Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex.

Abstract: On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility--the Katrina Clinic--at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.

Key Words: disaster relief, Hurricane Katrina, emergency medical response, surge capacity

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On Monday, August 29, 2005, a category 4 hurricane struck New Orleans and the adjacent Gulf Coast, resulting in the largest natural disaster in US history. Hurricane Katrina displaced hundreds of thousands of people from their homes on the Gulf Coast and severely damaged the historic city of New Orleans. The thousands who could not leave New Orleans found themselves in local shelters of last resort, without food, medicine, or care. Houston, the nearest large city, was a logical destination for those who could be evacuated, and the political and medical leaders of Houston and Harris County immediately agreed to participate in the relief effort. Using the Astrodome/Reliant Center Complex as a home base, they organized housing, food, and medical facilities in preparing for the arrival of an estimated 25,000 people. Disembarking from buses after struggling for days without adequate food, water, or rest, many of the 27,000 who eventually arrived at the Complex were found to be dehydrated, delirious, and suffering from the neglect of chronic medical and psychiatric conditions. Among other local, national, and regional groups and organizations, the medical community of Houston and Harris County scrambled to meet the extraordinary requirements of these displaced people--their neighbors in need.

Medical Response at the Astrodome/Reliant Center Complex

Overview

The medical facility at the Houston Astrodome/Reliant Center Complex, known as the Katrina Clinic, bore the brunt of patient care for the first wave of evacuees and subsequently served the large population housed at the mass shelter within the Complex. More than 11,000 patients were seen by the medical staff over the course of two weeks. Figure 1 and Table 1 provide specific data concerning the evacuees housed at the Complex who were seen by medical staff at the Katrina Clinic.

The majority of patients who required more extensive care, including hospital admission, were referred for further evaluation to publicly funded hospitals within the Harris County Hospital District, specifically, Ben Taub General Hospital and Lyndon B. Johnson Hospital.

Creating an Infrastructure

Leaders from the political, public health, Harris County Hospital District, and Harris County medical community met on August 31, 2005, to plan housing, medical care, and social services (see Table 2 for a partial list of organizations participating in this medical response) for Katrina evacuees, some of whom were already en route to Houston. The initial leadership group established a unified command and control system to direct and coordinate the services they anticipated the evacuees would need, as well as a public health infrastructure comparable to that of a small town. The system followed Federal Emergency Management Agency (FEMA) guidelines for creating a Unified Area Command. The Medical Branch of the Operations Section was authorized to direct all health and medical initiatives for the evacuee population at the Houston Astrodome/Reliant Center Complex. Representatives met several times a day to reassess operations and accommodate the fluid situation. Flexibility, frequency of communication, and adequate medical staff and resources were key to staying abreast of the Complex population's needs. (1)

The Medical Branch of the Katrina Relief Operation at the Houston Astrodome/Reliant Center Complex was led by Harris County Public Health and Environmental Services (HCPHES). The Ambulatory Care Group within the Medical Branch at the Complex was led by faculty from the Harris County Hospital District (HCHD) and Baylor College of Medicine (BCM). The Katrina Clinic eventually included 65 examination rooms, with defined areas for triage, adult medicine, pediatrics, obstetrics and gynecology, orthopaedics, emergency psychiatry, and other specialties. The Clinic was built in a 100,000-square-foot space in the Astrodome/Reliant Center Complex--more specifically, in the Reliant Arena. Construction required about 12 hours. Existing exhibit hall materials made possible the rapid construction of examination rooms and other facilities within the Complex. Other rooms were added as demand increased, including vision and dental care facilities during the second week.

Patients at the Katrina Clinic were registered and medical records were established via the HCHD patient registration system, which was in operation by September 1, 2005. Initial clinic intake included a history and physical examination, as well as a public health syndromic surveillance survey (see Table 3 for a list of the most common health problems of Katrina patients).

As evacuees arrived in buses of 40 to 50 per vehicle, they were briefly categorized, according to need. Five levels of care characterized treatment:

* First level: Immediate triage as people exited buses. The sickest went directly to area hospitals. On average, one person on each bus had to be transported by emergency ambulance to Ben Taub General Hospital, Lyndon B. Johnson Hospital, or other community hospitals. Most of the evacuees who had been without necessary oxygen for a period of time required emergency transport. Approximately 80 patients were initially sent to hospitals with extreme dehydration. Primary triage kept low-acuity patients out of the hospital and allowed the on-site Katrina Clinic to treat and return patients to their accommodations in the Complex. Evacuees not in need of urgent or emergency medical attention received a bottle of water, directions to the showers, new clothes, a bag containing necessities for bathing and personal hygiene, a hot meal, and a cot with a warm blanket. This initial attention to comfort addressed immediate dehydration, exhaustion, and hunger, while establishing a foundation for evacuee recovery from emotional distress.

* Second level: On-site triage in specific Astrodome/Reliant Center Complex locations separate from the main Katrina Clinic, but near evacuee housing in the Complex. Medical personnel also roamed the floor in an attempt to identify those who were very ill. Minor problems were handled on site, thereby enabling treatment in the Complex, where patients felt more comfortable.

* Third level: The Katrina Clinic itself, where patients could be assessed, diagnosed, and treated--or referred to hospitals. Laboratory and x-ray services, which were available on site, increased efficiency.

* Fourth level: Community resources for patients who needed services such as dialysis or geriatric care.

* Fifth level: Public and environmental health provided by HCPHES.

Response to Adult Needs

Chronic disease or medication refills prompted most adult visits to the Katrina Clinic. Lacking the requested FEMA medication cache, HCHD initially made provisions for the pharmacy. Later, this responsibility was assumed by CVS Pharmacy Corp., through a donated mobile pharmacy. On Days 3 and 4, more than 2,700 prescriptions were filled to replace those lost in consequence of Katrina. Narcotic prescriptions were filled for only a few individuals, including cancer patients in need of pain control.

In addition to addressing chronic medical conditions (eg, diabetes, hypertension, and mental health), physicians diagnosed over 100 cases of dermatitis, cellulitis, and other skin conditions, probably resulting from exposure to tainted water after the flooding in New Orleans. No cases of active tuberculosis were confirmed by the Katrina Clinic. An outbreak of acute gastroenteritis in the Complex--among evacuees and volunteers--contributed to the increased number of persons seeking care in the Clinic. The Harris County Medical Examiner reported 37 Katrina evacuee deaths from September 1 through September 19, 2005. Only two of these deaths occurred at the Astrodome/Reliant Center Complex; other Katrina evacuees expired in area hospitals.

Response to Pediatric Needs

Baylor College of Medicine pediatricians from Texas Children's Hospital (TCH) and Ben Taub General Hospital (BTGH) treated infants and children. TCH supplied and maintained the pediatric section of the Katrina Clinic around the clock. During peak operations, the pediatric clinic housed more than 65 patients receiving IV fluids. By the time the clinic closed, an estimated 3,500 infants and children had been seen over a two-week period; fewer than 50 were transported to the hospital. None of the Katrina Clinic pediatric patients died.

Radiology

Two state-of-the-art portable digital x-ray units--which were provided, gratis, by Siemens Medical Solutions--arrived at the Katrina Clinic on the morning of September 2, 2005. Siemens also provided two digital ultrasound units. By noon of September 2, the equipment was in place and radiology services were initiated. A mobile CT scanner was also provided by Siemens Medical Solutions and parked at the Ben Taub General Hospital for exclusive use by Katrina patients. Initially, image interpretation was provided by radiology residents from BCM and the University of Texas; subsequently, images were transferred electronically to BTGH, where all studies were interpreted by staff radiologists. A total of 461 patients were signed into radiology, with 382 diagnostic x-rays and 155 ultrasounds performed on site.

Mental Health

The Katrina evacuees who arrived in Houston were often disoriented, emotionally distressed, and frightened. Many with acute emotional problems needed immediate intervention. Moreover, we found an unusual number of people with pre-existing psychiatric diagnoses that were indicative of potentially serious problems, if untreated. A wide variety of mental health agencies--including the BCM Department of Psychiatry, the Mental Health and Mental Retardation Authority of Harris County, and the Children's Assessment Center--provided staffing and created a Psychiatric Emergency Service (PES) that served approximately 500 patients who had mental health emergencies. Crisis counseling was employed to help prevent major depression and post-traumatic stress disorder. Suicidality and homicidality, as well as acute aggression and agitation, were treated on site to avoid transferring patients to already overcrowded emergency rooms and psychiatric inpatient units. Patients with chronic mental disorders were provided prescriptions for medications lost or left behind during the evacuation, along with refills. Uncomplicated substance intoxication and withdrawal were treated, with arrangements for the daily transport of methadone patients to a local methadone clinic. Psychiatrists and counselors circulated in the living areas of the Complex to identify patients with unaddressed mental health needs. Fewer than 2% of these patients were referred to a more intensive setting.

Geriatrics 

Many elderly persons did not leave New Orleans before Hurricane Katrina because they either did not have the means to travel or would not evacuate. Older persons who left their homes or healthcare facilities suffered overwhelming stress in New Orleans shelters, and many died. Of the 37 evacuee deaths reported by the Harris County Medical Examiner during this period, 23 occurred in persons over the age of 65.

Approximately 56% of the patients seen in the Katrina Clinic were 65 or older. Many of these evacuees were able to reach Houston because they were accompanied by family members who were able to care for them. Still, many arrived dehydrated and in need of care for chronic health conditions.

There were unique challenges to the rapid identification of special needs among some of the older evacuees. A number of these individuals were not initially triaged to the Katrina Clinic because they either appeared well or were unable to communicate their needs. Sensory impairment prevented some from reading signs or hearing announcements; others had significant mobility or cognitive impairments such as dementia. A further complication was the relocation of several patients by area nursing homes, in the absence of tracking mechanisms that would enable authorities to assist relatives in finding these elders.

Eventually, the frail seniors were clustered together in the Complex, next to the triage area, as well as in a cordoned section within Reliant Center, where they could receive social services easily or be transferred to more appropriate living/care venues. Later, the establishment of a single point-of-contact to authorize the transfer of elderly evacuees partially resolved the tracking problem by preventing nursing homes from removing patients without prior medical team approval.

Physical Medicine and Rehabilitation 

Acute complications can also occur from lack of medical attention in persons with disabilities, including autonomic dysreflexic hypertensive crises for lack of intermittent urinary catheter devices in patients with spinal cord injury; stiffening of joints in recent postoperative joint replacement patients; and complications from the discontinuation of medicines for spasticity, pain, and hypertension. Obtaining prescriptions for narcotic pain medication or refills of implanted narcotic and baclofen pumps proved difficult. Foam overlays on cots helped prevent ulcers in patients unable to turn by themselves. Patients with disabilities, including frail elders, were sometimes placed in separate groups, in the interest of safety and improved care.

Obstetrics and Gynecology

Over the two-week period, approximately 500 patients were seen by obstetrician-gynecologists and certified nurse midwives in three examination rooms, with an adjacent ultrasonography suite staffed by volunteer technicians. Services included prenatal/postnatal care, postoperative care, contraception, and gynecologic problem visits. When appropriate, patients were transferred to area hospitals for further emergency care. There were no deliveries, and only one patient suffered an intrauterine fetal demise.

Personnel Management

Performing licensing and credentialing checks to verify the training of those who offered to help was critical, as was setting standards for care provided in the Katrina Clinic. At times, altruistic volunteers stood in long registration lines; when their numbers exceeded the need, their names were added to a back-up list for future contact. Several doctors and nurses with expired or suspended licenses attempted to volunteer as medical staff--and one poseur, who claimed to be a doctor, was identified; in each case, these persons were removed from the Complex. During the two-week period, a number of unauthorized medical providers setup independent, unmonitored medical clinics in the Astrodome/Reliant Center Complex shelter area; in every instance, these clinics were closed, to ensure that all patients received quality care in facilities that met established community standards. Daily updates were disseminated to medical providers, including clinical care, security issues, service availability, and public health measures. (2)

Public Health Response

The public health response was provided by Harris County Public Health and Environmental Services (HCPHES). During the two weeks of Astrodome/Reliant Center Complex operation, HCPHES directed a NIMS-compliant Incident Command Structure for medical operations and worked in coordination with multiple local, state, and federal agencies, including the Centers for Disease Control and Prevention (CDC), to obtain technical assistance. A comprehensive public health infrastructure was established for the Complex, including activities such as conducting disease and syndromic surveillance, implementing a variety of communicable disease control strategies, ensuring food safety and environmental safety and sanitation, managing animal control issues, developing health education messages, and overseeing public health and medical media issues.

An outbreak of acute gastroenteritis associated with norovirus brought an estimated 1,000 cases to the clinic. (3,4) An observation/rehydration unit was constructed, and a specially designed isolation unit housed patients after they were treated, but still infectious. Sanitation measures to limit the spread of disease included increased hand washing, use of nonwater-based hand sanitizers, cleaning contaminated areas with chlorine, and the increased availability of showers for residents.

A joint effort in the provision of immunizations was provided by HCHD and HCPHES. Immunizations for evacuees and emergency responders followed CDC guidelines, with priority given to updating individuals (mainly adults) with tetanus-containing vaccines. Routine childhood and adolescent vaccines, including hepatitis A, were also offered. HCHD immunized 4,189 evacuees and 488 FEMA workers, providing a total of 6,318 vaccine doses.

Discussion

Medical management of large-scale population movements has been described more often in international settings than in the United States. (5) However, in the wake of September 11, 2001, the mounting threat of terrorism, along with the inevitability of natural disasters and the potential for an influenza pandemic, have made it necessary to prepare for major catastrophes. Issues that must be considered include pre-disaster planning, postevent rescue and triage, healthcare service delivery, the control of infectious disease outbreaks, and mental health effects during disaster. The CDC has disseminated hurricane response guidelines for healthcare providers and relief workers (MMWR), as well as information related to bioterrorism agents/diseases and influenza (on the cdc.gov website).

In Houston, we were fortunate that the situation--both logistically and politically--was conducive to receiving and treating large numbers of evacuees. First, as Houston was unaffected by the disaster, the regional infrastructure was intact, including transportation, water, electricity, communication, and healthcare. Second, a large empty sports complex with over 100,000 square footage of space was available for housing evacuees.

The Red Cross was able to supply cots and food supplies quickly, including fluids for oral rehydration of arriving evacuees. Being close to the Texas Medical Center (TMC) and its resources was critical. Its institutions provided an important source of volunteers, who were essential to operating the Katrina Clinic. The relationship among TMC institutions facilitated rapid collaboration in extending health services to this population.

HCHD resources provided the infrastructure for medical records, computerized registration, reporting of labs and x-rays via a computerized system, and forms use. The positive pre-existing relationship between BCM physicians and HCHD made possible rapid collaboration vis-a-vis clinic construction and operations. Operations utilizing a NIMS-compliant command structure throughout medical branch operations ensured collaboration and effective coordination with such agencies such as law enforcement, the fire department, EMS, etc.

Notwithstanding, the medical response to Katrina did confront some serious challenges. Perhaps the greatest was the lack of a system for identifying and registering evacuees in the overall shelter population within the Complex. This caused difficulties in measuring the population and its demographics and ensuring that patients received the services they required--particularly, care in the wake of critical laboratory tests. The lack of identification also made it difficult to reunite families with relatives who had cognition problems.

In addition, the unique stresses affecting Katrina Clinic patients made some aspects of operation more difficult. For example, families were permitted to remain with patients who were in isolation due to gastrointestinal illness, to reduce the emotional burden of those who had just survived the stress of the hurricane and evacuation.

Conclusion

Other major urban localities can achieve the same results as those realized at the Houston Astrodome/Reliant Center Complex; however, advance planning will make the task easier. Such preparation should include the mobilization of medical professionals from neighboring cities unaffected by the disaster through a variety of means, including hospital-based organizations or physician groups, medical schools, or governmental organizations. Local agencies and professionals should develop a local response plan. (6)

Based on the experiences of the Katrina Clinic, we recommend the following:

* There should be early screening for critical conditions/illnesses, such as pediatric dehydration or delirium in fragile elders, with prompt transfer to hospitals, rapid triage, and designation of people who are best able to execute it.

* Particular consideration should be given to addressing the special health needs of isolated elderly or disabled individuals. It may be useful to move these individuals to more protected groups located in areas proximal to social and medical services to better meet their unique needs. Planning the care of special populations, such as nursing home patients, patients with cancer, diabetes, dementia, or psychiatric disorders, or patients receiving long-term dialysis or methadone treatment is essential.

* Laboratory, radiology, and pharmacy services, along with attendant recordkeeping, should be established on site as early as possible.

* From the outset, there must be a system whereby the credentials of volunteers can be quickly verified.

* Advance planning must include collaboration with public health officials to ensure that hygiene, safety, and environmental issues are properly addressed.

* There should be a system to record the name and identifying information of any child, elder, or disabled person who is removed from the shelter facility; this will prove invaluable when attempting to locate these persons for anxious families. Further research and planning should seek to develop rapid population identification systems linked to evolving medical records.

Having conveyed specifics concerning the Katrina medical response, along with our recommendations for those who undertake similar efforts, we realize that the optimal conditions experienced at the Katrina Clinic will not always be possible when a community confronts unique public health challenges. For instance, in the event of large-scale influenza outbreaks or natural or man-made catastrophes, there could be serious shortages of healthy staff, vaccines, medications, food, potable water, equipment, and other supplies. In view of this fact, health systems should, whenever possible, consider storing additional quantities of essential supplies. However, developing a contingency plan that will expand a health system's surge capacity during emergencies is essential; in particular, population relocation sites that are adjacent to health facilities (eg, Astrodome/Reliant Center Complex near the Texas Medical Center) should be identified and incorporated into emergency strategic planning.

Ultimately, the medical effort in the Astrodome/Reliant Center Complex involved multiple groups working together to provide the comprehensive care required by people who have endured a disaster. With adequate planning and organization, supervision and cooperation, resources and leadership, other communities can respond fully and successfully, as did Houston and Harris County in the aftermath of Katrina. Although catastrophes are never pleasant to contemplate, it is nonetheless our obligation to improve our competence in addressing them. It is inevitable that similar medical response efforts will be necessary in the future.

Acknowledgments

The authors wish to express their appreciation for the editorial assistance provided by Ruth SoRelle and J.E. Young.

References

1. Mattox KL. Hurricanes Katrina and Rita: role of individuals and collaborative networks in mobilizing/coordinating societal and professional resources for major disasters. Crit Care 2005;10:205.

2. Centers for Disease Control and Prevention (CDC). Hurricane Katrina response and guidance for health-care providers, relief workers, and shelter operators. MMWR Morb Mortal Wkly Rep 2005;54:877.

3. Hutson AM, Atmar RL, Estes MK. Norovirus disease: changing epidemiology and host susceptibility factors. Trends Microbiol 2004; 12:279-287.

4. Centers for Disease Control and Prevention (CDC). Norovirus outbreak among evacuees from hurricane Katrina-Houston, Texas, September 2005. MMWR Morb Mortal Wkly Rep 2005;54:1016-1018.

5. Salama P, Spiegel P, Talley L, et al. Lessons learned from complex emergencies over past decade. Lancet 2004;364:1801-1813.

6. Joint Commission on Accreditation of Healthcare Organizations. Surge hospitals: Providing safe care in emergencies (Special Report). JCAHO 2006;1-23.

I believe in human dignity as the source of national purpose, human
liberty as the source of national action, the human heart as the source
of national compassion, and in the human mind as the source of our
invention and our ideas.
--John Fitzgerald Kennedy

Thomas F. Gavagan, MD, MPH, Kieran Smart, MB ChB, MSc, MPH, MRCGP, Herminia Palacio, MD, MPH, Carmel Dyer, MD, Stephen Greenberg, MD, Paul Sirbaugh, DO, Avrim Fishkind, MD, Douglas Hamilton, MD, MSc, PhD, FRCPC, Umair Shah, MD, MPH, George Masi, FACHE, R. Todd Ivey, MD, Julie Jones, MD, Faye Y. Chiou-Tan, MD, Donna Bloodworth, MD, David Hyman, MD, MPH, Cliff Whigham, DO, Valory Pavlik, PhD, Ralph D. Feigin, MD, and Kenneth Mattox, MD

From the Departments of Family and Community Medicine, Internal Medicine, Pediatrics, Radiology, Surgery, Obstetrics and Gynecology, and Physical Medicine and Rehabilitation, Baylor College of Medicine; Mental Health and Mental Retardation Authority of Harris County; Harris County, Public Health and Environmental Services; and Harris County Hospital District, Houston, TX

Reprint requests to Thomas F. Gavagan, MD, MPH, Vice Chair for Community Health, Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby, Suite 600, Houston, TX 77098. Email: [e-mail]

Dr. Carmel Dyer receives research grants from Novartis. Dr. Stephen Greenberg is on the Speaker's Bureau for Pri-Med Course. The other authors have no disclosures to declare.

Accepted June 1, 2006.

RELATED ARTICLE: Key Points

* The Hurricane Katrina evacuee medical response in the Houston Astrodome/Reliant Center Complex involved multiple groups working together to provide the comprehensive care required by people who have endured a disaster.

* In order to effectively manage similar situations, including widespread influenza outbreaks, communities must have the capacity for quickly creating a large medical infrastructure and for identifying and preparing adequate operational space. Moreover, a unified system of command is critical, as is a system to verify the credentials of volunteer medical personnel. Finally, political, corporate, and community leaders must be willing to commit immediate resources and sustain support over the short term.

* With adequate planning, organization, supervision, cooperation, resources and leadeship, other communities can respond fully and successfully, as did Houston and Harris County in the aftermath of Katrina.

* Although catastrophes are never pleasant to contemplate, it is nonetheless our obligation to improve our competence in addressing them. It is inevitable that similar medical response efforts will be necessary in the future.

Astrodome/Reliant Center Complex Population Compared to Clinic Visits

                       1-Sep  2    3    4    5    6    7    8    9

Evacuee Population     120    160  206  243  236  101  673  718  696
Katrina Clinic Visits  410    203  162  129  112  735  797  664  486

                       10   11   12   13   14   15   16   17   18   19

Evacuee Population     603  418  359  376  308  267  236  168  144  128
Katrina Clinic Visits  396  240  408  418  324  361  781    0    0    0

Katrina Clinic Visic among the Astrodome/Reliant Center Complex
Population (September 1-19, 2005).

Table 1. Katrina Clinic data, September 1-19, 2005

Patient Visits              11,245
Prescriptions Written       16,622
Radiologic Studies Ordered  382 x-rays
                            155 ultrasound studies
Vaccinations Administered   6318

Table 2. A partial list of academic, governmental, and private
organizations participating in the medical response to Hurricane Katrina
at the Houston Astrodome/Reliant Center Complex

Abbott Laboratories
American Red Cross
Baylor College of Medicine
CVS Pharmacy Corporation
Children's Development Center
Harris County Hospital District
Harris County officials
Harris County, Public Health and Environmental Services
Mental Health and Mental Retardation Authority of Harris County
Siemens Medical Solutions
Texas Children's Hospital

Table 3. A list of the most common health and health-related problems of
Katrina Clinic patients

1. Uncontrolled hypertension
2. Respiratory infection, upper and lower
3. Acute gastroenteritis
4. Medication refills
5. Diabetes, uncontrolled
6. Asthma
7. Dermatitis
8. Mental health problems