1. Nine Days at the Airport: The Medical Response to Hurricane Katrina Co-Director, Travel Clinic, Clinical Assistant Professor School of Medicine University of Washington November 1, 2005 Christopher Sanford, MD, MPH, DTM&H

2. Hurricane Katrina: Sunday, August 28, 2005 10:00 am: US National Weather Service predicts catastrophic damage to New Orleans. Over 10,000 people enter the New Orleans Superdome for the night at the urging of Mayor C. Ray Nagin.

3. Monday, August 29 5:20 am: New Orleans International Airport loses commercial electricity, and begins to utilize back-up generators, which provide sufficient electricity for minimal lighting, but no air conditioning. The temperature inside the airport quickly soars to 100º F (38 ºC). 5:35 am: Katrina, now a Category-4 hurricane, with winds reaching 140 miles per hour, makes landfall at the Louisiana-Mississippi border of the Gulf Coast. Accompanying the hurricane is a 29-foot surge of ocean water, the largest ever recorded.

4. Monday, August 29 8:00 am: Hurricane Katrina passes 20 miles to the east of New Orleans. 11:00 am: Floodwall of the Industrial Canal breaks open in two places, flooding the 9 th Ward with 3-10 feet of water. Thousands of residents climb to their rooftops.

5. Tuesday, August 30 1:30 am: 17 th Street Canal barriers along two blocks fail, flooding 80% of New Orleans. The local pump station fails. A 300-foot section of the floodwall lining the London Avenue Canal fails, worsening the flood. 9:00 am: First helicopter arrives at New Orleans airport with evacuees from rooftops and hospitals.

6. Disaster Medical Assistance Team (DMAT) Disaster Medical Assistance Team Established 1984 by United States Public Health Service 61 DMATs in the US. Approx. 27 are Level I; deployable within 8 hours, are self-sufficient for 72 hours Configured to manage 100-200 patients/day

7. Wednesday August 31 1:00 am: Initial 3 DMATs arrive at airport. Over 25,000 evacuees are in the Superdome, which is three-feet deep in floodwater. Water level continues to rise. Efforts to sandbag the failed 17 th St. Canal barriers begins.

8. DMAT Team Meeting 35 team members 4 physicians: Dr. Helen Miller: Team Commander ER and pediatrics Dr. Jon Jui: public health, infectious disease, critical care Dr. James Judge Hicks: anesthesiologist Dr. Chris Sanford: family practice, travel and tropical medicine, public health Nurses, mid-level practitioners, pharmacists, EMTs, logistics, communications, ops

9. Thursday, September 1 DMAT OR-2 drove in convoy from Houston to Baton Rouge (60 miles NW of New Orleans). Radio contact with 3 DMATs at airport: no sleep for two and a half days, running out of medical supplies, food, and water. Bizarrely, DMAT OR-2 told by NDMS (National Disaster Medical System) to remain in Baton Rouge.

10. The players: Department of Homeland Security (DHS) Disaster Medical Assistance Teams (DMATs) Federal Emergency Management Agency (FEMA) National disaster Medical System (NDMS)

11. Thursday, September 1 DMAT OR-2 drove in convoy to New Orleans Airport despite instruction from NDMS to remain in Baton Rouge.

12. Thursday, September 1 At the New Orleans International Airport: 23 of 26 New Orleans hospitals were flooded or otherwise incapacitated by flooding. Virtually all of these patients were transported to the airport. Approx. 500 people on the floor: residents of nursing homes, hospitals, evacuees. Approx. 2,000 people waiting for triage. Medical teams on-site exhausted.

13. Thursday, September 1 3:00 pm: DMAT OR-2 arrives at airport. (Three days after Hurricane Katrina hit the Gulf Coast).

14. First Impressions

15. No onenot Vietnam veterans, not those who responded to 9/11, not those with international relief workhad ever seen so dire and calamitous a scene. This is the worst Ive ever seen.

16. Triaging at airport Holding area for shelter Green Tent: ambulatory patients Yellow Tent: moderately ill patients Red Tent: critically ill patients Hospice: expectant care only

17. Friday, September 2 - Saturday, September 3 Medical staffing at the airport remains inadequate to address even basic nursing care.

18. Primary task at hospital: triage Rapid stabilization, then transport to either: hospital or shelter

19. Most patients were not injured by the direct effects of hurricane Most were ill as a result of the abrupt withdrawal of medical infrastructure, including medications. Diabetics without insulin for 5-7 days. Patients with chronic renal failure who had not had dialysis for 5-7 days. Hypertensives off antihypertensive medications having strokes and myocardial infarctions.

20. Patients with skin damage from flooding

21. Abrupt withdrawal of medical services Epileptics, asthmatics, and schizophrenics without medications. Recent surgery, including brain surgery and organ transplant.

22. Jets, helicopters, and buses continued to bring evacuees and hospital patients to the airport. In the peak hour, 160 helicopters landed and took off in one hour. Evacuee transport

23. Transporting patients

24. Crude mortality rate (CMR) Usually expressed in deaths per 10,000 population per day. In developing nations, CMR is usually 0.4- 0.6/10,000/day. A CMR of over 1 is considered elevated, and over 2 is considered critical.

25. CMR at airport impossible to calculate accurately Exact logs of patients and evacuees were not kept. However, as population at airport varied from 2,000-10,000, and approximately 36 deaths occurred between August 31 and September 3, it appears that the CMR was well in excess of the generally accepted critical value.

26. Immediately prior to being loaded onto aircraft Loading of wounded

27. 2,700 patients were evacuated from the airport to hospitals; this represents the largest air evacuation in history. Approximately 25,000 people were transported from the airport to shelters. Mass evacuations

28. At Louis Armstrong New Orleans International Airport: "The hallways are filled, the floors are filled. A lot more than eight to 10 people are dying a day. It's a distribution problem. The doctors are doing a great job, the nurses are doing a great job." --Majority Leader Bill Frist, R-Tenn. …a distribution problem.

29. Our bedroom: luggage carousels Noisy! Overhead announcements Barking dogs Passers-by

30. Incoming food and water

31. Sunday, September 4 Increasing staff and a lessened flow of incoming patients allows transport of surviving occupants of the hospice to hospitals. Thereafter no patients are designated to receive hospice care only.

32. Pets

33. Kudos to: US military, including Army, Air Force, and National Guard Transported patients Kept order US Forest Service Provided hot meals, showers, handwashing stations for staff PRC Compassion Faith-based group. Cleaned, performed nursing care for patients

34. Kudos to: (cont.) Health care providers who stayed at hospitals in New Orleans. Many remained and worked without electricity until patients rescued by boat.

35. Kudos to: (cont.) DMAT leaders Kept calm, provided team members with daily briefings DMAT members Worked extremely long hours. Didnt complain. Improvised. Converted airport bar into pharmacy.

36. Suggestions Management Support Team (MST) should be staffed not by DMAT commanders, but by their own staff. NDMS does not now have control over its logistical supply chain, human resources, communications, or travel of staff. It needs to.

37. Suggestions (cont.) Traditional doctrine of DMATs: they are to reinforce local and state assets. At the New Orleans Airport, we operated without those assets, which were overwhelmed by the crisis. Training should include scenarios in which DMATS are trained to be free-standing providers.

38. Suggestions (cont.) Standardization is good. At the airport, we used at least five different types of models/brands of glucose monitors, each with its own proprietary strips, which were not interexchangable.

39. Acknowledgements Dr. Helen Miller, Dr. Jon Jui, and Joel McNamara, for their DMAT OR-2 Hurricane Katrina After- Action Report. www.odmt.org/Katrina AAR.pdf Dr. Jon Jui for his analysis of command structure issues.

40. References FEMA website: http://teams.fema.gov/dmat/ Oregon Disaster Medical Team website: http://www.odmt.org/links.html Medical Reserve Corps website: http://www.medicalreservecorps.gov/page.cfm?pageID=152 Briggs SM; Leong M: Classical concepts in disaster medical response, in: Leaning, J; Briggs, SM, Chen, LC: Humanitarian Crises. Cambridge, Harvard University Press, 1999, pp. 69-79. Vankawala, Hemant reported to Josh Fischman, US News and World Report website: http://www.usnews.com/usnews/health/articles/050910/10emergency. htm

41. References (cont.) Thomas, Evan: The Lost City. Newsweek, Sept. 12, 2005, p. 44 VanRooyen MJ; Holliman CJ: Protecting yourself: traveling healthy. in VanRooyen, M; Kirsch, T; Clem K; Holliman, CJ: Emergent Field Medicine. New York, McGraw-Hill, 2002. Childress, Sarah: Critical Condition. Newsweek, Sept. 12, 2005, p. 51. Leaning, J; Briggs, SM, Chen, LC: Humanitarian Crises. Cambridge, Harvard University Press, 1999, p. 25. Giardet, ER: Somalia. Rwanda, and Beyond: The Role of International Media in Wars and Humanitarian Crises. Dublin: Crosslines Communications, 1995.

42. References (cont.) Toole, MF; Walkman, RJ: The public health aspects of complex emergencies and refugee situations. Annual Review of Public Health, 1996, 18. Lowell, Jeffrey A. Medical Readiness Responsibilities and Capabilities: A Strategy for Realigning and Strengthening the Federal Medical Response. Department of Homeland Security internal document. http://wid.ap.org/documents/dhsmedical.pdf PRC Compassion website: http://www.prccompassion.org// Miller H; McNamara J, Jui J: Hurricane Katrina: After-Action Report, DMAT OR-2. ttp://www.odmt.org/Katrina_AAR.pdf The shaming of America. The Economist, Sept. 10-16, 2005, p 11.

43. References (cont.) Hurricane Katrina from the Airport s Point of View. http://www.flymsy.com/Katrinastory.htm Thomas, Evan: The Lost City. Newsweek, Sept. 12, 2005, pp. 46B-C. FEMA website: http://teams.fema.gov/dmat/about/ndms.html#dmat