Written By: Cecile C. Guin, Linda C. Robinson, Ezra C. Boyd and Marc L. Levitan State University Table of Contents

Author’s Note...... 3 Chapter 4...... 43 i. Findings and Recommendations : Health Outcomes and the from Selected Official Documents Purpose of the Project...... 5 Medical Response Chapter 7...... 81 Chapter 1...... 7 a. Direct Morbidity and Mortality b. Displacement from Home, Comparison of Hurricanes Gustav and Ike to Overview of Disasters and Effects Hurricanes Katrina and Rita on the Medical Community Social Network, Providers and Medical History a. Overview a. Introduction c. Disruption of Medical Services b. Major Problems Affecting the b. Natural Disasters and the d. Emergent Effects of Exposure Medical Community during Vulnerability of the Health Care to Hazards Katrina and Rita Sector e. Medical Response c. Post-Katrina and Rita changes c . Hazard Types and the Associated f. Initial Response to Public Health that were Made for Gustav and Impacts Emergency Ike d. Effects of Disasters on Health Care g. Exemplary Medical Service d. Examples of Leadership and e. Disaster Frequencies and Impacts Organizational Effectiveness in Chapter 5...... 57 Gustav and Ike Chapter 2...... 17 : Preparation, Impact and Anticipating Potential Disasters Response of the Medical Community Chapter 8...... 97 Across the a. Physical Hazards and the Lessons Learned and Best Practice a. High Fatality Events Vulnerability of Southwest Recommendations b. Deadly Hurricanes Since 1950 Louisiana a. Overview c. The 1993 Blizzard and the 1995 b. Population of Southwestern b. Communication Chicago Heat Wave Louisiana c. Transportation d. Multi-Billion Dollar Events c. Physical Impact d. Sanitation e. Potential Disasters d. Impact on the General Population e. Consumables and Supplies f. Assessing Preparedness for e. Medical Response f. Utilities Potential Disasters f. Health Outcomes g. Specific Medically Related Concerns Chapter 3...... 29 Chapter 6...... 67 Hurricane Katrina: Preparation for and Impact Summary of Reports and Official Records on Appendices: ...... 106 on the Medical Community Hurricanes Katrina and Rita a. Physical Hazards and the a. General Findings 1. Morbidity and Mortality Outcomes Vulnerability of b. Transportation from Hurricane Katrina...... 107 b. Planning for Catastrophe c. Communication c. Hurricane Katrina’s Physical d. Sanitation 2. References...... 110 Hazards e. Consumables 3. Photo and Figure Credits...... 119 d. Impact on the General Population f. Utilities e. Impact on the Medical g. Medical Records 4. Interview Reference List...... 121 Community h. Barriers to Physician Efforts to Assist Author’s Note

Cecile C. Guin, School of Social Work, Of- We would like to acknowledge the assistance ent in an easily read format, we have in- fice of Social Service Research and Develop- of Terri C. Michel, OSSRD, for project cluded an extensive reference list at the end ment (OSSRD), Louisiana State University; management and final document prepara- of the project providing credit to the many Linda C. Robinson, Family and Consumer tion; Vicky Tiller, OSSRD, for creating the authors of material that we used, as opposed Sciences, Louisiana State University Agri- survey, coordinating the survey dissemina- to the traditional academic in-text citation. culture Center; Ezra C. Boyd, LSU Hurri- tion, and editing; Mary Lynn Thames, There is some in-text citation that was nec- cane Center, Louisiana State University; LSUHSC, for invaluable input and editorial essary, but the majority of citations are in- Marc L. Levitan, LSU Hurricane Center, assistance; Nedra Davis, LSU Hurricane cluded at the end of this report. Louisiana State University. Center, Louisiana State University, for preparation of the Power Point training ma- Finally, we are appreciative to the Louisiana Contributing authors include: Emily DiSte- terial; Paul Watts, OSSRD, for the litera- State Medical Society Educational & Re- fano, DiStefano & Associates, Baton Rouge, ture review and editing; Ivor van Heerden, search Foundation for selecting us for this Louisiana; Justin Ulrich, School of Social LSU Hurricane Center, for input on the im- project, especially all of the physicians, local Work, Office of Social Service Research and pact of Hurricanes Katrina and Rita; S. medical societies, and others in the medical Development, Louisiana State University Ahmet Binselam, LSU Hurricane Center, field that contributed to this project by co- for cartographic support; Daniel Novak, ordinating or participating in the personal James H. Diaz, LSUHSC School of Public LSU English Department, for technical re- interviews, focus groups, and surveys. We es- Health, Louisiana State University Health view; Ra’Quel Shavers and Rakinzie Fisher, pecially thank the physicians who so gra- Sciences Center School of Medicine in New OSSRD, for the literature review and assist- ciously gave their time to tell their personal Orleans served as the medical consultant for ing with the focus groups; Marion Loyd, stories about Hurricanes Katrina and Rita, the project. Wanda Azema-Watts, and Dustin Drewes, and the LSMS staff including Dave Tarver, OSSRD, for general office support. Jeff Williams, Amy Phillips and Sadie Wilks. This project was funded by the Louisiana State Medical Society Educational and Re- In addition, the authors acknowledge the Correspondence concerning the project search Foundation through a grant from the important contribution of content gathered should be addressed to Sadie D. Wilks, De- Physicians Foundation for Health Systems from all of the published reports, articles, partment of Public Affairs, Louisiana State Excellence. news reports, and official documents upon Medical Society, 6767 Perkins Road, Suite which we have partially relied. Because the 100, Baton Rouge, Louisiana 70808. Email: funding body desired that the report pres- [email protected]. Phone: (225) 763.8500.

www.healthcaredisasterplanning.org

3

Purpose of the PROJECT

his project was undertaken to share many of the same principles and practices in pened in Louisiana and it can happen any- the experiences of the Louisiana order to avoid the worst case scenarios. This where. To protect their patients and their Tmedical community during and after report communicates to other medical com- practices, all physicians should take note of Hurricanes Katrina and Rita in hopes that munities through the words of physicians, the mistakes made and lessons learned in other regions can be better prepared to deal health care providers and administrators Louisiana. with the short term and long range impact who have shared their “lessons learned” in of a major disaster. Three and one half years detailed and informative accounts. This The Louisiana State Medical Society Educa- post disaster, south Louisiana and the other work has been expanded by the research of tional and Research Foundation (LSMS impacted Gulf Coast states continue their the LSU Hurricane Center, through collec- ERF) has undertaken this project to docu- struggle to recover from the storms and re- tion of information showing the real threat ment lessons learned in the aftermath of store the health care infrastructure that was of additional disasters across the nation – major hurricanes in 2005 and 2008. The literally washed away. Perhaps no profes- disasters for which many communities are project documents the major breakdowns sional community suffered greater impact unprepared. and failures of emergency preparedness plans from the storms than the medical commu- and emergency responses related to health nity. Hospitals, medical facilities, and many Prior to Hurricanes Katrina and Rita, the care in an effort to persuade physicians and medical practices were changed forever or Louisiana health care community was un- the health care community to reassess their completely lost. This report attempts to pro- aware of the myriad of problems that could emergency preparedness plans. The Physi- vide insight to what can happen to a medical be encountered in meeting patient health cians Foundation for Health Systems Excel- community when a catastrophic event takes care needs during and after a large-scale dis- lence (PFHSE) funded this project because place. The information is presented through aster. The ability of a physician to render, or of its belief that Louisiana is in an unfortu- empirical literature and, most importantly, the ability of a patient to receive, appropri- nate but unique position to share lessons through the experiences of medical profes- ate healthcare was fragmented or destroyed learned from a major disaster with other sionals who worked on the front lines during by the disaster. This fragmentation greatly states. The primary goal is to share with Katrina and Rita and who have continued impeded the delivery of emergency medical physicians, patients, state medical societies, to deal with the impact of post-disaster re- care and disrupted the continuity of care in and others vested in the delivery of health covery efforts. the post-disaster period. Immediately after care the first-hand perspectives on how and the hurricanes, many Louisiana physicians why the health care delivery system col- This is an important story, not because of were unable to access vital patient informa- lapsed during these disasters. The project what happened in Louisiana, but because of tion, locate patients, prescribe medications also has a secondary goal of inspiring mean- the real probability that other communities or communicate with their patients, staff, ingful dialogue between physicians, state face similar catastrophic events as well. hospitals, and colleagues. Without proper medical societies, and local, state, and fed- Whether it is a hurricane, a pandemic flu, a planning, a disaster will seriously compro- eral agencies as they evaluate various long terrorist attack, or an earthquake, all disaster mise the ability of physicians to render even term solutions to the problems that were re- preparedness and recovery planning involve basic medical care. The unthinkable hap- vealed during the Katrina and Rita disasters.

5

Chapter 1

Overview of Disasters and Effects on the Medical Community

t is around midnight, and the water is rising in the hospital basement. The region’s flood control system Ihas been overwhelmed and everyone expects the flood conditions to worsen during the night. Both pri- mary and backup power have been lost to the hospital and its Level 1 trauma center. Over 1,000 patients need evac- uation immediately. The flooded streets have blocked ve- hicular access to the hospital and tomorrow morning’s Opposite left: Survivors of Hurricane Katrina arrive at New Orleans Airport evacuation will be difficult. Such a scene could only de- where FEMA's D-MAT teams have set up a medical hospital scribe a New Orleans area hospital, probably the infamous and where people will be flown to shelters in other states. Photo Credit: FEMA / Michael Rieger Charity Hospital, after Hurricane Katrina, right?

7 Wrong. It is June 2001, and this scene is taking place just south of downtown . The Memorial Hermann Hospital, part of the Texas Medical Center (TMC), is the medical fa- cility in peril this time. Over the last 10 hours , with winds that never topped 60 mph, has dropped over 10 inches of rain on the Houston area. Located on the banks of Brays Bayou, the TMC has been described as a huge medical “city within a city” and as “one of the most sophisticated medical centers in the world.” It spreads over 695 acres and contains two medical schools, four nursing schools, and 13 hospitals. Of the 13 hospitals on the TMC, nine closed due to flooding, including the Me- morial Hermann Hospital, a Level 1 trauma center with over 1,000 patients. Many roads, including bridges and elevated highways were damaged by the 6.7 magnitude Northridge earthquake. Approximately 114,000 residential and commercial structures were damaged and 72 deaths Hurricane Katrina brought an unprecedented were attributed to the earthquake. Damage costs were estimated at $25 billion. level of attention to the impact that disasters can Photo Credit: FEMA News Photo have on health care and the medical community; however, many of the themes that are so deeply It is mid-July 1995 and a heat wave has gripped many air conditioners running simultaneously associated with the disaster in New Orleans are Chicago. The city’s Emergency Medical Services has overwhelmed the electric grid and blackouts not without precedent. Unfortunately, too much (EMS) are overwhelmed by the thousands of are occurring. During this period daytime high of the post-Katrina dialogue has instilled an calls they have received. For nearly 4,000 im- temperatures reached well over 100° F and “only in New Orleans” mentality towards the periled callers, no ambulances are available, and nighttime temperatures rarely dropped below dismal conditions that occurred after Hurricane the city sends fire trucks. Some callers succumb 80° F. Over 700 deaths were observed during Katrina, particularly the conditions seen in hos- to the heat before help arrives. Many hospitals the week of July 14th to 20th, the majority of pitals, nursing homes, and other health care re- go into “Bypass Status” and start to turn away them elderly residents of the city’s poorer neigh- lated facilities. As such, an extra effort is needed new patients. The morgue at the Cook County borhoods. Just as the hot and dry weather con- to remind all members of the medical profession Medical Examiner’s Office has filled up and a ditions overwhelmed Chicago’s health care that much of what happened in New Orleans line has formed outside. The medical examiner system, Katrina’s wind and water would similarly has happened before and can happen in any has had to order refrigerated trucks to store the overwhelm the medical response capabilities of community or facility across the nation. hundreds of deceased victims. The strain of so southeast Louisiana.

8 It is early on the morning of January 17, 1994, to die down and the hospital is about to receive and EMS fall victim to these hazards at a time and a massive 6.7 magnitude earthquake has a surge of patients. There is a severe shortage of when they are expected to show leadership and struck the Los Angeles area. Nearly 9,000 peo- personnel to handle this crisis. provide help to the impacted population. ple have been injured and 1,600 require hospi- talization. However, the earthquake has These are just a few examples of the challenges Physical hazards alone are not enough to cause a damaged many of the area hospitals and 11 had that confront the medical community during disaster. Disasters result when vulnerable popu- to close. The surge of injured people along with disasters. These examples illustrate that some of lations and infrastructure are exposed to these a flood of patients evacuated from other hospi- the problems that were seen in New Orleans physical hazards. It is this exposure that results tals strain the hospitals that remain open. In the after Hurricane Katrina have been seen in previ- in injuries, deaths, and destruction. In turn, days and weeks that follow, the emergency re- ous disasters and will be seen again in future dis- these outcomes reflect both the magnitude of sponse phase, gives way to the disaster recovery asters. Instead of dismissing these horrible the hazards and the level of vulnerability of the phase and new health threats emerge. The dust circumstances as something that can only hap- population and infrastructure. Although vul- and mold from numerous landslides caused by pen in New Orleans, those involved in the med- nerability is a difficult concept to measure di- the earthquake has resulted in 200 cases of Val- ical community need to acknowledge that, rectly, it is generally accepted that more ley Fever, an additional strain on the recovering without adequate preparation, disasters can crip- vulnerable populations experience the worst im- health care system. ple an entire medical community. pact from hazardous events. There are a number of social, economic, and demographic variables It is the peak of the 2004 hurricane season, and Natural Disasters and the Vulnerability that are linked to a population’s vulnerability to is bearing down on Ormond of the Health Care Sector disasters, including characteristics such as in- Beach, . The nursing shift manager is come level and age. huddled with other administrators and man- Natural disasters are becoming more frequent agers at the Florida Hospital-Ormond Memo- and more severe, and the capabilities of the med- The vulnerability of the medical community to rial Hospital reviewing the hospital’s ical community are increasingly being pushed to disasters must be an important consideration for preparations and current status. Everyone in the the limit. Every disaster brings new challenges; all involved in health care. First, the medical room is concerned about their home and family. a few disasters create what seem to be intractable community centers around one of the most vul- But currently, the biggest concern is fulfilling challenges. The disasters described in this sec- nerable segments of the population: the patients. professional obligations, including 25 nurses tion provide just a small sample of events that People seek treatment for different reasons, in- who are no shows. It is difficult to blame them, resemble aspects of the 2005 Gulf Coast hurri- cluding injuries, chronic conditions, and diseases as most of the nurses are dedicated employees canes. There are many more cases of floods, – nearly all of which potentially hinder the pa- with legitimate reasons for not arriving for work. winds, seismic movements, landslides, heat tient’s physical ability to confront the hazards Conditions outside are horrible, making com- waves, and other physical hazards creating both present during a disaster. Paradoxically, while muting to work difficult, and (like everyone else) an increased need for health care services and a the medical facility often provides safe refuge to nurses have families, homes, and pets to worry significant loss of capability to provide such serv- shield patients’ exposure to physical hazards, the about during disasters. Still, the winds are about ices. On numerous occasions, hospitals, clinics, unique vulnerability of these same facilities also

9 framework, health care practitioners can con- duct quantitative risk assessments of their facil- It is not unusual for nurses, doctors, administrators, and ities, human resources, and services. Once others to face a basic conflict between their professional information is gathered, it can be used to guide and their personal obligations during a disaster. priority setting, policy making, and action plan- ning aimed at reducing risk. In practice, quan- titative risk assessment requires thorough assessments of potential hazards and vulnerabil- threatens patients, health care providers, and professional and their personal obligations dur- ities along with quantitative estimates of the their respective families in the days following a ing a disaster. Clearly, the personal stresses ex- probability and consequences of the different disaster. perienced by nurses, doctors, and other possible disasters. Implementing the results of personnel during times of crisis create an addi- the quantitative risk assessment can be even The second source of vulnerability for the health tional vulnerability for the medical community. more difficult, as numerous resources, manage- care community reflects the dependence of the rial, and institutional constraints will be en- medical system on outside resources. A fully Disasters are complex processes with complex countered. In spite of these complications, risk functioning hospital consumes large amounts of consequences. Because of this inherent com- analysis is an important tool in preparing the energy; requires daily deliveries of food, medi- plexity, analyzing disasters is a difficult task. Ef- health care system for disasters. cine, and other supplies; and depends on a fective disaster planning, which requires a highly skilled and specialized workforce. In the thorough analysis of hazards and vulnerability, Hazard Types and the Associated Impacts modern world, most hospitals also depend on is even more difficult. Thorough disaster plan- high bandwidth telecommunications systems for ning requires the consideration of numerous Disasters occur when vulnerable people and in- a variety of functions. During disasters some or hazards and the potential impact that they have frastructure are exposed to some type of physical all of these outside lifelines are disrupted, limit- on different populations and various types of in- hazard. Many types of physical hazards exist on ing the ability of the facility to function. frastructure. Additional complications result earth and each hazard type has certain associated from the high degree of uncertainty, both in pre- impacts on the general population and on the Finally, when discussing the vulnerability of the dicting the occurrence of an event and in esti- health care system. These hazards include medical community, it is essential to consider mating the consequences of that event. floods, earthquakes, heat waves, windstorms, the effects of a disaster on the people who work Fortunately, the science of risk analysis provides and mass displacement of earth materials. In in hospitals and other facilities. Often, when a simple but powerful tool for disaster analysis general terms, floods are the most frequent haz- medical personnel must work through a disas- and planning. ards and are responsible for the greatest accu- ter, they are very preoccupied with the safety of mulated damage. Earthquakes tend to produce their homes, possessions, and loved ones. It is In the science of risk analysis, risk is typically de- the most destructive and deadly events. This not unusual for nurses, doctors, administrators, fined as the probability of an adverse event times section briefly describes these different hazard and others to face a basic conflict between their the consequences of that event. Using this basic types and their associated impacts.

10 Floods are generally described as the presence which can cause injuries and deaths. Also of and accumulation of water in an otherwise dry concern, floods disrupt public services, cut off location. They are the most common type of access to health care facilities, and block the de- natural disaster. During 2008, the Federal livery of important supplies. Once the waters Emergency Management Agency (FEMA) re- recede, mold remains as an important environ- sponded to 52 flood related federal disaster dec- mental health concern. larations, approximately one every week (FEMA, 2009). Because floods are so common, Although, not as common as floods, many of the they are also responsible for the greatest total loss most severe disasters result from earthquakes. of the different disaster types. A variety of This fact reflects the extensive structural damage processes cause the accumulation of water in an that earthquakes can cause. Within a matter of otherwise dry location, leading to different types a few seconds, an earthquake can level thousands of flood events. Four main flood types are 1) of buildings, including hospitals. Two nurses, riverine flooding, 2) coastal flooding, 3) dam describing the 1971 San Fernando Valley Earth- break floods, and 4) floods that result from poor quake, observed that “the earth shrugged, and drainage in urban areas. Additionally, flood con- 1,700 hospital beds were lost in 52 seconds” The remnants of cause extensive flooding in Munster, Indiana. Residents shown (Braverman and Jenks, 1971). Earthquakes ditions can vary along a wide variety of physical boating down the street. characteristics. Naturally, water depth is an im- occur when tectonic energy is suddenly released, Photo Credit: FEMA / Leo Skinner portant physical characteristic of the flood, but resulting in seismic waves that cause shaking and the rate-of-rise, the flow velocity, the height of displacement on the surface. waves, the water temperature, and the duration of inundation all influence the severity of the The widespread damage that earthquakes cause flood disaster. reflects the response of the built environment to the ground shaking and displacement. Injuries The most obvious and direct impact of floods is and deaths result from the collapse of structures the inundation of communities and structures. during earthquakes. This fact distinguishes Such inundation causes damage to structures earthquakes from floods, heat waves, and wind and creates a drowning risk for those exposed to storms, where the physical forces are directly re- flood waters. Persons exposed to cold tempera- sponsible for many of the injuries and deaths. ture flood waters also face a hypothermia risk. Although considerable progress has been In addition to inundation, floods cause struc- achieved in earthquake resistant designs for tural damage when the waters are either fast homes and other structures, earthquakes still moving or have significant wave action. Dam- pose a significant threat to people and infra- aged structures then become water borne debris, structure.

11 Heat waves do not produce the images of loss and destruction associated with floods, earth- quakes, and landslides; however, it is likely that they result in more deaths than all other natural hazards combined. It is estimated that heat waves result in nearly 400 deaths in the United States (US) every year. In 2003, a heat wave in Europe was responsible for nearly 35,000 deaths. High temperature, as a physical hazard, is most threatening to frail, elderly persons. Al- though not as destructive as other types of phys- ical hazards, heat waves can still cause damage to infrastructure. Roads and bridges can buckle and bend in the heat, sometimes becoming in- operable. Additionally, electrical transformers and other parts of the electric grid can also suffer damage during high temperature periods. Dam- age to the electric grid is especially problematic during heat waves because of the extra strain put on the grid by increased use of air conditioners. Tornado outbreak on March 8, 2007, causes damage in many areas of . Sumter Regional Hospital The human body also responds adversely to high shown here was damaged extensively. temperatures. After about 48 hours of uninter- Photo Credit: FEMA / Wolfe rupted exposure to excess heat, the body’s natu- ral heat regulation mechanism begins to become Windstorms constitute a broad class of weather Effects of Disasters on Health Care overwhelmed. As the body’s temperature rises related hazards, characterized by extreme winds to 104°F and above, damage to the central nerv- along with lightening and precipitation. Wind- Regardless of the type of disaster, the impact felt ous system starts to occur. The heat conditions storms include hurricanes, tornadoes, and severe by the medical community can be summarized are more likely to occur in urban areas, where storms. The wind alone is capable of widespread in five basic areas: 1) physical destruction of fa- the “heat island” effect causes extreme daytime physical destruction and injuries. Additional cilities, 2) loss of crucial lifelines, 3) surge of per- high temperatures, along with little cooling dur- losses can result from the lightening and precip- sons needing medical care, 4) loss of personnel, ing nighttime. When coupled with the popula- itation. When extreme winds occur over water, and 5) emerging long-term threats. tion densities of urban areas, heat wave disasters they can push the water onshore resulting in occur when hot, dry air masses envelop these flooding. Earthquakes, floods, and windstorms are all ca- areas. pable of causing considerable physical damage

12 to the facilities that house the medical commu- to electronic medical records and diagnostics, nity. Floods can inundate lower levels, destroy- hinders communication among staff, and, ulti- ing any equipment, including generators and mately, leads to reduced patient care. data servers that may be located on flooded lower-level floors. Windstorms can cause win- At the same time that disasters reduce the capa- dows to blow out, and then toss about any bilities of the medical system, they also create equipment that may be located in rooms that substantial additional demand for medical serv- have lost windows. Earthquakes can cause sec- ices. Nearly every disaster is accompanied by a tions of buildings or even entire buildings to col- surge of patients with a variety of ailments. lapse. Although not as common a threat, heat Many patients require treatment for injuries that waves can also damage any equipment, such as resulted directly from the disaster. Other pa- air conditioners and backup generators that are tients seek medical attention for chronic condi- located in areas without cooling. tions that can be exacerbated during stressful times. When a disaster forces a hospital to close When equipment and facilities suffer damage, and evacuate its patients, those patients in- the capabilities of the medical system become A FEMA National Disaster Medical Team evitably arrive at nearby facilities. Even though (DMAT) truck drives through floodwaters at compromised. Certain procedures that require the nearby facilities may have escaped the worst the New Orleans Superdome to assist victims specialized equipment are not possible if that of Hurricane Katrina. of the disaster and may even have experienced equipment has been rendered inoperable. Dam- Photo Credit: FEMA / Marty Bahamonde no physical damage, they usually suffer from re- aged facilities sometimes must be evacuated. duced capabilities alongside a surge in admis- Other times, they simply go into lockdown occasions; however, backup generators only sions. This surge (both in regular and mode. In rare occasions, the destruction of a fa- work if they survived the event without major emergency admissions) regularly results in seri- cility has meant that medical care must be de- damage and if they have fuel. Once the fuel ous shortages in personnel and supplies. livered in temporary clinics setup in parking lots stored at the facility has been used, it must be and greenspace. delivered from outside, a complicated task when Shortage of personnel is another important im- roads are blocked by floodwaters, wind debris, pact that the medical community will experience In addition to the physical destruction of facili- or collapsed buildings. Delivery of other sup- during disasters. For many in the profession, ties and equipment, the capabilities of the med- plies, both basic and crucial lifesaving medicines, these times of crisis create conflicting obliga- ical community are further reduced when crucial can also be difficult or impossible when a disas- tions. The need to take care of personal respon- lifelines, such as power, water and sewerage, sup- ter has rendered the roads impassable. Finally, sibilities often outweighs the obligation to ply deliveries, and telecommunications, are lost no modern hospital operates without high band- perform professional duties during a community during disasters. One common characteristic of width data connections for communication and crisis. Even when personnel are willing to work, almost all disasters is the loss of electric power. data transfer. Losing this asset during disasters they are sometimes unable to work. Personal Most hospitals have backup generators for such complicates facility management, cuts off access vehicles may have been destroyed and roads may

13 have been blocked. Other times, medical pro- the additional load. Even if the facility has been fessionals might find themselves in a situation repaired and external services are available, per- where they must deliver medical care to disaster sonnel shortages can continue, especially if the victims on the spot. Although the community disaster has destroyed a significant portion of the certainly benefits when a nurse or doctor is able housing stock. Finally, emerging health threats to treat injured people in the disaster zone – can last for years and decades – a problem that often without communication with the medical emerges especially when the disaster has resulted facility – this still leaves the hospital short of per- in large numbers of people being exposed to sonnel. some sort of environmental toxin because of the disaster. For example, the Katrina evacuees have Disasters also impact the medical community by been exposed to formaldehyde, which was found facilitating the emergence of new health threats. extensively throughout the FEMA trailers. Such threats can result from a variety of circum- stances. Mold and similar air borne particulate Disaster Frequencies and Impacts hazards are common problems following disas- Damaged photograph on a wall of a home in the ters. Damage to water supplies and treatment Planning for disasters begins with an assessment Lower 9th Ward. Flood waters from Hurricane facilities also poses a health threat. In some of the hazards that may be confronted. This as- Katrina destroyed everything in the house and cases, harmful substances get released into the turned the walls green from mold. sessment should look at both the frequency and Photo Credit: FEMA / Andrea Booher community because of a disaster. Even the mass consequences of different hazard events. This as- trauma experienced by the survivors can lead to sessment can be conducted on a variety of spa- widespread mental and physical health chal- tial scales, from the exact city block where a lenges. medical facility is located to a global scale that covers the entire population of earth. This sec- In addition to the immediate challenges during tion covers a preliminary county-level hazard as- the emergency phase, a disaster also produces a sessment for the US. Hazard assessment variety of long-term challenges. Once a hospi- knowledge is critically important for adminis- tal has been evacuated and forced to close, the trators of all medical facilities, because the US is process of reopening it can be complex, time prone to a variety of disasters and every element consuming, and resource extensive. This com- of the health care system needs to be prepared. plexity extends to many of the external lifelines, In Table 1, an assessment of the frequency and such as water and sewerage that have been sev- level with which different hazard types impact ered because of a disaster. When evacuation fa- the US is shown. This assessment utilizes data cilities are closed, other medical facilities in the from the SHELDUS (Spatial Hazard Events and area that remain open will be forced to accept Losses Database for the United States) Database,

14 which is maintained and provided by the Uni- is based on all disasters listed in the database be- This dataset makes it clear that local jurisdictions versity of ’s Hazard Research Lab- tween 1990 and 2005. are regularly impacted by hazard events. During oratory. The SHELDUS Database provides one the period 1990-2005, a total 170,467 hazard of the most comprehensive listings of disasters The SHELDUS Database records disaster events events are recorded in the database, as seen in for the US. It spans from 1960 until 2005 and based on the counties (or equivalent unit of ju- Table 1. This corresponds to approximately 30 lists important information on each disaster, risdiction) that have been impacted by natural county-level natural hazard events each day. such as the hazard type and subtypes, the state hazard events. Each entry in the database re- During this period, nearly 55,000 people have and county affected, the number injured and flects a county that has been impacted by single been injured and over 7,000 fatalities have oc- killed, the total property damage, and the total events and any events that impact multiple curred. According to the database, severe storms crop damage. The database is compiled from counties. This method of organizing the data- are the most common event, with almost nine publications of various government agencies, in- base makes it useful for county-level hazard as- occurring per day. Tornados produce the most cluding the National Oceanic and Atmospheric sessments. Each hazard event is classified injuries, with over 15,000 tornados reported. Administration (NOAA) and the United States according to one primary hazard type, with ad- Heat waves cause the most fatalities, with over Geological Survey (USGS). This particular table ditional hazard sub-types listed when necessary. 2,300 listed. Hurricanes are responsible for the most property damage and droughts have caused the most crop damage. Table 1 (http://www.cas.sc.edu/geog/hrl/SHELDUS.html) *In dollars. Type Number of County Events Injuries Fatalities Property Damage* Crop Damage* Avalanche 298 79 119 1,610,001 0 Coastal 1,063 638 369 992,897,015 655,000 Drought 3,114 15 111 1,396,027,167 11,519,937,119 Earthquakes 21 70 70 22,622,200,000 0 Floods 27,500 8,807 1,051 25,691,824,788 7,537,414,281 Fog 344 1,174 100 18,635,500 0 Hail 13,209 2,028 14 7,636,473,695 1,798,531,171 Heat 3,256 5,912 2,370 22,677,526 464,797,000 Hurricane 1,749 1,142 159 39,359,786,599 4,358,195,821 Landslide 100 24 26 919,016,100 0 7,216 3,115 484 406,092,080 7,100,146 Severe Storm 51,633 4,734 334 9,441,631,955 2,888,170,921 Tornado 8,520 15,145 782 9,597,711,402 142,074,310 Tsunami 5 0 0 20,855,000 0 Wild Fire 867 1,423 67 9,023,645,600 187,522,000 Wind 21,993 2,456 357 4,790,780,832 672,469,060 Winter Weather 29,579 7,446 943 5,975,459,038 4,104,101,128 Total 170,467 54,207 7,355 137,917,324,298 33,680,967,956

15

Anticipating Potential Disasters Across the United States

mergencies, such as severe storms or industrial accidents, Chapter 2 are an everyday occurrence within the US. Similarly, on Ea daily basis, a community somewhere in the US will see a small number of homes damaged or businesses disrupted due to floods or high winds. Few communities have escaped the impact of such regularly occurring, low-level natural weather events. Res- idents of communities are likely to experience significant destruc- tion from floods, high winds, earthquakes, heat waves, or other possible natural disasters at some point in their lives. Major ca- tastrophes, on the other hand, are infrequent and relatively rare throughout history. It is unusual for a community to lose a large portion of its housing stock, see most of its businesses disrupted, and have so many of its citizens in a state of disarray. Although in- frequent, America has experienced a number of catastrophes since the beginning of the 20th Century. This chapter describes some of these major events, from the perspective of the number of fa-

Opposite left: talities and the degree of economic loss. In the latter part of the People standing on the overpasses and bridges to keep out of the New Orleans flood waters. chapter, there is an examination of the research related to poten- Photo Credit: FEMA / Marty Bahamonde tial disasters that will likely affect the US sometime in the future.

17 High Fatality Events 3) 1928 Lake Okeechobee Hurricane 6) September 11, 2001 In mid-September 1928, a major hurricane By means of comparison, the coordinated ter- 1) 1900 Galveston Hurricane made on the Florida coast near Palm rorist attacks on September 11, 2001, resulted In 1900, a Category 4 hurricane made landfall Beach and then followed a track that took the in 2,974 known deaths, with 24 people still near Galveston, Texas, with 135 mph winds and storm up the Florida peninsula. Although there missing and presumed dead. Thorough investi- a 15 foot storm surge. With a population of were no reliable wind measurements available in gations have provided significant insight into 42,000 and located where the Houston Bay Florida, 144 mph winds (Category 4) were how these victims died. Of the known deaths, meets the , Galveston was the measured in from this storm. Be- 2,603 occurred in or around the World Trade largest city in Texas and a prominent port of fore turning northeast, the of the storm Center, 125 at the Pentagon, and 246 on the entry. The town sits on a low lying barrier is- skirted Lake Okeechobee in south central plane that crashed in . In the final land. The highest point was just below 9 feet el- Florida, causing a lake surge of 6 – 9 feet. Over- report on the World Trade Center disaster, the evation. The storm caught the town largely by all 1,836 people (some experts estimate up to National Institutes of Standards and Technology surprise and few preparations had been under- 3,000) died in Florida because of this hurricane, (NIST) provide a thorough analysis of the fatal- taken. As the storm passed overhead, the storm most of them from the Lake Okeechobee surge. ities and the population at risk. surge completely washed over the island. Over 3,600 homes were destroyed and it is estimated 4) Heat Wave June-September 1980 Deadly Hurricanes Since 1950 that between 6,000 and 12,000 people lost their During the summer of 1980, a high-pressure lives. ridge over the south and central US caused ex- During the first 30 years of the 20th century, treme heat throughout these regions of the two hurricanes caused fatality counts over 1,000. 2) 1906 San Francisco Earthquake country. From June to September, temperatures No tropical system, prior to Hurricane Katrina, In 1906, a major earthquake struck San Fran- well over 90˚ F occurred daily in numerous cities resulted in the comparable loss of life since that cisco, California, which had a population of across these regions. The Heat Wave of 1980 re- time. Still, hurricanes have been a deadly part of about 400,000 at the time. Many structures sulted in 1,700 deaths and nearly $20 billion in US disaster experiences since the middle of the were destroyed in the initial earthquake and nu- damage to crops. A concurrent drought con- century. Between 1950 and 1975, four hurri- merous fires burned throughout the city, con- tributed to crop damage. canes resulted in over 100 deaths. These include: tributing significantly to the extent of the (1) Diane (1950) – 180 deaths; (2) Audrey disaster. Nearly 225,000 people were left home- 5) Drought/Heat Wave Summer 1988 (1957) – 390 deaths; (3) Camille (1969) – 256 less. In the days that followed, the impacted res- Eight years later, the central and eastern regions deaths; and (4) Agnes (1972) – 172 deaths. idents faced dire circumstances. An evacuation of the US experienced more losses to drought Following in 1972, no hurri- of the city was soon ordered. Early estimates and extreme heat. Agricultural damages were es- canes or tropical systems had caused over 100 placed the number of fatalities in the hundreds; timated at $40 billion and the deaths attributed deaths in the US until Hurricane Katrina in however, it is now widely believed that as many to this disaster are estimated to be between 2005. This trend is often attributed to im- as 3,000 people perished due to the earthquake, 5,000 and 10,000. provements in hurricane forecasting and evacu- the fire, and the lawlessness. ation procedures. However, it is also possible

18 that this trend simply coincides with the phase a wildfire, two freezes, and a severe weather ricane of 1900 ranks second in the list of most of the North Atlantic Oscillation characterized event. It seems that billion dollar disasters are a expensive natural disasters. Estimates of the by less frequent and intense Atlantic basin hur- relatively common occurrence in the US. The damage, normalized to 2005 dollars, range from ricanes. NCDC scientists count 78 events with costs $38 to $78 billion. over one billion dollars that have occurred be- The 1993 Blizzard and the 1995 Chicago tween 1980 and 2007, an average of nearly three 3) Galveston Hurricane 1915 Heat Wave per year. Fifteen years after the 1900 hurricane, Galveston was again struck by a hurricane in 1915. Fol- Prior to Hurricane Katrina, only two natural dis- Similarly, a list of billion dollar disasters com- lowing a very similar path to the previous hurri- asters in the US since 1990 had resulted in over piled by Dr. Wayne Blanchard for FEMA lists cane, this storm still resulted in considerable loss 100 deaths. In March 1993, a large blizzard de- 118 events. The top five natural disasters on this of life (over 400 fatalities) and an estimated $32 livered freezing temperatures and significant list, excluding Hurricane Katrina, are described - $62 billion (normalized to 2005) in damages. snowfall to much of the southeast region of the below. As would be expected, some, but not all, country. In parts of , over 60 inches of of the disasters on this list appear on the list of 4) 1992 snow fell and the Florida panhandle experienced the most lethal disasters also. From an exami- In August 1992, Hurricane Andrew became the 2 inches of snow along with hurricane force nation of the list, it is apparent that all five of first named hurricane (the National Hurricane winds (>74 mph). The 1993 blizzard resulted the billion dollar events were Atlantic basin hur- Center started naming storms in 1953) to be in 300 deaths throughout the US. ricanes, with four of the five impacting the Gulf placed on the list of most expensive natural dis- Coast. These include: asters. First crossing Florida and then making a In July 1995, an extreme heat wave gripped the second landfall in Louisiana, Andrew resulted in Midwestern cities of Chicago and Milwaukee. 1) Great Hurricane 1926 61 deaths and between $54 and $84 billion Over 600 heat-related deaths occurred in Although not on the list of deadliest disasters, (normalized to 2005) in damages. Chicago and nearly 200 people succumbed to this unnamed hurricane that struck Miami in the heat in Milwaukee. September 1926 tops the list of the most expen- 5) Hurricane 1938 sive disasters. When normalized to 2005 dol- In September 1938, the New England region ex- Multi-Billion Dollar Events lars, estimates of damage are in the $100 - $160 perienced its first major hurricane in nearly 70 billion range. Interestingly, this estimate may years. This storm, which made landfall on Long In 2005, the National Climatic Data Center make the Great Miami Hurricane more expen- Island, , as a Category 3 storm, re- (NCDC) added five events to its ongoing list of sive than Hurricane Katrina. sulted in 682 deaths and between $37 and $70 billion dollar weather related disasters. In addi- billion in damage (normalized to 2005). For tion to Hurricane Katrina, three other Atlantic 2) Galveston Hurricane 1900 means of comparison, the September 11, 2001, basin hurricanes and a Midwest drought caused In addition to causing the greatest loss of life terrorist attacks are listed by Dr. Blanchard with over $1 billion in damage. In 2007, scientists from a natural disaster in the US since the be- damage estimates to be $27 to $80 billion. added five more disasters to the list: a drought, ginning of the 20th century, the Galveston Hur-

19 Table 2 Comparison Katrina and Rita to Other Disasters

Disaster Description Damage (Year of Currency) Homes Damaged Deaths

Hurricane Katrina 110 mph winds and 20 ft storm surge in SE La. $100 - $150 billion (2005) 140,000 ~1,500

Hurricane Rita 115 mph winds and 15 ft storm surge in SW La $27 to $80 billion September 11, 2001 Terrorist hijack four airplanes, crash two in WTC 2,998 and one into pentagon 1900 Galveston Hurricane 135 mph winds and a 15 ft storm surge Over 3,600 6,000 to 12,000 1906 San Francisco Earthquake 225,000 people ~3,000 left homeless 1928 Lake Okeechobee Hurricane Category 4, a lake surge of 6 – 9 ft high temperatures over 90˚ F 1,836 Heat Wave June-September 1980 $20 billion in damage crops 1,700

Drought/Heat Wave Summer 1988 $40 billion in crop damage 5,000 - 10,000

Hurricane Diane (1950) 180

Hurricane Audrey (1957) 390

Hurricane Camille (1969) 256

Hurricane Agnes (1972) 172 300 throughout 1993 Blizzard Tennessee, over 60” inches of snow fell the United States 1995 Midwest Heat Wave 800

Great Miami Hurricane 1926 $100 - $160 billion (2005)

Galveston Hurricane 1900 $38 to $78 billion (2005) Galveston Hurricane 1915 $32 - $62 billion (2005) >400

Hurricane Andrew 1992 $54 - $84 billion (2005) 61

New England Hurricane 1938 $37 - $70 billion (2005) 682

20 Potential Disasters was felt over an area estimated to be greater than 3) California Earthquake 50,000 square miles. Given the low population Third on the list of potential catastrophes is a Since disasters of all sizes and types occur density of that region at the time, the damage major earthquake striking California. Accord- throughout the US on a regular basis, every and death estimates were small. ing to a recent report by the United States Geo- health care community needs to be prepared. logical Survey (USGS), within the next 30 years, The impact of these disasters varies greatly as Two major cities, St. Louis and Memphis, are there is a 99% chance that shifting in the San both a reflection of the physical hazards and the now located near this fault line, creating the po- Andreas Fault will cause a magnitude 6.7 or vulnerabilities of the population being affected. tential that a similar seismic event today would larger earthquake and a 46% chance of a mag- In a few rare cases, major catastrophes occur have major consequences. Recognizing this po- nitude 7.5 or greater. Recently, residents from when extreme hazards affect extremely vulnera- tential for catastrophe, FEMA has initiated the Los Angeles to San Diego felt shaking from a 5.4 ble people and infrastructure. During these New Madrid Seismic Zone Catastrophic Plan- magnitude earthquake. This caused minimal events, widespread destruction and injury are ning project. According to modeling for the damage and rattled nerves; however, most resi- compounded by significant disruption to the project, such an event would cause an estimated dents and officials felt relief when they found basic public safety infrastructure. During these $70 billion in damages to buildings. Damage out this event was not “the Big One.” times of crises, hospitals and medical profes- would cover eight states and four different sionals must be prepared for a leadership role in FEMA regions. Over 1 million people would preparedness and recovery efforts. Preparedness lose access to water and an estimated 250,000 begins with the recognition of what could hap- households would be displaced long term. De- pen in a major disaster. This section describes pending on the time of such an event – for ex- some of the major catastrophes that empirical ample, in relation to commuter trends – the evidence suggests will eventually happen in the number of casualties could be as high as 17,000. US. Such a list could never include all possibil- ities; rather, these scenarios are meant to illus- 2) Hurricane Hits Miami / Herbert Hoover trate the possibilities that are known and whose Dam Breaks effects can be mitigated. A second catastrophic planning initiative looks at two possible disaster scenarios in southern 1) New Madrid Fault Earthquake Florida. One scenario, a break in the Herbert The New Madrid Fault runs through southeast Hoover Dike around Lake Okeechobee, would Missouri, northeast Arkansas, and parts of west- flood approximately 45,000 people. As many as ern Tennessee. One of the largest earthquakes 7 million people would be impacted in the sec- Older masonry buildings are particularly ever recorded on the continental US occurred ond scenario, which depicts a major hurricane vulnerable to damage from earthquakes, as along this fault in 1812. Almost half of the town striking Miami. Hurricane Ono, the fictitious shown in this photo from the Northridge of Madrid, population 400, was destroyed. With storm developed for this catastrophic planning Earthquake in 1994. an estimated magnitude of 8.0, ground shaking initiative, would do both. Photo Credit: FEMA News Photo

21 According to modeling from the USGS, “the Big Much of the area depends on aged and deficient Sacramento region would suffer catastrophic One” could potentially result in damages to levees to prevent flooding. Historically, settled consequences. Many areas in the region would buildings totaling $30 billion, and could cause areas are protected by levees that were built long experience water depths over 15 feet. The Cali- significant damage to municipal water distribu- ago and not sufficiently maintained. Recent fornia capital building, located in historic Sacra- tion systems and other crucial parts of the pub- urban expansion has occurred on low lying mento, could be surrounded by 5 feet of water. lic safety infrastructure. Additionally, an farmlands protected by levees built to protect As many as eight hospitals could experience estimated 1,600 building fires would take place. crops, not neighborhoods. Throughout the area, flooding. Approximately 1,800 fatalities will occur, with neighborhoods depend on levees that do not a projected surge of 50,000 patients to undam- meet basic engineering standards. A recent sur- 5) Mississippi River Flood aged and open hospitals. The total damage is es- vey by the Corps of Engineers found 36 sub- The Mississippi River watershed constitutes the timated to be over $200 billion. standard levees within the Sacramento district. largest drainage basin in North America and

According to modeling from the USGS, “the Big One” could potentially result in damages to buildings totaling $30 billion, and could cause significant damage to municipal water distribution systems and other crucial parts of the public safety infrastructure.

4) Sacramento Flood In January 2006, heavy rain caused flooding third largest in the world. The lower portion of Located near the confluence of the Sacramento throughout the Sacramento Valley, though most this watershed, referred to as the Mississippi Al- River and the American River, the Sacramento of Sacramento was spared. Shortly afterward, luvial Plain, consists of low lying land created metropolitan area is home to over 2 million res- the governor of California declared a state of over the eons through deposition from floods idents and sits on low lying, flood prone land. emergency to prioritize levee repairs, upgrades, along the Mississippi River and its tributaries. Originating as a pioneer town, Sacramento grew and maintenance. This floodplain stretches from southern Illinois into a major distribution center during the gold through parts of Kentucky, Tennessee, Arkansas, rush years. The urban area has expanded con- Extreme rainfall in the Sacramento Valley would Mississippi, and Louisiana, and includes a hand- siderably in recent years. cause high water levels in the Sacramento River. ful of major cities along with numerous small If the worst case scenario of multiple levee communities and agricultural areas. breaches were to occur, most of the metropolitan

22 During the 20th century, numerous floods have occurred through the Mississippi Alluvial Plain, though two events are the most memorable. In 1927 and 1993, record snowmelt and precipita- tion in the Mississippi River watershed caused widespread flooding throughout the alluvial plain. In 1927, water overtopped levees and flowed through over 140 breaches, causing flooding that reached 30 feet in some places, over $400 million in damage, and 246 deaths spread across seven states. This disaster event and the response to it also exerted an undeniable impact on American politics. In 1993, flooding impacted an area of comparable size in the allu- vial plain, causing $15 billion in damage and over 50 deaths.

A future, worst case flooding event in the Mis- sissippi Alluvial Plain could impact millions of people. Memphis, St. Louis, Little Rock, Vicks- Cadaver locating dog (upper left) works a pile of debris on Bolívar Peninsula after Hurricane Ike, while burg, Baton Rouge, and New Orleans could all his trainer and flanker look on. be impacted. Crop losses throughout the region Photo Credit: FEMA / Mike Moore could be devastating and commerce along the river system would be disrupted. In addition to Peninsula and destroyed most homes, including Houston and Galveston certainly did not dodge thousands of displaced residents, these cities many built on stilts. In Galveston, the surge in- the bullet during Ike; however, the region did would have to deal with injured residents and undated most of the island while Houston ex- escape a direct hit from “the Big One.” Perhaps widespread disruption of medical services. perienced widespread wind damage and limited a nearly lethal grazing hit is an accurate descrip- flooding. Over 30 persons died in the Houston- tion. At the time of landfall, Hurricane Ike had 6) Hurricane hits Houston / Galveston Galveston area from Ike and damages have sur- wind speeds around 110 mph, making it a weak In September 2008, residents of Houston and passed $10 billion. Over 6 million people were Category 3. Further, Ike’s trajectory brought the Galveston experienced what many perceived to left without power, with millions in Houston in eye over Galveston Bay, about 10 miles east of be the “Big One” when Hurricane Ike traveled the dark for many weeks. Over 100,000 homes downtown Houston. This placed Houston and up Galveston Bay. East of the bay, Ike’s 20 foot suffered flood damage. Four months later, 45 Galveston on the “good side” of the storm, with storm surge completely inundated the Bolivar people remain missing. Ike’s most severe winds and surge impacting

23 7) Hurricane Hits The last major hurricane strike near New York City occurred in 1938 and it has been nearly 18 years since the residents of New York City felt any hurricane winds. Considered sufficiently north of the southern East Coast’s Hurricane Coast, hurricane strikes near New York City are rare and most of the residents of the area do not consider hurricanes to be a major source of risk. Still the risk of a major strike is considerable and the consequences could be catastrophic.

Following a path that brings the eye of the hur- ricane southwest of the city, a major hurricane could push a storm surge up New York Bay into the Hudson River and even into the Sound. All five of the boroughs that make up Hurricane Katrina heavily damaged or destroyed dozens of bridges in coastal Louisiana and Mississippi, New York City could be impacted by flooding, severely disrupting response and recovery activities. with Brooklyn and Queens suffering the worst Photo Credit: LSU Hurricane Center/ Marc Levitan impact. Much of south , including the World Trade Center site, would be inun- areas east of Houston-Galveston. Bolivar Penin- strophic consequences. With a trajectory moved dated with water. sula, where Ike’s worst impact was felt, consisted a few miles west, Galveston Bay would suffer of low density beach homes, many of which complete inundation along with the ravaging ef- 8) East Coast Tsunami were vacation homes. As the surge still pushed fects of monster waves. If the eye passes over In December 2004, the world watched in shock inland, many residents escaped flooding because Galveston Island and moves inland toward as much of the coast of the Indian Ocean suf- the peninsula diminished the height of the storm Houston, the 20 foot surge would be pushed fered a devastating tsunami producing waves as surge. unimpeded into Galveston Bay, and then am- high as 30 feet that destroyed coastal cities and plified as the Bay topography funnels the surge villages from Indonesia to India and resulted in Having spared Galveston and Houston from the toward downtown Houston. Flooding in Hous- hundreds of thousands of deaths. Even the parts worst effects, Hurricane Ike still ranks as the ton would be widespread and catastrophic. of the east coast of Africa experienced tsunami third costliest Atlantic basin hurricane with a Medical services in the US’s sixth largest metro- damage. A large earthquake along the Sumatra total estimated damage at just under $30 billion. politan area would be devastated and over- fault line at the ocean bottom caused this Given Ike’s impact, one should expect a direct whelmed. tsunami. Many experts fear that a massive land- hit on Galveston and Houston to have cata-

24 slide on the Canary Islands could send a huge result if a major supply disruption occurred dur- describe a broad set of software and instruments tsunami racing across the , strik- ing an extended period of widespread frigid for gathering, compiling, storing, analyzing, ing numerous US cities along the east coast. weather. modeling, and visualizing geographic data. Cities from Boston to Miami would suffer A Geographic Information System (GIS) is one deadly and destructive flooding. Assessing Preparedness for Potential type of geospatial technology that is used exten- Disasters sively in hazard assessment handbooks. Simply 9) National Heat Wave and Blackout put, GIS is software for making maps. More Though little noticed, heat waves are one of the Since disasters are inherently geographic specifically, a GIS user has the ability to store, most common and lethal types of natural disas- processes, it makes sense that geospatial tech- manipulate, and represent spatial data. There- ters. During summer months, cities throughout nologies are important tools in preparing for, re- fore, one can look at the spatial extent of possi- America experience crippling heat resulting in sponding to, and recovering from disasters. ble hazards overlaid on data that shows many deaths. Air conditioning usage during Geospatial technology is a general term used to vulnerable populations and infrastructure. even a normal summer places strain on the na- tion’s energy infrastructure and often causes lo- calized temporary blackouts. A widespread and sustained heat wave could cause considerable strains on vulnerable individuals and the nation’s vulnerable grid. Numerous heat illness patients would seek medical care, but many hospitals that lack backup power would close and those that remain open would quickly fill to capacity.

10) Extreme Winter and Heating Fuel Shortage Every winter, millions of Americans depend on a fragile network of fields, process- ing plants, pipelines, and liquid natural gas ter- minals to maintain warm, safe homes. Although natural gas fields exist throughout the US, main- taining adequate supply depends on significant production along the central Gulf Coast and five liquid natural gas terminals spread across the US. Any supply disruption could impact the en- Plows work to keep street passable as a December 2006 blizzard hits Denver with up to 28 inches of snow. tire system. A particularly deadly disaster could Photo Credit: FEMA / Michael Rieger

25 Other geospatial technologies include Global 2. Spatial Hazard Events and Losses Database 4. UCLA Center for Public Health and Positions Systems (GPS) and Remote Sensing for the United States 1960-2007 Disaster (CPHD) “Hazard Risk Assessment (RS). GPS provides high precision measure- (SHELDUS) Instrument” ments of an individual position. It utilizes a “SHELDUS is a county-level hazard data set for “HRAI utilizes a standardized emergency man- handheld receiver and a system of satellites. RS the US for 18 different natural hazard events agement approach to identifying locally relevant refers to instrumentation and data analysis tech- types such thunderstorms, hurricanes, floods, hazards, assessing the probability of occurrence, niques that provide data on location without vis- wildfires, and tornados. For each event, the data- and quantifying the potential impacts of maxi- iting that location. Using RS, hazard scientists base includes the beginning date, location mum credible events. The instrument varies can map flood and seismic hazards. (county and state), property losses, crop losses, from most emergency management tools by injuries, and fatalities that affected each county. specifically identifying impacts that are relevant Hazard Assessment guidebooks provide lists of The data set does not include Puerto Rico, to public health” (CPHD 2006). Geared toward relevant datasets and analysis techniques for haz- Guam, or other US territories” (Hazards and public health planners, the HRAI relies on sim- ard and/or vulnerability assessments. A handful Vulnerability, 2008). ilar methods as the above handbook but includes of hazard assessment guidebooks and references a more refined analysis that provides specific es- are listed below: 3. Handbook for Conducting GIS-Based timates of impacts that can be used for planning Hazards Assessment at the County Level the medical response. This planning tool con- 1. Social Vulnerability Index for the United This guidebook provides the user with a county- sists of four steps. In the first step, the user goes States (SoVI) level method for hazards analysis. It begins with through a list of possible hazards and scores the “The SoVI measures the social vulnerability of a list of computer hardware, software, and basic relative probability that it will affect the com- US counties to environmental hazards. The requirements. It then provides a list of GIS data munity. The second and third steps involve scor- index is a comparative metric that facilitates the and techniques needed to identify and map haz- ing the consequences of an event for each of the examination of the differences in social vulnera- ard zones along with estimating vulnerable pop- most likely hazard types. In the fourth step, the bility among counties. It graphically illustrates ulations within the hazard zones. Additional two results are combined into a basic risk analy- the geographic variation in social vulnerability. It steps include special-needs populations, key in- sis. The final table helps planners prioritize haz- shows where there is uneven capacity for pre- frastructure and lifelines within the hazard ard types based on this quantitative risk paredness and response and where resources zones. This guidebook is geared toward county- assessment (Shoaf, Seligson, Stratton & might be used most effectively to reduce the pre- level emergency managers, but it also provides Rottman, 2006). existing vulnerability. SoVI is also useful as an planning insight for medical professionals. The indicator in determining the differential recovery guidebook helps determine the hazards that an 5. Morrow’s “Community Vulnerability from disasters” (Hazards and Vulnerability, institution and its market community might Maps” 2008). face, helps identify the crucial infrastructure, and “Examples from recent disasters, Hurricane An- lifelines that could cease, and it helps estimate drew in particular, illustrate how certain cate- the population that may need medical assistance gories of people…are at greater risk throughout (Cutter, Mitchell & Scott, 1997). the disaster response process. Knowledge of

26 where these groups are concentrated within tify which natural hazards (out of the range of communities and the general nature of their cir- possible types) could occur at a location. The cumstances is an important step towards effec- interactive map allows the user to zoom on par- tive emergency management” (Morrow, 1999). ticular regions of the world, for example the Gulf Coast or New England, and view the major 6. PACER Computer Program Helps natural hazards that have affected that region. Hospitals Prepare for Mass Casualties The map includes earthquakes, volcanoes, “The Electronic Mass Casualty Assessment and tsunami and storm surge, tropical storm and cy- Planning Scenarios (EMCAPS) computer pro- clones, extra tropical / winter storm, and navi- gram calculates the impact of such crises as a flu gational hazards. Cities that are prone to epidemic, bioterrorist attack, flood, or plane liquefaction during earthquakes are also marked crash, accounting for such elements as numbers (Munich Re Group, 2008). of victims, wind direction, available medical re- sources, bacterial incubation periods and bomb Every component of the medical and healthcare size… [and] depends heavily on population den- community should identify potential disasters sity estimates to derive "plausible estimates" of that may affect their area of the US and should what hospitals may expect in the first minutes utilize an applicable hazards tool to ensure ef- or hours of a disaster” (PACER, 2009). fective preparedness and recovery planning.

7. USGS Hazard Atlas “The US Geological Survey (USGS) provides real-time hazard information on earthquakes, landslides, geomagnetics, and volcanoes, as well Every component of the medical and healthcare as background information on all the types of hazards” (National Atlas, 2008). community should identify potential disasters

8. World Map of Natural Hazards - that may affect their area of the US and should Munich Re The reinsurance company Munich Re provides utilize an applicable hazards tool to ensure an interactive, web-enabled World Map of Nat- ural Hazards that depicts the geographical ex- effective preparedness and recovery planning. tent of various hazards. While not a complete risk assessment tool, this map provides the user with a quick and straightforward way to iden-

27

Hurricane Katrina: Preparation for and Impact 3 on the Medical Community Chapter Physical Hazards and the Vulnerability of New Orleans

here is little doubt that New Orleans is located in a region that leaves it exposed to many weather Tbased hazards. In addition to the region’s well- known experience with hurricanes, the area’s humid sub tropical climate means that mid-latitude cyclonic storms and intense thunderstorms also pose a threat. Like hurri- canes, these weather systems can bring heavy wind, rain, high tides, and tornados. Located on a low lying river delta and surrounded by water and wetlands, New Or- leans has experienced a number of wind and flood-related disasters. Given the record of past experience, along with the widespread knowledge of the area’s wetland destruc- tion, it was known prior to Katrina that New Orleans Opposite left: Satellite image of Hurricane Katrina approaching would inevitably experience a catastrophic storm surge New Orleans. Source: NOAA flood.

29 Figure 1 – Map of coastal Louisiana indicating parish locations and major cities and roads. Source: LSU Hurricane Center

Additionally, there is irrefutable documentation In addition to the vulnerability of the popula- Other aspects of the region’s flood protection that the region’s population and infrastructure tion, the infrastructure in the region also con- also contributed to the risk level. Approximately are highly vulnerable to disaster because of sys- tributed to New Orleans’ catastrophic risk. The 150 years ago, southeast Louisiana was com- temic poverty. For the inner city population of drainage system, which is one of the world’s prised of a large expanse of marshes, swamps, New Orleans, poverty, poor education, and lack most complex, was frequently overwhelmed by and bayous. New Orleans and the surrounding of personal transportation all made preparing for heavy precipitation prior to Katrina. It was communities were somewhat protected by these a catastrophe difficult. In addition, the 2000 common for a neighborhood to experience street coastal wetlands from hurricane and storm census counted over 150,000 persons over age level flooding during normal rain storms. As an surges. However, in the 1850’s, federal engineers 65 and over 250,000 persons with disabilities example, in May 1995, a two-day rainstorm decided to pursue a “levees only” policy for within the New Orleans Metropolitan Statisti- dropped 20 inches of rain on the region, flood- maintaining the Mississippi River for naviga- cal Area (MSA), which includes heavily popu- ing 56,000 homes and businesses, and causing tion. This decision meant that the many dis- lated Orleans and Jefferson Parishes along with six deaths. It was common knowledge that, if a tributaries of the Mississippi would be blocked. five surrounding parishes. Figures 1 and 2 show May storm could cause this much damage, then These distributaries delivered the fresh water and the geography of coastal Louisiana and the a hurricane could create catastrophic damage. nutrients that sustained the coastal wetlands pro- Greater New Orleans area, respectively. tecting New Orleans. With these distributaries

30 blocked, the coastal wetlands were starved of the freshwater and nutrients and slowly began to die.

In years that followed, many other decisions and actions contributed to the destruction of the coastal wetlands. Following the 1927 Missis- sippi River flood, federal engineers continued to strengthen the “levees only” policy. Over the years, many new navigation canals were dug throughout the region, including the Inner Har- bor Navigational Canal, the Intracoastal Water- way, the Mississippi River Gulf Outlet, and the Harvey Canal. These are all examples of large- scale, human made navigational canals dug through the wetlands surrounding New Orleans. Additionally, hundreds of smaller navigational canals also tear through the wetlands. Other contributors to wetland loss include regional subsidence, global sea level rise, and polluted agricultural runoff. For decades, coastal scien- tists have worked on plans to restore the wet- lands, but little meaningful restoration has taken place. As the destruction of the wetlands con- tinued, emergency managers and others became increasingly aware that the risk of a storm surge Figure 2 – Map of southeast Louisiana – Greater New Orleans Area. flood disaster increased with each passing year. Source: LSU Hurricane Center

Given the known threat, plans were developed at seen as the best strategy to preserve life. How- limited to four highways and five secondary a variety of levels to prepare for the “Big One” ever, the limitations of this approach were ap- roads. Additionally, access to some of the out- that would “fill the bowl” (referring to the parent. Limited highway capacity was one of lying coastal communities is limited to only a unique geography of New Orleans). Within the the major problems with this approach. Access single, low-lying, two lane road that tends to state and local governments, large-scale evacua- to the urban core of New Orleans, where the flood early when hurricanes approach. tion in the face of a threatening hurricane was majority of the evacuating population lives, is

31 Limited access to personal transportation also In the realm of risk management and planning, struck. One year prior to Katrina, Hurricane complicated planning for large-scale evacuation. these activities were described as planning for a Ivan dealt a passing blow to the region but still The 2000 Census revealed that approximately low-probability, high-consequence event. Al- caused significant destruction to the Chandeleur 51,000 households (27.2% of the total number) though hard to measure exactly, it was well rec- Islands, a chain of barrier islands that served as in Orleans Parish lacked access to a personal ve- ognized that the annual probability of an intense an ever shrinking obstacle to hurricanes and hicle. In surrounding Jefferson, St. Bernard and storm striking close enough to cause massive storm surges. The damages caused by Ivan Plaquemines Parishes, approximately 10% of overtopping of the levee system was low. At the meant that subsequent hurricanes would be able households lacked personal transportation. same time, it was also recognized that the oc- to push their surges further inland and closer to Many of these same households contained eld- currence of such an event would have devastat- the inhabitants and infrastructure, including erly persons and persons with physical and men- ing consequences, particularly in terms of lives, hospitals and health clinics of the Greater New tal disabilities, resulting in difficulties convincing homes, and businesses lost. Assessing risk and Orleans region. them to leave and then helping them leave. For making risk-based decisions within such a situ- these reasons and other similar reasons, New Or- ation is difficult and far from an exact science. leans had earned a place near the top of FEMA’s On the one hand, directing resources to plan- list of possible catastrophes within the US. ning for an event that is unlikely to occur ap- pears to divert time and resources away from The medical community in New Orleans was other important objectives that would have also known to be vulnerable to hurricane dam- more immediate and definitive benefits. On the age. In particular, it was recognized that many other hand, it is recognized that insufficient hospitals, which were expected to serve as havens planning and mitigation makes heavy losses all during a disaster, would have their own prob- the more likely. lems during a hurricane or flood. For many, though not all, backup generators were located Even in a static risk environment, planning for on ground levels, backup water supplies did not a low-probability, high-consequence event is dif- exist and stockpiling emergency supplies was ficult. This task is made even more difficult constrained by tight budgets and was often con- when the hazard profile changes with time, as sidered waste when another hurricane season was the case for the New Orleans region. In this passed without major incident. particular context, two important environmen- tal processes meant that the risk faced by the re- Planning for Catastrophe gion was not static but highly dynamic. Locally, Destruction of Chandeleur Islands from 2001 coastal land loss was one of these processes. The (top) to 2005 (bottom) due to Katrina and other Planning for the inevitable hurricane striking the destruction of Louisiana’s coastal wetlands, the storms. Yellow arrows in both pictures indicate New Orleans region was an important priority region’s natural storm surge buffer, had been the same water feature. in the years leading up to the Katrina disaster. studied for nearly half a century when Katrina Photo Credit: USGS

32 In addition to regional landscape changes, global ricane Ivan, the state Southeast and Southwest complex and challenging. No one had defini- climate patterns were another dynamic factor Louisiana Hurricane Evacuation Taskforces, tive answers for important questions, such as: that impacted the hazard profile for the region. comprised of state and local transportation, law How many people would not evacuate? Where The North Atlantic Oscillation had recently enforcement, and emergency planning officials, would they be? What types of hazards would been recognized as an Atlantic Ocean current worked diligently to develop and distribute a re- they experience? How would they be transported pattern that influenced the strength and trajec- gional, phased contraflow evacuation plan be- to safety? And, what would their medical need tory of hurricanes within the Atlantic Basin. fore the start of the 2005 hurricane season. be? To address these issues, numerous planning Additionally, many climate scientists believed With this plan in place, over one million people exercises had taken place. Many of these exer- that global warming would result in conditions within the “at risk” areas were able to evacuate cises involved individual agencies or jurisdic- conducive to more frequent and more intense before Katrina, making the vehicular evacuation tions, and others involved collaborative efforts hurricanes. Regardless of the impact of global plan one of the few successes in this hurricane. between agencies and jurisdictions. warming, global sea level rise, along with the dis- Most people, who had access to an automobile appearing coastal wetlands, simply meant higher and desired to leave, were able to evacuate. Traf- In June 2004, however, the Hurricane Pam ex- storm surges. fic on the major evacuation routes had cleared ercise brought together people from all the out before the storm arrived. major agencies at the local, state, and federal Developing and implementing risk-based poli- level, along with non-profit organizations and cies is a difficult task even for the experts. As- In addition to this coordinated effort to evacu- key corporate entities. During a week of intense sessing risk in the context of low-probability, ate as many people with access to cars as effi- planning, over 250 people considered the Hur- high-consequence events is even more difficult. ciently as possible, numerous local governments ricane Pam scenario, which was a strong Cate- When regional and global environmental started to look into ways to assist those without gory 3 hurricane passing just south of the city changes result in a changing hazard profile, this personal transportation or other mobility limi- on a northwesterly track. Computer models pre- task becomes extremely challenging. In the New tations. Some parishes had attained relative suc- dicted that such a storm would flood most of the Orleans area, both hospital administrators and cess in their efforts to provide evacuation Greater New Orleans area and include over average citizens faced a difficult task when trying assistance to those who needed it and others 100,000 people that needed rescue and medical to assess their risk and make decisions related to were still developing these plans and capabilities care. Using this scenario, the group worked this assessment. when Katrina struck. through the details of responding to this over- whelming emergency. This exercise produced In spite of these limitations in assessing the hur- For those involved in planning, it was recognized the backbone of the Southeast Louisiana Cata- ricane risk for the region, a variety of officials that the limitations of evacuation meant that an strophic Hurricane Response Plan. The plan, and agencies were engaged in planning activi- untold number of people would stay behind, while still a work in progress during the summer ties. At the state level, improving the hurricane creating widespread human suffering and neces- of 2005, nevertheless provided a solid frame- evacuation plan was a big priority. After experi- sitating a large-scale emergency response. Al- work for the response to Katrina. encing major problems with the evacuation of though evacuation planning was difficult, New Orleans during the 2004 near miss of Hur- planning the emergency response was even more

33 The day before landfall - residents lining up to get into the Superdome; this was Figure 3 – Hurricane Katrina current conditions and forecast track opened as a hurricane shelter. on Sunday morning, August 28 (one day before landfall). Photo Credit: FEMA / Marty Bahamonde Source: National Hurricane Center

Hurricane Katrina’s Physical Hazards preparations and evacuations by this time and ing over 1 million evacuees. As evening ap- sixty miles to the north in New Orleans, prepa- proached and conditions worsened, nearly Southeast Louisiana first began to feel the effects rations were starting to wind down. Contraflow 12,000 people found refuge in the Superdome of Hurricane Katrina on the afternoon of Sun- continued and westbound traffic along Interstate and an estimated 130,000 people rode out the day, August 28, 2005. The storm had intensified 10 flowed at a rate of about 2,500 vehicles per storm in their homes, their businesses, or with to a Category 5 hurricane on the Saffir Simpson hour, which had been the rate for most of that nearby friends and family. scale earlier that morning, even though it was day. In addition, thousands of people seeking still located several hundred miles south of refuge lined up outside the Superdome. By The eye of Hurricane Katrina made landfall near Louisiana (see Figure 3). That afternoon, the around 4 p.m., the outer rain bands of Hurri- Buras, Louisiana, around 6:00 a.m. on August storm surge started to push inland and shortly cane Katrina reached New Orleans, soaking 29, with wind speeds in the Category 2 range. after 2 p.m. surge waters started to flood High- those waiting to enter the Superdome. Con- In the ensuing hours, the storm tracked nearly way 1, the only evacuation route for coastal traflow was terminated at 5 p.m. due to deteri- due north, passing about 20 miles east of New communities, such as Port Fourchon and Grand orating weather conditions. Nearly 450,000 Orleans around 10:00 a.m. Shortly thereafter, Isle. The coastal region had completed their vehicles were counted leaving the region, carry- the storm made final landfall near the Louisiana-

34 Mississippi state line, very close to the predicted areas south and east of New Orleans experienced track shown in Figure 3. The worst had passed winds in the 90 – 95 mph range, but none of southeast Louisiana, but Katrina continued to the urban areas experienced winds greater than pound Mississippi with wind and rain through- about 85 mph, as seen in Figure 4. out the day. Rainfall in southeast Louisiana due to Hurricane The hurricane had weakened significantly in the Katrina was moderate but not intense. The Na- hours before landfall. Officially, the National tional Hurricane Center estimates that 10-12 Hurricane Center designated Katrina as a Cate- inches of rain fell over the region (as shown in gory 3 hurricane when it made first landfall Figure 5), with 11.63 inches measured at a Na- along the Gulf Coast. However, ground-based tional Weather Service office in Slidell. This wind measurements do not generally substanti- amount of rainfall was about half of the amount ate this classification and the hurricane was most that fell during the May 1995 flood, yet is sim- likely a Category 2, with maximum sustained ilar to a 1978 rainstorm that dropped 10 inches winds of around 105 mph at landfall. For a on New Orleans and caused five deaths. The storm to be designated Category 3, its maxi- National Hurricane Center attributes 43 torna- Figure 4 – Maximum sustained surface wind con- mum sustained wind speeds must be greater does to Hurricane Katrina, but none of them oc- tours during Hurricane Katrina (in mph). than 110 mph. Some of the suburban and rural curred in Louisiana. Source: NOAA Hurricane Research Division

Petrochemical facility near Katrina landfall location that experienced serious wind and flooding damage, releasing products Figure 5 – Hurricane Katrina current conditions and forecast track on into the environment. Sunday morning, August 28 (one day before landfall). Photo Credit: LSU Hurricane Center/ Marc Levitan Source: National Hurricane Center

35 In Louisiana, a 17-foot surge inundated coastal wetlands southeast of New Orleans (in St. Bernard and Plaquemines Parishes). To the north of New Orleans, surge levels reached 9 feet in Lake Pontchartrain and to the east of the city, Lake Borgne filled with a 15-foot surge. Because of the configuration of levees along the Gulf In- tracoastal Waterway and the Mississippi River- Gulf Outlet that skirts Lake Borgne, an artificial storm surge funnel created a high-velocity surge pushing towards New Orleans. Surge waters moved at a speed of approximately 8 feet per sec- ond along this surge superhighway, where they entered the Inner Harbor Navigational Canal and quickly overwhelmed levees.

Hurricane Katrina’s storm surge inundated nu- merous Gulf Coast communities without levee protection and caused limited overtopping of levees around New Orleans. Although flood wa- ters caused by overtopping and rainfall would Figure 6 – Predicted storm surge elevations, above normal sea level, based on the Sunday night have caused damage to neighborhoods in New forecast several hours before landfall of Hurricane Katrina. Source: LSU Center for the Study of Public Health Impacts of Hurricanes Orleans, most of the floodwaters and the ensu- ing tragedy resulted from numerous breaches in the levee system. Along the southern shore of Hurricane Katrina’s storm surge was massive, storm made landfall along the Gulf Coast, its Lake Borgne, an earthen levee largely eroded very destructive, and deadly. Computer models storm surge stretched from LaPlace, Louisiana, away before it was overtopped. Closer to the predicted water elevations as high as 24 feet to Pensacola, Florida. Nearly 350 miles of coast- urban population of New Orleans, concrete above normal based on the National Hurricane line was inundated. The entire Mississippi Gulf floodwalls along the Inner Harbor Navigational Center’s forecast on Sunday evening (Figure 6). Coast experienced surge levels of at least 17 feet, Canal, the 17th Street Canal and the London Although the hurricane’s wind speeds dropped with a surge of over 24 feet inundating a 20 mile Avenue Outfall Canal gave way in numerous lo- as Katrina approached the coast, lessening wind swath of the Mississippi coast. A peak surge cations. For days after Katrina had passed damage, the storm surge did not similarly de- height of nearly 28 feet was measured near Bay through, floodwaters in New Orleans continued crease due to the inertia of the water. As the St. Louis, Mississippi. to rise as water flowed through these breaches.

36 In all, much of southeast Louisiana flooded ei- to the North and the Inner Harbor Navigational floodwalls. Figure 7 shows the estimated depth ther directly because of the surge, because of Canal to the east. North of St. Bernard Parish, of flooding in the New Orleans area, along with levee failures, or other causes. Southeast of New New Orleans East suffered moderate flooding, locations of the major levees, where they Orleans, Plaquemines Parish suffered the most as the surge overtopped levees at various points. breached, and recovery locations for deceased catastrophic flooding as surge waters overtopped On the north shore of Lake Pontchartrain, the victims. and breached levees on the east bank of the Mis- towns of Slidell, LaCombe, Mandeville, and sissippi, then crossed the river to overtop and Madisonville all suffered flooding directly from breach levees on the west bank. To the east of the surge in Lake Pontchartrain. To the west of New Orleans, St. Bernard Parish, along with the New Orleans, suburban Metairie and Kenner adjacent , suffered a two- flooded due to rainfall and backflow through fronted assault. Surge waters breached levees their drainage pipes. Finally, central New Or- and entered these areas both from Lake Borgne leans flooded from numerous breaches in its

Remains of a home near breached floodwall in New Orleans. The high velocity water com- pletely gutted the home. Photo Credit: LSU Hurricane Center / Ezra Boyd

Canal Street in New Orleans lives up to its name. Mode of transportation is still by boat nine days after Katrina. Photo Credit: LSU Hurricane Center / Paul Kemp

37 Plaquemines Parishes. Some of the people who stayed chose to stay behind, while others en- countered insurmountable obstacles to leaving.

Of the 130,000 that remained, approximately 65,000 had to be rescued from floodwaters. For many of these people, the initial rescue and transport to the nearest high ground was only a first step in the journey to safety. An untold number of people spent days and nights on highway overpasses and other locations, which, while above the floodwaters, still left people ex- posed to the elements and with limited food, water, and medical supplies. In the next rescue phase, many people were brought to crowded collection points at the Superdome, the Con- vention Center, the Louis Armstrong Airport, or the I-10/ Causeway Cloverleaf. An estimated

Figure 7 – Observed flood depths for the Greater New Orleans region. Map also shows locations of major levees, levee breaches, and deceased victim recovery locations. Note the concentration of victims in areas of deeper flooding (darker blue). Source: LSU Hurricane Center / Ezra Boyd

Impact on the General Population people in the region evacuated their homes, and over 60,000 people moved to the numerous Hurricane Katrina and the failures in the levee public shelters outside of the region. In spite of Search and rescue crews cut through thousands system caused considerable damage and disrup- the successes of the pre-storm evacuation, an es- of roofs looking for survivors, and later, storm tion to the people and infrastructure of south- timated 130,000 people remained in soon-to-be casualties. east Louisiana. Before landfall, over 1 million devastated Orleans, Jefferson, St. Bernard, and Photo Credit: LSU Hurricane Center / Ezra Boyd

38 100,000 people passed through these chaotic much of southeast Louisiana. Downed trees and collection points before being evacuated out of power lines blocked roads throughout the re- the region. An estimated 178,084 homes in gion, making delivery of essential commodities southeast Louisiana suffered flood damage, and difficult. Many hospitals in the areas were closed over 500,000 people were displaced from their and/or severely damaged, while those that re- homes for many months. By August 2008, an mained open suffered from a surge of patients estimated 160,000 pre-Katrina residents of New and a lack of staff. Businesses, both family- Orleans had not returned. owned and corporate, were shut down. And, many essential public services, including water Clearly, the human suffering was greatest where and sewerage, were unavailable. Numerous fires the flood conditions were worse; however, the raged through New Orleans and firefighters had area also suffered from a regional emergency that very little water pressure to adequately control extended well beyond the flooded areas. Power them. and communications were destroyed across

Top: New Orleans on August 31, 2005 - Local residents arrive at ramp to the Superdome after being rescued from their homes. New Orleans is being evacuated due to flooding caused by Hurricane Katrina. Photo Credit: FEMA / Jocelyn Augustino

Right: People standing on the overpasses and bridges to keep out of the New Orleans flood waters. Photo Credit: FEMA / Marty Bahamonde

39 steps to prepare. Most of these facilities simply The direct and immediate physical hazards of closed and encouraged employees to evacuate. Katrina included wind, rain, and storm surge. However, some facilities, specifically hospitals Like much of the city, health professionals on and nursing homes, faced more complex pre- storm duty around the city experienced initial paredness plans and decisions. relief when the city and their facility escaped the direct impact of the storm with minimal damage One of the most complex decisions faced by ad- and disruption. However, relief soon turned to ministrators in these facilities was the extent to dismay as flood waters rose around town and which they should shut down and evacuate pa- news of levee breaches spread. Soon, many hos- tients or residents. Nursing homes were faced pitals and nursing homes would become over- with the seemingly straightforward option of ei- whelmed, requiring immediate aid and rescue. ther sheltering-in-place or evacuating. Some Three hospitals in the region did remain open, a nursing home residents evacuated with their result of both previous mitigation efforts and Aerial view of extensive flooding in the Lower 9th families. Although the options were simple, the pure luck. Ward after Katrina. logistical challenges and risks involved were Photo Credit: LSU Hurricane Center / Ivor van Heerden highly complex. In comparison, hospital ad- As floodwaters surrounded these institutions, ministrators faced a more complex set of possi- power went out, supplies ran short, and calls for ble options. What patients should they rescue were sent. Inside the facilities, human Impact on the Medical Community discharge? What patients should be evacuated? misery and suffering began. In numerous hos- What patients can shelter-in-place? When does pitals, doctors, nurses, and others worked Like the general population, the medical com- the hospital quit accepting new patients? Can valiantly to protect patients without access to munity suffered from a wide range of over- the hospital remain functional throughout the life-saving and life-sustaining health care equip- whelming consequences because of Hurricane passage of the hurricane? Or, should it shut ment. Hand-operated bags replaced machine Katrina and the many failures in the flood pro- down and implement a complete evacuation? ventilators. Sadly, hours and days would pass tection system. These consequences began with What should be done to protect medical records, before their calls for rescue were answered. preparations for the storm, and they continue diagnostic equipment, and data servers? Given long into the recovery. This section describes this situation, these medical facilities imple- Outside of these flooded hospitals, human mis- some of these impacts. mented a wide range of preparedness plans. ery and suffering was widespread. An estimated 65,000 people were trapped in flooded homes During the roughly 42 hours between the first In total, one hospital in the region evacuated all and neighborhoods. Search and rescue teams forecast that predicted landfall near New Or- of its patients before landfall, as did 21 nursing clearly were overwhelmed by the numbers and leans and the onset of hazard conditions homes. It is worth noting that patients from the simply not equipped to handle the medical con- throughout the region, hospitals, clinics, nurs- evacuated hospital did not reach their destina- cerns of people who had been rescued from ing homes, physicians, and pharmacies all took tion before the hurricane reached the region. floodwaters. During this time of unprecedented

40 need for medical services, many hospitals were unable to accept patients.

Approximately 43 days after the passage of Hur- ricane Katrina, the floodwaters had receded, leaving the region and its healthcare system in shambles. Most of the hospitals that closed faced many difficulties in reopening. In addition to substantial damage to facilities, key personnel and essential services were not available. Doc- tors, nurses, technicians, and other support per- sonnel were no longer available in the Greater New Orleans area. Similarly, electricity, natural gas, sewerage and water, and other public serv- ices were interrupted.

A resident is transported by a FEMA Urban Search and Rescue Team away from her house, which she was unable to vacate due to Hurricane Katrina. Photo Credit: FEMA / Jocelyn Augustino

In the months that followed, the availability of the burden fell on the emergency departments health care services would remain an important of the three hospitals that remained open. This issue impacting recovery. As people returned to burden proved to be overwhelming. For many rebuild, doctors did not return. Few hospital months, the demand at the three emergency de- beds were available. Various clinics run by gov- partments exceeded the capabilities of these fa- Flooding persists in New Orleans 10 days after ernment agencies, non-profits, and private cor- cilities with a detrimental impact on service. Katrina. porations filled some of this void, but much of Photo Credit: FEMA / Michael Rieger

41

Hurricane Katrina: Chapter 4 Health Outcomes and the Medical Response

he health outcomes associated with Hurricane Katrina’s impact on Louisiana spread across both Tspace and time. The negative health outcomes are concentrated greatest in the most heavily impacted re- gions and during the first days after the passage of the hur- ricane. However, adverse outcomes have been observed many miles and months away from the extreme hurricane winds and the catastrophic flood waters. The first part of this chapter divides health outcomes into four categories: 1) direct morbidity and mortality, 2) morbidity and mor-

Opposit left: tality associated with displacement, 3) disruption of med- One of the thousands of elderly residents ical services, and 4) emergent effects associated with evacuated from the city, being wheeled from the evacuation helicopter to the triage area set up in- exposure to various hazards. A second section of the chap- side the New Orleans Airport. Photo Credit: FEMA / Win Henderson ter will describe the medical response.

43 Direct Morbidity and Mortality lack of safe drinking water, lack of medical serv- ices, breakdown of law and order, and many Morbidity and mortality information associated other consequences of this regional emergency. with Katrina over a period of 4-6 weeks after In addition, an estimated 2,500 patients re- landfall are used to explain the storm’s direct ef- mained in hospitals that had lost power, lacked fects (See statistical data in Appendix A). Many supplies and staff, while flood waters and anar- people died or suffered injuries from exposure chy surrounded their facilities. Additionally dis- to wind, water, windborne debris, and water- persed among the 130,000 people were borne debris. Geographically speaking, signifi- numerous independently living persons with cant wind damage occurred throughout special needs, such as dialysis, oxygen, mental southeast Louisiana and flooding was wide- health, and heart medications, in addition to spread but restricted to particular areas. While medical needs resulting from injuries or illness the winds died down quickly, some areas re- from the wind and water. Throughout the re- mained flooded for over five weeks after the pas- gion, the public health situation deteriorated sage of Hurricane Katrina. Many ongoing drastically, causing various types of morbidity hazards resulted from the extensive wind and and mortality. flood damage. Cleaning up the debris was a haz- ardous activity, including all of the debris strewn across roads that created traffic hazards. Nu- merous tree limbs were left dangling, some of which would later fall on residents and relief workers causing both injuries and deaths. Rusty and contaminated flood debris caused infections in both residents and relief workers. As Katrina’s floodwaters climbed higher, residents of one story structures were forced to retreat into In addition to the physical hazards resulting attics, where many died from exposure. from the storm’s wind, flood waters and debris, Photo Credit: LSU Hurricane Center / Ezra Boyd Katrina left in its wake a regional public health emergency along with widespread breakdowns in the public safety infrastructure. This situa- tion would cause deaths and injuries during the days and weeks after the windstorm had passed. Search and rescue markings indicate one body In the four parish region around New Orleans, found in this New Orleans house after Katrina. a general population of 130,000 experienced a Photo credit: LSU Hurricane Center/Ezra Boyd

44 Approximately ten days after Hurricane Katrina Displacement from Home, Social Net- passed, nearly all of the general population and work, Providers and Medical History all endangered hospitals had been evacuated, and the regional emergency moved into the The first three deaths associated with Hurricane cleanup and initial recovery phase. There were Katrina’s impact on Louisiana were three nursing a number of the identified hazards still present, home patients who died due to circumstances but the exposed population was smaller and related to displacement from their residence. qualitatively different since most of the residents These individuals evacuated with fellow residents were gone. At the completion of the evacuation and their social support network, along with operations, an estimated 10,000 people re- health providers and the residents’ medical his- mained in Orleans Parish, a combination of es- tories. For these three elderly residents, simple sential city workers and emergency response displacement from their residences proved officials from the state and federal government, deadly. private and government relief workers, and a People sitting on a roof waiting to be rescued as handful of diehard residents who disobeyed flood water surround their New Orleans home. An estimated 1 million people evacuated and mandatory evacuation orders. By the end of Photo Credit: FEMA / Jocelyn Augustino were displaced from their homes for at least a September, residents of some zip codes in Or- few days. For an estimated 500,000 residents, leans Parish were allowed to return, though MMWR, 2006). Of these, it is estimated that cleanup and initial recovery activities continued approximately 500 persons died as a result of ex- around them. Throughout the clean-up period, posure to floodwaters, while an additional 500 deaths and injuries occurred as a result of wind, people died of circumstances related to the wide- water, debris, and destruction. spread public health emergency that followed the hurricane and flooding. In Louisiana, the State Medical Examiner’s Of- fice (SMEO) was responsible for the mission of As part of its medical response to the catastro- recovering, examining, and identifying the de- phe, the Centers for Disease Control (CDC) ceased, along with providing information on the worked with state health agencies, hospitals, and deceased to the public. Operationally, a de- emergency response teams to implement nu- ceased person was considered hurricane related if merous morbidity and mortality surveillance they died between August 28 and October 1, systems. These surveillance systems provided 2005, and the circumstances of death were con- various types of information on the morbidity sidered related to the hurricane’s impact on and mortality associated with Hurricane Katrina Thousands of patient medical records were Louisiana (as determined by the SMEO). Offi- (see Appendix A, Morbidity and Mortality Out- damaged or destroyed. cially, 1,464 victims met these criteria (CDC, comes from Hurricane Katrina). Photo Credit: Floyd A. Buras, MD

45 providers and were forced to identify new providers who had to construct new medical his- tories. Previously managed chronic conditions became unmanageable when individuals became displaced from their medical providers, their pharmacies, and their health records.

Among the victims considered hurricane related by the SMEO, an estimated 500 deaths occurred after the person had evacuated from the hurri- cane impacted area. Approximately 150 of these deaths occurred inside Louisiana and 350 oc- curred outside of the state.

Disruption of Medical Services

The widespread and catastrophic disruption of Many medical offices were destroyed, leaving patients to find new providers in unknown environments. medical services also resulted in numerous ad- Photo Credit: Floyd A. Buras, MD verse health outcomes linked to the disaster. Healthcare facilities suffered damage that ranged from minor wind damage to flood waters that damage to their home and/or parish meant that For some, even these tasks coupled with the new destroyed any equipment located below the the temporary evacuation would be followed by living environment and housing situation cre- flood line. Regardless of the level of damage, all extended displacement. As noted above, some ated conditions conducive to injury and death. hospitals in the heavily impacted region lost mu- residents of Orleans and Jefferson Parishes were In Houston, one toddler drowned in the bath- nicipal services such as water and electricity. allowed to return home by the end of Septem- room of the family’s FEMA sponsored hotel Many faced disrupted delivery of key medica- ber. However, for many hundreds of thousands, room. Although not a direct impact of Hurri- tions and supplies. Communication lines went displacement would last many months and cane Katrina, the circumstances of this death are down. Medical facilities lost staff and were un- years. clearly linked with displacement due to the dis- able to locate others to come into work. Over aster. the short-term, blocked roads, poor communi- In general, displacement involved setting up a cation, and gas shortages kept doctors and new life in an unknown environment. Many Other displaced residents faced more daunting nurses from reporting to work. Over the long people set about the basic tasks of finding hous- tasks as so many people evacuated without their term, the lack of housing along with the gener- ing, employment, and schooling for children. medical records, lost contact with their medical ally dismal prospects for the region’s future

46 prompted many health care professionals to re- most of the population, hurricane damage to of the Lower Ninth Ward were even allowed to locate permanently from the area. The shortage their parish and possibly their home was cata- see their homes. When they did, they found a of medical professionals has become an ongoing strophic. Their evacuation became short-term destroyed neighborhood with debris everywhere, recovery challenge. displacement. Their stress intensified as they cars, boats, and homes tossed around yards and worried about their homes, processed the lim- streets, and a thick layer of dried flood muck Many hospitals faced an additional loss as cen- ited, often inaccurate information that became covering the first floors of their homes. An esti- tralized computer servers were completely un- available, and contemplated the uncertain fu- mated 400,000 individuals returned to flood workable. Over the short term, this loss left ture. damaged residences in the three years that have doctors and nurses largely in the dark while try- followed. Even though the return process oc- ing to treat remaining patients. Over the long Of the estimated 130,000 people who did not curred in stages and spanned many months, term, the lost computer systems resulted in hos- leave Greater New Orleans before Katrina, ap- with varying individual responses, this initial as- pitals facing numerous challenges in restoring proximately 65,000 experienced exposure to sessment of their flood damaged homes and services. Hospitals that lost their centralized sys- flood waters, followed by rescue. Many tens of communities was undoubtedly a traumatic ex- tems were unable to reopen quickly. thousands of people spent the night on highways perience that was repeated by hundreds of thou- and bridges, and another 100,000 people expe- sands of people. Emergent Effects of Exposure to Hazards rienced horrible conditions in the four emer- gency shelters. For this large population that As the acute emergency gave way to long term directly experienced the storm and its aftermath, recovery, a number of health issues and concerns stress and trauma was most certainly a prevalent emerged. A large population suffered from the health concern. stress and trauma of the event and their personal losses. Rescue and recovery activities, which were For the displaced population, returning home inherently dangerous, also involved exposure to was a process that occurred in stages and persistent toxic substances. Numerous adverse spanned many months. Some were able to health outcomes unfolded and will continue to begin this process quickly, while others would unfold for many years. have to wait months. Jefferson Parish, which suffered only moderate flood damage, was al- At the very least, the pre-storm evacuation was a lowed back in for a “look and leave” about one stressful experience for the over 1 million people week post-Katrina. This policy allowed residents A resident of Chalmette, Louisiana, walks through that evacuated. For a lucky few, actual hurricane to make day visits to assess damage and secure the front of her damaged home. There is mold damage was minimal to their residence and their property. Many residents in Jefferson growing on all the walls and furniture. She and community, and they were able to quickly re- Parish were allowed to re-inhabit their homes her family were trying to salvage personal items turn home, experiencing only limited stress, within a few weeks. In contrast, weeks would from their home which was flooded during pass before residents of the most devastated parts Hurricane Katrina six weeks earlier. with a quick return to normalcy. However, for Photo Credit: FEMA / Patsy Lynch

47 In addition to this stress and trauma, residents As part of the federal response to the housing and relief workers experienced exposure to a va- crisis created by Hurricane Katrina, FEMA pro- riety of environmental health concerns. Rashes vided an estimated 50,000 travel trailers as tem- and other symptoms were observed on thou- porary housing to impacted residents in sands of residents and rescue workers that swam Louisiana. Initially considered a blessing to res- and waded through contaminated flood waters. idents who had endured crammed shelters, these In some places, emergency response teams iden- trailers eventually caused many health concerns tified locations where unknown chemicals had over the long term. Some of the trailer models mixed with flood waters. LSU researchers con- relied on propane gas for heating and cooking. ducted extensive testing for chemical and mi- Propane explosions resulted in deaths among crobiological contaminants in the flood waters hurricane survivors. Some of the trailers were in different regions of New Orleans. A report set up in group sites, often resulting in survivors Flooded gas station next to the Medical School. of this seminal work is summarized by Pardue et living in isolated locations where they lacked ac- Most of the many gas stations that flooded were al. (2005). In many areas, chemical and cess to education, employment, health care, and nearly out of fuel due to pre-storm evacuation pathogen concentrations were similar to those social services. Finally, after FEMA initially de- traffic, reducing contamination of floodwaters. typically found in urban storm water runoff, be- nied reports on concerns related to formalde- Photo Credit: LSU Hurricane Center / Marc Levitan cause the larger amounts of contaminants were hyde in travel trailers, congressional hearings in offset by the sheer volume of water. September 2007 revealed that many residents experienced formaldehyde exposure over an ex- In the immediate aftermath, water quality and tended period of time. The exact health effects food safety were crucial concerns. Damages to of formaldehyde exposure are unknown, but municipal water and sewerage networks were many tens of thousands may face increased can- catastrophic. Once the waters receded, mold- cer risks due to the exposure. infested structures posed a threat to individuals engaged in clean-up activities. The New Orleans health department estimated 2,300 excess deaths among the residents of the As the recovery went forward, soil samples found New Orleans during the first six months of 2006 arsenic, lead, and various other contaminants based on their review of obituaries from The throughout the flood impacted area. In St. Times-Picayune. Data from the first months of Bernard Parish, petroleum oil mixed with flood 2004 was used as a baseline. waters after a pipe on a storage tank ruptured. Some New Orleans residents were still out Homes in this neighborhood suffered additional foraging through floodwaters for supplies a week and a half after the hurricane. pollution from oil mixed with water, which con- Photo Credit: LSU Hurricane Center / Marc Levitan taminated the buildings and the soil.

48 To prepare for the storm, hospitals cancelled elective surgeries and discharged the patients that could leave. They called staff for storm duty, checked their supplies, and prepared to shelter on site. One hospital did evacuate from the New Orleans area. However, they did not reach their destination before the storm arrived and the patients rode out the storm while in transit. Another hospital, hoping for the best but antic- ipating the worst, began planning for a possible post-hurricane evacuation. Nursing homes dis- charged residents who could evacuate with fam- ily, then faced the complex choice of evacuating the facility or sheltering on site. Nineteen nurs- ing homes evacuated before the storm and 34 did not.

Researchers from the Louisiana Water Resources Research Institute and LSU Hurricane Center sampling and testing floodwaters for contaminants in the medical district, under the watchful eye of LSU Police, which provided security. Photo Credit: LSU Hurricane Center / Marc Levitan

Medical Response berculosis clinics, dialysis centers, outpatient clinics, and related health care facilities simply The National Hurricane Center’s Advisory #15, canceled services, secured the facility, updated released on Friday, August 26th at 10:00 p.m. emergency contact lists, and encouraged em- Black mud residue on the ground in St. Bernard local time, marks the start of the medical re- ployees to evacuate. Hospitals and nursing Parish, after oil contaminated floodwaters receded. sponse to Hurricane Katrina. Less than 45 homes, with extremely vulnerable persons under The flood depth in this neighborhood was slightly hours later, hazard conditions started to impact their care, faced more difficult decisions. In gen- higher than the roof eave height. The cars floated the region. Across the region identified by Advi- eral, the practice was for hospitals to remain in the flood, and then the wind pushed them back sory #15, health related facilities implemented open and for nursing homes to evacuate only as up against the houses. As the water receded, the a last resort. cars got hung up on roofs and fences. their preparedness plans. Most pharmacies, tu- Photo Credit: LSU Hurricane Center / Marc Levitan

49 In comparison, hospital administrators faced a Parish, the health department established a spe- more complex set of possible options. Cancel- cial-needs shelter in the Superdome and the re- ing all elective surgeries was one simple solution. gional transit agency dispatched buses to But, what patients could be discharged? What pick-up points throughout Orleans Parish. Sim- patients should the hospital evacuate out of the ilarly, local health departments throughout the region? What patients could shelter-in-place? region instituted plans to provide for special- When does the hospital quit accepting new pa- needs residents. DHH provided assistance to tients? Can the hospital remain functional the locally run special needs shelters and opened throughout the passage of the hurricane? Or, seven additional special-needs shelters through- should it shut down and implement a complete out the state. evacuation? What should be done to protect medical records, diagnostic equipment, and data In general, special needs persons did not receive servers? Given this situation and the lack of transportation assistance out of the region. Baton Rouge, Louisiana, on Sepember 3, 2005 -- standardized guidelines, it should be no surprise Local governments largely used their trans- Cots at the LSU Field House await evacuees of that a wide range of preparedness plans were ob- portation assets to move special needs persons to Hurricane Katrina. This is a special needs shelter served. refuge within the parish. However, a few excep- for those with disabilities, senior citizens, and tions are noteworthy. In areas under mandatory people seeking medical attention. In an attempt to prepare for the coming crisis, evacuation, DHH maintained an adolescent Photo Credit: FEMA / Liz Roll the Louisiana Hospital Association (LHA) and care home, a residence for persons with devel- the Louisiana Nursing Home Association opmental disorders and a mental health hospital. For these facilities, the evacuation decision was (LNHA) canvassed their member institutions in All of these facilities were evacuated completely complex and lacked clear solutions. Nursing the region for a status check, including infor- by DHH before Katrina hit. In St. Bernard homes, with a relatively homogenous popula- mation about generators, fuel supplies, medical Parish, administrators of an inpatient, chronic tion, were faced with the seemingly straightfor- supplies, and water sources. Once gathered, this care facility for elderly residents moved their res- ward options of either sheltering-in-place or information was passed on to the Department idents to what they believed was the relative evacuating. The options appeared simple and of Health and Hospitals (DHH) and the state safety of Memorial Hospital in Orleans Parish. evacuation appeared to be the straightforward emergency operations center. In Orleans Parish, city owned transit buses and choice, but the logistical challenges and risks in- state chartered ambulances were used to evacu- volved in evacuating elderly and frail residents As hospitals and nursing homes addressed their ate 500 patients from the special-needs shelter were highly complex. This prompted many problems, local and state health departments in the Superdome to the special-needs shelter at nursing home administrators to make the deci- began setting up special-needs shelters for per- LSU in Baton Rouge. In spite of these special- sion to shelter on site and prepare to care for sons among the general, non-institutionalized needs evacuation efforts, an additional 500 pa- their residents through the passage of the hurri- population that would require medical attention tients remained in the special-needs shelter in cane. during the passage of the hurricane. In Orleans the Superdome, and many hundreds more re-

50 mained in their homes, businesses, and churches New Orleans Arena. The state continued to throughout the region that would be hit the provide services, mostly chronic disease man- hardest. agement, to the patients that arrived before Ka- trina’s landfall, but they also began receiving Anticipating the catastrophe to come, the state people from the growing crowd in the Super- began the process of obtaining external assis- dome. Search and rescue teams provided lim- tance during the preparatory period. On Sun- ited first aid but were not capable of handling day, the day before Katrina’s landfall, DHH the variety of injuries and other illnesses that requested activation of the strategic national were presented. State health workers set up an stockpile, a large cache of various medications aid station at the interstate I-10 /I-610 split to maintained by CDC. The state also requested service flood rescues and to begin using the few that the DHH begin staging Disaster Medical available ambulances to evacuate the most severe cases to Baton Rouge. The single DMAT ini- Assistance Teams (DMATs) along with other Waiting for transportation at the I-10/I-610 possible medical response capabilities. tially deployed to the Superdome quickly be- interchange. came overwhelmed. Photo Credit: LSU Hurricane Center / Marc Levitan Initial Response to Public Health Emergency As the patient population at the Superdome gion included thousands of diabetics and peo- grew, additional medical emergencies developed ple requiring dialysis treatment, oxygen tanks, Hurricane Katrina reduced the local medical ca- at 25 hospitals, which collectively held 2,500 pa- and numerous medications. Additionally, the pabilities to nearly zero. Wind damage and the tients and 11,000 staff and family members. storm and flood caused numerous injuries re- loss of crucial services affected all hospitals. Some hospitals become de-facto refuges for res- quiring care, including the persons suffering Many hospitals were crippled by extensive flood- idents flooded out of their homes. Another 34 from stress and trauma. With medical capabil- ing. In hospitals throughout the region, the cen- nursing homes held hundreds of elderly resi- ities limited and overwhelmed, the number of tralized computer systems began to falter, dents and required emergency assistance. With people with medical needs grew. rendering diagnostic equipment, electronic the 65,000 persons requiring rescue from flood- records, and telecommunications unavailable. waters, along with the growing population in During the initial response, external medical as- Three hospitals remained open, but they were emergency shelters, hospitals and nursing homes sistance was almost non-existent. One DMAT overwhelmed with the needs of their own pa- were not the priority of the available response reached the Superdome late on the evening of tients and largely unable to provide assistance to teams. August 29, the day of landfall. Three others ar- others. rived days later. The strategic national stockpile Among the general population suffering the di- of medical assistance never arrived in Louisiana. As conditions in the Superdome deteriorated, rect effects of the disaster were many individuals State assets were deployed, but they were com- the special-needs clinic run by state and local with chronic health issues. The 130,000 people pletely insufficient for the magnitude of the health officials was relocated to the neighboring scattered throughout the heavily impacted re- emergency.

51 On Tuesday, August 30, the day after Hurricane Katrina made landfall, federal officials activated the medical evacuation mission of the National Disaster Medical System (NDMS). The Louis Armstrong Airport, located about 10 miles west of the Superdome, was designated as the med- ical evacuation collection point/triage center. DMAT teams at the airport would triage pa- tients and then load them onto Air Force aircraft that would deliver them to receiving hospitals. However, getting patients from hospitals and nursing homes to this location was difficult.

Among the 25 hospitals that evacuated post-Ka- trina, a variety of approaches were utilized to evacuate patients, staff, and family. The Veterans Administration Hospital, as part of the Depart- ment of Defense (DOD), was able to access DOD helicopters and other assets for evacuat- ing patients. Tulane Hospital reached out to the Thousands of victims plucked from the floodwaters left behind by Hurricane Katrina await evacuation Association of Air Medical Services, which was out of the city following their rescue. Hundreds of buses worked throughout the day and night to carry able to supply privately owned air ambulances these people to safe shelter. to Tulane. Additional air evacuations were per- Photo Credit: FEMA / Win Henderson formed by Acadian Ambulance, a Louisiana am- bulance company that possessed a small number Early Aftermath had clinics, though they were understaffed, un- of medical helicopters. However, many hospi- derequipped, undersupplied, and suffered from tals lacked their own capabilities to evacuate pa- As search and rescue operations were completed, a lack of management and support. At the Con- tients and had to rely on the Louisiana an estimated 100,000 people were spread across vention Center, an estimated 19,000 residents Department of Wildlife and Fisheries, the four emergency shelters/collection points. These took refuge, but there was no organized medical Louisiana National Guard, or the US Coast locations would soon serve as evacuation hubs. response to serve these people. As conditions in Guard to transport patients from the hospital to A variety of health conditions, both old and new, hospitals continued to deteriorate, administra- the medical evacuation point at the airport. As were present among the displaced population in tors made the decision to evacuate and began to time went on, an estimated 3,000 persons with New Orleans. Three of these collection points send out calls for assistance. medical conditions along with an additional

52 23,000 residents without medical conditions ar- assured their transportation and admission to without assistance from NDMS. To meet the rived at the Superdome. the receiving hospital. In all, an estimated 3,000 needs of these people, Temporary Medical and medical evacuations took place at the airport. Operations Staging Areas (TMOSAs) and surge The medical evacuation component of NDMS hospitals were set up throughout Louisiana. utilized pre-selected reception hospitals that had Not everyone with medical needs was brought agreed to provide open beds to patients who had to this collection point. Some wound up among Transitional Period been evacuated from their facilities. Once the the general population on evacuation buses; oth- patient arrived at the collection point, NDMS ers were evacuated directly out of the region For the many thousands of displaced persons with medical needs, arrival at a TMOSA or the NDMS collection point marked an important transition point. Having been evacuated from the widespread public health emergency in greater New Orleans, over 4,000 patients needed a new medical care community. As noted above, NDMS relied on prearranged agreements with hospitals to supply their open beds. For others, finding their new medical care community was a much more daunting task.

Health workers at the two TMOSAs triaged an estimated 60,000 persons that had been evacu- ated out of New Orleans. Many of these people were deemed healthy and put back on evacua- tion buses that delivered them to shelters both inside and outside of Louisiana. For others, triage doctors determined whether medical con- ditions existed that required treatment. For these patients, available local hospital beds were utilized and when these filled up, DHH set up surge hospitals. Additionally, the TMOSA sys- tem did not detect every evacuee with medical needs, and it became necessary to setup health Survivors of Hurricane Katrina arrive at airport where FEMA's D-MAT teams have set up a medical hospital and where people will be flown to shelters in other states. clinics at the shelters. The “Katrina Clinic” set Photo Credit: FEMA / Michael Rieger up in Houston’s Reliant Arena, was the largest

53 such clinic. At this clinic, the doctors provided and providers scattered across the country, basic medical treatment, including tetanus shots Louisiana health officials found themselves ad- and prescription drugs, to an estimated 10,000 ministering a “National Medicare program.” evacuees. With most hospitals closed and the three open hospitals overwhelmed, New Orleans lacked the Whether in a traditional hospital, a surge hospi- medical care capabilities to meet the needs of re- tal, or in a clinic at a shelter, health care covery workers and residents eager to cleanup providers assisting evacuees all faced a similar and rebuild. Temporary clinics were the only so- challenge: new patients arrived without medical lution. The LSU Health Sciences Center, the records or even knowledge of their exact pre- organization that administered Charity Hospi- scription medications. Lacking detailed medical tal and its Level 1 Trauma Center, set up a lim- histories, care providers reconstructed diagnosis ited emergency care clinic. In December 2005, and treatment from the information supplied by this clinic saw over 4,500 patients. As time went the patient. on, LSU and other government agencies and non-governmental organizations would set up Long-Term Recovery basic clinics.

Patients are loaded on C-130's for evacuation For long-term recovery, the medical response in- Reopening closed hospitals was a difficult task, from the New Orleans airport on September 2, volved two sets of activities. In New Orleans, yet progress was made on this front over many 2005. Photo Credit: FEMA / Michael Rieger the medical response focused on rebuilding the months. By April 2006, approximately six local medical capabilities. Outside of New Or- months after Hurricane Katrina passed, six of leans, the medical response focused on providing the closed hospitals in Greater New Orleans had health services to displaced residents. reopened and seven remained closed. In total, nine open facilities provided 1,678 staffed beds; Medicaid was a primary vehicle for providing 1,583 of which were constantly occupied. services to residents displaced by Hurricane Ka- trina. In addition to arranging services for pre- At the start of 2009, over three years after Hur- enrolled beneficiaries, Louisiana health officials ricane Katrina hit southeast Louisiana, a number urged Congress to expand eligibility to include of ongoing medical needs remain. Plans to build a category of temporary beneficiaries. Congress a new Charity Hospital, adjacent to a VA hospi- allocated $2 billion to provide services to both tal, are moving forward. However, obstacles re- existing and new beneficiaries, along with funds One of the thousands of elderly residents main, and it will be some time before this facility evacuated from the city, being wheeled from the to pay providers for uncompensated care associ- reopens, if at all. The need to restore acute care evacuation helicopter to the triage area set up ated with the disaster. With both beneficiaries facilities is perhaps the greatest in New Orleans inside the New Orleans airport. Photo Credit: FEMA / Win Henderson

54 East and in St. Bernard Parish. Each parish had professionals at these locations to provide care a pre-Katrina population of approximately without support or supplies. Third, throughout 60,000 residents. Each parish lost their only hos- the nation, patients arrived at hospitals and shel- pital. Now each parish has a population of ap- ters with limited understanding of their diagno- proximately 40,000 people and both areas lack a sis or treatment. Medical professionals at these hospital. Residents must rely on small clinics run host locations worked diligently to re-establish out of modular buildings. Plans to reopen hos- medical care and medical histories. Finally, for pitals in these areas are just getting started. Ad- both individuals from the impacted area and in- ditionally, there is still a huge need for mental dividuals throughout the nation, the recovery health providers and medical specialists. tasks in southeast Louisiana represented a unique chance to make a difference. The many medical professionals who have endured the lack Thousands of displaced New Orleans residents Exemplary Medical Service were sheltered at Reliant Arena in Houston. In of adequate housing, the debris strewn neigh- this photo, a volunteer from Houston helps an The Katrina catastrophe has been described as borhoods, the limited services and the uncertain evacuee move her belongings. both the “largest disaster in recent American his- long-term prospects so they could remain in Photo Credit: FEMA / Ed Edahl tory” and as a “failure of all levels of govern- their communities to help re-build, continue to ment.” During the darkest days and months suffer within a disrupted medical infrastructure after Katrina, widespread human suffering was and continue to make a difference in the recov- met with bureaucratic failure. Often lacking re- ery of the New Orleans area. sources and leadership, medical professionals emerged as the unsung heroes of the disaster. Throughout the ordeal, there were four particu- lar areas where health professionals made sig- nificant contributions. First, the doctors, nurses, administrators, and other professionals who stayed behind to work disaster rotations in hos- pitals endured horrible conditions for extended periods. Through the dedication, determina- A Medical Corps person aboard the USNS tion, persistence, and inventiveness of these pro- Comfort, a 1,000 bed hospital ship now docked fessionals, many lives were saved. Secondly, with in New Orleans to provide medical backup health care infrastructure destroyed and in the support to the city, prepares an oxygen delivery face of widespread suffering, numerous tempo- system for use by the next patient admitted with Disinterred coffins - just one more problem to a respiratory ailment. rary clinics provided life saving care to many deal with after Hurricane Katrina. Photo Credit: FEMA / Win Henderson people. It was not uncommon for the medical Photo credit: LSU Hurricane Center / Ezra Boyd

55

Hurricane Rita: Preparation, Impact, and Response of the Medical Community

ust weeks after Hurricane Katrina decimated south- Chapter 5 east Louisiana, record setting Hurricane Rita made Jlandfall on the southwest end of the state, causing considerable impact across the entire Louisiana coastline. In southwest Louisiana, the Lake Charles metropolitan area was heavily impacted by both the surge and wind of Hurricane Rita. In south central Louisiana, the Houma- Thibodaux region experienced considerable flooding, and even some parts of southeast Louisiana flooded a second time. Louisiana, still in the emergency response mode for Hurricane Katrina, now faced a new potential catastro- phe. Thousands of residents displaced by Hurricane Ka- trina were now being forced to flee a hurricane once again. These evacuees added to the millions of people leaving southwest Louisiana and southeast Texas. Although, com- parable to Katrina in intensity, Hurricane Rita’s damage and deaths were much less than Katrina. The difference in impact from the two storms can be attributed to a num- Opposite left: ber of factors, including different geographies and physi- Satellite image of Hurricane Rita approaching southwest Louisiana. cal vulnerabilities, different populations, and different Source: NOAA emergency preparedness steps or strategies.

57 about 30 miles from the coast, with widespread are sand ridges about 5 – 10 feet above sea level, marsh truncated with Chenier Ridges toward surrounded by marshland, swamps, and lakes. the coast. Like the delta in southeast Louisiana, Unlike southeast Louisiana, the landscape of the Chenier Ridges are believed to be landforms southwest Louisiana did not possess the same ex- that were created from deposited sediment. It is tensive system of levees and other flood protec- believed that longshore currents running paral- tion structures. Southwest Louisiana largely lel to the coast and toward the west carried sed- reflects the concentration of population on the iment from the Mississippi and Atchafalaya terrace, relatively distant from the coastline. The Rivers to the west. Then, the Gulf waves de- result is that the southwest Louisiana population posited the sediment along the coastline to build enjoys the relative safety of elevation and dis- new landforms. Over thousands of years, this tance from the Gulf of Mexico. However, it lacks An EMT takes a nap while waiting pre deploy- process resulted in the Chenier Ridges, which the levees and other flood protection means to ment in response to Hurricane Rita. Long and un- predictable hours at work and on call necessitate sleeping whenever possible. Photo Credit: FEMA / Ed Edahl

Physical Hazards and the Vulnerability of Southwest Louisiana

Southwest and south central Louisiana experi- enced similar meteorological hazards as south- east Louisiana. In particular, both regions are exposed to hurricanes and their extreme tidal surges, waves, rains, and winds. However, ge- ography and settlement patterns meant that the vulnerability of the population within this re- gion of the state was much different than the vulnerability of the population impacted by Hurricane Katrina.

Southeast Louisiana sits on the deltaic plain of the Mississippi River, and the geography of Figure 8 – Map of south central and southwest Louisiana and southeast Texas. southwest Louisiana consists of terrace highlands Source: LSU Hurricane Center

58 Population of Southwestern Louisiana

In addition to the differences in the landscape and settlement patterns, the two areas differ in terms of the vulnerability of their population. The pre-Katrina New Orleans metropolitan re- gion included over 1.1 million people in the 2000 Census. Only 193,000 people inhabit the Lake Charles metropolitan area. The city of Lake Charles serves as the population and eco- nomic center of southwest Louisiana (see Figure 8). In 2000, an estimated 70,000 people lived in the city of Lake Charles. Another 110,000 peo- ple inhabited the rest of Calcasieu Parish, the southern edge of which is about 20 miles from the coast. Only about 10,000 people lived in the pre-Rita coastal parish of Cameron. South of the urban center of Lake Charles, the rural settlements of Creole, Cameron, and Grand Chenier exist on the narrow Chenier Ridges. Pre- Rita Holly Beach, also known as the Cajun Riviera, consisted of a small beachside commu- nity of elevated homes, many of which were va- cation homes.

The population within these two areas of the Figure 9 – Hurricane Rita current conditions and forecast track on Thursday morning, September 22. The state also varies in physical well-being and so- storm made landfall two days later, east of the forecast track at the Texas/Louisiana border, placing south- cioeconomic indicators. The pre-Katrina New west Louisiana in the most dangerous right front quadrant of the hurricane. Orleans metropolitan area was home to approx- Source: National Hurricane Center imately 183,000 persons with disabilities, and the number of disabled people in the pre-Rita limit their exposure to storms with sufficient in- storm surge over the ridges, resulting in 400 - Lake Charles metropolitan area was only about tensity to push the surge over the ridges. In 500 deaths and destroying nearly 90% of all 42,000. Similarly, the New Orleans metropoli- 1957, pushed a monster buildings along the coastal area. tan area contained 147,224 persons over 65, as

59 cane before making landfall along the Texas / Louisiana border with estimated sustained wind speeds of 115 mph. In terms of ground based One difference between Hurricanes Katrina and Rita is wind measurements, the highest recorded sus- tained wind speed in Louisiana was 76 mph at seen in the level of federal assistance provided during the Lake Charles Calcasieu Parish Agriculture the preparatory stage. Center. In Lake Charles, sustained wind speeds reached 58 mph. Gusts reached 95 mph and 74 mph at those two locations respectively.

By Friday morning, mandatory evacuation or- compared to the 22,120 persons over 65 in the Thus, the people most impacted by Hurricane ders had been enacted for Calcasieu and Lake Charles metropolitan area. In the New Or- Rita had fewer risk factors than those most af- Cameron Parishes along with all of Jefferson leans area, 67,000 households lacked access to a fected by Hurricane Katrina. Davis Parish and southern portions of Vermil- vehicle, compared to less than 7,000 for the lion, St. Mary, Acadia, and Iberia Parishes. Lake Charles area (US Census, 2000). Physical Impact Nearly 10,000 displaced persons from Katrina being sheltered south of Interstate 10 joined the Although located over 150 miles from where the Hurricane Rita entered the Gulf of Mexico, due nearly 250,000 residents under evacuation or- eye of Rita made landfall, the coastal parishes of south of the , early in the morning ders because of Rita. One difference between Terrebonne and Lafourche also experienced the of Tuesday, September 20, 2005. Initially, it was Hurricanes Katrina and Rita is seen in the level impact of Hurricane Rita. Centered on the forecast to travel mostly due west and make of federal assistance provided during the Houma-Thibodaux metropolitan region, these landfall somewhere along the central Texas coast. preparatory stage. During the preparatory phase two parishes had a population of approximately By Wednesday morning, the National Hurricane before Hurricane Katrina, the activities of 195,000 residents. Located southwest of New Center Rita Advisory #16 placed southwest FEMA and other federal agencies were essen- Orleans, these parishes largely consist of coastal Louisiana within the cone of uncertainty, indi- tially limited to pre-staging assets and com- wetlands that are part of the Mississippi deltaic cating significant probability that it would make modities for quick deployment following the plain, along with a handful of bayous accompa- landfall there, though the landfall was expected landfall of the hurricane. However, federal assis- nied by elevated ridges. For the most part, these almost four days later. By Thursday, the pre- tance was provided during the evacuation prior parishes lack protection from hurricane storm dicted landfall location had moved closer to the to Hurricane Rita. Instead of opening shelters in surges. Within these two parishes, there were Texas / Louisiana border and reached Category flood risk areas, the state provided nearly 1000 approximately 35,000 people with disabilities, 5 status on the Saffir-Simpson scale, the most in- buses to assist those without access to personal nearly 25,000 people over 65 years of age, and tense category (see Figure 9). Governor Blanco transportation. In contrast to the preparations less than 7,000 households without access to a declared a for Louisiana. for Hurricane Katrina, shelters were not pro- vehicle. Hurricane Rita weakened to a Category 3 hurri- vided in the areas potentially flooded by Rita, which included everything south of Interstate

60 10. By the time Rita arrived, near 100% com- cane Rita’s storm surge flooding. Rita’s storm pliance with evacuation orders had been surge peaked at about 15 feet above sea level achieved for the Cameron and Calcasieu along coastal Cameron Parish. After overtop- Parishes. The areas that eventually suffered the ping the Chenier Ridges, the surge pushed in- worst flooding were essentially empty. land across Calcasieu Lake and up the Calcasieu River, flooding parts of Lake Charles. The Heavy rain from Hurricane Rita fell across most strong winds from the south managed to push of coastal Louisiana, with most gauges in south- water as far north as sections of Interstate 10 in west Louisiana measuring over 5 inches. Rain Lake Charles, more than 30 miles from the gauges in the Lake Charles area measured rain- coast. Approximately one-third of Lake Charles fall amounts between 6 and 9 inches. The Baton experienced flooding. East of Cameron Parish, Rouge area experienced the worst rainfall, with the coastal parishes of Vermillion, Iberia and St. one station recording over 9 inches of accumu- Mary all experienced flooding due to 8 – 12 foot lated rainfall. This rainfall amount is attributed surge levels. Moving further east, surge levels to a “railroad” effect of rainclouds, as a feeder reaching 8 feet flooded parts of Terrebonne and Figure 10 – Modeled storm surge flooding due band of the hurricane moved across the Baton Lafourche Parishes, both of which are located to Hurricane Rita Source: LSU Center for the Study of Public Health Impacts of Rouge area. between the Atchafalaya and Mississippi Rivers. Hurricanes Rita’s surge also caused additional flooding in The National Hurricane Center reported that areas that had flooded due to Hurricane Katrina. there were at least 90 tornados associated with In Slidell, a 5 – 6 foot flood surge pushed over most entirely evacuated, and only a handful of Hurricane Rita. Many of these occurred far highways and flooded debris left by Hurricane people had to be rescued in this area. Small north and east of the center of circulation, with Katrina. In New Orleans, the surge over- towns further east were caught off guard as Rita’s 23 tornados occurring as far east as and whelmed emergency sandbag repairs to levees surge pushed further inland than expected. In 11 as far north as Arkansas. In the area around breached during Hurricane Katrina, causing ad- Vermillion Parish, the towns of Erath and Jackson, Mississippi, 56 tornados were observed. ditional flooding there and delaying efforts to re- Abbeville (nearly 80 miles east of Lake Charles There is no documentation indicating that any move water from the city after Hurricane and 30 miles north of the coast) experienced un- tornadoes occurred in Louisiana. Katrina. expected flooding as the water pushed inland by the storm surge met rain water draining south. The storm surge from Rita inundated the entire Impact on the General Population Approximately 1,000 people were rescued from coast of Louisiana. Beyond Louisiana, the floodwaters in this area. In addition, flooding Florida panhandle experienced elevated water Lake Charles was the most densely populated in and around Lafitte, located about 30 miles levels in the Gulf, while Galveston Island expe- area to be flooded by Hurricane Rita. However, south of New Orleans, trapped about 500 peo- rienced a “bay surge” due to winds from the rural Cameron Parish received the heaviest ple in floodwaters. north. Figure 10 indicates the extent of Hurri- flooding. The southwest coastal region was al-

61 people were able to quickly return to their homes and work toward their community’s cleanup and recovery. However, flood devas- tated Cameron, where small communities line the Chenier Ridges, tells a much different story. Damage to housing and infrastructure was cat- astrophic and when the waters receded, houses, business, and health care facilities were damaged beyond repair. Electricity, telephone, natural gas, and water service were unavailable for a long time. Cameron Parish remained closed to the public until June 2006, nine months after Hur- ricane Rita passed.

Rescuers in Erath, Louisiana, guide a boat through shallow Hurricane Rita floodwaters with evacuees from the storm. Photo Credit: FEMA / Win Henderson

Overall, Hurricane Rita forced nearly 3 million minor wind damage and fewer than 1,000 had people from their homes, the overwhelming ma- flood damage. In Vermillion Parish, nearly jority of which evacuated from the Houston re- 7,700 homes were damaged, nearly half of gion and returned home shortly after the which were flooded. In Cameron, a much hurricane passed. In Texas, approximately 3,000 smaller number of homes were damaged, but of homes suffered damage, mostly due to either the 3,200 homes, an overwhelming portion (al- wind or minor flooding. In Louisiana, over most 94%) suffered from severe flood damage. 55,000 homes suffered damage, most of which Hurricane Rita flooded many neighborhoods and were in Calcasieu Parish, which includes Lake Hurricane Rita’s floodwaters receded quickly in small towns across south central and southwest Charles. In Calcasieu Parish, 44,000 homes most of the impacted areas. Damage to infra- Louisiana. were damaged, about 38,000 of which had structure and housing was not catastrophic and Photo Credit: FEMA / Greg Henshall

62 Medical Response needs persons before the storm. This key differ- occur in hospitals and nursing homes that re- ence in the sequence of events explains much of ceived comprehensive evacuation assistance be- The sequence of events surrounding Hurricanes the difference in outcomes. Over 65,000 people fore Rita. Katrina and Rita are similar in many ways, with had to be rescued after Katrina, fewer than only one key detail differentiating the two dis- 2,000 required rescue after Rita. Similarly, the The arrival of Hurricane Rita was preceded by asters. Both sequence of events began with the dire events that occurred in dozens of nursing the largest emergency evacuation in US history monitoring of the storm, followed by evacuation homes and hospitals following Katrina did not - over 3 million people fled southeast Texas and during the days and hours preceding the arrival of hazard conditions. Next, the outer bands of the hurricane arrived, bringing wind and rain, followed by the arrival of the storm surge, which peaked as the eye made landfall. During this se- quence, homes, businesses, pharmacies, doctor’s offices, and hospitals flooded and suffered ex- tensive wind damage. In the aftermath of these events, communities were left in shambles, peo- ple were rescued from floodwaters and collapsed structures, and the emergency response eventu- ally phased into recovery. At some point, the federal emergency response teams arrived to re- lieve overwhelmed local and state governments along with hospitals and nursing homes. Both disasters followed this basic sequence of events.

What accounts for the different effects of the two storms is the time at which federal assistance arrived. During Katrina, federal assistance ar- rived only after the storm had passed; during Rita, federal assistance began before the storm. In addition to the nearly 1,000 buses provided to evacuate the general population before Rita, Veterinarians from the National Veterinarian Response Team (NVRT) examine dogs brought in to the numerous assets, including buses, ambulances, Animal Disaster Response Facility staged in the Ford Arena outside Beaumont, Texas, following and aircraft, were provided to evacuate hospitals, Hurricane Rita's landfall. nursing homes, and other persons with medical Photo Credit: FEMA / Bob McMillan

63 southwest Louisiana. In addition, hospitals and to evacuate patients and establish field hospitals Katrina. Throughout most of the impacted area, nursing homes took unprecedented steps, aided to support 2,500 beds. Before the arrival of the lack of intensive and pervasive flood damage by an unprecedented level of federal emergency Hurricane Rita, DOT airlifted 4,000 special- meant that the initial clean-up quickly moved assistance, to evacuate their patients, residents, needs patients from evacuation hubs in Beau- into long term recovery. Businesses and govern- and staff. In Louisiana, a total of nine hospitals mont, Houston, and Lake Charles. Overall, ment offices quickly reopened, as did pharma- fully evacuated before Hurricane Rita, and four more than 500 medical response personnel and cies, clinics, and hospitals. However, most partially evacuated. In southwest Louisiana, 1,350 urban search and rescue personnel were structures in coastal Cameron Parish (including only Lake Charles Memorial Hospital remained pre-staged in Texas and Louisiana. the towns of Creole, Grand Chenier, and Holly open with a skeleton crew operating an inten- Beach) suffered catastrophic damage that in- sive care unit to provide emergency care in the Given the unprecedented level of federal support cluded the complete destruction of all health immediate aftermath of the storm. for evacuating residents and patients before Rita, care related facilities in the parish. The first

Because of the complete evacuation of the parish and the health care facilities, the catastrophic damage to these health facilities was not accompanied by the human catastrophe that was witnessed following Katrina.

Similar to the medical evacuation following Ka- the initial response was not overwhelmed with medical clinic in the parish did not reopen for trina, the full scale and complete evacuation of the need to rescue thousands of flood trapped over a year. It was nearly two and one-half years hospitals and nursing homes located along Texas’ residents and evacuate dozens of disabled per- before the hospital reopened. southeast coast and Louisiana’s southwest coast sons from hospitals and nursing homes. Still required numerous transportation assets which with millions displaced, hundreds of thousands Health Outcomes were provided by federal emergency response in shelters, and a coastal landscape in shambles, teams. Working with FEMA, the US Depart- medical needs were still critical during this pe- The direct health impacts of Rita are limited in ment of Transportation (DOT) provided ambu- riod. number, certainly in comparison to Katrina. A lances and buses to support medical evacuations, drowning in Calcasieu Parish accounts for the along with a tanker of diesel fuel. Additionally, Most of the area impacted by Hurricane Rita es- only Rita related death in Louisiana. Through- FEMA tasked the DOT to provide helicopters caped the catastrophic damage witnessed during out the Gulf Coast region, Rita caused seven

64 wind-related deaths. An estimated 700,000 experienced the large-scale and extended loss of tor in the differential. Even though the absence homes in Louisiana lost power, but there are no medical capabilities following Rita; however, all of a levee system in the southwestern part of the known incidents of fatal carbon monoxide poi- of the other hospitals in the impacted area re- state left those areas more vulnerable to storm soning. In Texas, where millions were without turned to full capacity once electricity was re- surge, particularly in Cameron Parish, a catas- power, 41 non-fatal cases of carbon monoxide stored and staff returned. Few patients trophe was averted because of an effective evac- poisoning and 10 fatal cases were observed. experienced sustained disruption of their treat- uation system. Getting people out of harm’s way ment programs or displacement from their can be credited for the fact that there was only By far, displacement was Hurricane Rita’s biggest providers and medical records. one drowning. killer. Over 110 deaths are attributed to cir- cumstances related to the evacuation of over 3 In regard to the health effects of various toxic ex- The physician interviews described in Part II of million people from the Houston / Galveston posures due to Rita, one might expect some of the report point out, repeatedly, that the legacy region. Many of the deaths were caused by heat the same outcomes witnessed following Katrina. of Hurricane Rita is greatly tempered by the exhaustion, as the poor evacuation planning for In many ways, the similar circumstances of the leadership of the mayor of Lake Charles and this area caused massive gridlock during the two events resulted in similar toxic exposures. those involved in disaster preparedness in south- summer heat. During the evacuation, a vehicle For example, one would expect the same house- west Louisiana. Calcasieu Parish, including the transporting nursing homes patients caught fire hold chemicals that mixed with floodwaters in medical community, provided a model of local after an oxygen tank exploded, resulting in 23 New Orleans to be found in the kitchens and initiative and accountability that should serve as deaths. Even though this particular incident has garbage areas flooded by Rita. Similarly, indus- a refreshing inspiration to the leaders, medical been attributed to negligence by the transporta- trial facilities located in both of the impacted re- professionals, and citizens of our state. tion company, it still demonstrates the extreme gions suffered wind damage and the release of risks encountered when evacuating the most vul- materials. Finally, the same formaldehyde-laden nerable persons. trailers were used to house residents impacted by disasters. However, due to minimal research In general, damage to medical facilities was iso- conducted on the health outcomes related to lated and limited, with Cameron Parish being possible toxic exposure from Rita, these health the one exception. Every medical facility in this outcomes are not well known. coastal Louisiana parish was severely damaged by Rita. The damage from the wind and surge The long-term physical devastation resulting left this area without any medical care capabili- from Hurricane Rita was much less dramatic ties. Because of the complete evacuation of the than that resulting from Hurricane Katrina. As Cameron Memorial Hospital was severely parish and the health care facilities, the cata- discussed above, the timing of evacuation and damaged from Hurricane Rita's tidal surge and strophic damage to these health facilities was not federal assistance was critical to the improved had to be demolished and rebuilt. Demolition accompanied by the human catastrophe that was outcome. Additionally, the breach of the levee and debris removal was funded by FEMA. witnessed following Katrina. Cameron Parish system in the New Orleans area was a major fac- Photo Credit: FEMA / Marvin Nauman

65

Summary of Reports and Official Records on Hurricanes Katrina and Rita

Chapter 6 n assessing the impact of Hurricanes Katrina and Rita on the Louisiana medical community, this report Icombines quantitative information from official re- ports, media coverage, and academic literature, with more qualitative information from direct involvement with the medical community. In the three and one-half years fol- lowing the storms, there has been a great deal of research conducted on the impact of the storms on Louisiana, par- ticularly south Louisiana. Much of this information was collected and has been summarized in the various sections discussed in this chapter. Official reports and records were used to substantiate the amount of damage and the cir- cumstances to which the medical community had to re- spond. The purpose of this chapter is to describe information about the impact of the storms, in order to provide a context for the situation within which the med- ical community was placed. Without knowing the extent Opposite left: Fully portable fully self contained DMAT (Disaster of impact, it is difficult to place physician interviews in Medical Assistance Team) centers play a vital role in providing needed disaster services after Katrina. context, as their stories are intricately involved with the Photo Credit: FEMA / Marvin Nauman official accounts of what took place.

67 Chapters 3-5 provide an in depth examina- tion of all aspects of the impact of Katrina and Rita. Part II of this report is specifically dedicated to the physicians who worked in General Findings the various situations created by the storms, ranging from sheltering-on-site in a hospi- tal to working long hours in a shelter or spe- 1. During the same year that Katrina 4. As a result of Katrina, 90,000 square cial-needs temporary facility. Additionally, and Rita hit (2005), natural disasters miles of the Gulf Coast region were the physicians have discussed what hap- destroyed; pened to their practices, where they live affected over 1 billion people world- now, and the struggles they have had with wide. Of those affected, nearly 100,000 recovery and restoration. As indicated died; 5. After Katrina, 80% of New Orleans above, the focus in this chapter is to de- was under water after storm surges scribe, in detail, the conditions under which 2. The US is becoming more vulnerable overtopped levees and caused breaches; the healthcare community tried to function. to natural hazards mostly because of Categories have been developed highlight- changes in the population and in the 6. As a result of the levee failures, ing the primary issues, barriers, and prob- national wealth density, in which 400,000 New Orleans residents were lems that critically impacted the operation infrastructure and people have become displaced; of physicians and the health care commu- concentrated in disaster prone areas. nity. The main issues identified through In New Orleans, the vulnerable 7. In New Orleans, more than 1,300 data collection efforts as well as the plethora population is generally comprised of people lost their lives during Katrina of research that has been released in the the poor and elderly, although Katrina and in the flooding that followed; three years after the storm, includes trans- impacted all ages, incomes, and portation problems, communication, sani- 8. All nine acute care hospitals in the tation, consumable supplies, utilities, educational levels; medical records, and barriers to physician ef- Greater New Orleans area were rendered forts to assist. 3. Hurricanes Katrina and Rita inoperable, and it became necessary to displaced 2.5 million residents evacuate all patients and staff. Flood and killed at least 1,800 along the waters damaged generators and rising US Gulf Coast; flood water made supplying the hospitals impossible.

68 Other information that has been documented Many people drowned especially the elderly, dis- 3. New Orleans police and fire communication from a variety of sources includes the following: abled, and poor, due to the lack of accessible sites were evacuated because of rising waters; transportation and the inability of vehicles to Transportation enter areas where they lived. 4. Thirty-eight 911 call centers were destroyed in the Orleans region after Katrina In the past, approximately 60% of the popula- Communication tion would leave or have the capability to leave 5. Over 2,000 New Orleans police and firemen the area before a disaster strikes. This was cer- Almost the entire communications infrastruc- had to communicate on a single channel after tainly the case with Katrina, as it is estimated ture was destroyed by Katrina. The system was Katrina; that 200,000 to 300,000 residents did not have minimally restored before Rita hit several weeks access to reliable transportation, which would later. 6. Local wireless connections were seriously have taken them out of the storm impacted area. damaged, with up to 2,000 cell phone sites out The elderly population was greatly affected be- The widespread effects of this failure can be seen of service after Katrina hit; cause those who were immobile or ill simply by: could not evacuate. 7. Over 20 million calls did not go through the 1. More than 3 million customer telephone day after Katrina because of destroyed connec- Emergency response personnel with transporta- lines were down in Louisiana, Mississippi, and tions, the impossibility of recharging phones, tion are usually the designated responders to deal Alabama after Katrina; and overload of the entire system; with the evacuation of the elderly. However, in 2. New Orleans lost two primary communica- the case of Katrina, the New Orleans flooding 8. Thirty-seven of 41 radio stations in the tion tower sites; happened so quickly that the emergency per- Orleans area were knocked off the air; sonnel could not get to vulnerable populations in time. The emergency personnel in the Lake Charles area were much more effective in their response to Rita because of effective prior plan- ning and significant time to evacuate prior to Rita’s approach.

After Katrina hit and the levees broke, hospitals faced the overwhelming task of finding trans- portation. By the time they realized everyone would be trapped in the rising flood waters, it was impossible to get transportation into the A mobile home lies across the road blocking two lanes of traffic near Empire, Louisiana, after Hurricane area and even harder to communicate the need Katrina. for transportation to those outside the area. Photo Credit: FEMA / Robert Kaufmann

69 Secondary effects of this situation caused much after Katrina passed. In the days that followed, Consumables of the chaos and confusion that occurred as Ka- conditions such as those listed below existed: trina hit and in the subsequent flooding. For ex- With the entire medical community disrupted, ample, since the media could not verify reports 1. The EPA determined that 159 of 683 water the shortage of medicine and medical supplies from various residents and officials, inaccurate facilities and 36 of 86 wastewater treatment quickly became a crisis. In particular, insulin information was rampant and resulted in a host plants serving 2.8 million people in south and tetanus vaccine were in great demand and of additional problems. One of the most chaotic Louisiana were either completely inoperable or there was not enough of either of these drugs. situations took place when Jefferson Parish offi- their status was unknown; cials were advised that a band of looters were at- The lack of medical supplies and consumables tempting to gain entry into the parish. This was a huge problem during Katrina. In the information was based on what was reported to 2. There were so many dead bodies floating in month that followed, it was even worse as the them from other law enforcement officials. As it the water in New Orleans, most of the water was few physicians who were left in town and those turned out, those headed toward Jefferson Parish completely unusable; who were able to return were left with the task (west of New Orleans) were evacuees looking for of providing tetanus and other shots to workers shelter. The lack of communication made it im- 3. Within two days of the passing of Katrina, who were coming back into the area to help with possible for well-meaning officials to know the all New Orleans hospitals were without power recovery. An additional barrier was the lack of truth. and water; postal services and the fact that all entrances to New Orleans were blocked by the National In the Superdome evacuation site, the public ad- 4. The lack of water rendered conditions in hos- Guard. Lack of mail services prevented delivery dress system did not work, so officials tried to pitals unlivable because of the lack of plumbing, of medicine to the health care community when maintain order among hysterical evacuees with personal hygiene supplies, and fresh water for it was needed the most. Specific examples of the bullhorns. FEMA dispatched amateur radio op- patients; problems with consumables include: erators to hospitals, evacuation centers, and parish emergency operations centers in an at- 5. In addition to the problems posed by the lack 1. Physicians found it necessary to break into tempt to restore some communication, but it of bacteria-free water, the flood water attracted hospital pharmacies for essential supplies, such was too late in most cases, especially for the hos- mosquitoes, which increased concern about the as water, food, and medicine; pitals that were completely inaccessible. spread of West Nile Virus; 2. Urgent requests for pain medication, IV lines, Sanitation 6. Many evacuation sites were unable to deter- catheters, and other equipment were delayed for mine if their water supply was safe, thus running days because of the breakdown in communica- Hurricane Katrina destroyed major water mains the risk of spreading illness among this huge tion, disorganized response, and lack of access and water treatment facilities in south Louisiana. post-storm population; to funds; There was great concern among the medical community about the effect of bacteria seeping 7. There was a general lack of understanding 3. Physicians also reported that the lack of satel- into south Louisiana’s water supply. Thus, water within the community as to how to determine if lite phones affected their ability to get help. supplies were completely cut off within two days water was safe.

70 Utilities

Over one million customers lost power for days, weeks and months after Katrina. Three and one- half years after Katrina hit, there are still entire neighborhoods in New Orleans and the sur- rounding parishes that are uninhabitable. The lack of utilities had an overwhelming effect on the health care providers and the patients who remained in the hospitals as Katrina approached.

1. Nearly 800 staff and 1,600 patients were trapped in hospitals with no power;

2. Generators initially provided power to the hospitals after the electricity went out but were eventually lost to the flood waters, because so many of the hospital generators were on the first floor of buildings;

3. Even if the generators were in operation, the Hurricane Rita blew down trees and power poles all across Lake Charles, Louisiana, blocking roads and hospitals quickly ran out of fuel; leaving the area residents and businesses without electricity. Photo Credit: FEMA / Greg Henshall 4. It has been estimated that the hospitals needed about 200 gallons of fuel per hour to keep the emergency generators in operation; 7. The Centers for Disease Control (CDC) sur- 8. Other post-Katrina and Rita surveys indi- cated that 41% of the evacuees had at least one 5. Lack of power and water severely compro- veyed evacuation centers after Katrina and Rita chronic health problem. mised the health of critically ill patients, most of and found that 5 of the 6 illnesses affecting the whom were exposed to temperatures over 100 evacuees were related to chronic diseases, in- degrees in the sweltering hospitals; cluding medication refills and oral problems that often affect vulnerable populations, such as the 6. The Department of Agriculture used civilian elderly, disabled, and poor. The leading condi- and military 4-wheel-drive vehicles in their at- tions were hypertension, cardiovascular disease, tempts to deliver fuel to the hospitals; diabetes, and psychiatric disorders;

71 Medical Records Barriers to Physician Efforts to Assist

Inaccessible medical records likely had one of the There are a number of other miscellaneous types biggest effects on the health care community and of problems that the health care community the patients they served. All across the Gulf faced that can be resolved and are being resolved Coast and into Texas, Georgia, and other areas through policy and procedural changes. Unfor- where many of the evacuees were being housed, tunately, it has taken a major disaster for practi- shelter care workers, volunteer physicians, and tioners and policymakers to identify the many hospitals were at a complete loss as to how to barriers faced when trying to provide help to deal with the medical needs of persons from the communities in need of disaster assistance. Gulf Coast, particularly residents of south Louisiana and southern Mississippi. 1. The lack of coordination, and often the lack of cooperation, among local, state, and federal 1. The medical files of more than one million agencies posed a number of problems for physi- people along the Gulf Coast were lost or de- cians: blocking volunteer doctors from coming stroyed during Katrina; into the area, the refusal of medication from out- side the state, and the failure to accept help from 2. Up to 250,000 evacuees housed in shelters others if not licensed in Louisiana; required some sort of medical attention post-Ka- trina; 2. Hundreds of doctors and other health care Veterinary services were available at the New professionals attempted to try to help in 3. Approximately 8,000 people were in critical Orleans airport staging area for stray animals and Louisiana and were turned away because of li- care shelters post-Katrina; pets of the victims of Hurricane Katrina. This censing issues, liability concerns and poor coor- dog waits for his turn under his owner's cot. Photo Credit: FEMA / Liz Roll dination among officials; 4. The Orleans area had 7,600 participants in experimental medical trials, whose progress was 3. Medical equipment and supplies that were either halted or disrupted; flown into Louisiana could not get to their des- tination because there was no process set up to 7. Displaced persons with mental and behav- 5. Nearly 8,000 people being treated for receive supplies, and the delivery trucks were ioral disabilities caused a huge strain on numer- HIV/AIDS were displaced by Katrina; blocked from high-impact areas; ous entities in communities where they 6. Healthcare providers in the Astrodome re- evacuated. Baton Rouge, Houston, and other 4. Policies prohibited evacuees from taking their ported major problems with vulnerable evacuees north Louisiana cities reported major difficulties pets with them; thus, many persons stayed be- who could not say what medicine they were on, in homeless shelters, local jails, and emergency hind or tried to get through the waters to the but who were clearly showing a variety of symp- rooms. Superdome with their pets. Snakebites were also toms; a big problem following Katrina;

72 5. Physicians who stayed behind often had to port existing facilities; thus, many of the federal Findings and Recommendations do so either at the price of separating from their medical teams who came in had no place to from Selected Official Documents families or bringing their families and pets into practice medicine; the medical facility. The reported stress and fear Given the catastrophic level of destruction and among family members was significant; 12. Facilities that remained open were not pre- unprecedented level of response, the 2005 Hur- pared for looters and snipers who targeted sev- ricane Season provided an important opportu- 6. There was a great deal of concern among eral facilities in south Louisiana (snipers were nity to assess the national, state, and local level physicians about liability as there were no poli- shooting at helicopters arriving at a Jefferson of preparedness and response. Many papers, re- cies in place to protect them in situations such as Parish Hospital); ports, and books were published by academic re- having to administer medication without hav- searchers, government agencies, advocacy ing a patient’s medical file or history; 13. Much of the health care infrastructure and groups, and others. Given the magnitude of Ka- medical equipment was lost or destroyed trina’s impact, along with the perception that 7. There were numerous problems with Medi- throughout the hurricane impacted areas of preparation and response were lacking for this caid regulations effecting patients who were southeast and southwest Louisiana. Evacuees storm, most research efforts were directed to- from out of state, resulting in the inability of that left the Orleans area [southeast Louisiana] wards Katrina, as opposed to Rita. patients to get medication and failure to qualify to go to the Lake Charles area [southwest for services because of missing documention. Louisiana] because of Katrina had to evacuate Key points concerning the medical community this area, along with Texas evacuees, in order to and health care are summarized from selected 8. Medicaid regulations did not allow physi- escape the path of Rita. literature. Although most literature addresses cians to move patients from their current nurs- Katrina issues, other storms are included if the ing homes and in-patient facilities to other This information has been obtained through information seemed to be useful. There is an ad- outside facilities without prior government ap- published accounts of the conditions that im- ditional listing of reports by official government proval; pacted medical care and is well supported in the or corporate organizations at the end of this data collected in this research. The focus groups chapter. 9. Nursing homes were not required to evacu- and face-to-face interviews yielded much of the ate; thus, many sick residents remained in these same information, but in greater detail and with 1. The .The Federal Response to facilities. Many of them died in these facilities more poignant descriptions from physicians Hurricane Katrina: Lessons Learned (2006) because of poor conditions; who experienced Katrina and Rita. This document presents the White House’s com- 10. Many hospitals did not have helicopter prehensive review of the disaster and the federal landing pads, thus rendering late evacuation im- response. The narrative description of the dis- possible; aster is split between two chapters, one that cov- ers the pre-landfall preparations and another 11. There were no policies or procedures in that covers the post-hurricane response. This re- place to set up portable or field hospitals to sup- port also includes a number of lessons learned

73 and a broad ranging list of 125 specific recom- • The Surgeon General should routinely provide mendations, which are organized around a and communicate public health, as well as indi- handful of critical challenges. vidual and community preparedness guidance to the general population; In the report, “Public Health and Medical Sup- port” is recognized as a critical challenge with • Create and maintain a dedicated, full time, the following lesson learned: and equipped response team composed of Com- missioned Corps officers of the US Public • In coordination with the Department of Health Service; Homeland Security and other homeland secu- rity partners, the Department of Health and • DHS and HHS should look for the means to Human Services (HHS) should strengthen the increase the capabilities of local and State health Federal government’s capability to provide pub- infrastructures; Fully portable fully self contained DMAT (Dis- lic health and medical support during a crisis. aster Medical Assistance Team) centers play a This will require the improvement of command • Accelerate the HHS initiative to foster wide- vital role in providing needed disaster services and control of public health resources, the de- spread use of interoperable electronic health after Katrina. velopment of deliberate plans, an additional in- records (EHR) systems, to achieve development Photo Credit: FEMA / Marvin Nauman vestment in deployable operational resources, and certification of systems for emergency re- and an acceleration of the initiative to foster the sponders within the next 12 months. widespread use of interoperable electronic health records systems. Many of these recommendations are related to includes a broad-based review of the prepara- policies at the federal level; however, they are tions and response by all levels of government. Toward improving public health and medical policies that will trickle down to impact state, This report is organized along different themes, support during disasters, the White House rec- local, and private organizations involved in including a chapter devoted to “Medical Assis- ommends the following policy actions: health care. tance.” The report then provides a summary list of “Conclusions and Findings” before present- • HHS should lead a unified and strengthened 2. Senate Committee on Homeland Secu- ing a list of seven foundational recommenda- public health and medical command for federal rity and Government Affairs, Hurricane Ka- tions, which are supported by additional tactical disaster response; trina A Nation Still Unprepared (2006) recommendations.

• HHS should ensure coordination and over- Based on 22 committee hearings, along with Among the “Conclusions and Findings,” the sight of emergency, bioterrorism, and ongoing witness interviews and a review of internal doc- Senate report includes: public health preparedness needs; umentation from many agencies, this document

74 Federal Problems • Unlike Disaster Medical Assistance Teams, the medical supplies were pre positioned in the Gulf US Public Health Service is not organized or region. • While both FEMA and the Department of equipped to serve as medical first responders and Health and Human Services made efforts to ac- have no pre-established, readily deployable Louisiana Problems tivate the federal emergency health capabilities teams, personnel practices, transportation and, of the National Disaster Medical System other logistical difficulties; • The State of Louisiana failed to ensure that (NDMS) and the US Public Health Service, nursing homes and hospitals were incorporated only a limited number of federal medical teams • Although FEMA eventually deployed virtu- into the State’s emergency-planning process, and were actually in position prior to landfall to de- ally all of its National Disaster Medical System as a result failed to ensure that they had effective ploy into the affected area. Only one such team resources, having started with only a single team, evacuation plans or were genuinely prepared to was in a position to provide immediate medical there was a greater need for such teams than shelter their critical care patients in place, caus- care in the aftermath of the storm; could be filled, and those teams that did deploy ing loss of life and avoidable suffering; experienced difficulties in obtaining necessary • The federal government’s medical response logistical, communications, security, and man- • Louisiana failed to plan for known emergency suffered from a lack of planning, coordination, agement support; medical-response needs, such as post-storm and cooperation, particularly between the US evacuation of patients from hospitals or moving Health and Human Services and the Depart- • Despite efforts by both FEMA and HHS to large numbers of patients to medical treatment ment of Homeland Security; activate federal emergency-health capabilities of facilities; the National Disaster Medical System (NDMS) • Despite its lead role as the primary agency in and the US Public Health Service as Katrina ap- • Louisiana State University [Hospital System- charge of coordinating the federal medical re- proached the Gulf Coast, only a limited num- Charity Hospitals] failed to carry out its sponse, the Department of Health and Human ber of federal medical teams were actually in responsibilities under the state emergency- Services did not deploy its on-scene response- position prior to landfall to deploy into the af- operations plan to ensure adequate emergency coordination teams as rapidly as it should have, fected area, only one of which (the Oklahoma – preparedness for [its] health care facilities; and the agency lacked adequate emergency-co- 1 Disaster Medical Assistance Team) was in a po- ordination staff and resources; sition to provide immediate medical care in the • The Louisiana Office of Homeland Security aftermath of the storm; and Emergency Preparedness failed to ensure • The federal agencies involved in providing that its functions were implemented. medical assistance did not have adequate re- • Although a shipment of medical supplies was sources or the right type or mix of medical ca- dispatched from the Strategic National Stock- pabilities to fully meet the medical needs arising pile to Louisiana late on Sunday, August 28, in from Katrina, such as meeting the needs of large response to a last-minute request from the City evacuee populations, and were forced to use im- of New Orleans, it was not possible to get it to provised and unproven techniques to meet those Louisiana before landfall, and no other federal needs;

75 Additional recommendations, sure that all state emergency response personnel consideration the special needs of persons with specifically related to medical from departments and agencies with responsi- physical, mental and other disabilities, the most care include: bilities under the state emergency response plan, vulnerable, and those least able to help them- and volunteers, also have a standard credential selves, in their response and recovery plans. Federal Level based on the same credentialing system; DHS should coordinate with state and local gov- ernments to ensure that their response and re- • The scope of Emergency Support Function •HHS, in conjunction with DHS, should lead a covery plans also address persons with special (ESF-8, Public Health and Medical Services), as federal, state, and local initiative to roster and needs; defined in the National Response Plan (NRP), credential, in a centralized or linked manner, should be expanded to clearly include the pub- medical personnel and volunteers (National Dis- • DHS should coordinate with the private sec- lic health and medical needs not only of victims aster Medical System, Medical Reserve Corps, tor and non-governmental organizations of an emergency, but also those of evacuees, spe- US Public Health Service, etc.) to ensure that, (NGOs), including the American Red Cross, to cial-needs populations, and the general popula- in the case of national emergencies, properly ensure that the response and recovery plans of tion who may be impacted by the event or may qualified medical providers are quickly identi- those participating in emergency preparedness need to be evacuated or sheltered-in-place. The fied and able to gain appropriate access to the and response operations take into consideration NRP should also clarify that responsibility for affected area; the special needs of persons with physical, men- all mortuary activities, including collection of tal, and other disabilities. victims, resides with ESF-8. Appropriate mass •Private sector telecommunications, utilities, fatality plans and capabilities should also be de- critical infrastructure, and other private entities State and Local Preparations veloped; should be included in emergency response plan- ning and be assured appropriate access to disas- • States should ensure that effective communi- •DHS and HHS should improve their coordi- ter areas to repair critical infrastructure and cations lines and information sharing systems nation; restore essential services. DHS should coordi- exist between the state emergency operations nate with federal, state, local, and other emer- centers and all facilities, or mobile units that •DHS should ensure that all federal emergency gency management officials to develop a provide medical care or other assistance to vic- response personnel from federal departments standardized national credential that would tims of a catastrophic event; and agencies with responsibilities under the allow emergency management professionals, first NRP have a standard credential that details the responders, and other response personnel from • State agencies responsible for licensing of hos- emergency management positions for which the the private sector access to disaster areas, as ap- pitals and nursing homes should ensure those fa- person is qualified based on measurable criteria, propriate; cilities have evacuation plans and audit them performance, objectives, and standards so that annually, including an evaluation of the avail- they may easily integrate into emergency re- •DHS should ensure and direct that all federal ability of transportation resources, to verify that sponse operations (Red Card System). DHS departments and agencies with responsibilities they are viable; should coordinate with state governments to en- under the NRP, including the ESFs, take into

76 • State agencies responsible for special-needs shelters, working with local counterparts and emergency support organizations, should con- sider developing and maintaining a voluntary database of special-needs persons residing in the area.

3. Government Accountability Office, Hurricane Katrina: Allocation and Use of $2 Billion for Medicaid and Other Health Care Needs, 2007.

In addition to looking at the emergency prepa- rations and response to Hurricane Katrina, the GAO has also looked at a number of issues re- lated to long-term recovery. Two reports by the GAO examine the medical aspects of recovery. This report assessed the use of $2 billion in Con- gressional appropriations for Medicaid costs as- sociated with the impacts of Hurricanes Katrina and Rita. This review looked at how the funds were allocated to the states, how the states have used the funds, and whether states anticipated Cooks aboard the Texas Clipper II prepare a meal for displaced government workers who are being additional funding needs. The GAO found that housed on board. This ship is a Texas A & M training ship docked at the Port of Lake Charles. the biggest portion of the money ($1.5 billion) Due to the severe housing shortage, FEMA provides housing for local government workers displaced went to existing beneficiaries from the impacted by Hurricane Rita who are needed to keep local government running. Photo Credit: FEMA / Marvin Nauman states; that the majority of the claims were con- centrated in nursing facilities, inpatient hospital care, and prescription drugs; and that both Louisiana and Texas raised concerns that addi- tional funds might be needed. Also of note, is that this report describes what is termed a “na- tional Medicaid program” administrated by Louisiana for enrolled individuals and providers that were displaced and living in different states.

77 4. Government Accountability Office, Hur- ricane Katrina: Status of the Health Care Sys- tem in New Orleans and Difficult Decisions Related to Efforts to Rebuild It Approximately 6 Months after Hurricane Katrina, 2006.

In March 2006, the GAO assessed the recovery of health care in the New Orleans areas six months after Hurricane Katrina. Among its findings, the GAO states that:

• The health care infrastructure was significantly damaged;

• The number of staffed hospital beds in the City of New Orleans was about 80 percent less in February 2006 than before Hurricane Kat- rina;

• Increased demand has been reported at the open emergency departments and has led to the slower unloading of patients from ambulances Jefferson Parish emergency communications tower collapsed during Hurricane Katrina, and crushed a and to patients being housed in the emergency building where it fell. department because hospital beds were not avail- Photo Credit: LSU Hurricane Center/ Marc Levitan able;

• More than three-fourths of the safety net clin- ics in the New Orleans area were closed, and many of those that were open had limited ca- pacity.

78 There are a number of additional reports • Joint Commission on Accreditation of • Federal Emergency Management Agency. that provide recommendations for the fed- Healthcare Organizations. (2006). Surge Hospi- (2006). DHS/FEMA Initial Response Hotwash: eral, state, and local governments as well as tals: Providing Safe Care in Emergencies. Re- Hurricane Katrina in Louisiana. (Publication the medical profession and health care com- trieved February 5, 2009, from no. DR-1063-LA). FEMA: Baton Rouge, LA. munity. These include: http://www.jointcommission.org/NR/rdon- lyres/802E9DA4-AE80-4584-A205- • American College of Emergency Physicians. • The Select Bipartisan Committee to Investi- 48989C5BD684/0/surge_hospital.pdf. (2006). Emergency Medicine One Year after Kat- gate the Preparation for and Response to Hurri- rina. Retrieved February 5, 2009, from cane Katrina. (2006). A Failure of Initiative • Louisiana Office of Homeland Security and http://www.acep.org/Default.aspx (Publication no. 23950 PDF). Washington, Emergency Preparedness. (Compliance Audit, DC. Government Printing Office. Retrieved July 9, 2008). Lessons Learned, Event Name: Hur- • Emergency Management Assistance Compact. February 5, 2009, from http://www.gpoac- ricane Katrina and Rita. 2005 Hurricane Season Response After-Action Re- cess.gov/katrinareport/mainreport.pdf. port. Retrieved February 5, 2009, from • Price Waterhouse Coopers. (2006). Report on http://www.emacweb.org/. • Government Accountability Office. (2006). Louisiana Healthcare Delivery and Financing Sys- Disaster Preparedness: Limitations in Federal Evac- tem. Retrieved February 5, 2009, from From the number of reports, official documents uation Assistance for Health Facilities Should be http://pwchealth.com/cgi- and, now, the words of those in the medical Addressed (Publication no. GAO-06-826). local/hcregister.cgi?link=reg/lrasummary.pdf. community, every state has the information to Washington, DC. Retrieved February 5, 2009, avoid another Katrina failure. and response” from http://www.gao.gov/new.items/d06826.pdf. • Grey, B. & Hebert, K. (2006). Hospitals in (CPM, 2008). Hurricane Katrina: Challenges Facing Custodial • Government Accountability Office. (2006). Institutions in a Disaster. Retrieved February 5, Hurricane Katrina: Status of Hospital Inpatient 2009, from http://www.urban.org/Uploaded- and Emergency Departments in the Greater New PDF/411348_katrinahospitals.pdf. Orleans Area (Publication no. GAO-06-1003). Washington, DC. Retrieved February 5, 2009, • Arendt, L. A. & Hess, D. B. (2006). Hos- from http://www.gao.gov/new.items/d061003.pdf. pital Decision Making in the Wake of Katrina: The Case of New Orleans. I n, Engineering and • Emergency Management Assistance Compact Organizational Issues Before, During and After (EMAC), 2005 Hurricane Season Response Hurricane Katrina: Vol. 1. Hurricane Katrina: After-Action Report. Emergency Response. MCEER. Retrieved Feb- ruary 5, 2009, from http://www.prevention- web.net/files/1960_VL206317.pdf.

79

Comparison of Hurricanes Gustav and Ike to Chapter 7 Hurricanes Katrina and Rita

he experiences of Hurricanes Katrina and Rita led to powerful “lessons learned” changes across the Tentire tiered system of local, state, and federal gov- ernment, public and private agencies, and all medically related entities. In the ongoing aftermath of Katrina and Rita, it has never been more apparent that all responders must work together from the planning process to emer- gency preparation, response, and recovery. If any level of the government is not working effectively, the medical community cannot work well either. When communica- tions are down, hospitals and health care professionals cannot interact to provide care for their patients and those in need of medical assistance. Alternatively, if the medical community has a poor response to a disaster, it leaves pub- Opposite left: A resident is transported by a FEMA Urban Search lic officials, police, and citizens in a difficult situation be- and Rescue Team away from her house, which she was cause of unmet medical needs, and/or their inability to unable to vacate due to Hurricane Katrina. Photo Credit: FEMA / Jocelyn Augustino provide support to first responders and others.

81 Dr. John Fleming, a nationally recognized ex- or indirectly, with evacuation of populations and pert on emergency preparedness, described the recovery processes. comparison between the response to Katrina and Gustav as: Even though the greater New Orleans area was spared direct impact by Gustav, the entire area “A largely unorganized and dysfunctional [re- was placed under mandatory evacuation orders. sponse] at all levels of government,” compared Gustav hit the southeast Louisiana town of to “a highly coordinated and collaborative effort Cocodrie, in Terrebonne Parish, on the morn- where ensuring the life safety and the well being ing of September 1, 2008. In the days before it of those living in impacted areas became the hit, the following activities had taken place: ‘mission’ driving all aspects of the preparation and response” (CPM, 2008). • 450 special-needs patients were evacuated Red Cross volunteers discuss a floor plan to to the LSU Pete Maravich Assembly make the best use of the space in the aban- Although Hurricanes Gustav and Ike did not Center; doned mall that housed nearly 1,000 Houston make a direct hit in the New Orleans area, the • 700 buses were moved to New Orleans to residents after Hurricane Ike. damage and potential for greater damage across evacuate persons without transportation; Photo Credit: FEMA / Greg Henshall most of the state of Louisiana was quite signifi- • 500-600 hospital and home based medical cant. The threat of a New Orleans hit provided patients were moved out of state; Isle. In the hard hit areas of Gustav, power was the opportunity for the implementation of the • 8,200 nursing home patients were moved not restored to some homes for 3-4 weeks. In revised emergency plans across all parts of the from 92 nursing homes; the capital city, Baton Rouge, power was out in system, especially the hospitals. The devastating • Department of Defense airlifted 1,000 many parts of the city for days, with some resi- effects of wind damage throughout most of patients to safety; dents without power for almost two weeks. Traf- south Louisiana, especially the hard hit areas of • An estimated 2 million people left south fic signals did not work, and the operation of the Baton Rouge and its neighbors to the immedi- Louisiana before Gustav hit; city was compromised. Martial law was enacted ate southeast, resulted in the implementation of • Shelters were opened at numerous sites in most of the towns and cities in south emergency plans and recovery efforts. With throughout Louisiana. Louisiana, with Baton Rouge experiencing an Hurricane Ike following on the footsteps of Gus- 8:00 p.m. to 6:00 a.m. curfew for almost a week. tav, southwest Louisiana once again had to face Comparatively, Katrina caused flooding prob- The economic impact of the power outage was the flooding and wind damage from another lems and Gustav caused wind related problems. tremendous, with property damage estimated to storm. Gustav produced a substantial rain event Almost all of Louisiana’s 64 parishes were af- be $15 billion, compared to Katrina and Rita’s through much of central and north Louisiana. fected with some type of power outage during combined cost of $100 billion. The Louisiana Ike caused severe flooding all along the Gustav. Ike caused severe flooding all along Office of Economic Development estimated Louisiana coast. Most of Louisiana was im- Louisiana’s coast, from the Texas/Louisiana bor- that losses to the state’s gross national product pacted by one or both hurricanes, either directly der to the beleaguered coastal point at Grand were as high as $250 million a day following Gustav.

82 In spite of this catastrophic event, Louisiana care that hundreds of people were able to obtain, fared much better during Gustav and Ike than it as well as the prevention of a number of addi- did during Katrina and Rita. Clearly, the track tional deaths. The deficiency in government as- of the storms influenced the outcomes in 2008, sistance at all levels is well documented and when compared to 2005. However, the reor- accounts for the inability of the medical com- ganization of preparedness and response proto- munity to get outside help when their internal cols, in addition to improved local, state, and processes and procedures failed. federal leadership across all systems, was largely responsible for the collaborative efforts and bet- Communication ter outcomes. There was no place where this was more evident than in the medical community, Specifically, what happened with the communi- which again, underscores the fact that when one cation system during Katrina was unpredictable part of the emergency response system fails, it and, in reality, unbelievable. There is little doubt causes failure among the other entities. that the communication failure was the biggest contributor to the horrific situation that devel- Major Problems Affecting the Medical oped within the medical response. No one had Community during Katrina and Rita anticipated that cell phones, land lines, and the internet, would have all been compromised by Obviously, the overall problem was the rapid the impact of the storm and the ensuing chaos flooding from the breach in levees that no one and confusion. To make matters worse, few had anticipated. However, the devastating ef- radio stations were operating, so there was no fects could have been greatly reduced if other central location for public service announce- Power lines throughout Louisiana become components had been in place, such as commu- ments and no way to get information to the entangled in trees from 's powerful winds and rain, disrupting power nications, adequate preparation of consumables public. Even if hospitals and medical facilities throughout much of the state. and supplies, leadership, and the three-tiered had access to satellite phones, there was no one Photo Credit: FEMA / Jacinta Quesada government response. Communication capa- to call for help. Thus, the hospitals became bility completely collapsed. Pre-storm prepara- completely isolated from any type of assistance tion for supplies (water, food, medical and in fact ultimately received help in bizarre in to report their situations or see if they were necessities) and alternative power sources was to- ways, such as by text messaging family members needed. The medical community was widely tally inadequate. Leadership, at every level, was out-of-state, who contacted hospital branches or dispersed by the flooding and the chaos. Fol- lacking from local, state, and federal officials, as emergency personnel in out of state locations. lowing Katrina, operational radio stations could well as within the medical community. The have been one of the most important factors in leadership that emerged from the medical com- Staffing became impossible as no one could quelling the rampant rumors that caused so munity during the crisis was responsible for the reach employees and employees could not call much turmoil. Accurate news accounts would

83 conditions of the hospitals during Katrina and were unable to provide any help. In reality, pub- lic officials did not know the conditions sur- rounding them because they were unable to communicate. To add to this chaos, as patients were evacuated, there was minimal transfer of medical records and poor tracking of who was going where. The elderly and newborn babies were evacuated without family members, creat- ing additional chaos, as family members tried to determine where their evacuated family mem- bers were located.

In an interview with an older woman who be- came separated from her family in the flood wa- ters, she described her eventual air transport to a shelter in west Texas. She had a stroke while at the shelter and eventually her family members were located at a shelter in Ft. Worth, where she was moved so she could have family support during her recovery.

Another young woman delivered her baby at a Medical personnel from the Air Force National Guard prepare for the arrival of special needs patients private hospital in New Orleans the day before who are going to be evacuated from hospitals and nursing homes in the Corpus Christi, Texas, area in Katrina hit and was not allowed to evacuate by anticipation of Hurricane Ike's landfall. air with her baby, as only neonatal unit babies Photo Credit: FEMA / Patsy Lynch were given the precious air medical support. The distraught family eventually found the baby, have greatly aided emergency response. In short, Preparedness safe, in a Dallas hospital. These were not iso- no one was prepared for the rapid flooding. lated incidents. Medical facilities were simply cut off from the The medical community, emergency organiza- rest of the system as well as from each other. tions, and the three-tiered level of the govern- Those patients who could be evacuated when air They were isolated with the backup plan for gov- ment were all ill prepared for a catastrophic support was available were removed from the ernment assistance, an unanticipated failure. event. Public officials really did not know the hospitals and taken to other locations. Some pa-

84 tients were too ill to move or could not be trans- extensive damage, five suffered limited damage, area, particularly for the low income and med- ported without equipment. The medical per- two experienced moderate damage, and only ically needy population. The debate continues sonnel that remained with them primarily did two hospitals had no damage (Tulane Lakeside among state officials, DHH, and the LSU so on a voluntary basis, or because they were un- and Meadowcrest). Since Katrina, two hospitals Health Sciences Center as to how services are able or unwilling to evacuate. If a process ex- have been demolished, three have been closed, going to be provided to the indigent population. isted for assigning medical personnel to the and the other 10 have remained open, with facilities, it did not work during Katrina. To some under new ownership. This has had a huge The situation in southwest Louisiana after Rita make matters worse, even if employees wanted impact on the provision of medical care in the was also catastrophic, but the response was to get to their jobs at the medical facilities, it is doubtful that they could have reached their des- tination because of flooding, and later looting, followed by marshal law. Transportation, access to gas, and dealing with their own family needs were just a few of the problems that hampered medical support after Katrina. The situation was compounded in New Orleans because of the flooding and the lack of communication within the medical community.

For those who remained in medical facilities, a lack of supplies became a serious problem. Water and food did not last long. Without power, the heat was sweltering, and eventually the plumbing went out. In many cases, genera- tors had been placed on the first floor of the fa- cility and they quickly became nonfunctional because of the flood waters. Medical supplies for the patients did not last and physicians re- ported having to break into hospital pharmacies to look for medicine and supplies. The sanitary conditions could not have been much worse.

Of the 15 acute care hospitals that existed in the On Magazine Street in New Orleans, a warning to potential looters. greater New Orleans area in 2005, six suffered Photo credit: FEMA / Liz Roll

85 much more effective. According to post-Katrina begin and remain centralized at the local level; mental health organization? What was the role and Rita interviews and surveys, the medical those in command would know who to contact of the Red Cross and other organizations in re- community in southwest Louisiana had a col- at the state level, and where to go for assistance sponse to the disaster? To whom would these laborative network in place that functioned at the federal level. In Katrina and Rita, none of organizations report? How could supplies be de- when everything else failed. The communica- this took place, except at the local level in south- livered into the greater New Orleans area with tion problems were not as bad, but dealing with west Louisiana and in isolated medical facilities martial law in place and entrances to the city to- huge numbers of evacuees, first from southeast throughout south Louisiana. It was often un- tally blocked? Louisiana during Katrina, and then from Texas clear as to who was in charge locally. Options during Rita, placed a huge burden upon the en- included the local mayor, the National Guard, Issues of leadership and organization emerged tire medical community in southwest Louisiana. the governor, FEMA, and other organizations, throughout all phases of the disaster- prepara- The coastal towns in southwest Louisiana were such as the Red Cross and DHH. There is tion, response, recovery, and restoration. It lit- almost destroyed by flood waters in Rita, adding ample documentation of the New Orleans erally has taken the years since Katrina and Rita to the number of people with serious problems mayor, Ray Nagin, on television, outside of to establish the hierarchical relationships and or- moving to the more urban environment of Lake south Louisiana, begging for help from anyone ganizational leadership that must exist to be able Charles. With the majority of the government after the local response had totally collapsed. to effectively deal with any disaster and, cer- and media response focused on New Orleans, State officials were overwhelmed as their re- tainly, a catastrophic event. This has also been a southwest Louisiana was fairly isolated. The sponse failed, causing them to seek help from critical development in the medical community local-level organization and leadership was a the federal government. State and local law en- and within the facilities that will be affected by huge asset to this community during the crises, forcement and the military struggled over who future severe weather events in Louisiana. In and provides a good model for other communi- was in charge. Their efforts were hampered be- surveys and interviews with medical personnel ties in preparation and planning efforts. cause of the lack of policy governing such issues and physicians for this report, examples of orga- and the feeble communication capability. nizational leadership, or the lack of such a role, Leadership entered into almost every description of effec- Several days after Hurricane Katrina, state and tive or failed responses during and after the The importance of local, state, and national lead- local officials were able to convince President storms. ership from government officials and emergency Bush and the federal government that there was organizations, as well as from the medical com- a real emergency in Louisiana, and how local Government Failure munity, cannot be emphasized enough. In this and state resources were unable to deal with the type of catastrophic event, someone has to be in level of destruction and need. As resources Throughout the previous discussions, the undis- charge and the organization and reporting hier- poured into the state, the lack of leadership, or- puted failure of all three levels of government is archy has to be clear for all responding person- ganization and planning became even more ev- evident. When local systems cannot respond to nel and for citizens. In Katrina and Rita, this ident. Social service providers did not know an emergency, the federal government should be organization was lacking at all levels. Ideally who was in charge of making decisions. Was it able to step in to support the local structure. As preparation, response, and restoration would the local mental health authority, or the state a part of the local system, when the medical

86 community cannot effectively address disaster needs, it should be able to rely on local, state, and federal assistance. For all of the reasons dis- cussed, this did not happen with Katrina. Com- munication problems, the lack of resources, the leadership void, poor planning, overwhelming and rapid effects of flooding, and internal disor- ganization all hampered the government and medical community response. In Louisiana, these problems were exacerbated by the large percentage of persons living in poverty that ei- ther made poor decisions or were unable to pro- vide for themselves during a catastrophic event.

Outside of Louisiana, commentators and ana- lysts have remained puzzled over why people did not leave pre-Katrina New Orleans, as they did when Gustav approached. It did not occur to these analysts that poor and disabled citizens did not have transportation, and that government assistance checks, upon which many citizens rely, did not arrive until the day after Katrina hit. Be- cause of the local-level disorganization, public Thousands of people waiting for buses at highway pickup point in New Orleans, four days after Katrina. officials were unaware of the hundreds of school Photo Credit: LSU Hurricane Center / Marc Levitan buses that were available to transport people, or the offers from the local train station and air service providers to whom they could have ap- Guard, among others, who made the decision to had been delivered the Friday before because of plied for assistance in getting people to safety. save lives and address policy issues later. the Labor Day holiday falling on the 1st, which FEMA promised hundreds of buses that never was a Monday. Additionally, policies had been appeared. Evidence of multi-level failures can As Gustav approached on September 1, 2008, a changed that allowed persons to evacuate with be provided for many parts of the response. At preemptive state of emergency had been de- their pets, which had caused untold tragedy dur- the same time, evidence of effectiveness and clared and there were 700 buses in New Orleans ing Katrina and Rita. These are just a few ex- leadership in some aspects of Katrina and Rita ready to transport the poor and disabled out of amples of actions that were taken prior to were seen through the efforts of the Coast harm’s way. The government assistance checks Gustav that resulted in a more effective response.

87 Post-Katrina and Rita Changes that Were Made for Gustav and Ike

New Orleans residents clinging to their roofs and houses, begging to be saved from the flood waters, has become the national face of Katrina. Media coverage of dead bodies of people and an- imals swirling in the raging waters will never be forgotten. The other national story was the plight of patients and medical personnel strug- gling in the sweltering heat in flooded hospitals, medical facilities, and nursing homes. The on- going saga of the medical professionals who re- mained to take care of patients can also never be forgotten. Dr. Anna Pou, who has finally been cleared of legal charges for staying to help criti- cally ill patients, will face civil suits for a long time. The medical community in south Louisiana has been irrevocably impacted by the devastation caused by Katrina and Rita, with physicians struggling to maintain practices and hospitals dealing with severe shortages of per- sonnel.

However, the changes that were made within the medical community post-Katrina and Rita have clearly shown that adversity can be overcome, and that recovery can be the catalyst for the changes that must take place in order for the medical response to be effective in a disaster. Dogs displaced by Hurricane Ike are sheltered at the local center on Galveston Island, Texas, set up by These are not just lessons for south Louisiana the Humane Society. but for every community in the US. As dis- Photo Credit: FEMA / Jocelyn Augustino cussed in Chapter 2, hurricanes and floods are not the only disasters that will continue to

88 plague the country, and there is no community area. It must be clear who will assist with trans- the medical community had to be prepared for that can assume it is not “at risk” for a disaster portation, when this will take place, and where that possibility. Thus, plans for maintaining and possibly for a catastrophic event. the patients will be moved. Further, family good medical care within the New Orleans hos- members of all patients should be knowledge- pitals were put into effect as it became apparent In the form of a post-Gustav National Science able of the evacuation plan, so they will know that Gustav was heading toward the Gulf Coast. Foundation and Multidisciplinary Center for how and where their family member will be Because the structural rebuilding is not complete Earthquake Engineering Research (MCEER) transported. There must be a clear line of deci- in New Orleans and the soundness of the levees study (Arendt & Hess, 2008), many of the sion making and authority within the facilities is simply unknown, hospitals and medical facil- changes that have taken place within the New that cannot act independently, so that evacua- ities evacuated fragile patients and reduced the Orleans hospitals and medical community are tion can take place in an efficient manner. Fa- number of in-patients as much as possible. Ex- described through categorical themes that cility administrators must be held accountable tensive planning went into ensuring that gener- evolved out of extensive post-Katrina research. for participation in all regional disaster planning ators were available and not placed in areas MCEER is located at the University at Buffalo, sessions and communication of plans to all per- prone to flooding. New Orleans hospitals had State University of New York. The themes of sonnel. contractual arrangements to have portable gen- change MCEER describe include: (1) Con- erators delivered as Gustav headed toward structing Resilient Building Systems; (2) Plan- If all patients will not be evacuated, the facility Louisiana. ning to be Self Sufficient; (3) Networking; (4) administrators must also ensure that they can Staffing; (5) Communicating Emergency Plans; function independently with all of the patients Of course, Gustav took a much slower path to (6) Communicating in the Wake of Disaster and and personnel who remain behind. This in- Louisiana than did Katrina, so there was more (7) Leading Effectively. cludes structural resiliency, maintenance of a suf- time to put plans into action, but plans have ficient supply of consumables, proper staffing been made to deal with the need for fast deci- An overall theme that has continuously been dis- and training of staff, and communication/re- sion making. Additionally, New Orleans is not cussed is the need for hospitals and medical fa- porting processes. For the hospitals and medical taking a chance with the levee system again. The cilities to be able to function independently of facilities that plan on achieving self sufficiency, entire area surrounding New Orleans was placed government assistance. For the medically related and for disaster operations that are not depend- under mandatory evacuation orders and all non- entities that must rely on the government or ent upon outside assistance, they must take the essential medical personnel were asked to evac- emergency organizations for assistance, such as steps that many of the New Orleans hospitals uate. Medical personnel that stayed in New the nursing homes and charity hospitals, the of- have taken or are in the process of taking. Orleans to work were advised to evacuate their ficials in charge of these facilities must ensure families and pets, and avoid bringing people or that they have been a viable part of the overall Resiliency pets to the hospital (which had been a problem state planning process. This includes a detailed during Katrina). plan for identifying those patients who must be During Gustav, New Orleans and the southwest evacuated, if everyone in the facility does not part of Louisiana did not suffer from the extreme Several New Orleans hospitals have dug their have to be transported out of a potential impact flooding experienced in Katrina and Rita, yet; own water wells to ensure an adequate water

89 supply during disasters. Like the generators, also houses Earl K. Long Hospital, which is a ple, the Baton Rouge General Hospital antici- contractual arrangements were made to have large public hospital that provides care to the in- pates the cost to be in the range of $10 million portable water storage delivered as the storm en- digent population. The power was out for so for their system and Our Lady of the Lake Hos- tered the Gulf. Another change that the hospi- long after Gustav that Earl K. Long had to close pital in Baton Rouge estimates a cost of $15 mil- tals made was to have air conditioning systems down completely and send patients to other area lion. connected to emergency power sources. The hospitals. This put a burden on the other hos- high temperatures after Katrina and Rita caused pitals, who were already maintaining patients Self Sufficiency one of the biggest problems medical personnel longer than the length-of-stay guidelines because had to face. of their reluctance to release sick patients to For the medical professionals serving hospitals homes with no power. Additionally, with the as well as the hospital administration, self suffi- Interestingly, while the New Orleans hospitals extreme power outages, calling in additional staff ciency throughout the medical community be- fared well, the hospitals and medical facilities 75 and medical personnel became problematic but came a very important goal after Hurricanes miles away in Baton Rouge faced huge obstacles. not nearly as bad as it had been during Katrina. Katrina and Rita in 2005. To reach this goal, a These hospitals had taken the same steps as the Most hospitals established text messaging great deal of detailed planning has had to take New Orleans hospitals in regard to generators, processes to notify medical personnel. After Earl place across all parts of the medical community, water, medical supplies, and staffing but had se- K. Long closed, a regional hospital outside of including private practitioners, hospital staff, riously underestimated the amount of time that Baton Rouge also closed because of power out- non-physician medical staff, medical associa- they would be without electricity. All of the ages and ironically evacuated its patients to New tions, and facility administrators. All of the dif- Baton Rouge hospitals lost power and some hos- Orleans. The generator situation was greatly ex- ficulties have not been resolved or even pitals had to function off of generators for 5-7 acerbated by the lack of access to gasoline and, of identified yet, but south Louisiana’s experiences days. The situation in Baton Rouge would have course, the cost of gas at that time. with Gustav and Ike certainly indicated a vast been a disaster near the scope of Katrina medical improvement. Medical professionals and hospi- problems if communication, networking, good One of the biggest advantages that Baton Rouge tal administrators have had to determine what decision making, and leadership had not pre- maintained during Gustav was an effective radio their responsibilities are in a disaster and at what vailed. broadcast that was on air continuously to pro- point the government or emergency systems vide public announcements, communicate must step in. Once the boundaries become less Woman’s Hospital in Baton Rouge is the largest about various conditions, and provide briefings blurred, the medical community can take ap- provider of medical and health services to preg- during the day from the governor, the mayor, propriate steps to ensure self sufficiency, while nant women and babies. It has the best neona- and the necessary entities, such as energy com- becoming a full participant in local, regional, tal clinic in the area and provides care to babies panies, FEMA, and the Red Cross. Although the and state planning with all of the necessary part- who are born in need of extremely complicated medical situation was greatly improved, there is ners for effective disaster collaboration. medical care. In fact, most of the New Orleans little doubt that a major post-Gustav change will babies were evacuated to Woman’s Hospital after be related to upgrading generators, which im- Hospitals have the responsibility to maintain Katrina, until it reached capacity. Baton Rouge poses a huge cost on the hospitals. For exam- enough supplies and consumables, organize ad-

90 equate staffing, implement an infallible com- munication system, maintain a power supply that will work during a disaster, maintain a safe and strong building structure, and hire security to protect inhabitants of the hospital/medical fa- cility. These responsibilities create a self-suffi- cient environment, until there is a disaster-related intersection with problems out- side of their control. For example, during Kat- rina, there was not a hospital administrator who planned for, or had control over, a breach in the levee system. After Rita, Calcasieu Parish offi- cials were left to deal with the complete de- struction of at least one coastal parish, resulting in an immediate population increase at a time when flooding and wind damage was requiring all of the parish’s attention. After Gustav, hos- pital administrators were not prepared to deal with power outages for more than a few days, but unfortunately, it took much longer to restore power. These are points in time where proce- dures must be in place to interact with the three tiers of government, as well as emergency or- National Guard unloads commodities from a Chinook helicopter at the newly formed distribution center ganizations and outside entities who can help. in Franklin, Louisiana, six days after Hurricane Katrina. Photo Credit: FEMA / Jacinta Quesada In Katrina, as was clearly seen, there were no processes in place to get help. There was no help for the hospitals, medical practitioners, medical During and after Rita, the southwest Louisiana After Gustav, hospital officials had to depend on personnel, and, in many cases, their families. medical community had a process in place, as government intervention to help get additional Eventually, private citizens and the military were well as local leadership that enabled them to deal generators and access to gas in order to maintain able to get everyone to safety, but it was not a with most problems more effectively. Obviously, power. Several hospitals that had planned well planned or orderly process, and lives were lost they did not have the flooding and the huge in advance, maintained a huge surplus of gas for or traumatized because of this. Since Katrina, population that New Orleans had, but they cer- their employees’ cars, and other necessary med- most New Orleans hospitals have installed heli- tainly had problems with the sheer number of ical transportation. pads to evacuate patients if necessary. evacuees and the physical destruction in the area.

91 Hospitals in Baton Rouge will have to depend well as they did is because of an active and on- nicate with the medical community from a safe on outside assistance to resolve some of the fi- going association of medical community repre- place. nancial issues that evolved out of Gustav. Pay- sentatives. Because of proactive leadership in the ment for the indigent population that was mayor’s office, teams of people met regularly in In pre-Gustav Baton Rouge, the signs of inef- transferred to area hospitals when Earl K. Long Calcasieu Parish so that there was an under- fective regional and national network planning had to close, reimbursement waivers for patients standing of each person/profession’s role if a dis- were evident. The evacuation of nursing home who exceeded length-of-stay requirements be- aster occurred. Interestingly, Calcasieu Parish residents was repeatedly stalled because of con- cause of power outages, and government assis- had developed a disaster plan for pandemic flu, fusion with planes not arriving that were sup- tance to help pay for the expensive upgrades to and that process also worked for Katrina and posed to and ambulances being unavailable for hospital generators, are just three examples of Rita. As one physician pointed out, “If you services because of failure to receive clear in- appropriate reliance on the government. meet with all of the partners needed in disaster structions on which patients to pick up or pri- planning, everyone gets to know each other and oritize. As Gustav approached, the neediest

One of the first changes made within the greater New Orleans area after Katrina was the establishment of active relationships among the different parts of the medical community.

Networking trusting relationships develop.” When a disas- patients were finally air lifted out by helicopters, ter hits, it is much easier to operationalize the which had not been in the original plan. The Although a variation of several themes has been plan if all of the players know each other. important element in this example is that effec- discussed, one lesson that the New Orleans med- tive leadership can avoid making things worse, ical community learned is that there has to be a It should be noted that the networking within particularly when the person in charge knows all strong, dependable network with local, state, the medical community in Calcasieu Parish also options available to move patients and makes a and national sources of assistance, beginning involved relationships with the Louisiana State timely decision to call on others for assistance within the medical community itself. From in- Medical Society. In fact, one member’s role is to when the initial plan does not work. terviews with physicians, one of the reasons the remove important documents and contact in- southwest medical community performed as formation out of the disaster area and commu-

92 One of the first changes made within the greater signed to work during the crisis, with a support the flooding happened did not allow time to New Orleans area after Katrina was the estab- team on hold in case the effects of the disaster move the generators. Also, most of the hospitals lishment of active relationships among the dif- continue for a long time. Finally, a post-storm had satellite phones, but employees had not ferent parts of the medical community. All followup/cleanup crew is assigned. Disaster been trained in how to use them. Additionally, hospitals belong to the Metro Hospital Council teams are asked to evacuate their families and batteries were not available for the phones at of New Orleans, which is affiliated with the pets prior to a hurricane moving onto shore. In some hospitals. Louisiana Hospital Association (LHA). some of the major New Orleans hospitals, a cen- Through this group, emergency preparedness tralized location has been established through In post-Katrina New Orleans, all emergency planning is undertaken so that all hospitals can which all disaster functions are administered and planning is based upon the theme, “Plan for the collaborate to have effective outcomes after a dis- where all communications are located. After worst and make sure everyone knows their role.” aster. Many of the difficulties that happened Gustav, hospitals in Baton Rouge reported diffi- All emergency plans have been revised and all during Katrina are being addressed, such as culties in being able to locate staff since phones staff/medical personnel receive annual training methods for patient tracking and automated were down and power was out. They plan to im- at a minimum, especially before hurricane sea- prescription information. plement one of the text messaging systems be- son. In addition, the hierarchy of decision mak- fore next hurricane season. ing has been clearly established in most medical Staffing facilities within south Louisiana. Emergency Planning Before Disaster Strikes Most of the staffing problems that have been Communication During the Disaster previously discussed clearly revolve around issues Realistic planning efforts are the key to effec- such as inability to communicate, transportation tively dealing with any type of disaster, whether Regardless of the disaster type, communication problems because of flooding, no access to gas, a pandemic flu, a terrorist attack, or a weather breakdowns should be anticipated and a plan de- concern about family members, and over- event. There are numerous accounts of pre plan- veloped to address the issue. Even with the whelming job responsibilities for workers in ning in Louisiana prior to Katrina, but many of changes made in south Louisiana after Katrina shelters because there is so little staff. Numerous the plans were not tested, were outdated, or sim- and Rita, there were still problems during Gus- changes have been made to address these prob- ply not well conceived. Complacency also sets tav and Ike. Communication within the med- lems. The most significant change has been the in when plans are not drilled on a regular basis. ical community and among the three tiers of organizational planning around team efforts Two bizarre examples of poor or unrealistic plan- government must be clear prior to the disaster with very specific functions. ning that took place during Katrina involved striking. generators and satellite phones. Since the exist- Most of the facilities, whether a hospital, nurs- ing plan said generators had to be available if the ing home, or emergency medical shelter, now power went out, all of the hospitals had genera- have assigned teams to deal with disasters. There tors, but many of them were located on the first is generally one team responsible for the early floor of buildings. Thus, they were flooded preparations and evacuation; another team is as- when the levees broke. The rapidity with which

93 Some of the changes that have been made in merous examples of leadership voids and lead- If the failures of leadership during Katrina and south Louisiana include: ership “heroes” throughout all four of the severe Rita were made spectacularly visible to the na- storms that have impacted Louisiana since 2005. tion, the changes and the improvements in the • Updated satellite phones, with training of There are also examples of good leaders who functioning of all levels of the government, med- all employees; could not lead because they were blocked by ical facilities, and emergency organizations were • The purchase of numerous cell phones with higher level officials or existing policies. equally evident as Gustav and Ike struck most out-of-state area codes; of Louisiana and part of Texas. While the de- • The purchase of 800MH radios; With the crisis taking place in south Louisiana as struction of Louisiana communities was once • Housing of internet servers outside of the Katrina hit and the levees burst, it remains un- again made visible, the absence of the chaos and potential disaster area; believable that local and state officials were un- confusion demonstrated vast improvements in • The establishment of 1-800 numbers for able to get assistance in a timely manner from preparation and emergency response. There employees; the federal government. That situation con- were glitches in the evacuation processes, prob- • The establishment of a text messaging tributed significantly to the number of lost lives, lems at several shelters in north Louisiana, crit- system; the physical damage, and the mental health ical issues with power outages in the capital area • Designation of a Regional Coordinator problems that exist very prominently in south of Baton Rouge and surrounding parishes, but through whom communication would flow Louisiana today. The fear of that scenario hap- all were overcome within a reasonable amount by phones or EMS technology. pening again, however unlikely, continues to of time, with the exception of extreme damage have an impact on recovery efforts. to the power systems in the hardest hit areas. Obviously, communications systems should be implemented consistent with the likely type of In no place have we seen the impact of failed In examining some of the improved outcomes, disaster within each community: such as fires, leadership more than within the medical com- organizational effectiveness and leadership can floods, tornados, hurricanes, earthquakes, or ter- munity. Fortunately, there were plenty of lead- explain many of the changes. The amount of rorist attacks. ers and heroes that emerged out of the medical planning that had taken place across the state community during the storms and the recovery. helped local and state officials deal with the Effective Leadership However, the failed government leadership dur- problems that arose. People in charge knew that ing Katrina has no doubt led to physicians’ re- having a “Plan A” was not enough and that con- This particular theme may be the most impor- luctance to return to Louisiana, or their inability tingencies must be developed for every possible tant one of all, as the lack of decisive leadership to rebuild their practices in New Orleans and scenario. The contingencies included knowing at all levels during Katrina and Rita exacerbated coastal parishes. The failure to reopen and fund how to access assistance from other agencies, vol- what was already a horrific situation. Effective the medical schools in a timely manner, to de- unteers, and emergency organizations. leaders and decision makers can find solutions cide what to do about Charity Hospital in New in the wake of a disaster, but without that lead- Orleans, and to increase the rate at which re- Nearly two million people were evacuated from ership throughout the medical community, as covery is taking place, does not really make coastal Louisiana in an orderly manner before well as the government, chaos and confusion can south Louisiana an attractive place for physicians Gustav hit, primarily because of the planning cause insurmountable damage. There are nu- and other health care professionals to locate. and staggered approach to getting everyone out

94 of harm’s way. Pets and other animals were evac- uated first to designated sites across the state, fol- lowed by evacuation of critically ill patients and The failed government leadership during Katrina frail nursing home residents. Finally, when it was known that Gustav would hit the south has no doubt led to physicians’ reluctance to return Louisiana coast, residents were placed under to Louisiana, or their inability to rebuild their mandatory evacuation orders and martial law was implemented in deserted cities and towns. practices in New Orleans and coastal parishes. The governor had issued a preemptive state of emergency so the military was able to move rap- idly to areas in and around New Orleans. Fed- eral emergency organizations were in the state • 700 buses were in New Orleans at pre-adver- • The loss of life was minimal; fewer than 50 long before Gustav hit. There was a strong part- tised staging sites to get residents out of New people died as a result of Gustav, compared to nership among the three tiers of the government Orleans. There were several glitches, which were over 2,000 people in Louisiana from Katrina. and everyone knew what they were supposed to do. resolved quickly because of the organization and flexibility to give up “Plan A” and move to “Plan There are still many changes that need to be Examples of Leadership and B”; made and a number of new “lessons learned” from Gustav and Ike that need to be imple- Organizational Effectiveness in • There were problems with the delivery of gen- Gustav and Ike mented. Comparatively, Louisiana fared much erators from FEMA and the governor author- better in Gustav and Ike than in Katrina and ized a $20 million dollar expenditure from the Rita because of the planning that has taken place • When the planned planes and ambulances state budget to get generators to meet critical and the changes that have been made by the en- that were supposed to evacuate nursing home needs; tities impacted by hurricanes. Huge and costly residents did not appear or were inaccessible, the problems, such as upgraded generators for med- head of DHH located helicopters to start mov- • Local radio stations were able to stay on air ical facilities, complete electronic automation of ing residents out of south Louisiana. This was and coordinated public service announcements all medical records, and the development of possible because of access to emergency officials and daily reports from the governor and may- non-coastal nursing homes, will all take time who knew where the resources were; ors, as well as taking calls from citizens about and require assistance from government sources. • The local human services authority had the problems and information needs; The government, emergency organizations and LSU PMAC shelter in Baton Rouge ready and the medical community are critical to the effec- • When hospitals had to close because of power staffed for critically ill patients by noon on the tiveness with which disasters are handled. outages, the evacuation process for patients was Friday before the storm hit on Monday. The Hopefully, some of the hard lessons Louisiana timely and orderly; first patients started arriving that afternoon. All has learned can be used to help other states and volunteers and medical staff had been pre certi- communities prepare for effective disaster re- fied and trained to work in the shelter; sponse.

95

Lessons Learned and Best Practice Recommendations

Chapter 8 hrough an extensive examination of information from academic literature and from the medical Tcommunities that have experienced Hurricanes Katrina and Rita and their aftermath, the lessons learned have become all too clear. From the preliminary assess- ment of preparation and response to Hurricane Gustav (which took place three years after Katrina) it was very ev- ident that there were vast improvements within the med- ical community, mainly due to the independent responsibility of physicians, healthcare personnel, and hos- pitals. However, vast improvements were also made be- cause of enhanced system planning, preparation, and response. What are the primary lessons learned from the

Opposite left: 2005 and 2008 hurricane seasons? What can local med- This Mobile Medical Unit is set up as a clinic, ical communities do to ensure that a Katrina response which includes 575 sq. ft. of patient treatment area with diagnostic x-ray, clinical laboratory, never happens in their community? No community can pharmacy and minor surgery suite. FEMA pro- vided this transportable facility and several others control the onset of a disaster, but every community can like it to parishes affected by Hurricanes Katrina be prepared to meet whatever type of disaster they may and Rita in Louisiana. Photo Credit: FEMA / Robert Kaufmann face in the future.

97 ‘lessons learned’ in specific areas vital to effective Throughout the information gathered, there is response. These areas are described as the issues no doubt that leadership, coordination, and that hampered the medical response more than preparations are critical to effective response to others and that have required the attention of disasters. This theme evolved consistently the medical community as pre-Katrina emer- throughout the literature and through personal gency plans were being redesigned. The primary contact with medical personnel in south areas are delineated below, with a brief descrip- Louisiana. In the communities and isolated tion of the lessons learned and the action taken medical facilities that fared best in Katrina and to address the issues in an effective manner. Rita, the presence of a leader who had organized a strong and knowledgeable network of persons Communication and agencies to plan and respond to the disas- ters was the most significant factor differentiat- Lessons Learned: ing one response from another. This factor proved to be stronger as Gustav approached • Broadcast media plays a critically important The National Disaster Medical System (NDMS) south Louisiana and the effects of local, state, role during a disaster for general communica- set up one of the new, fully self-contained Mobile Medical Units (MMU) in Plaquemines Parish to national, and system leadership emerged. tion, alerting residents of danger, and making treat persons who lost access to medical care when public service announcements; Hurricanes Katrina and Rita slammed the area. In considering the effectiveness of the disaster The MMU is a complete mini-hospital. responses post-Katrina and Rita, it is obvious • Cell and radio towers are very vulnerable dur- Photo Credit: FEMA / Greg Henshall that the levee breaches exacerbated the difficul- ing a hurricane and cannot be the only commu- ties in New Orleans and the surrounding areas. nication source upon which to depend; However, the extent of preparation was a critical factor in the effectiveness of the disaster re- • Communication technology may vary across sponses. Although many of the factors that all systems, including first responders, hospitals, hampered effective disaster response were exter- law enforcement, military, and the three tiers of nal to the medical profession, interviews with government, rendering system-wide communi- physicians and medical personnel revealed many cation impossible (80% of city emergency net- ideas on how to be better prepared so that a re- works were incompatible with federal agencies); sponse is efficient, effective, and more within the control of physicians and hospitals. • The Internet works well for posting informa- tion at a centralized location if the disaster does Under the broad umbrella of leadership, coordi- not destroy utilities. It is helpful in the recovery nation and preparedness are very valuable process when power is restored, particularly for missing persons;

98 • Text messaging systems seem to work well; • Communication methods to consider are two way radios, text messaging capabilities, satellite • Hand-held radios have some difficulties in op- phones, and PDA’s, all used in conjunction with erating system wide; if used, compatibility and staff training; strength should be verified; • Establishment of a 1-800 number with a des- • Two-way radios, marine band radios and out ignated point of contact outside the disaster area of area cell phones are other options, considering is advisable; the geographic location; • Education should be undertaken with citizens • Even when a major Internet hub and and companies so that everyone will understand radio/television stay intact, if citizens are not ed- mail, bank services, automatic deposits, and tele- ucated on generator use or access to fuel and phones rarely work in high-impact areas. Bill maintenance of a good portable radio with bat- payment is disrupted and can rarely be explained Aerial of roughly 300 ambulances staged at teries, it does not help with communications; until power and utilities are restored. Compa- Kelly USA, in San Antonio, Texas, on July 20, nies should develop policies around these issues; 2007, in preparation for . The • Mail is not delivered during a disaster and is EMS resources were activated to assist the state in evacuation of hospitals, nursing homes, and not easily restored in high impact areas. • State officials should consider a single radio patients living at home with significant medical frequency exclusively for emergencies, if one is problems when the storm. Best Practices to Prepare for Effective not yet in place. Photo Credit: HHS / Sandy Bogucki Communication: Transportation require assistance; • Local government should test and upgrade local communications systems, in conjunction Lessons Learned: • Regardless of the planning, emergency re- with compatibility checks with state, national, sponse transportation is easily overwhelmed in and emergency systems; Even with a large-scale disaster, it is difficult to a disaster, particularly because of unplanned oc- evacuate all of the citizens without well planned currences (i.e., buses flood before put into use; • Local and state government should develop organization and massive government, emer- drivers delivering fuel cannot get through so their communication plan together, ensure con- gency, and volunteer assistance. there is no gas on the evacuation route); sistency with national and emergency organiza- tion plans, test and revise the plan annually, and • Elderly, critically ill, and disabled populations • Hospitals, medical facilities, and nursing have a backup plan for the worst case scenario; are less likely to evacuate on their own and will homes must be an integral part of all evacuation and emergency planning efforts;

99 Best Practices to Prepare for Effective Transportation:

• Include transportation issues in all aspects of emergency planning;

• Adopt philosophy of “Expect the best and plan for the worst scenario” when considering transportation, especially evacuation;

• Address transportation related staffing issues within separate systems, as well as system wide. Access to fuel and ability to get to work are but two major considerations for proper staffing; Two years after Hurricane Rita destroyed South Cameron Memorial Hospital, it reopened its doors this time mitigated to reduce potential loss of property and medical equipment against future disasters. • Ensure that a failsafe system is put into place Having weathered Hurricane Ike, the mitigation measures of building safer, smarter, stronger proved to to identify, contact, and evacuate vulnerable be invaluable, as the hospital received only minor damages. populations (Katrina lost many disabled and Photo Credit: FEMA / Calvin Tolleson wheelchair bound people who drowned because no one came to get them or move them to • Evacuation plans must be based on the pre- • All evacuation vehicles used to transport peo- higher ground); dicted amount of use of personal autos vs. the ple and pets should be tested for air circulation use of buses, trains, and air services. Katrina re- systems, safety, and operation under stress (long • Focus on mass transit evacuation vs. personal flected the failure to serve the non-driving pop- hours on highway, people boarding with large automobiles. Buses get more people out faster; ulation, while Rita reflected the failure in amounts of luggage); the use of cars by everyone can cause major con- planning related to the number of people using gestion. Trains and air support remove conges- their cars to get out of harm’s way; • All evacuation plans are dependent upon the tion from the highways; availability of fuel and the drivers who must • Evacuation planning must consider the need show up for work, get through the traffic, and • Effective communication ability and trans- to evacuate critically ill, special-needs, elderly, deliver the fuel, particularly along the evacua- portation go hand in hand. Extensive joint and other vulnerable populations first; tion route; planning, and testing should be undertaken;

• Evacuation planning must include people’s • The value of air transport cannot be underes- • Major trauma centers or centralized hospital pets or they will not leave; timated, especially if a disaster hits without no- locations should have a helipad. tice or with little time to respond.

100 Sanitation • Evacuees who walk through flood waters are very susceptible to a number of illnesses and in- Lessons Learned: fections from unsanitary conditions;

• A large-scale disaster can render drinking • Delivery of necessary equipment in shelters water facilities and water mains inoperable; may be delayed because of the traffic situation and delivery workers’ ability to get to their work- • Drinking water may be contaminated by place. flooded sewerage lines; Best Practices to Prepare for Effective Sani- • Water quality is a huge concern in the pre- tation Systems: vention of diseases, such as diarrheal disease, par- asitic infections, typhoid fever, and epidemics; • Hospitals, shelters, and medical facilities must have supplies on hand to test water quality; • Standing flood waters create a breeding ground for mosquitoes in areas generally im- • Educate appropriate agencies, as well as the pacted by hurricanes; citizenship, on procedures for disinfecting water; Flooding left behind unsanitary conditions, contaminated drinking water and mold in many medical facilities. • Sanitary conditions in shelters and medical fa- • Educate agencies and citizens on the risks of Photo Credit: Floyd A. Buras, MD cilities must be maintained. using or walking through flood waters;

• Water quality, airborne disease, and contami- • Develop a plan and train employees, who are • Have a backup plan for shower installation in nation of articles brought into shelters can cause placed in shelters at hospitals, and other medical shelters; serious illness and infection; facilities, on procedures to be used if water and plumbing become inoperable; make sure there • Develop a follow up and backup plan if nec- • Hospitals should maintain an independent is a backup plan; essary equipment is not delivered in a timely water supply; manner to shelters; • Alert citizens and shelters (human and pet) of • Hospitals and shelters can have serious prob- the signs of the most likely infections that will • Screen volunteers to ensure they have proper lems if plumbing goes out. Sanitary conditions develop as a result of unsanitary or overcrowded shots and are healthy enough to be involved with are difficult to maintain without good water and shelter facilities; human and pet shelters because of sanitation is- plumbing; sues.

101 Consumables and Supplies • All supplies should be kept in a safe place and • More powerful generators are needed; updated regularly or delivered in ample time Lessons Learned: pre-disaster; • Generators only work if there is access to fuel, unless it is a natural gas generator, which might • Medical facilities that remain open and/or are • There must be an effective post-disaster plan also be compromised; temporarily being used must have stockpiles of in place to get medication and supplies into the supplies on hand from drinking water to tetanus area for first responders, emergency workers, law • Hospitals need approximately 200 gallons of vaccines and insulin; enforcement, and medical facilities that may fuel per hour to keep their emergency genera- have remained open, especially if the impact area tors working; • Particularly needed items include water, pain is isolated and under martial law; medication, catheters, and IV lines; • If air systems are not connected to the power • Pre-arrange access to organizations/agencies source, when utilities return, electronic devices • Post-storm medications for workers and first that can provide four wheel drive or other emer- will overheat a room very quickly; responders must be deliverable within the im- gency transport vehicles for evacuation and /or pact area, especially if martial law has been es- delivery of supplies. • Valuable data can be lost from laboratory and tablished; other high-tech facilities when power outages Utilities occur; • Physicians do not have access to consumables and supplies without communication and trans- Lessons Learned: •Adequate utility plans must be made for the portation from outside of the impacted area. “special-needs” population in a potential disaster • Lack of utilities, including water quality and area, which is significant because of the coun- Best Practices to Prepare for Consumable availability, severely hampered medical opera- tries’ aging population. and Supply Shortages: tions in high-impact areas, and added new com- plications for post-disaster treatment; Best Practices to Prepare for Utility Mainte- • For hospitals that have been identified as re- nance and Shortages: maining open and for medical shelters to be es- • Air conditioning is not a luxury in south tablished, detailed planning must go into the Louisiana; it is a necessity in the hospitals and • Maintain a list of all equipment and utility supplies and medications that will be needed shelters at a minimum; systems that must be reset or restarted when during a worst case scenario. Depending on the power returns, with printed instructions clearly type of disaster, hospitals, nurses, and physicians • Generators fail for various reasons and with- posted for whoever might be responsible for should be able to identify the medical supplies out an alternative plan, the lack of utilities in restarting the system; necessary to sustain themselves during a cata- hospitals and shelters can be deadly; strophic event and have a back up communica- • Hospital and other facilities must adequately tion/transportation plan in place to get supplies plan for the amount of fuel they will need for if needed; utilities;

102 Specific Medically Related Concerns Lessons Learned:

• Medical Records

Some evacuees with medical conditions are unable to explain their diagnoses and prescriptions;

Physicians must determine how to treat patients in a temporary medical shelter with limited diagnostic equipment;

Physicians and other health care per- sonnel have expressed great concerns about liability, although medical care was provided in the most effective way possi- ble;

There was valuable time lost in the treatment of seriously injured people with- out any idea of their medical history; i.e., FEMA public assistance specialists inspect the Starr County Memorial Hospital in July 2007 with a hos- snake bites and heart attacks; pital administrator to determine if the county will be eligible for federal assistance to offset expenses caused by the recent flooding. Photo Credit: Bob McMillan/ FEMA Photo Most people do not evacuate with med- ical records and prescription information;

• Ensure that generators are in safe locations, • Plan and stockpile necessary supplies in the In a catastrophic disaster such as Kat- especially away from flood waters or where the event utilities are out for a week or two; rina, medical records and physician prac- exhaust can cause damage to people; tices are destroyed; • Consider upgrading hospital generators. • Ensure that critical data is backed up with off- The Veterans Administration does have site copies and computer servers are in a safe an automated records system available na- place; tionwide for participating veterans;

103 The law does not adequately deal with Most medical volunteers were gravely A national protocol for automated medical record issues during a catastrophic concerned about liability issues, although record keeping should be developed, with event; nor does state policy. they performed the work that needed to be incentives for physicians to implement this done. expensive record keeping system; • Volunteer Medical Personnel During Disasters • Reliance on Major Hospitals in Disaster Area Citizens should be educated to keep copies of prescriptions, insurance and med- Many badly needed physicians could not The major trauma centers and hospitals ical information, including maintenance of be utilized because of bureaucratic red tape in New Orleans were unable to function a copy with someone in another location, and an inability to get requirements waived after Katrina and there were major com- especially individuals with critical medical in an acceptable amount of time; plications from damage to the Calcasieu needs; Parish facilities post-Rita; Military personnel would not allow the Ensure that laws are consistent with Red Cross to enter into the high-impact Aside from the pre-storm population of modern medical needs; areas because of 1) fear for the personal critically ill, special-needs, and vulnerable safety of the Red Cross workers, and 2) persons, there were significant medical Ensure that physicians and other med- what might result in the unintended con- problems requiring treatment post storm, ical personnel are protected from liability sequence of encouraging local residents to such as asphyxiation from misuse of gen- concerns when treating persons during a stay in the devastated area when evacuation erators, broken limbs from falls, electrocu- disaster; of all non-essential persons was necessary tions from downed power lines, and mandated; snakebites, and the spreading of disease Stringent policies and laws must be de- due to poor sanitation; veloped to enable appropriate medical per- There was a serious problem with the or- sonnel to access anyone’s medical ganization of medically related services and Few medical facilities were independ- information during a disaster, while deter- assets that could be used by the medical ently equipped to deal with the huge surge ring inappropriate persons from violating community and individuals helping with and influx of persons needing medical privacy policies and laws. disaster response; care. • Volunteer Medical Personnel During Disaster Housing availability was a problem for Best Practices to Effectively Address volunteers and was especially difficult dur- Medically Related Issues: Pre-certification must be accomplished ing power outages; prior to admittance of volunteer physi- • Medical records cians, nurses, medical personnel, or veteri- Volunteer pharmacy personnel experi- narians to any disaster sites; enced a great deal of difficulty setting up pharmacies;

104 There is an abundance of outside help age area, and allowing pre-filling of pre- The lessons learned from Hurricanes Katrina available from medical personnel as well scriptions so people can get enough med- and Rita are numerous and complex. Some as medical supplies, but it has to be or- ication to last through an evacuation things can be easily corrected; other memories ganized prior to the disaster for the help period; and lessons must be placed in the past. Because to be available and effective; of the Louisiana experience, it has been the in- Setting up portable and surge hospitals tent of the Louisiana State Medical Society to Establish new policies or laws that with federal emergency medical teams to present this information in a way that will be waive liability issues for pre-certified med- augment existing medical help; helpful to other states and communities. In the ical personnel during a previously defined words of one Louisiana physician: disaster event; Establish mobile medical teams to help deal with medical needs during the recov- “I think it is fair to say that no one was really pre- Develop a housing plan for volunteers ery process; pared for Katrina. That was a shot out of the dark- who are on-site in a post-disaster area, es- ness that nobody, I think, in their wildest pecially when their assistance will be Ensure that security is considered a part imagination really thought would happen, you needed for weeks or months. of any disaster related medical facility; know. We all talked about the Armageddon sce- nario, the right hurricane coming right up the • Temporary Medical Facilities Address the issue of medical records, mouth of the river, blah, blah, blah. But, I don’t which most likely can only happen with think anyone really thought that it would happen.” Disaster plans should include the estab- electronic records. lishment of temporary field hospitals, with functioning pharmacies included; There must be a more effective plan for I think it is fair to say that no one was really transporting patients out of the disaster “ area into areas where medical services are prepared for Katrina. We all talked about available quickly. Air support is critical; the Armageddon scenario, the right hurricane Make sure that policies are set in place to waive Medicaid, Medicare, and insur- coming right up the mouth of the river, blah, ance rules across a wide range of difficul- ties, such as transporting people from blah, blah. But, I don’t think anyone really nursing and hospitals to outside facilities thought that it would happen. without getting prior approval, making prescriptions available outside the cover- ”

105 Appendices

1. Morbidity and Mortality Outcomes from Hurricane Katrina The appendix summarizes results from health surveillance systems published in the CDC, Morbidity and Mortality Weekly Reports [MMWR]; MMWR 2005:54#35; MMWR 2006:55#2; MMWR 2006:56#9.

2. References 3. Photo and Figure Credits 4. Interview List

106 Health Outcomes o 1,037 of the events were for relief - Illness surveillance and rapid needs assess- workers, 2,567 were for residents, ment of evacuee evacuation centers in Col- A) Direct morbidity and mortality: Outcome and for the remaining 3,904 status orado, Sept 1 - 23: associated with direct storm effects & immediate was unknown. o Sept 7 – 21: 3,600 evacuees arrive at aftermath Lowry Evacuation Center, Clinic at - The above described active surveillance pro- Lowry has 509 evacuee visits. 10 - Disease Surveillance, Louisiana and Mis- gram was interrupted by Hurricane Rita, but cases of vomiting or diarrheara,10 sissippi, Aug 29 – Sept 11: 22 cases of vib- reestablished on Sept 25, which corresponds cases of acute cough and fever, 15 rio illness in Louisiana and Mississippi to repopulation. Between Sept. 25 and Oct. cases of wound infection or cellulitis, between August 29 and September 11. 15, it recorded 17,446 visits to participating 17 mental health concerns. facilities: Majority of visit were for medication - Admissions to CO poisoning treatment fa- o 8,997 (52%) for illness refills (not counted). No outbreaks cilities in Louisiana, Alabama, and Missis- o 4,579 (26%) for injury of infectious disease were identified. sippi: 51 total cases, 16 cases on non-fatal o 3,870 (22%) for non-acute or CO poisoning and five fatal cases in undetermined reasons - Health hazard evaluation of New Orleans Louisiana o For the 13,717 for which disposition police and fire, Oct 17 – 28 and Nov 30 – was known, 11,169 were discharged, Dec 5 included 912 police officers (~70% of - An active surveillance system of functions 1,500 were admitted to a hospital, the current force) and 525 (77% of the cur- emergency treatment locations including 537 left without medical advice or rent number of firefighters): open hospitals and emergency clinics in Or- treatment, 486 were transferred to o 51% of firefighters and 30% of police leans, Jefferson, Plaquemines, and St. another facility, and 25 died. reported floodwater contact with Bernard Parishes between Sept 8 – 25, 2005 o 1,235 visits by relief workers were nose, mouth, or eye. 52% of police reported 7,508 total health related incidents: reported, 5,437 were among and 63% of firefighters reported o 4,168 (56%) were for illnesses residents, and 6,904 were unknown rescuing citizens from flooded areas. o 2,018 (27%) were for injuries status. o 69% of police officers and 59% of o 1,321 (17.5%) were for non-acute o Of the patients admitted to a firefighters reported that they were complaints, including medication hospital, 27% had heart conditions, not living with family refills, wound checks, cast removals. 12% had nondiarrheal o 28% of police and 31% of o 14 cases of CO poisoning and 27 gastrointestinal illness, 7% had a firefighters reported upper respiratory cases of exposure to toxic substances mental health condition, and 6 had symptoms. 21% of police and 23% were found. heat related illness. of firefighters reported cough. 54 of o For the 6,167 cases where disposition o Of the 25 patient deaths, 23 had police and 49% of firefighters was known, five died and 552 were illnesses while 2 died of injuries. reported rash. admitted to hospitals.

107 o Numerous police and fire reported o Approximately 20 clusters of medication refill, 11% chronic lacerations, sprains/strains, falls, and diarrheal illness in shelters in disease, 11% for respiratory illness, animal bites/stings. Louisiana, and 1,000 cases of 15% other reasons including o 19% of police and 22% of diarrhea and vomiting in shelters in dizziness, allergic reaction, sore firefighters reported symptoms of Texas and Mississippi. throat. 23% were admitted to the PTSD, 25% of police and 27% of hospital. One died of pneumonia firefighters reported major depressive - Clinic at Reliant Park, Sept 2 – 12: 1,169 after refusing hospital admission symptoms. persons who reported symptoms of acute gas- troenteritis at the Reliant Park evacuation - Morbidity surveillance of emergency clin- - Morbidity surveillance of emergency clin- center in Houston. This number corresponds ics (ECs) and health-care facilities (HCFs) ics (ECs) and health-care facilities (HCFs) to 18% of persons treated at the health clinic that served Katrina affected population in that served Katrina affected population in there. Medical personnel, police and volun- Arkansas, Louisiana, Mississippi, and Texas, Arkansas, Louisiana, Mississippi, and Texas, teers also report symptoms. No deaths re- Sept 1 – 22: Sept 1 – 22: ported. o EC surveillance, Sept 1 – 22: 14,531 o EC surveillance, Sept 1 – 22: 14,531 visits. 33% for chronic illnesses, 27% visits. 33% for chronic illnesses, 27% - State wide daily syndromic surveillance for GI illnesses, 20% for respiratory for GI illnesses, 20% for respiratory from Sept 8 – Oct 26 at approximately 500 illnesses, 18% for rashes, < 6% for illnesses, 18% for rashes, < 6% for evacuation shelters in Louisiana sheltering injury and mental illnesses injury and mental illnesses over 50,000 persons recorded 39,217 patient o HCF surveillance, Sept 5 – 22: 9,772 o HCF surveillance, Sept 5 – 22: 9,772 encounters: visits, 58% for injury, 16% for visits, 58% for injury, 16% for o Including influenza like illness and respiratory illness, < 10% GI, rash, respiratory illness, < 10% GI, rash, rash along with cases of skin chronic conditions and mental chronic conditions and mental infection. illnesses combined illnesses combined o Chronic conditions, which accounted for 31% of encounters. C) Disruption of Medical Service B) Displacement from home, social network, o Mental health conditions accounted providers, & medical history. for 9% of patient encounters. - A Rapid Health Needs assessment of 1,360 displaced heads of households in evacuation - Surveillance of evacuation centers during - Illness surveillance and rapid needs assess- centers in San Antonio, TX found, 91% are the first 3 weeks after the Hurricane: ment of evacuee evacuation centers in Col- from Orleans Parish: o One case of norovirus at an evacuee orado, Sept 1 - 23: center in Texas. o Sept 1 – 23: 124 evacuees visits to o 42% reported household member o A cluster of 30 cases of MRSA at an Colorado Hospital EDs. 20% for with chronic medical condition, 28% evacuee center in Texas. pain or headache, 13% for with physical or mental disability,

108 20% with someone needing o EC surveillance, Sept 1 – 22: 14,531 health services on the SPRINT-E counseling visits. 33% for chronic illnesses, 27% assessment, 33% indicate probable for GI illnesses, 20% for respiratory need on SPRINT-E -Illness surveillance and rapid needs assess- illnesses, 18% for rashes, < 6% for ment of evacuee evacuation centers in Col- injury and mental illnesses - A survey of 112 occupied homes in areas of orado, Sept 1 - 23: o HCF surveillance, Sept 5 – 22: 9,772 four parish region where residents were per- o Sept 4 – 9: Rapid needs assessment of visits, 58% for injury, 16% for mitted entry found: 106 heads of households at the respiratory illness, < 10% GI, rash, o Flood levels are > 6 ft in 19%, Lowry. Nearly all report member of chronic conditions and mental 3 – 6 ft in 17%, 0 - 3 ft in 25%, and household with common acute illnesses combined zero in 39%. 68% of homes had medical condition, 34% report water leaking through roof damage. thirst/dehydration, 22% report D) Emergent Effects of Exposure to Hazards o Visible mold growth was found in dizziness/lightheadedness, 19% 46% of homes, 17% displayed mold report problem breathing, 17% - During Oct 17 – 22, CDC teams surveyed coverage > 50% on interior wall in report cough, 12% report residents that had returned to Orleans and Jef- most affected room diarrhea/vomiting, 12% report skin ferson Parishes: o Participants reported an average of rashes. Many also reported members o Housing Units: 22% lacked water, 13 hrs heavy cleaning and 15 hrs with chronic medication conditions, 25% lacked electricity, 43% lack tele light cleaning since the hurricane. 28% report hypertension, 23% phone. 61% of participants stated that they depression or other psychiatric illness, o 50% of adults exhibited emotional had inhabited their homes overnight, 21% asthma or chronic lung disease, distress 25 hrs average number of nights 18% report cardiovascular disease, o 56% of homes included at least on inhabited and 14% report diabetes. 60% of member with a preexisting chronic households report one or more health condition, 53% of homes - A convenience sample of 159 residents and member requiring prescription included a person that had been ill in 76 remediation workers with potential mold medications, of which 39% were the 7 -8 weeks since Hurricane exposure: lacking them at the time, and 435 Katrina. 23% of household reported o Residents: 42% had cleaned up mold had gone without them as result of problems obtaining health care, only of which 69% did not always use Katrina. 9% reported problems obtaining appropriate respirators prescriptions. o Workers: 91% had cleaned up mold - Morbidity surveillance of emergency clin- o Emotional concerns reported: 43% of which 35% did not always use ics (ECs) and health-care facilities (HCFs) report feeling isolated, 26% of appropriate respirators that served Katrina affected population in households contain one or more Arkansas, Louisiana, Mississippi, and Texas, members need counseling, 50% Sept 1 – 22: measure possible need to mental

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115 Nadel, B.A. (2006). Security and disaster planning: Power outages and hurricane season. Retrieved March 13, 2007 from http://www.buildings.com/Articles/detail.asp?articleID=3250.

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118 Photo and Figure Credits

Photographs, Aerial and Satellite Images

FEMA and HHS photographs were obtained from the Federal Emergency Management Agency Photo Library, retrieved February 9, 2009, from http://www.photolibrary.fema.gov/photolibrary/index.jsp.

NOAA satellite images of hurricanes Katrina and Rita were obtained from the National Oceanic and Atmospheric Administration’s Satellite Services Divi- sion hurricane archives, retrieved February 12, 2009, from http://www.ssd.noaa.gov/GOES/2005/Katrina/gmex/vis-l.jpg and http://www.ssd.noaa.gov/GOES/2005/Rita/gmex/vis.jpg respectively.

USGS images of the destruction of Chandelour Islands were obtained from the United States Geological Survey’s Coastal Change Hazards web site, re- trieved February 9, 2009, from http://coastal.er.usgs.gov/hurricanes/katrina/photo-comparisons/chandeleur.html

119 Figures

Figures 1, 2, and 8: Cartography by S. Ahmet Binselam, LSU Hurricane Center. Data sources: US base map vector data layers extracted from ESRI Data & Maps 2006 dataset, and Louisiana vector data layers from The Louisiana GIS Digital Map - May 2007 Compilation DVD Set.

Figure 3: National Hurricane Center (2005). Retrieved February 9, 2009, from http://www.nhc.noaa.gov/archive/2005/KATRINA_graphics.shtml

Figure 4: National Oceanic and Atmospheric Administration, Hurricane Research Division (2005). Retrieved February 9, 2009, from ftp://ftp.aoml.noaa.gov/hrd/pub/hwind/PostAnalyses/2005/AL122005/AL122005_swath_LA_max1minWind_mph.pdf

Figure 5: United States Army Corps of Engineers (2008). Performance Evaluation of the New Orleans and Southeast Louisiana Hurricane Protection System. Draft Final Report of the Interagency Performance Evaluation Task Force Volume I – Executive Summary and Overview Retrieved February 13, 2009, from https://ipet.wes.army.mil/

Figure 6: LSU Center for the Study of Public Health Impacts of Hurricanes (2005). Retrieved February 9, 2009, from http://hurricane.lsu.edu/floodprediction/katrina25/images/Katrina25_LA_MS.jpg

Figure 7: Cartography by Ezra Boyd, LSU Hurricane Center. Data sources Ezra Boyd, LSU Hurricane Center, and LSU Natural Systems Lab.

Figure 9: National Hurricane Center (2005). Retrieved February 12, 2009, from http://www.nhc.noaa.gov/archive/2005/RITA_graphics.shtml

Figure 10: LSU Center for the Study of Public Health Impacts of Hurricanes (2005). Retrieved February 9, 2009, from http://hurricane.lsu.edu/floodprediction/rita24/images/adv24_SurgeTX_LA.jpg

120 Interview Reference List

Personal interviews were conducted by Linda Robinson with the following individuals on the dates noted:

Dr. Albert Barrocas (March 20, 2008) Dr. Ken Mattox (May 8, 2008) Ms. Charlene Baudier (March 12, 2008) Dr. Louis Minsky (April 18, 2008) Dr. Floyd Buras (November 17, 2008) Dr. Melanie McKnight (April 23, 2008) Dr. William Cassidy (April 17, 2008) Dr. Norman McSwain (July 7, 2008) Dr. Kevin Contreary (May 6, 2008) Dr. Kate Rathbun (March 28, 2008) Ms. Susan Dantoni (February 28, 2008) Dr. Kevin Stephens (April 17, 2008) Dr. Peter Deblieux (June 12, 2008) Dr. Mark Townsend (June 16, 2008) Dr. Karen DeSalvo (June 14, 2008) Dr. Louis Trachtman (March 26, 2008) Dr. Phillip Gardner (April 15, 2008) Dr. John Van Hoose (May 14, 2008) Dr. Lenworth Jacobs (June 17, 2008) Dr. John Wales (May 8, 2008) Dr. Kevin Jordan (June 16, 2008) Ms. Linda Wranosky (May 14, 2008) Captain Joe Leonard (May 13, 2008) Mr. Fred Young (May 26, 2008)

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