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Life in Astrocity, Population

2005; Lippincott Williams & Wilkins; Volume: 27; Issue: 10 Linguagem: Inglês

10.1097/00132981-200510000-00020

1552-3624

Kenneth L. Mattox,

Disaster Response and Management

Sept. 3: Day 1 at the Astrodome I have been very busy today since before dawn, working with state, county, city, and other agencies to bring almost 30,000 evacuees to Houston from New Orleans. Massive multiagency activity has been going on since 2 a.m. today. Some patients are being evacuated from New Orleans area hospitals directly to Houston hospitals. Numerous special needs patients are going to special facilities. The Houston Veterans Affairs Medical Center will serve as a regional receiving point for up to 140 patients and families under the National Disaster Medical System (NDMS) and the New Orleans VA Medical Center. We have more than 1,000 evacuees in a number of Red Cross centers, and thousands more in the homes of friends and relatives. The big evacuation is from the New Orleans Superdome to the Astrodome. Up to 23,000 people are being transported from the Superdome to the empty Astrodome. We spent the morning addressing 10 different planning and logistic categories, with medical care being one major category. I am co-chair of that activity. We spent the middle part of the day designing a health care facility, not an in-patient hospital. It will be housed in 100,000 square feet with pediatric, mental health, urgent care, pharmacy, laboratory, and radiographic capabilities. We will have a refill pharmacy and the capability to transfer to Ben Taub General Hospital or other area hospitals for those who need hospitalization.Figure: Hurricane Katrina survivors were evacuated from New Orleans to the Houston Astrodome Red Cross Shelter.We will staff it 24 hours a day, 7 days a week, and will have 20 examination rooms, five doctors a shift, and a holding bay of 20 beds where patients might be observed for up to four to six hours. Imagine designing a clinic facility for a town of 23,000 in four hours. We did it. We went out to the Astrodome, and with almost military-like command, got it staffed, equipped, computerized, and curtained off, and set up telephones and medical records in about eight hours. Volunteerism by doctors, nurses, and technicians has been overwhelming. I am very tired, and many of you never thought you would ever hear me say that. I plan to sleep an hour and be out there at midnight when they arrive. We have no names, no records, and no warning about what their medical needs might be. Food, clothing, soap, water, and cots are under the planning authority of others. Baylor College of Medicine and the Harris County Hospital District, with help from the University of Texas Health Science Center at Houston and the Harris County Medical Society, are the medical lead agencies for health care. I want to thank the many people on the list server who have made things happen, and have displayed a tremendous outpouring of love, concern, and leadership. I give my strongest congratulations for a job well done to those dedicated doctors and nurses who have served these and other patients and evacuees over the past three days and under some terrible circumstances.Figure: Members of the Louisiana National Guard and the Dallas Disaster Medical Assistance Team ferry litter-borne evacuees from a truck for transport to a triage area inside the New Orleans airport.Sept. 4: Day 2 at the Astrodome AHC stands for Astrodome Health Clinic, where I have been since 5 a.m. this morning. First, it must be understood that this is only one part of a tremendous effort to address the issues of the displaced persons. By 10 p.m. tonight, we expect more than 40,000 displaced persons from Louisiana in Houston. The supervision and governance is very much like a military operation with specific missions and disciplines. Some of the private hospitals have made arrangements with hospitals in New Orleans to fly patients to Houston. Under the National Disaster Medical System, several C-130 flights were made. Harris County was assigned one specific mission: Move no more than 25,000 of the inhabitants of the Superdome to the Astrodome and provide health care for them. (I was part of this last assignment.) Our mission was clearly defined by the governor, mayor, and county judge. We were not to receive or care for NDMS patients at the AHC; they were to go elsewhere, and not Harris County hospitals, including Ben Taub. AHC opened at 8 a.m., and we had seen 500 patients by noon. We sent 25 to Ben Taub at opening and another 30 during the day. We admitted three patients during the night and 15 during the day. We had one heart attack, one case of chest pain, and the death of an elderly patient. During the night we received five patients from NDMS, and had to call command and remind them of our individual missions. The problems are much like those seen in any primary care clinic, with virtually no surgical problems. There are some superficial skin infections from the dirty water, lots of asthma, lots of diabetes concerns, and huge numbers of people who needed prescription refills. We saw about 10 patients who had chronic renal failure, whose last dialysis was five days earlier. Significant numbers of mental health issues exist. We have had a tremendous response to appeals for nurses, doctors, clerks, and registrars. The contributions from the community — everything from food, blankets, and towels to time — have been fantastic. The most amazing thing was how 400 local, state, and federal agencies worked together. We have absolutely rigid communication and authority standards and twice-daily meetings. We have some rigid agreed-upon rules. This is a very fluid situation with lessons learned at this minute influencing our next move. Our planning yesterday morning was based on thinking outside the box, not trying to do more with less. Today brings new lessons, new calm, new crises, and new observations. The organization of volunteerism and humanity nationwide is so overwhelming. I cannot begin to know how to thank the millions of people and corporations who have given from the heart because others are in need. I saw looks of hope today where there was once great despair. Today there were four attempted suicides by displaced people from Louisiana. One will be fatal. This is the time when increased suicide attempts begin to appear following such a catastrophe. We were aware of this during our initial planning, and the mental health program was one of the first pieces of medical planning. From the moment of arrival, we wanted to do many things to give these people hope, starting with a bath, new clothes and shoes, a personal pack containing a toothbrush, toothpaste, deodorant, soap, a razor, shaving cream, a blanket, and a cot — a beginning. Innumerable accoutrements of hope are added at every level by all personnel. Be aware that despair leads to attempted suicide.Figure: Emergency workers at the New Orleans airport slept on cots in baggage claim, and were fed outside behind the airport. Some 2,700 workers were housed there, and although they had portable showers, the city's water was undrinkable.For the first time, the etiology of clinic registrants began to change to gastroenteritis rather than asthma and prescription refills. The epidemiologists are on top of possible outbreaks of Hepatitis A and other infectious or contagious diseases. No symptoms of cholera, however. We involved the public health authorities when the first patient presented with diarrhea. I cannot tell you how incorrect our hospital disaster plans and even trauma incident command plans have been. I recently re-read several of the classic and much publicized disaster and mass casualty guidelines written by “disaster specialists,” surgeons, and various agencies, some governmental. They are really distant from reality, written from theories based on incorrect assumptions.Figure: Evacuees from Hurricane Katrina are transported to the New Orleans airport where they were given food, water, and medical attention provided by FEMA's Disaster Medical Assistance Teams, who came from all over the United States to serve these victims.The almost complete absence of trauma cases has been extremely interesting. I have made lots of notes concerning the composition of such a treatment team. It was my decision at the Incident Command Center to appoint a family and community medicine physician as the medical director of the clinic at Astrocity. He did a lot of things differently from how the disaster manuals and I would have. We gave him authority and orders to think outside the box and develop innovative approaches based on traditional proven clinic principles. He cleared these infrastructure ideas with the command center, but he and the administrative structure were some of the best decisions that we made as far as appointments were concerned. I am envious of the clinic he created, which responded to the peaks and valleys of an ever-changing caseload, etiology, and multitude of specialty egos. One new observation is that many of the mental health patients on the floor of Astrocity do not wish to leave the floor to go to the clinic. So we have had to adapt. Special needs patients emerge: deaf, wheelchair-bound, paraplegic, and on home oxygen therapy. One of the rogue groups yesterday afternoon spread word among the volunteers that they must protect themselves from respiratory disease by wearing masks. Suddenly, we saw a wave of masks on all the volunteers. A wave of paranoia went through Astrocity that there was a tuberculosis epidemic and that the workers were protected but the people were not. It took a high-level command and stepping on some fairly big toes to make this mask issue go away. After the discovery, it took about 37 minutes to remove the masks from workers in more than 45 different Astrocity locations. As suggested by personnel at the Astrocity command center and quickly adapted and amplified by the Mayor, County Judge, Governor, and now President Bush, we are charged with implementing by Monday morning a plan to combining a distribution plan across the United States, with Houston being the west side receiving and redirection center. Dozens of cities in Texas and hundreds of cities in other states such as Utah and Michigan will set up small, dignified shelters, community-based job fairs, skills training, and economy-building programs. It can and will work. I spent several hours on the floor today talking to displaced people about the plan, and they are eager to start. This will require us to move quickly to keep buses moving west and north after initial registration, medical screening, bath, hot meal, and tetanus immunization. They will become a thousand points of hope and rebuilding. Please join me and others throughout this country in providing leadership in your community to rebuild America. You do not need to head to Houston, New Orleans, or other places for medical voyeurism, but spend your energy and those of your eager nurses and medics to be part of this magnificent wave of opportunity. This train is moving and about to leave the station. Do not be left behind.Figure: A Disaster Medical Assistance Team member, left, assures a rescued man that the trip to Louis Armstrong International Airport in New Orleans will be safe. Thousands of people were airlifted from the Ernest N. Morial Convention Center pickup site every day.Sept. 5: Day 3 at the Astrodome I will be brief today because I am tired. We have 200,000 people from Louisiana in Houston tonight, with up to 40,000 in the motels and hotels of the city. The count in the Astrodome tonight is 15,000, with new plans for up to 16,000 in the next couple of days as Houston becomes an in-transit city, a city of initial evaluation and registration before a controlled distribution to other locations throughout Texas and other states. Last night more than 400 buses arrived, most of which we knew nothing about until they did. Today many, many volunteers arrived, some with their own idea of mass casualities and set up rogue medical facilities outside our perimeter of control, at least initially. We have a tight and disciplined Incident Command Center, but it is getting more difficult to control the fringes outside our perimeter. I have several lessons: ▪ There are far too many do-gooders who do not want to obey the rules and who want to be the “authority.” ▪ Many rumors have been started by rogue medical personnel roaming amid the many people, some of these posing as Red Cross volunteers after medical control was unable to verfy their licensure. ▪ Some professional people are here who only want to say they were here, to be big shots, and to drink the bottled water. ▪ A tightly controlled incident command center is mandatory. ▪ One must not allow any rogue clinics or rogue physicians. All decisions must go through the medical control decision central command. ▪ We have registered about 4,200 patients so far, about 100 to 130 patients per hour with surges and valleys. The distribution of cases is the same as yesterday. We have given more than 4,000 tetanus shots. No epidemics yet. ▪ Surgeons, immunologists, and other specialists all become primary care doctors. There are no major surgical problems here. ▪ No obstetricians are needed. There was no reason for a major hospital in the area to set up an unauthorized perimeter OB/Gyn clinic complete with ultrasonography. Sept. 7: Day 5 at the Astrodome We have a mini-diarrhea epidemic in kids on our hands. About a third of the 200 pediatric visits over the past 36 hours have been diarrhea. It's probably Norwalk virus, but the infectious disease people are on top of it. We tried to send the kids and parents out into community facilities (homes) rather than put them back on the floor of the dome. Mental health problems continue to grow. This evening I met with the Mayor, Secretary of Health and Human Services, the Commissioner of the Centers for Medicare and Medicaid Services, the Assistant Secretary of Defense for Health Affairs, the Surgeon General for the Public Health Service, and the Director of Centers for Disease Control and Prevention to discuss short- and long-term solutions. Others talked about trying to get more dollars for clinics and hospitals in Houston, but I focused on the following points: ▪ This and any shelter should have an exit strategy; the shorter the stay, the better. ▪ This and other shelters should be a conduit to a distribution program of redirection, creating a thousand points of hope. ▪ HHS and other federal agencies should work with the Accreditation Council for Graduate Medical Education to use the medical students, residents, and faculty of New Orleans' two waterlogged medical schools in multiple communities, perhaps Houston. I said not to forget the GME. I drove it home, and I don't think they will forget it. ▪ Do not just send doctors and nurses from outside Houston to keep people jailed in a shelter, discouraging them further. Do keep the physicians and nurses in their communities to develop a distribution point to give the displaced persons dignity. ▪ Do not just throw money at displaced persons unless they work for it. It creates dignity to be paid for a job performed. It creates a continuing welfare recipient to figure out ways to pay people for doing nothing. Tomorrow morning former Presidents Bush and Clinton will be at the Astrodome for about five hours, and the previously mentioned dignitaries will be there all day. I am very tired, so this will be the limit of today's post. Sept. 8: Day 6 at the Astrodome I am in the middle of a lot of tasks, many now political. Our Astrocity is now down to 8,000 people from a high of 23,000. We developed an exit strategy before we ever opened this world's largest shelter. We developed a relocation plan the first day, as well as a job fair, church group acceptances, and enrollment of the many children in area schools. It has already happened. It is my personal goal as part of the AREA Incident Command Staff to be out of this shelter by Sept. 18. That is my personal objective, not command's. Our clinic is downsizing; we last saw about 10 patients per hour. The cases over the past 24 hours are those of a general community clinic. We have had only two surgical problems: one case of appendicitis and one incarcerated hernia. There is no escalation of the Norwalk GI flu. The incidence of neuropsychiatric problems and mental health problems have decreased, although we anticipated an increase by days 5 or 6. This is a success story.