E-Mail from Hurricane Katrina

Delivering Medical Care During Crisis

E-mail

By: James T. Montgomery

Date: September 5, 2005

Source: Yahoo! Groups. Tulane Hospital Evacuation-Jim Montgomery's Story. 〈http://groups.yahoo.com/group/tulanepsychiatryfaculty/message/44"〉 (January 01, 2006).

About the Author: James T. Montgomery is the president and chief executive officer of Tulane University Hospital and Clinic (TUHC) in New Orleans, Louisiana.

INTRODUCTION

On August 29, 2005, Hurricane Katrina made landfall in New Orleans, Louisiana. Officials had previously ordered the entire city evacuated, but many residents were either unable or unwilling to comply with the directive. Many of those living in New Orleans' lowest-lying neighborhoods or parishes (some were two yards or more below sea level) were poor, sick, or elderly; this meant they were physically or financially unable to travel, lacked transportation, were chronically or seriously ill, or had no place to go. Others were in skilled nursing facilities or hospitals, still others in jails or penitentiaries. The city, like virtually all cities in hurricane-prone coastal states, had hurricane, emergency preparedness, evacuation, and disaster-response plans. New Orleans' levees were purportedly constructed to be able to withstand the force of a category four hurricane.

When the rains started and the winds hit, however, the force of the storm proved too much for the levees, and portions began to crumble. Within fewer than twenty-four hours, according to U. S. news and government reports, approximately 80-85 percent of the city was flooded, more than 1,000 people were dead, and the city's resources were largely paralyzed. The water rose so swiftly that many people had no time to leave, others drowned as they fell on their way to roofs or other high ground. Some were bedridden and could not escape, others survived the hurricane and subsequent flooding only to die while waiting for help to arrive.

In hospitals and medical centers many patients were too ill to be transported to other facilities before the storm hit. Some were on ventilators or other life-sustaining medical equipment, others were medically unstable, or were undergoing treatments that could not easily be interrupted. Some were brought in as casualties of the hurricane or its aftermath; others arrived at the hospital in labor.

Because hospitals are equipped with redundant power systems, typically backup generators capable of powering all necessary electrical equipment, it was assumed that the New Orleans hospitals would be able to get through the hurricane and its immediate aftermath without undue difficulty. James T. Montgomery weathered hurricane Katrina at the facility Tulane University Hospital and Clinic.

PRIMARY SOURCE

From: Randall Legeai Date: Thu Sep 8, 2005 4:45 pm Subject: Tulane Hospital Evacuation—Jim Montgomery's Story Dr. Winstead asked that I forward the attached writeup by Jim Montgomery that details his experiences at Tulane Hospital following the hurricane.

I thought it might be easier to compose an e-mail to all of you at once that tells some of the story of the past few days. First and foremost I felt your prayers and heard your concerns that were registered with Donna and others and they comforted me and kept me calm which was essential in this time.

In Dylan's song, "A Hard Rain's a-Gonna Fall," the singer is asked the questions of where have you been, what did you see, what did you hear, who did you meet, and what'll you do now, my blue-eyed son, to which he answers with a collage of images of his experience that attempts to answer each question. In this crisis the images were moving so fast that I think it'll take awhile to put it together but here's an attempt to do so.

This storm as of noon Friday the 25th didn't seem like it would be muchof an event, but by 5 pm things began to look different. We met as a group on Saturday to begin our routine preparations for a hurricane. Donna left for her brother's home and I went home to put things together there. I started to think what do I absolutely not want to lose in case the house would be swept away and the answer only revealed the photos of the family thru the years so that and few clothes was all I took.

The Storm: God's Natural World has an awesome power. From the small observation windows from our tallest floors, we observed awnings being blown off, a blinding rain and a general sense [that] if God's ever angry we're going to lose big. Our first inspections revealed little damage. A few broken windows and some roof damage but the building held up well. In fact, if you were in the inner core of the facility you only vaguely heard it. We even walked around late in the afternoon since there was only limited flooding no worse than a heavy thunderstorm. Overconfident, we even stated we had absorbed the best punch that nature could throw and we seemed intact.

At 1:30 am on Tuesday morning began the biggest crisis and challenge of my life and in the life of Tulane and no doubt New Orleans. I was awakened by my COO who told me the water in the boiler room was rising a foot an hour since midnight and if it continued at that rate at best we had only another two to three hours before we would lose all power since we already were on emergency power since early Monday morning. We had only 7 ventilator patients whose lives would be in jeopardy, and we had to move fast to get them out. We had no boat and no helicopter pad. Houston we have a problem.

I called Acadian Ambulance (who I know well) but had no business connection to our hospital and asked their immediate help. We have a parking deck connected to the hospital that we had evaluated as sturdy enough to support helicopter flight, but it had four light poles in the middle. I want to tell you what happened in the next four hours was nothing short of a miracle. Our maintenance group got the light poles down; Acadian agreed to pick our patients up, we made arrangements with our other HCA [Corporate operator of hospitals and health systems] hospitals to take them. Our staff and physicians got their patients ready, and most importantly, the water rise began to slow to an inch/hr and a little after the sun came up copters were on the roof and patients began to be transported.

Early on Tuesday morning we met with our key managers who were at the hospital. We prayed for support and comfort and guidance for what we knew was going to be a difficult period. We talked about what we knew, and what we didn't know, which was considerable because we had no contact from FEMA or the Mayor's office. We had no idea why the water was rising and from what limited facts we had, no one did. We had to assume that it would keep rising and we would lose power and then we would have no power at all. Thus, no light, no ac [air-conditioning], suction, oxygen, elevators, phones ie [sic]. Everything that is precious to good care. We had to get out so we hatched a plan and I tried to stay out of the way and let our physicians and nurses triage patients; others determined what vital supplies we needed replenishing; HCA was working frantically to coordinate a transportation effort to pick up patients and eventually, our staff. How many people? Good question. At least 1,200, which included a total of 160 patients, employees, and physicians and their families and 76 dogs and cats that I didn't know about at the time.

Tuesday: The looting began. We witnessed people, dozens of them, wading in front of the hospital with bag after bag of stuff from different stores in the vicinity. Bandits took over two hotels adjacent to us and forced out many of our employees' families who had been housed there, forcing them back to the hospital [and] creating further complications.

That night our people on the roof evacuating patients heard gunshots in the air but they continued their work. The lawlessness and insurrection certainly was a distraction but our Tulane Police were great, and they are very capable. Late in the day we ran out of fuel so our generators shut down and the building began to get hot. The last of the ventilator patients had to go up six stories by way of pickup trucks since the elevators shut down and our ambulance was too tall to squeeze to the top. During the day, I had a conversation with a patient's father who told me that the parking deck pad would hold big helicopters. How did he know? Because he was a Blackhawk pilot. Ok. Then there appeared out of nowhere this guy, John Holland, who was sent in by HCA to be our Flight Coordinator—whatever that is. "The man" had arrived who would communicate with the birds in the air and boy is that important because our patients had begun to fly away.

Wednesday: If you would like to know if we slept, here's a little experiment: Try heating the bedroom up to about 90-95 degrees. First, you're hot and then you sweat and get cold and then the cycle repeats. Daybreak and I tell you patients are being moved into a queue to move. I saw our staff, residents, and faculty move sick patients with a grace and dignity that was most impressive. This was our third day and the stress on our people began to show. Everyone was asking when, where, & how were we going to get out. The city sewer system was obviously backing up and spilling out and creating an acrid smell that over the next few days made it almost impossible to breathe. With no water pressure you can't bathe.

But here's a general observation: If everyone smells the same you really don't notice it, you just feel unclean. On this day, the La. Wildlife and Fisheries Department showed up to help us move some patients that we had inherited from the Superdome on Sunday night. Yes, over 60 extra medically needy people with chronic conditions. So by boat we sent them and their loved ones away. I met a woman whose most valuable possession was her pillow and her radio that I personally promised her to protect. It's in my office now.

The Big Birds began to fly. Blackhawk's down. Instead of one or two patients they could move up to four with some additional staff. Beautiful sight but there was more to come. By the end of the day we had moved all but about twenty patients including two who weighed more than 400 lbs and one artificial heart assist-device patient, which was the challenge of the week since the device itself weighed more than 500 lbs. So imagine hauling this weight three to four floors down a dark stairwell at 90-plus degrees. It was a young man's job and it was done.

Let me tell you that the coordination from the patient's room to the staging area to the helipad into the helicopter was a work of art composed by many painters. It truly was a thing of beauty and it touched everyone who was there.

By the end of day, HCA had constructed an extraction plan for the remaining staff. Helicopter to the airport, buses to pick up and take to Lafayette. Sounds good but there were lots of needs and who knows what the government may decide to do.

Thursday: Line up and get ready. Have a little breakfast. We basically were living on Strawberry Pop-Tarts, honey oat bars, and for dinner a little protein, tuna fish. Fortunately, I like all of them but I'm sure I lost ten lbs or so. Anyway, the line was formed and I personally counted 700 hundred people. Our staff, physicians, theirchildren and spouses, and just to top it off 76 dogs and cats. Holy God. How are we going to deal with that? So we relegated them immediately to second-class citizenship to another line and pray we don't have to put the pets to sleep if no one will haul them.

At first there were just a few small copters and we had some patients to move and it was slow. Moving through the line people were calm with a few exceptions but overall they managed their plight well. Then a situation developed. A frantic medical director of critical care showed up by boat from Charity. Major problem. Charity was in a meltdown. He had 21 critical care patients many being hand ventilated for two days and he couldn't get any help from the state. You may have heard this story reported by CNN. Their version and ours differ but raise your hand if you think the media gets it right all the time. Can you help me he asked? This was a tough question, but it had only one answer. We would give them access to the small aircraft, which wasn't going to help us move our staff anyway. So that process began much to the chagrin of our nonprofessional staff and family. They just didn't understand it. Our nurses and doctors did, but it increased the crowd's intensity. Midday and it was moving slow. It didn't look good. Then from 3 to 5 things happened.

A Chinook helicopter is big. Two rotors and it carries about 50-60 people. It moves with a slow deliberate confidence that is hard to describe. But one showed up. We had questions about could it land so we asked "the man, John" and he said yes but nothing else could be on the pad when it did due to the turbulence. I want to tell you as it approached cheers broke out from below and people thought they had a chance. So for a few hours we made progress and then it stopped. No more big birds, big problem. What happened? Don't know. I called my daughter Megan where Donna was staying and she seemed elated. "You're back." "What?" I asked. She tells me Gov. Blanco had just announced that Tulane had totally been evacuated. According to my account she was about 400 people short in her analysis. But we now had a new problem. They think we're not here. Better let someone know.

I called the La. Nat'l Guard. Guess who answered, Brad Smith, the patient's father I spoke of earlier. He had gotten a ride back with some of the Wildlife boys and was now flying sorties into New Orleans. He quickly got a hold of the Office of Emergency Preparedness and let them know we still needed help. So maybe Friday we'd get out. People were remarkably calm when we told them they'd be there another day. They just sat down and began to prepare to go to bed.

We left the hospital and remained in the parking deck. One it was cooler, two there would be less confusion in the morning, and three it was safer since there was less territory for our Tulane Police to patrol. I know the media has played up the anarchy, and no doubt there was some concern, but I always thought we were safe.

So imagine trying to fall asleep on your concrete driveway without a pad or pillow. It's kind of tough. Then throw in an unexpected helicopter landing at 1 am. The wind is a little dicey. The bird dropped off 50 percent of the Marines in New Orleans. One guy needed to go to Charity so we had to take him over. Next event for the evening: at 4 am we were treated to a massive explosion at a warehouse on the river several miles away. I happened to be looking directly at it at the time. It must have reached a 1,000 ft in the air. Then by the end of the evening we began actually to get cold. But it finally ended.

Friday: The end is pretty anticlimatic. At 8 o'clock unexpected Chinooks began showing up taking 60 people at a time. I wonder if our pilot friend in the Guard had anything to do we it but I haven't asked him yet. So in a matter of 2 1/2 hrs. everyone was gone but our police and the last remnants of management. So after attempts to arrange a coordination with Charity to use the helipad, we left for home sweet home.

Obviously, this is only phase one of a complicated recovery for New Orleans. Each of you no doubt is praying for this recovery. So many people have lost so much and it reaches far beyond New Orleans. I talked to the Chairman of the Board of HCA yesterday upon returning and told him it was the worst and most difficult challenge I have ever been personally involved with but at the same time I don't think I've ever felt as great a sense of accomplishment from anything I've been involved with. Our staff performed like clockwork and it was a beautiful thing to observe. Our success in this week is simply measured by the fact that we didn't lose a patient during this trying time.

Jim

P.S. This event is just below a nuclear catastrophe in its degree of magnitude, and it's clear we're not ready and if we don't do better the next time a really hard rain's a-gonna fall.

SIGNIFICANCE

In the aftermath of Hurricane Katrina, many New Orleans hospitals have closed either temporarily or permanently. Several have been condemned. Initially, military and civilians worked side-by-side in an outdoor tented facility set up across the street from University Hospital, designed to render low-level medical, dental, and pharmacy services. A military field hospital was set up at the Convention Center to handle more serious medical or surgical concerns. It had a maximum stay of two days before patients were transported to one of the three remaining fully functioning New Orleans hospitals.

During the crisis (the hurricane surge and ensuing flooding), there were many unexpected heroes. Shelters were set up in neighboring areas (both within the hurricane-affected states of Louisiana, Alabama, Florida, and Mississippi and in other states, both bordering and distant from the Gulf Coast region), and thousands of people offered to shelter displaced persons or families in their homes. Relief organizations received large donations of money and supplies. Volunteers from across the nation, and from other countries such as Mexico, Israel, Germany, and Georgia, helped with search and rescue efforts, medical care, power restoration, and general crisis management; and they brought in massive quantities of first aid, medical and pharmaceutical supplies, and clean drinking water.

Many local citizens, who were themselves profoundly affected by the storm: losing property, homes, personal possessions, pets, or, worst of all, family members, worked tirelessly to assist others. They used boats (their own or those they "borrowed" from boatyards) to rescue people who were stranded, and to move the sick and disabled from damaged or powerless medical or nursing facilities to functioning sites. Health care providers remained at their posts in hospitals and medical centers for several days without relief. When generators became flooded or ran out of fuel many staff members spent hours hand-ventilating patients who could not breathe on their own. Staff carried patients up or down many flights of stairs, often accompanied by heavy medical equipment and supplies, to get them to locations from which they could be transported to receiving facilities. Lifesaving work continued under unimaginable conditions: no running water, no lights, no air-conditioning amid temperatures verging on 100 degrees Fahrenheit; sewage systems failed; and food and water were scarce. By all available reports, people in the medical settings acted with a profound sense of dedication, doing their best to save lives.

When some hospitals that had been seriously damaged by the storm began to reach critical shortages, staff went to other local facilities to summon help. Physicians, nurses, emergency medical technicians, and other physical and behavioral health care workers (both professionals and paraprofessionals) volunteered to come to the hardest-hit areas to aid in rescue and relief efforts. Cadres of ambulances, air medical transport equipment, and mobile hospitals were brought in from around the country, often before they could even be requested. Eventually, all of the severely damaged hospitals were evacuated, patients were safely transported to other facilities, and staff members were finally able to leave. Despite the critical shortages, unsanitary and primitive conditions, few lives were lost among the hospital patients.

FURTHER RESOURCES

Web sites

EMSNETWORK.org. "Hurricane Katrina: Our Experiences by Paramedics Larry Bradshaw and Lorrie Beth Slonsky." 〈http://www.emsnetwork.org/artman/publish/article_18427.shtml〉 (January 1, 2006).

Meadowcrest Hospital, Tenet, Louisiana. "A Disaster Beyond Comparison." 〈http://www.meadowcresthosp.com/CWSContent/meadowcresthosp/aboutUs/phillipsowakatrina.htm〉 (January 1, 2006).

USINFO.STATE.GOV. "Acts of Kindness, Heroism Reported in the Wake of Hurricane." 〈http://usinfo.state.gov/gi/Archive/2005/Sep/02-225769.html〉 (January 1, 2006).

USINFO.STATE.GOV. "U.S. Launches Massive Response to Aid Hurricane Katrina Victims." 〈http://usinfo.state.gov/gi/Archive/2005/Sep/02-225769.html〉 (January 1, 2006).

USINFO.STATE.GOV. "World Community Offers Support to Victims of Hurricane Katrina." 〈http://usinfo.state.gov/gi/Archive/2005/Sep/06-611544.html〉 (January 1, 2006).