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From the Pages of EMS Insider
In the aftermath of Katrina
EMS preparedness & response lessons begin to emerge
The levees broke, flooding New Orleans, three weeks ago as of press time, but already the response to the disaster has revealed many lessons for EMS administrators and others involved in emergency preparedness and response. Although dissections and investigations of the Katrina response will no doubt teach us much more in the coming months, here are some of the EMS lessons gleaned from Katrina thus far.
EMS responders were key to the Katrina response.
Ken Bouvier, acting deputy director of New Orleans EMS and president of the National Association of EMTs, reported that New Orleans EMS crews hit the streets in ambulances, in boats and on foot in many areas to help rescue people, although many of the EMTs and paramedics had lost their own homes. The department’s personnel provided emergency response and rescue in areas they could reach on land or by boats and began to render much needed medical care at the city’s convention center once the military arrived and restored order at the overcrowded facility.
By all accounts, Acadian Ambulance Service, which serves much of Louisiana, played a huge role in the New Orleans response. According to Keith Simon, Acadian vice president for communications, Acadian evacuated some 700 patients from hospitals, nursing homes and private homes before Katrina hit. After the flooding, Acadian’s fleet of helicopters evacuated patients from hospitals, highway overpasses and the Superdome. Acadian paramedics, physicians and nurses staffed the Superdome medical aid station with the help of EMS personnel who had been in New Orleans for an EMS conference and stayed to help.
One of those who stayed was Bill Brown, RN, executive director of the National Registry of EMTs, who helped staff the medical aid center in the Superdome from Sunday, Aug. 28, through Wednesday, Aug. 31. “There were only 12 of us, and by the end of the day on Sunday, there were about 15,000 to 20,000 people there, about 1,000 of them with special medical needs,” he said. “We had patients with diabetes, hypertension, on dialysis and with a lot of physical disorders, and no one had any medication. We got some insulin on Wednesday, but we quickly ran out of glucometer strips. Many people reported chest pains, and we put them on a monitor and gave them an IV, but there was no hospital to transfer them to and no medications. It was totally chaotic survival medicine.”
“We ended up being the people in charge [at the Superdome],” said Ray Bias, EMT-P, RN, Acadian’s director of governmental relations and a former twotime chair of the National Registry’s Board of Directors. “We had LIFEPAK 12s and some other ALS gear and some bandages, but nothing to sustain 20,000 people over a period of days.”
Large-scale disasters require creativity & the willingness to sometimes break the rules.
High water marooned several ambulances and wheelchair vans outside the Superdome, and Acadian medics stripped them of equipment and supplies to use at the medical aid station inside. “We allowed the Army to use our wheelchair vans to transport patients from the [Disaster Medical Assistance Team] center at the arena to the helipad,” Bias said. “We went back and picked up our units at the end of the week, and they were completely trashed with medical waste, and it looked like civilians had been living in them.”
After he left the Superdome, Bias helped evacuate Charity Hospital. He said one Acadian employee convinced the drivers of four, empty 18-wheel trucks to help. “We put 14 stretchers and nurses into each 18-wheeler and took them to the airport so they could be airlifted out,” he said. “These were really sick people with chest tubes, haloes, etc.”
Another Acadian employee discovered that a helicopter could carry half a dozen neonates at once if they were transported in padded empty water bottle boxes.
The Wall Street Journal reported that a group of paramedics was “holed up” in a house in the French Quarter a week after the storm and was helping a former city health director scrounge medical equipment and supplies to provide impromptu health care to area residents.
Disasters change response patterns & deployment needs. Acadian reported that call patterns changed dramatically following Katrina. Because of the mass evacuation, Bias said, “our patient base in the threeparish New Orleans area is down considerably. We usually run 100 calls a day in that area, and yesterday we ran three.” On the other hand, Acadian has needed to redeploy ambulances and crews to other parts of the state where call volumes have risen due to an influx of evacuees.
Acadian is also looking to immediately hire 200 additional paramedics and EMTs—at least temporarily. “Many of our people have reported in, but many haven’t,” Simon said. “Many lost their homes and probably decided to move out of the area.”
The nation needs a system to pre-qualify & prepare staffed ambulances for rapid deployment. It wasn’t until Sat., Sept. 3, that the Federal Emergency Management Agency contacted the American Ambulance Association to formally request 220 staffed ambulances for 30 days. The AAA put out the call to its members, and within a day those staffed units were en route to the Gulf Coast. A year ago, the AAA had offered to create a database of EMS resources that federal officials could deploy for large-scale disasters, but no one took the AAA up on the offer.
“The first few days, we could get no ambulances at all. I did a couple of codes on a bridge and put people in whatever car was there. Then outside ambulance services began showing up with 10 to 15 ambulances,” said Tennessee EMS Medical Director Joe Holley, MD, who arrived in Louisiana two days before Katrina hit. He serves as medical director of the Tennessee Task Force One Urban Search and Rescue Team and spent much of the next 10 days helping evacuate people who were trapped in their homes.
“Triage became the question, ‘Can you walk or not?’ If they couldn’t walk, we tried to do rapid intervention to get them into that category because transportation options were much fewer for those who couldn’t walk,” he said. Some states have taken the initiative to line up EMS resources in anticipation of major disasters.
According to Peg Trimble, a former Pennsylvania EMS director, after Sept. 11, 2001, Pennsylvania pre-designated 160 ambulances and prepared their crews to be ready to respond rapidly to a large disaster. “We put out $5,000 grants and asked each region to designate 10 ambulances,” she said. “Personnel needed immunizations and must be prepared to be on their own for a specific period. In case of disaster, both private ambulance and governmental [crews] are deployed as government employees and become covered by state liability coverage.” Trimble is now leading a project to create a national EMS credential that should help with deployment in future disasters. (See “DHS Sponsors National EMS Credentialing Initiative,” p. 4.)
Every jurisdiction needs comprehensive mutual aid agreements with other jurisdictions.
Trimble advises every state EMS office and EMS system to draft Emergency Mutual Aid Compacts with other jurisdictions. “These agreements could be signed ahead of time, just not dated, then it will take a minute instead of a day,” she said.
“If Columbus [Ohio] has a major disaster, the city had better know how to get resources from Pittsburgh and Cleveland because [its] county resources could be toast,” Brown said.
“Our state EMS office has learned that we should coordinate with the response plans and strike teams of our coastal sister states so we will be ready to go on a moment’s notice,” said Russ Crowley, Alabama EMS education coordinator, who spent the week after Katrina hit in Gulfport, Miss., coordinating the transport of patients to Alabama hospitals.
Planners need a comprehensive system to quickly plug in & coordinate responders who arrive at a disaster scene. “It’s difficult to coordinate something of this magnitude if the people who want to provide rescue and recovery don’t know the proper chain of command,” Crowley said. “We need one agency we can all contact to offer aid regardless of where we are in the country.”
Holley said more than 20 urban search and rescue teams responded to the Gulf Coast before or after Katrina. “The USAR medical system worked very well and moved a huge number of resources and victims, considering the small amount of resources we had there,” he said. The DMATs also did a good job, noted Holley, but took two to three days to get up and running. Holley also reported seeing little organized response except for the FEMAsponsored USAR teams and DMATs for the first few days.
Maryland EMS Director Bob Bass, MD, said the Maryland Institute for EMS Systems sent a staff member, Clay Stamp, to the Gulf Coast shortly after Katrina “to reconnoiter and ID a mission.” MIEMSS also established a registry of medical personnel who volunteered to respond to the Gulf Coast, and state agencies credentialed and immunized some 200 paramedics, EMTs, nurses and physicians and sent them to provide health care for a parish (or county) outside New Orleans.
“I detailed Clay to the [Maryland] governor’s office, and he is now writing a strategic plan on what we’re doing there, our mission, how long we will be there and how we transition care back to the local community,” Bass said. “We are also coordinating with [the Department of Health and Human Services] because we don’t want to work there in a vacuum.” Bass said Maryland now screens potential Gulf Coast volunteers to assess their mental health and ensure they can handle the emotional strain. “We want to make sure that folks are aware of what they’re getting into and that they don’t have a significant history.”
“If you don’t have tremendous physical and mental toughness and can’t brush off a bad call, you should never go to a disaster zone,” Brown said.
Self-deployed responders can prove problematic & may find it difficult or impossible to help effectively. Newspapers nationwide reported on the frustrations of many responders who showed up to help only to be turned away or forced to sit idle. But many people who worked within response systems—once those systems became operational—said it was hard for rescue officials to use those who self-deployed.
“Many kind-hearted people who tried to help may have caused more problems— not harm, but problems,” Crowley said. “For example, helpful people were picking up busloads of people and dumping them into shelters and systems in parts of Alabama that weren’t expecting them, while we were sending C-130s to bring those needing medical care to Birmingham and dispersing them to surrounding hospitals.” According to Bias, he received e-mails from many people who said they tried to help but were turned away, especially by FEMA. “I think you get less of a black eye if you let the people help who come to help,” he said.
Acadian headquarters are located in Lafayette, La., some two hours from the Gulf, and did not lose power or communications, so its call center and dispatch became critical. “We were the only [response agency] in the area getting e-mails and phone calls, so we were getting tons of calls from people who wanted to come and help,” Simon said. “We were telling them to call emergency management in Baton Rouge, but [that office was] overwhelmed.”
Ben Hinson, owner of Mid-Georgia Ambulance Service in Macon, Ga., remained in Louisiana after the EMS conference, and Acadian put him to work coordinating EMS personnel who called offering to help. “If paramedics showed up two per unit with their own rigs and equipment, we put them to work,” Simon said. “If they were BLS units, the triage officer decided how best to use them.”
Holley said he hopes Katrina will be a “wake-up call for physicians” to learn how they can really help in a disaster. Without such knowledge, he said, “Most physicians wouldn’t have done much good and would have gotten in the way,” during the New Orleans response.
He also advised physicians and other health-care providers to help by covering shifts so those trained for disaster response can respond to New Orleans and other disaster sites. “They could also go to Baton Rouge and see patients there or take evacuees into their practice,” he said. “Everyone wants to be at the front end of the pipeline, but we need people all along the pipeline where people need care to make it work.”
Gold Cross Ambulance in Minnesota sent three ambulances, a staff-response vehicle and nine paramedics to the Gulf area as part of the contingent deployed by the AAA on behalf of FEMA. “They felt it was productive, and they were contributing and able to accomplish something as part of a system,” said Gold Cross Director of Communications Glenn Lyden. “But the people who stayed at home and worked extra shifts to cover for them are equally important.”
Every hospital & nursing home must have workable evacuation plans.
Scores—perhaps hundreds—of patients died while awaiting rescue from flooded hospitals and nursing homes. Although the New Orleans hospital association was working on an evacuation plan, that plan was incomplete and was never implemented. Some of the wealthier hospitals and nursing homes hired ambulances and helicopters to evacuate patients, while those facilities that served mostly poorer patients waited nearly a week for evacuation.
Ambulance services that contract with facilities for evacuation need plans to ensure they can secure enough backup units to fulfill those contracts in a timely manner—even in a worst-case scenario. “We worked with other USAR teams evacuating a nursing home where a … Catholic nun, and [a licensed practical nurse] and three aids had been caring for 80 very sick patients for three days,” Holley said. “They had even carried all the patients up three flights and were caring for them in the hallways. They were an amazing group of people.”
Ambulance service administrators also should consider where to station units for various disaster scenarios and how to keep track of personnel when regular communications go down. For example, EMS administrators should ensure their units are not left in areas where they will be inaccessible. Bias said many New Orleans EMS units were left parked on the roof of the Superdome and could not deploy when water surrounded the building.
All future disaster planning must recognize the critical role of EMS.
“Planners need to take a very careful look at EMS resources and make sure they have what they need,” Brown said. “If the resources go to fire and law enforcement, and you don’t adequately plan for EMS resources, you’re going to get New Orleans all over again.
“EMS played a gigantic role in the response to hurricane Katrina,” he said. “Fire and law enforcement also had a role, but this natural disaster was a health catastrophe, and EMS was on the front line to deliver public health.”
He encourages every EMS responder who went to the Gulf Coast to contact lawmakers “to explain what they did in this disaster and to show Congress that’s what EMS does.”
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