Angels of the Storm

TMA Mobilizes Texas Physicians to Treat Katrina Victims

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Cover Story - November 2005   

They came by bus. They came by car. They came by truck, airplane, helicopter, and ambulance. Some even walked. They came with the few possessions they were able to stuff in a sack or pillowcase. Some came with nothing but the clothes on their backs. But they came to Texas seeking refuge. Many were sick. Many were injured. Many were both. All were devastated, their lives torn apart by an unreasoning force of nature called Katrina.

They were greeted by Texas physicians, medical students, nurses, and other health care professionals who responded to their suffering with an unprecedented effort to care for the sick and injured.

Prompted by calls to action from the Texas Medical Association, physicians across the state left their own practices to do what they could to help hurricane evacuees in shelters in Houston, Dallas, Fort Worth, San Antonio, Austin, El Paso, Lubbock, and many medium-size and small cities throughout Texas.

TMA used its organizational, communications, and physician education strengths to coordinate with local medical societies to mobilize more than 1,000 doctors to care for people who were going about their normal routines one day, but fighting for survival the next day as the hurricane obliterated their coastal communities and the water from Lake Pontchartrain spilled over the levees and into the neighborhoods of New Orleans. It was a lesson in the power of organized medicine.

TMA Board of Trustees Chair William W. Hinchey, MD, summarized TMA's actions when he spoke at a forum on medicine's response during the TMA Summit in September.

TMA compiled a database of more than 1,000 Texas physicians willing to volunteer to help hurricane victims. Physician leaders and staff participated daily in conference calls with the Texas Department of State Health Services to get updates and status reports of evacuees' and volunteers' needs and shelters across Texas. A Web site established at was updated daily with the most current information on volunteer needs, legal issues, announcements from commercial health plans and government health agencies, and clinical concerns. Finally, relief updates were sent twice weekly to TMA members, volunteers both in and out of state, county medical societies, and staff.

"These are great times to remind ourselves why we became physicians," Dr. Hinchey said. "These are also great times to remind ourselves why we joined TMA."

For evacuees, the medical care they received was, in some cases, literally a lifesaver; at the minimum it made their ordeal bearable. For physicians, it was a chance to care for people desperately in need, unencumbered by the all-too-frequent hassles of daily practice. It reminded many of them why they endured the rigors of medical school, internship, and residency to earn the right to be called "doctor."

Texas Medicine Senior Editor Ken Ortolon and Associate Editor Erin Prather visited the largest shelter operations in Houston, Dallas, San Antonio, and Austin. They saw firsthand the complex medical treatment facilities that sprang up overnight. They talked to the physicians who volunteered there and they heard their stories of compassion for the victims, their heartbreak over what the people were going through, and their pride in participating in perhaps the noblest chapter of Texas medicine. 

Houston   |  Dallas   |  San Antonio  |  Austin  

Houston: "We Are All in This Together"

Dubbed the "Eighth Wonder of the World" when it opened in 1965, the Astrodome has hosted some of the most memorable moments in American sports. It's where Muhammad Ali knocked out Cleveland "Big Cat" Williams in 1966. The Houston Cougars ended UCLA's 47-game basketball winning streak there in 1968. Bobby Riggs and Billie Jean King staged their tawdry "Battle of the Sexes" tennis match in its cavernous environs in 1973. Its tenants, the Astros and Oilers, mounted their ill-fated quest for the World Series and Super Bowl in the '70s, '80s, and '90s. And, finally, it gave the world Astroturf.

But the Astrodome (its real name is the Harris County Domed Stadium) was never more important than in early September when it became an oasis for thousands of hurricane-devastated evacuees seeking a safe place to begin putting their lives back together.

"The medical efforts at Reliant Park were nothing short of miraculous. Only the great state of Texas and the City of Houston could have pulled something like this off. The effort should make every Texan proud of our state's resilience and 'can-do' attitude," said Baylor surgeon John Sweeney, MD.

It started in the early hours of Wednesday, Aug. 31, as a series of phone calls, e-mails, and conference calls flashed across Houston. Gov. Rick Perry had agreed to receive 23,000 Hurricane Katrina victims. Those who had sought shelter in the now decrepit Superdome were to be bused to Houston's Astrodome. Earlier, the governor had spoken to Harris County Judge Robert Eckels about turning the Astrodome into a long-term shelter to provide housing, food, and medical care to evacuees already in Texas.

"We are all in this together," the governor said. "We will continue to do what it takes, from offering assistance to offering prayers, to get through this together, as one American family."

Unsure when the buses would arrive, Harris County workers rushed to transform the 40-year-old dome into the largest evacuee shelter of its kind. Baylor College of Medicine was tapped to staff the medical relief effort, and its physicians and administrators worked with The University of Texas Health Science Center at Houston, the Harris County Hospital District, the City of Houston, the Harris County Medical Society (HCMS), and other local organizations to provide care.

Originally, said Doug Graham, administrative associate of the community health division at Baylor, the school thought it had enough volunteers to staff the Astrodome clinic. However, as the number of expected evacuees grew larger, it became apparent that more physicians would be needed. Baylor President Peter Traber, MD, sent an e-mail asking for more volunteers, especially emergency and family physicians. Affirmative replies came immediately.

Baylor faculty volunteers were scheduled to work one of two 12-hour work shifts: 7 am to 7 pm or 7 pm to 7 am. As reports predicted that the Astrodome's population would grow, the county medical society was asked to recruit members to volunteer.

Meanwhile, American Red Cross workers organized the housing area within the Astrodome. By 4 pm Wednesday, the Astrodome floor had been marked in tape and chalk lines of 5-foot-by-7-foot rectangles to indicate where cots should be placed. Food services began setting up at 7 pm. At 11:35 pm, volunteers quickly unloaded a truckload of cots.

The hospital district erected the 100,000-square-foot "Katrina Clinic" to care for evacuees. The clinic included 20 curtained exam rooms, mental health service facilities, a laboratory, and radiographic capabilities.

In a personal report to the critical care community, Ken Mattox, MD, cochair of the medical effort at Katrina Clinic and chief of surgery at Ben Taub General Hospital, recounted medicine's determination to have the clinic operational when evacuees arrived.

"Imagine designing a clinic facility for a town of 23,000 in four hours," he wrote. "We did it, went out to the Astrodome and with almost military-like command authority, got it staffed, equipped, computerized, telephoned, curtained off, office, medical recorded, etc. in about eight hours. The voluntarism for 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."

Dr. Mattox issued a memo listing the physician groups that were immediately approved to volunteer at the clinic. It included Baylor and UT-Houston physicians, any TMA or HCMS member, and displaced physicians from Charity Hospital in New Orleans and faculty from the medical schools at Louisiana State University and Tulane.  

The First Wave

The first evacuees reached the Astrodome late Wednesday and early Thursday. Physicians were seeing 150 patients an hour as evacuee-laden buses descended upon the shelter.

Drugs and medical supplies were supposed to arrive through a federally deployed Disaster Medical Assistance Team; they never came. Instead, Dr. Mattox raided Ben Taub's pharmacy to make it through the night. The next day, CVS Pharmacy delivered a complete mobile operation with 20 pharmacists ready to dispense free medications.

By late Thursday morning, 2,000 people had arrived. The buses kept coming.

By the time Carlos Vallbona, MD, chief of staff of Baylor's community health program, arrived at the Katrina Clinic for his Thursday evening shift, more than 1,000 evacuees were congregated in the clinic's small waiting area. They were registered as quickly as possible, triaged, and escorted to one of nine separate treatment areas.

Dr. Sweeney also volunteered that evening for the 7 pm to 7 am shift and was directed to the Katrina Clinic command center, staffed by hospital district employees. For him, the starkest memory is passing a message board covered with hundreds of messages from evacuees looking for the family members.

"It was surreal, reminded me of a scene in the latest War of the Worlds movie where Tom Cruise's character walks by notes left by people looking for their missing loved ones," he said.

Most of the evacuees requiring medical care suffered from conditions typical of primary care clinics. They had skin infections, diabetes, asthma, and heart conditions; many were dehydrated. The majority also needed their prescriptions refilled, and some required mental health services.

Throughout his shift, Dr. Sweeney worked in the triage area and wrote prescriptions. He also inadvertently helped a man find his lost family members.

"A lady in her 50s or 60s came to me with her mother, who was in a wheelchair. Both were on a lot of medication and needed their prescriptions refilled. About an hour later, an elderly man came up, also needing a prescription refill. I noticed the name and knew I had seen it before. I asked the man if the name was common in New Orleans, he said no. I then asked if he was missing family members and he said he was … his sister and mother. I told him they were here and that I had sent them to the pharmacy for medicine."

Niraj Patel, a second-year student at Baylor, and a colleague walked along the rows of cots, dressing cuts, scratches, and other wounds with supplies from the Katrina Clinic.

"We yelled, 'Anyone need us to dress cuts?' every few paces as we walked between the rows and tended to more than a dozen wounds," she said. "We told evacuees who had punctures and lacerations to ask for a tetanus shot at the triage desk. Other classmates also were tending to wounds, checking heart rates, and accompanying physicians as they saw special cases in the cordoned-off section for sick patients."

Around 3 am Friday morning , the flow of evacuees began to ebb, relieving physicians who were overwhelmed by the sheer number of patients.

Although Houston officials initially said the Astrodome could hold 23,000 to 25,000 evacuees, the fire marshal ordered the shelter closed at a little more than 11,000 evacuees due to fears of overcrowding. But the buses kept rolling in; Houston obviously needed a new plan.        

More Shelters Needed

On Friday morning, Houston officials announced that the nearby Reliant Center would be used to shelter evacuees. Those who arrived during the night had slept in Astrodome bleachers, on its floor, and along the grassy areas outside. All were awaiting cots to be set up in Reliant Center. (The Astrodome and Reliant Center are part of the Reliant Park complex.)

Additionally, officials had opted to open the adjacent Reliant Arena as a larger medical clinic to provide medical care for those staying at Houston shelters. Like those in the Katrina Clinic, evacuees at Reliant Arena were triaged and assisted in the waiting area by nurses and registrars who collected health information. Based on their needs, evacuees were then sent to appropriate treatment areas, separated by curtains. Hospital district employees also set up a technology area where they created electronic records for each patient seen in the clinic.

Dr. Traber estimated that physicians saw about 4,000 evacuees by 4:30 pm Friday.

City officials also opened the George R. Brown Convention Center in downtown Houston as a shelter. Its clinic was staffed by UT-Houston personnel who also saw evacuees at Reliant Park.

Larry C. Gilstrap, MD, chair of UT-Houston's Department of Obstetrics, Gynecology, and Reproductive Sciences, learned around noon that the convention center was being opened as a shelter. After meeting with city officials and hearing the fire department limit the shelter to 7,000 evacuees, the UT-Houston faculty went to work.

"About 4 pm we began to put together the medical clinic for the convention center. The medical school worked closely with Memorial Hermann Hospital, which provided most of our supplies. It became a huge area. It reminded me of my days in the military. I'm a retired Air Force colonel, and this operation was similar to the field hospitals we set up."

In addition to Memorial Hermann, Dr. Gilstrap says other medical sources sent supplies, which included EKG machines, heart defibrillators, and extra wheelchairs. Walgreen's set up a pharmacy, and there were also laboratory, x-ray, and mental health services. The UT Dental Branch's mobile dental van arrived to treat severe toothaches and abscesses, and to help evacuees who had lost their dentures in the storm. An acute trauma emergency room was erected; physicians waited for the patients behind trade-show drapes that separated the clinic into specialty areas and exam rooms.

The first patients came from Baytown, a temporary haven after leaving New Orleans. By 11:30 pm, about 200 evacuees were at the convention center. Similar to those at the Astrodome, many suffered from going without medication for several days. Others required care for abrasions and skin rashes.

"We weren't sure what we were going to get when the first bus came, if someone would have a laceration or broken arm," Dr. Gilstrap said. "Evacuees who were sick were brought to us first so we could determine if it was a problem we could treat on site or if we should have them transported to one of the area hospitals. The city's emergency people were providing the transport and alternated hospitals to which they took evacuees so no one would be overwhelmed."

Carlos Moreno, MD, professor and head of the UT-Houston Department of Family Practice and Community Medicine, volunteered at the convention center on the first night. Having been part of the shelter's initial logistics meeting, he was impressed with how quickly the clinic was constructed. He was also moved by the evacuees' spirit and the volunteers' determination to provide care.

"These people are calm. They're glad to have someone taking care of them, and if they show up, we will take care of them," he said.

In fact, not everyone who received care at the convention center was housed there. UT-Houston reports that although more than 4,000 evacuees were processed at the convention center over the weekend, only about 2,000 stayed. The others were reunited with family or found alterative housing.

"Some evacuees were sent over from other shelters, others just walked in," said Dr. Gilstrap. "If they were from Louisiana, we treated them. Many would just hold your hand and thank you for what you were doing."

On Saturday morning, the U.S. Postal Service gave Reliant Park its own ZIP code, 77230. Outside, many evacuees walked around with signs bearing the names of people they were trying to find. Inside, Reliant Arena's clinic buzzed as people continued to line up for care. The facility had received a facelift overnight to handle the steady stream of evacuees; the clattering of metal rods could still be heard by mid-afternoon as work crews created additional treatment areas. The clinic was split more efficiently into subspecialty areas. Half was designated for pediatrics and medical specialties, the other for general medicine.

"General medicine continues to be significantly busier than our area," Audra Timmins, MD, assistant professor of obstetrics and gynecology at Baylor, said as the patients lined up for treatment. "Pretty much every evacuee is receiving a tetanus shot, and it seems that most are suffering from chronic disease problems. There are quite a few pregnant women, hence the OB/Gyn section. We actually have an ultrasound machine, donated by Siemens. I've also seen a lot of abdominal pain issues since many of the women had to walk through sewage water for who knows how many days."

Added Houston obstetrician-gynecologist Betty Jo Edwards, MD, "The concerns for a lot of OB/Gyn patients have been dehydration and pre-term labor. This is my first day at the clinic, and I've really been impressed by its sophistication."

Beyond the medical area, volunteers established a supervised children's play zone, which gave evacuees with children a chance to seek treatment. "God bless you," an elderly man leaning against a wall called out as physicians approached the clinic to check in.

Psychiatrists and other mental health workers walked among the Reliant Park evacuees, offering assistance to those suffering from escalated conditions and posttraumatic stress disorder. In his fourth report to the critical care community, Dr. Mattox said those suffering from mental health conditions often did not seek out assistance at the clinic, but volunteers had learned to find them.

Tomball family physician Linda Flower, MD, heard some harrowing stories.

"One mom told me how her family had been trapped in the attic in their house in Mobile and exited through a hole they made in their roof. Mom, Dad, two kids under 12, and her parents were out in an open boat, still attached to the house for two days, watching helicopters rescue some folks, but no one came back for them. She said that while on that boat, it was the first time in her life she had heard her father pray out loud. They had very little food or water by then, so they waded in waist-deep mud to a highway, were passed by several vehicles, and finally made it to a 'shelter' that had no food or water. They managed to save only one of their 12 puppies. Her name is Katrina."

Dr. Flower says the woman was grateful for the help she and her family received in Texas, but was still very angry.

"I tried to get her to think more about the positive things, like the fact that her family is safe. Twice, total strangers have given the family $100 for food and clothing."

 By Labor Day, more than 1,000 physicians, 1,500 nurses or other health professionals, and 1,300 community volunteers were at Reliant Park. The Katrina Clinic now treated only minor problems, while serious conditions were immediately bused to Reliant Arena.

A few miles away, volunteers at the convention center continued to serve their growing evacuee population. Memorial Hermann Healthcare System collaborated with UT-Houston to offer an Internet-based volunteer scheduling system to improve staffing efficiency.

Throughout Saturday afternoon and early evening, the convention center clinic saw around 550 patients. That number grew to 2,000 by Monday.

"Like a Military Organization"

Over the next two weeks, the population at Reliant Park and the convention center dwindled. Local officials had maintained that the shelters would be temporary and that it was important for each one to develop an exit strategy for evacuees. Many left with friends and relatives, while others found some form of permanent housing through assistance programs.

By Friday, Sept. 16, the dwindling Astrodome and Reliant Center populations were consolidated into the Reliant Arena, and the clinic operation at Reliant Park finally closed. Reliant Arena now had 1,655 residents; two weeks earlier, Reliant Park had sheltered as many as 27,100.

Dr. Vallbona was touched by the efforts of Houston's medical community.

"For me, it was an exhilarating experience to work alongside so many contemporary colleagues, resident physicians, and two generations of former Baylor medical students at Reliant Park. They worked extremely well with professionals from other cities throughout the United States. In an admirable team spirit, they all took care of the health needs."

A few days later, on Sept. 21, the convention center ceased functioning as a shelter after more than 28,000 evacuees were registered for shelter and other relief services. Although Reliant Arena experienced a brief outbreak of norovirus, neither the convention center nor the Astrodome had an epidemic, a possibility that had worried health officials.

New Orleans otolaryngologist Michael Ellis, MD, who had evacuated to Texas, was impressed by Houston's relief efforts.

"Houston did an amazing job at both medical clinics. The way they set them up and operated them like a military organization with a clear chain of command and ways of handling the supplies as they came in. When I went to both facilities, they almost had more volunteers than they had evacuees."

Added Dr. Gilstrap, "You can tell by the attitude of the physicians and nurses that this is why they went into medicine. I know that sounds 'foo foo,' but that is how it really is. It means so much to hear people say, 'Doesn't this make you feel good? Isn't this why you went into medicine?' That is a wonderful thing to hear. I'm 60 years old and I just don't hear that much anymore. I love to hear it now."

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Dallas: More on the Way

On Aug. 31, two days after Hurricane Katrina roared ashore, Dallas sheltered about 600 evacuees who fled the Gulf Coast as the hurricane approached. All were being taken care of at Reunion Arena (once home to the NBA Dallas Mavericks and the NHL Dallas Stars), and the city's relief operation was running smoothly.

But then the next day, Governor Perry toured Reunion and asked Dallas to take in another 25,000 evacuees as the magnitude of the disaster on the coast worsened and shelters in Houston and elsewhere in Southeast Texas were overwhelmed with storm victims. That sent Dallas officials scrambling to find facilities to house them and medical personnel to care for them.

As evacuees continued to swell buses and planes bound for Texas, Dallas County Health and Human Services (DCHHS) officials met with the local American Red Cross, city leaders, and other agencies to coordinate the effort.

It was unknown when the additional evacuees would arrive, but it was obvious that Reunion alone could not handle them, so officials began transforming the Dallas Convention Center, which had already been designated as a backup shelter, into the city's largest shelter. At the same time, the City of Dallas took control of the Reunion shelter.

"Running this type of shelter is complicated, especially because no one had done it before," said David Buhner, MD, DCHHS medical director. "There were some growing pains, but eventually a tight-knit operation was set up. It was a difficult time because everyone had to keep changing what he or she was doing to stay on top of a changing situation. Eventually both Reunion and the convention center were run on a military model or what's called an incident command model."

In a Public Health and Preparedness Update , DCHHS Services Director Zachary Thompson said the arrival of evacuees displaced by Hurricane Katrina "moved public health response from practice to reality. Most of us have never seen disaster of this magnitude involving the mass evacuation of a total city population."

A key component to the Dallas convention center's medical unit operation was the construction of an onsite clinic. Kathy Rinnert, MD, MPH, assistant professor of emergency medicine at The University of Texas Southwestern Medical Center at Dallas and faculty physician in the Emergency Services Department for Parkland Health & Hospital Services, recalled going down to the convention center to plan logistics.

"On Friday morning, after an emergency staff meeting, we basically scratched out on paper how we thought the clinic should be organized. We had 12 hours to set everything up," she said.

The convention center's shelter was erected in its 200,000-square-foot parking garage, which included a curtained-off 8,200-square-foot medical clinic. DCHHS established a medical command center at both Reunion and the convention center where representatives from the various organizations involved could communicate. John Carlo, MD, chief epidemiologist at DCHHS, said members of the Dallas County Medical Reserve Corp. (run by DCHHS) provided much of the staffing, as did physicians from UT Southwestern, Parkland, Children's Medical Center, and the Dallas County Medical Society (DCMS).

"Michael Darrouzet and his staff at DCMS provided us with list of physician volunteers. Throughout the clinic's operation, I would call him if I needed a physician at a particular time, which was unbelievably helpful," said Dr. Carlo.

Added Dr. Buhner, "The response to the call for volunteers, both mental health and medical, was great. We got hundreds and hundreds of volunteers. I also think this situation demonstrates how the Medical Reserve Corp. can be a valuable asset during disasters."

With beds for 60 patients and seating capacity for more than 170, the convention center clinic offered services that included routine care, pediatrics, obstetrics-gynecology, podiatry, ophthalmology, dentistry, and chiropractic services.

 UT Southwestern's Department of Psychiatry, with help from the City of Dallas Crisis Team, established the mental health clinic. Tables were stocked with medical supplies and on Saturday, Walgreen's placed a mobile pharmacy on site to fill prescriptions. Before Walgreen's arrival, area hospitals and physicians donated stocks of their own medications.

Significant Problems

The first evacuees arrived at the convention center on Friday evening, Sept. 2. Like the evacuees at other shelters in Texas, many suffered from chronic disease complications, dehydration, and lack of medication. Others had soft-tissue injuries from water exposure or cuts from crawling over debris. They had been rescued from rooftops, the Superdome, Interstate 10, and the convention center in New Orleans.

"The Reunion population was mainly evacuees who were able to leave Louisiana before Katrina hit," Dr. Carlo said. "Overall, their medical needs were not as severe as those at the Dallas Convention Center. Most of those folks had actually been in the storm and were evacuated days later by officials. For them, the most minor medical problem had become significant by the time they arrived in Dallas."

Most evacuees were separated from family members and had no way to contact them. Wayne Denton, MD, PhD, associate professor of psychiatry and director of the Family Studies Center at UT Southwestern, says many of the evacuees thought they were going to Houston, only to discover halfway to Dallas that the destination had changed. Although he could not immediately reunite those who were separated in Louisiana, he was able to help one man who needed to reach his son.

"A man I talked to spoke only Spanish. He told me he was from Venezuela and that he had a son in Miami. I finally figured out he was trying to reach his son. I let him use my cell phone to call Miami and spoke to the son for a little bit. He said he would be in Dallas in 24 hours to get his father and I told him where to come."

On Saturday, a convoy of 50 buses arrived in Dallas. Soon 6,600 evacuees were at both the sports facility and the convention center. Alan LaGrone, MD, PhD, associate professor of psychiatry at UT Southwestern and medical director of psychiatric emergency service at Parkland and the City of Dallas Crisis Team, was among the mental health professionals who provided care for patients.

"The clinic was up and running by Friday evening, and it was pretty much nonstop though the weekend," he said. "We saw well over 500 evacuees Saturday and Sunday. There were at least that many, because we were working with folks throughout the entire convention center. Physicians would have to go into the housing area because there were evacuees who would not come to the clinic. Either they were too scared or afraid to leave their family."

As more buses arrived, officials had to find other North Texas cities willing to assist evacuees. Additional shelters opened in surrounding counties, and Dallas officials elected to use the Decker Detention Center as a shelter. The facility had once been a hotel where the Beatles stayed in 1965. Evacuees received medication, and those who needed more extensive treatment were taken to the convention center.

DCHHS estimates the convention center clinic saw an average of 700 people per day. Curtained off from housing, the clinic had a sign-in and waiting area. Folded chairs were arranged in rows as volunteers checked patients' vital signs and decided where they should be directed. Often noisy during the day, the 24-hour clinic was quiet when Dr. Rinnert arrived for her shift.

"For me, the convention center was a little city. I worked the night shifts, so I became accustomed to walking through the shelter because things are much calmer at night. It was amazing to watch the change in people. The first few days they looked down, shuffled their feet, cried throughout the night. After a few days, some became accustomed to me, each other, the situation. They started looking up, smiling, and saying, 'Hi Doc' when I came by."

Two individuals stuck out in particular. One was a man who adopted the job of delivering papers. The other was a woman determined to tend to the cleanliness of the clinic's waiting room.

"Around 3 am this gentleman would come to the clinic to borrow a wheelchair. He would then go to where the Dallas Morning News was dropped off, then wheel the papers throughout the shelter, leaving them at areas he knew wanted them. There was also an elderly woman from New Orleans who volunteered to tidy up the waiting room. One night I noticed she was straightening all of the chairs. When I asked what she was doing, she said, 'This is the entrance to our hospital and I want it to be straight. If you give me a broom I'll sweep, too.'"

On Monday, 100 cases of norovirus were detected among evacuees at the convention center, but physicians were able to keep it from spreading.

Dr. Buhner pointed out that one thing the shelter could have used more of was antiseptic hand wash. "We went through, I cannot tell you, how many bottles of hand sanitizer. They were all over the place, every time you went in or out of the shelter, every time you went to the bathroom, before you ate, after you ate. I basically had people squirting it into my hands as I walked by. But we couldn't afford to have 50 sick folks turning into 500 sick folks, including the volunteers," he said.  

By Tuesday, Sept. 6, Reunion Arena and the convention center population began to decrease. Evacuees had either moved to smaller shelters or hotels, or had found relatives who could provide housing. On Friday, DCHHS and its affiliates began administering free vaccines to protect evacuees from tetanus, hepatitis A and B, and pneumococcal diseases. The following Monday, Sept. 12, only 1,200 were still registered at the two shelters.

Exit Katrina, Enter Rita

The convention center medical unit was closed Sept. 16, and city officials began moving the remaining evacuees to Reunion.

On Sept. 22, DCHHS, DCMS, and Parkland announced they were joining forces to provide continuing care for the hurricane victims who had blended into the Dallas population. Named Project Katrina, the temporary program is part of Dallas's Project Access, which coordinates physicians, hospitals, laboratories, pharmaceutical care, continuity of care, and ancillary services for hundreds of uninsured, medically indigent patients in Dallas County.

Officials planned to close Reunion Arena by Friday, Sept. 23. Only five of the original 20,155 people who had been in Dallas's shelters remained. However, by that afternoon, evacuees from Hurricane Rita began to flood Big D as the storm bore down on the Texas and Louisiana coasts. Nearly all of the hotels were booked and officials elected to keep Reunion open for those seeking shelter. They soon reopened the convention center, as well, as more Texans fled the coast.

Following Rita's passage, the convention center was closed again, while Reunion remained open as evacuees from Beaumont and other Texas cities realized they could not return to their homes. About 800 Hurricane Rita evacuees joined those who were still homeless from Hurricane Katrina.

"We've now run through three different groups of evacuee populations at the Reunion Center," Dr. Carlo said. "We had the New Orleans evacuees, then the Houston evacuees, and now we have the Beaumont/Port Arthur evacuees."

Dr. Buhner had high praise for the medical care the evacuees received.

"The medical community of Dallas County responded to an unprecedented and unexpected challenge in a really outstanding way. There certainly were no complaints from evacuees about their medical care. The fact that Dallas welcomed this many folks with open arms and really bent over backwards for these folks is pretty amazing."

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San Antonio: A Parade of Airliners

Since the terrorist attacks of Sept. 11, 2001, San Antonio public health officials have paid a considerable amount of attention to how they would handle bioterrorism or a natural disaster. Fortunately, they haven't had to put their plans into action.

The mass evacuation of Hurricane Katrina survivors from New Orleans to San Antonio and other cities across Texas over the Labor Day weekend, however, gave them a good look at how effective their disaster planning was. And they were generally pleased by what they saw.

On Thursday and Friday, Sept. 1 and 2, bus- and planeloads of evacuees fleeing the aftermath of the hurricane began pouring into San Antonio even as city officials, the American Red Cross, the U.S. military, and other organizations hurriedly readied shelters to house them. Ultimately, nearly 13,000 evacuees ended up at almost a dozen shelters throughout the city.

Fernando Guerra, MD, MPH, director of the San Antonio Metropolitan Health District, says the speed at which the situation developed and the large number of evacuees needing both shelter and medical care presented some major challenges.

"This incident happened very quickly, and the anticipated numbers of individuals moving into our community directly from New Orleans told us we were probably going to have to modify our thinking and the plans that we had in place," Dr. Guerra said.

Mercy Flights

Evacuees arrived in San Antonio even before officials there could finish preparing shelters to receive them. Nine busloads arrived on the morning of Friday, Sept. 2, and flights from New Orleans' Louis Armstrong Airport began touching down at KellyUSA, a short time later. Some 47 planeloads of evacuees landed at Kelly during the weekend.

"They were brought from the tarmac directly to the building that served as a processing center, which was a large building that also housed quite a few evacuees," Dr. Guerra said. "As that shelter reached capacity, the next shelter would open, and then the next one and the next one."

At times, he says, it seemed a nonstop parade of airliners was landing at the former Air Force base. "There were times when you just really couldn't catch up."

Two buildings at the base were designated to receive evacuees, and military personnel and others worked rapidly to clear out spaces and set up cots and equipment.

"It was an incredible experience," Dr. Guerra said. "We had people being bused from the tarmac into this area that we were still in the process of setting up."

While San Antonio officials were setting up shelters and makeshift clinics, a team of medical professionals from Lackland Air Force Base was deployed to the New Orleans airport to triage evacuees and determine who was medically stable enough to fly to San Antonio.

Among the earliest arrivals in San Antonio were patients evacuated from New Orleans area hospitals. That evacuation was coordinated by the National Defense Medical System (NDMS), with assistance of local hospital officials and volunteers from the Texas Medical Rangers, a subdivision of the Texas National Guard.

San Antonio family physician Ann Burgardt, MD, is a member of the Medical Rangers team mobilized to receive those patients. She says that through coordination between NDMS and San Antonio hospital officials, hospital beds were lined up for the patients before their planes ever landed.

The first group of hospital evacuees arrived Thursday night, while others continued coming throughout the weekend. The rangers greeted each planeload.

"If they came off the plane in an acute situation, we were right there to offer them definite medical care at that point," said Dr. Burgardt, a member of The University of Texas Health Science Center at San Antonio faculty.

Two flights had to turn back to New Orleans before reaching San Antonio because one or more patients were not stable enough to reach their destination alive. Even so, most of the patients she saw were "fairly stable in the sense that they didn't need acute airway management, they didn't need any intubation," Dr. Burgardt said. "Some of them were comatose and basically were not alert. But they were tagged and they had identification and they had a specific destination within the system."

Once triaged at Kelly, the patients were transported to hospitals by emergency medical services and private ambulances.

One postoperative patient with a head injury arrived unconscious with numerous staples in his head. "Everything that we knew about him was on a handwritten medical record," Dr. Burgardt said. "It was so nice that people had done a good job wherever they triaged him, putting all that information on that sheet of paper because he couldn't tell us anything."

Good-Bye and Good Luck

While the Medical Rangers were handling hospitalized patients, other evacuees arrived with medical conditions that needed care. Clinics were set up at each of the two shelters at Kelly and at shelters in the former Windsor Park shopping mall, a Levi Strauss factory, and several Baptist churches.

The Bexar County Medical Society issued a call for physicians, nurses, physician assistants, and other health professionals to volunteer to staff those clinics. San Antonio pathologist David Henkes, MD, medical society president, says the response was overwhelming.

"I was totally surprised by the number of doctors who turned out. We had 300 doctors pretty much on their own calling the medical society to ask what they could do."

A large number of medical students from UT-San Antonio also volunteered at the shelters.

"The student and faculty response has been nothing short of outstanding," said Pete Cashio, a first-year medical student who volunteered at KellyUSA along with several classmates.

As was the case in other cities, many of the evacuees arriving in San Antonio had chronic conditions that had been exacerbated by having been without their medications for several days. Dr. Guerra says it took the medical volunteers some time to sort out what medications the evacuees needed, write them prescriptions, and get the drugs sent over to the shelters.

Dr. Burgardt, whose Medical Ranger team also assisted with the general evacuees, says several patients had minor wounds, infections, swollen legs, and other conditions. Many were simply exhausted.

"These were tired, tired people," she said. "They had that same vacuous look that refugees have."

Mr. Cashio says the images he saw and heard on television and radio "cannot begin to describe the plight of these people. Busloads of refugees poured into the triage area where I was working, most without shoes and most owning nothing more than the clothes on their backs." Many of them were lacerated by flying glass and other objects hurled about by the storm. Others had just had major surgery.

"One man had had a heart attack on the 23rd   of August. He had surgery and was recovering in the ICU when Hurricane Katrina hit," Mr. Cashio said. "His hospital was so devastated that they handed him his chart and wished him luck trying to find a way out."

Two Disaster Medical Assistance Teams (DMATs) - the Texas-1 DMAT from El Paso and the Florida-2 DMAT - flew in to help provide emergency care. They arrived in San Antonio on Friday and received patients in a mini-emergency room set up at one of the Kelly shelters within a few hours.

"Mainly what we saw were chronic health problems that people had prior to the hurricane hitting but then had no medical care for a week," said Michael Simmons, EMT-B, administrative officer for Texas-1 DMAT. "We saw very few actual cuts and scrapes and bruises, really no injuries from the storm itself."

Texas-1 DMAT is a team of 35 physicians, nurses, physician assistants, pharmacists, and other health care workers that Mr. Simmons says can care for up to 250 patients for three days without being resupplied. While the team is headquartered in El Paso, individual team members are from throughout Texas, he says.

Because its equipment had been deployed to Louisiana before the airlift operation, the Texas team shared equipment and supplies of the Florida team, Mr. Simmons says.

Across a wide walkway from the Texas-1 DMAT clinic inside the huge warehouse that served as the main receiving point at Kelly, local medical volunteers set up a special needs area for patients who needed supervised care. While the shelter population began dwindling within a few days of the first evacuees' arrival, about 120 patients were still receiving care in the special needs area on Friday, Sept. 9.

Amy Black, RN, the nurse in charge of that area that day, says most of her patients were elderly or suffered from chronic diseases such as diabetes or hypertension.

"A lot of them are elderly who can't care for themselves," she said. "It ranges from needing a wheelchair to get to the restroom to the point of being incontinent in the bed. A lot are diabetics who need help doing their blood sugars. Other patients have not gotten their medications and need their blood pressure watched."

Many of the patients there seemed to be in shock even days after arriving in San Antonio. Although a large screen television was playing at one end of the 158-bed area, few of the patients appeared to be watching it. One elderly man sat on his cot and stared blankly at a fixed point across the room.

Outside the shelter, CVS Pharmacy set up a mobile pharmacy to supply prescriptions, and Ms. Black says CVS donated a lot of other materials they needed to care for patients.

"They Didn't Complain"

Dr. Guerra says he was generally pleased with the response effort in San Antonio. "I would say that overall we did quite well, given the magnitude of what we were dealing with."

He described the response of physicians, nurses, and other health professionals as tremendous. "They could not have been more generous. Within hours of the arrival of the first wave, we were greeting physicians from our community in the medical clinics or they were calling or e-mailing asking where they could go, what they could do to help. And the nurses really did a lot of good work, as well."

Donald Gordon, MD, PhD, the EMS medical director for the San Antonio Fire Department, also praised the efforts of Metropolitan Health District, EMS personnel, private ambulance companies, and others who helped care for the evacuees.

"Appreciated also are all of the local ER staffs and hospitals who readily and willingly accepted the great number of patients who were so quickly generated by this mass evacuation," he said, adding that EMS transported 536 patients to local emergency departments over the holiday weekend.

But not everything went smoothly. "There were a lot of logistical logjams," said Dr. Guerra. "There were a number of bureaucratic obstacles that we had to work through."

One of the early problems was with medications. By the time prescriptions were written, filled, and delivered to KellyUSA, the patients often had been transferred to other shelters.

"The system that had been set up at the front end did not allow us to link people who needed these prescriptions with the shelter that they had been assigned to," Dr. Guerra said.

Another problem was that many of the prescriptions were being sent to University Hospital, but the hospital pharmacists were reluctant to fill them because the physicians who wrote them often were not on the hospital staff. Dr. Guerra says he worked out a solution with hospital Chief Executive Officer George Hernandez, "who was able to help us get some of the physicians from my staff, and volunteers who were helping us credentialed on an emergency basis, and/or allow the pharmacists to fill their prescriptions with my credentials that were on record in the pharmacy. After the first day we were able to get additional pharmacy support from Walgreen's, HEB, and CVS pharmacies, who together with UHS did a truly remarkable job of dispensing well over 7,500 prescriptions."

He added that emergency officials "had not really had a chance to work out all the kinks in terms of how we would get the prescriptions sent over, who or where they would be filled, and once they were filled how to get them back to the patient."           

Still, Dr. Guerra says the early assessment showed that all of the agencies and volunteers performed well.

"We did the best we possibly could for many people across all age groups who had some profound personal needs -- physical, emotional, spiritual," he said. "We had to have in place a well-integrated and supported system to respond to those needs.

"And, in addition to taking care of very acute needs and those with chronic illnesses, we certainly wanted to do the best that we could to prevent disease from emerging that would put a lot of people at risk. I can with considerable pride tell you that we've done that."

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Austin: "A Great Response"

On Sunday, Sept. 3, Austin Regional Clinic family physician Jim Merryman, DO, looked out over the makeshift clinic at Austin's Palmer Events Center, where the previous day he and other medical volunteers had treated hundreds of patients evacuated to Austin from Louisiana.

That morning, the clinic was mostly quiet, its multiple rows of white-sheeted cots largely empty.

"I'm seeing the poorest of the poor here," Dr. Merryman said. "All they have is a plastic grocery bag as their luggage."

Dr. Merryman was one of more than 130 physicians and countless nurses, emergency medical personnel, mental health experts, pharmacy technicians, and other health care professionals who gave up all or part of their Labor Day holiday weekend to treat more than 4,000 evacuees airlifted from New Orleans after Hurricane Katrina.

Austin mounted a well-organized effort to house, feed, and clothe Katrina evacuees, as well as care for their medical needs. Run from the City of Austin's Emergency Operations Center (EOC), the effort involved city officials, the American Red Cross, city-owned Brackenridge Hospital, Seton Health Network, St. David's HealthCare Partnership, the Travis County Medical Society, and thousands of volunteers.

Except for some early confusion about when the first evacuees would arrive and the specific role the medical volunteers were to play at the various shelters, it appears the entire response went off with very few hitches.

"It was a great response by everyone in the community,"   said Pat Crocker, DO, chief of emergency medicine at Brackenridge and Children's Hospital of Austin at Brackenridge. "I can't imagine things could have gone smoother."  

Drawing Up a Plan

A small number of Katrina evacuees made it to Austin on their own as the hurricane slammed the Louisiana, Mississippi, and Alabama coastlines. But the city scrambled to prepare for large numbers to arrive as early as Thursday, Sept. 1, when it was reported that the Federal Emergency Management Agency had asked Capital Metro, the city's transit authority, to send six buses to Houston to pick up evacuees. That report turned out to be false, but the advance warning enabled the city to have a plan in place when evacuees did begin arriving by plane on Saturday.

A medical team met the planes as they arrived at Austin Bergstrom International Airport. The evacuees were quickly evaluated, then bused to the Austin Convention Center. There, they were met by a large team of volunteers who conducted a much more extensive triage.   

The first evacuees were ushered into the convention center via the loading dock around 10 am. Many appeared dazed or in shock. Some were too tired or ill to stand or walk without assistance. Most were disheveled. Some had been plucked off rooftops just that morning.

One woman wore only a hospital gown. A young man wore only a pair of athletic shorts and running shoes. While some carried suitcases or backpacks, many carried what few belongings they had in plastic bags. Some appeared to have nothing at all.

Evacuees who did not need medical care were immediately directed to a shelter area where they could get clean clothes, food, showers, and a place to sleep. Those who needed some care were directed into a clinic set up in a large conference room. Dozens of paramedics from fire departments from throughout Central Texas did initial examinations and directed patients needing additional care to several tables in the rear where physicians conducted more thorough examinations and gave minor treatment.

Physicians at the convention center were asked to perform largely a triage role, mainly assessing patients' conditions and providing little direct care. Patients needing urgent care were immediately transferred to the Brackenridge Emergency Department. Buses carried those requiring less urgent care to the Palmer Events Center, where dozens of cots were set up in rows that resembled hospital wards and a makeshift pharmacy operated out of a concession stand.

Family physician Mark Levy, MD, was among about 20 physician volunteers triaging patients at the convention center that morning. He and the others had responded to calls for volunteers from the county medical society, which had been directed by officials at the Emergency Operations Center to line up about two dozen physicians who could be available on 30 minutes notice to staff the clinics as evacuees began to arrive.

There were surprisingly few traumatic injuries among the evacuees at the convention center.

"Most of it was chronic care, people without their medicine," Dr. Levy said. "They just needed to get plugged back into services."

Many of the patients had diabetes and had been without their insulin for several days. Others had hypertension but no access to their medications. A few were drug addicts who needed methadone.

Most of those patients ended up at the Palmer Events Center, where Dr. Merryman and other physicians stabilized their conditions.

A few patients had minor wounds. Dr. Levy treated an elderly man with a lacerated thumb who had spent three or four days in a flat-bottom aluminum boat helping neighbors get off rooftops and out of attics.

The storm had interrupted other evacuees' treatment for more serious medical conditions. One woman with lung cancer was scheduled to begin radiation treatment the day the hurricane hit New Orleans. Her body still bore the markings where the radiation therapy was to have been applied.

Another man wearing a knee brace had just undergone a surgical procedure on his knee in preparation for a more extensive operation. The incision from that procedure had been exposed to contaminated water for several days, but it did not appear infected.

Dr. Levy, who spent about 10 hours at the convention center that Saturday, says he does not know what happened to those patients. "Ultimately, the lady with lung cancer is going to need somebody to call one of the oncologists here in town and get her plugged into resources here," he said.

Still other patients needed mental health services.

Convention center volunteer Sarah Goodpastor, a third-year medical student at The University of Texas Health Science Center at San Antonio, encountered one man from Chalmette, La. - one of the hardest hit areas - with multiple chronic conditions and posttraumatic stress syndrome from his service during the Vietnam War. The trauma he witnessed in the storm had triggered some unpleasant memories, so Ms. Goodpastor helped direct him to a clinical psychologist on site.

Putting a Plan in Action

At Brackenridge Hospital, officials invoked a disaster plan developed after the terrorist attacks of Sept. 11, 2001. An emergency services area was set up in a parking garage underneath the hospital's helipad so the emergency department could handle the Katrina victims and its normal patient flow.

The area included 72 military-style litters, a crash cart, oxygen bottles, decontamination showers, space coolers, and other equipment. Several physicians were on 30-minute standby, if needed, but ultimately the hospital handled the Katrina evacuees sent there with the emergency physicians already on duty.

"We treated about 200 patients in our disaster emergency room under the helipad," Dr. Crocker said. "In addition, we had about 30 other hurricane victims in the ED who did not come as part of the organized evacuation."

Most of the patients who went to Brackenridge had chest pains, skin infections, and foot infections. One had a possible hypertensive hemorrhage and another suffered from dysrhythmia. Only six were admitted to the hospital, while the rest were treated and returned to the convention center.

"We started to see some acute diarrhea illness late Saturday and through Sunday," Dr. Crocker said. "And the rest were probably people with very minor skin trauma, hypertensives who needed medicines, and diabetics with high blood sugar. We had a satellite pharmacy set up so we filled all their prescriptions before they left."

By Monday, Sept. 4, most evacuees needing urgent care had been treated, and the special emergency area had been shut down. Dr. Crocker says the relief operation went "as smoothly as could be expected," but officials learned a few things he says will be incorporated into their disaster plan.

The first was the need for a critical care area, where patients can be intubated and put on a ventilator. A two-bed mini-critical-care area was set up that weekend and will be part of future disaster operations.

Second, Brackenridge officials added a portable x-ray unit to the special emergency area. "We set it up over in a corner that was distant from the rest of the patients so the scatter radiation wouldn't be an issue," Dr. Crocker said. "It was much easier to have a portable machine down there, take films, and run the films up to get developed than trying to move those patients all around."

Third, all of the litters used in the crisis sat only inches off the ground. Brackenridge will add about a dozen waist-high litters so physicians can assess and treat patients without having to bend over.

Order Out of Chaos

While just about everyone involved praised the relief efforts in Austin, there were some early snafus and confusion. Pat Alba, a city employee drafted into duty as the shelter manager at the Palmer Events Center, says the clinic there initially had no wheelchairs, so patients had to be wheeled in from the buses on rolling office chairs.

At the convention center, some physician volunteers found it difficult to adjust to a triage-only mode because they were seeing conditions they could treat on the spot. But local health authority Aldolfo M. Valadez, MD, of the Austin-Travis County Health and Human Services Department, made it clear that a planeload of evacuees landing every hour required physicians at the convention center to limit their activity to triage to keep the process flowing smoothly.

Family physician Ann Messer, MD, came to the convention center the first morning as a volunteer, but quickly found herself more or less in charge of the physicians there. Once the initial triage was completed, she led the transformation of the medical operations to focus more on long-term needs. By Sunday evening, the whole operation had been redrawn, says Ms. Goodpastor, who helped with the transformation.

Winding Down

While a large number of evacuees remained in Austin in late September, city officials and the Red Cross began winding down shelter operations quickly. By Sunday evening, Sept. 10, the Palmer shelter, which had housed mainly families of patients receiving treatment there, was closed. When Hurricane Rita hit the Texas and Louisiana coasts on Sept. 24, virtually all of the evacuees at the convention center had been moved to more permanent housing.

While the shelters were open, however, physicians and other health care workers provided care around the clock. Travis County Medical Society officials estimate that more than 300 local physicians took part in either the initial intake of evacuees or follow up care while the shelters were in operation.

Medical Society President Guadalupe Zamora, MD, says he is "truly amazed" at the kindness and generosity shown by the people of Central Texas, including its physicians.

"I thank the medical community for widening their circle of compassion," Dr. Zamora said. "Thank you, Austin and medical personnel of Austin, for realizing the importance of preserving these people's lives and their human dignity."

For their part, physicians say it was the least they could do to help their Louisiana neighbors.

"That's why we're doctors," said Austin emergency physician Charles Valadez, MD, who was among physicians at the Palmer Events Center over the Labor Day weekend. "It's an inner calling. You just have this urge that you want to help."

Austin Regional Clinic family physician Hillary Miller, MD, says everyone needs to do their part when they see a need.

"These are just people. That could have been me," she said. "They are very, very grateful for our help, but I'm sure they would have done the same if it had been our town."

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