29, during the storm. Although the winds blew out windows and demolished much of the hospital's top floor, Dr. Lopez was relieved there wasn't more initial damage. "Then the levees broke and we were under sea level," he said. "If the city was a bowl, we were at the bottom of that bowl—and it was filling up."
'If the city was a bowl, we were at the bottom of that bowl—and it was filling up.'
—Fred A. Lopez, FACP
He and his colleagues moved patients from the ground-level emergency room to the second floor and established a triage system. With no power, lab facilities, imaging services or access to specialists, medical care was limited to monitoring patients, dispensing medications, and lending clinical and diagnostic expertise.
It wasn’t until major media outlets began flooding into the city on Thursday that government rescue vehicles finally arrived. Dr. Lopez and his team transferred several hundred patients onto stretchers, down the stairs and onto rescue trucks.
And Dr. Berggren and her colleagues watched as helicopters evacuated the “mostly white, insured patients” at neighboring Tulane Hospital, "while our mostly black, uninsured patients were not getting out." The biggest challenge, she said, was maintaining sanity and professionalism in the face of personal discomfort and unexpected threats.
Both Dr. Lopez, vice chair and associate professor of medicine at Louisiana State University (LSU) Health Sciences Center and head of LSU’s internal medicine service at Charity Hospital, and Dr. Berggren spoke at Annual Session about lessons learned living through a major disaster.
Humanity amid chaos
Maintaining morale was critical to survival, said Dr. Berggren, who is also associate professor of medicine at Tulane University Health Sciences Center.
In a commentary published in the Oct. 13, 2005, issue of New England Journal of Medicine (NEJM), she offered some practical tips for getting through a disaster. Be sure to carry nonsteroidal anti-inflammatory pills—to relieve the headaches of caffeine-deprived staff—as well as D batteries and comfortable shoes.
The real peril came not from Katrina's wrath, she wrote, but from "agitated, fearful human beings bearing firearms." In one instance, unknown snipers forced a halt to the evacuation effort.
And on Thursday night, a young armed Marine came “tromping through our ward looking for looters,” said Dr. Berggren. “He had been informed that our ward had been evacuated and was startled to find us there—almost pulling the trigger until we could convince him of who we were.”
Traditional medical training doesn't teach physicians how to defuse such confrontations, she said. “We are all required to attend mandatory HIPAA and sexual-harassment training in the workplace. How about mandatory disaster-management and survival-skills training?”
Amid that week's chaos, Dr. Berggren reflected in the NEJM article, one of the only things left in people’s control was maintaining their sense of humanity.
“The most critical necessity is a team of professionals who care about their patients and one another,” she wrote. “All 18 members of our team (black, white, rich, poor, gay, or straight) had chosen to care for the disenfranchised, the tuberculous, and the HIV-infected.”
Lessons in the aftermath
At another Annual Session panel presentation on emergency preparedness, audience members who volunteered in storm states questioned the federal response. William E. Fox, FACP, a general internist from Charlottesville, Va., who treated patients in Mississippi post-Katrina, said he witnessed “minimal federal and state response. Most of the chronic disease issues were being handled on an ad hoc basis by volunteer doctors.”
CAPT. Ann Yoshihashi, MD
The fact that Gulf Coast citizens were stranded across the country makes a strong case for electronic health records, said panelist CAPT. Ann Yoshihashi, MD, an endocrinologist with the Naval Operational Medicine Institute in Pensacola, Fla. Many patients who sought medical relief in the wake of Katrina were those with chronic diseases who’d never received care before the hurricane.
“The disaster heightened awareness of the large population of underserved that exists even in normal times,” she said.
Katrina also exposed the need for advanced planning, she added. “You need to have a transition strategy in place in advance of a disaster.” Federal and local government officials have since expanded preparedness resources including the Emergency System for Advanced Registration of Volunteer Health Professionals, a national database of registered health care volunteers that will expand to include all 50 states this year.
Tracking avian flu
Panel members also outlined a coordinated national strategy to prepare for an avian flu outbreak. Panelist Anna M. Likos, MD, a CDC epidemiologist, said that outbreaks in animals have risen rapidly, with the number of countries affected rising from seven in 2004 to 31 this year. Nine countries have reported a total of 190 human cases.
According to Dr. Likos, the CDC is tracking the disease through a network of 1,300 health care providers across the country, who report weekly to the CDC on any patient visits involving influenza-like symptoms. The federal government last month released an implementation plan for responding to a pandemic. The plan calls for stockpiling 75 million doses of antiviral drugs and 20 million doses of vaccine.
As Dr. Likos pointed out, however, experts don’t know whether a human outbreak of avian flu would be transmitted by respiratory droplets or through true airborne transmission. They therefore don’t know what kind of protection would be most useful.
“It may be valuable to stockpile N95 respirators” especially in health care settings if this is a true airborne illness, she said. Alternatively, facemasks will be essential if the virus is transmitted via respiratory droplets.
At a press conference during Annual Session, ACP leaders introduced a newly approved position paper, "The Health Care Response to Pandemic Influenza."
The policy supports strengthening public health preparedness by developing local task forces, which would include physicians from all practice settings.
The policy also states that primary care physicians should play a key role in developing strategies for addressing a pandemic or other public health crises. And it calls for local providers to have access to two-way communications with public health authorities and to information technology.
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