Medical management on the bayou: one year after Katrina.

Steven Deitelzweig's home was not destroyed in Hurricane Katrina, but his willingness to drive a long commute to work was.

The president of the medical staff at Ochsner Health System in New Orleans, Deitelzweig, an MD, lived at the hospital for three weeks after the August 2005 hurricane. The experience revealed the strengths and weaknesses of America's emergency response capability. Like every other health care provider who worked through the disaster, Deitelzweig was changed by the hurricane.

"It's really made me refocus on what my short- and long-term goals are personally and professionally," he says. "I felt I was pretty engaged before, but now I'm kind of super-charged about what I know I need to accomplish."

[ILLUSTRATION OMITTED]

A daily commute--20 minutes one way before Katrina, and today more than an hour because repair crews clog the highways--became unacceptable. Deitelzweig sold his house and relocated his family near the medical center.

"I'm not wasting time in a car," he says. "I just won't do it."

Deitelzweig and five other physician executives who survived Katrina assessed the lessons they learned from that experience. Here is what they want other physician executives to know.

Lessons from the Superdome

When Katrina slammed into New Orleans, Evangeline R.H. Franklin, MD, MPH, served as one of the two medical directors at the Louisiana Superdome, designated as a shelter for people with medical conditions or other factors that prevented them from evacuating the city. What did Franklin learn from Katrina?

[ILLUSTRATION OMITTED]

Everybody must plan.

Disaster plans by the big institutions--city governments, hospitals, fire departments--are not enough. Health care providers who work with patients must take responsibility for those with no transportation who cannot evacuate a disaster on their own--the frail, the elderly, the poor.

"We have to engage the home health agencies and the doctors who work with those people to help them build a hurricane plan," Franklin says. "Everyone has to look at what it is that they can do specifically to evacuate the city."

Do it yourself: Give patients a portable health record.

Knowing that most patients cannot remember their diagnoses and treatment plans in normal circumstances, let alone a crisis, physicians should provide patients with written information about their health that could save their lives.

"Some kind of portable health information, even if it is a Word document or a copy of an EKG that can be put in the wallet, will help whatever doctor needs to take care of that patient later," Franklin says.

Every record should list the patient's active and inactive problems, medications, immunizations and the doctor's name and contact information.

Good intentions do not equate with good help.

Physicians who want to help in a big disaster should arrange a conduit into the health care system before showing up on the scene.

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

"Sometimes they just got on a plane and came down unannounced with no prearranged assignment, and it wasn't all that effective," Franklin says. "Imagine your office collapsing and all of a sudden 150 people show up to take over."

Rebuilding a health care system is a bigger task than anyone can imagine.

The New Orleans Health Department needs money, medical equipment, supplies and physicians who can help. Nearly six months after Katrina, Franklin, the health department's chief of clinical services and employee health, directed a health fair that provided medical services--from Pap smears to dental exams to free pharmaceutical products and eyeglasses--for people who had no health care home.

"We saw 5,000 people in seven days--people who were laid off, professional people, people who were underinsured, migrant construction workers, all kinds of people," she says. "The medical need in New Orleans is still tremendous and the safety-net requirements, given the loss of infrastructure, is huge."

Lessons from a hospital corridor

Deitelzweig, chairman of Ochsner's hospital medicine department, oversees 35 hospitalists at three hospitals. He is one name on Ochsner's roster of 1,000 "essential personnel" who are required to be onsite for hurricane duty.

Ochsner Medical Center, the system's flagship, remained open for business throughout Katrina, a fact that Deitelzweig attributes to good planning and lucky geography. While he is proud of the hospital's service during the storm, he is under no delusion that an institutional disaster plan guarantees an individual's survival.

"Everybody should keep a week or two's worth of canned food products in their office," Deitelzweig says. "I'm not kidding."

His take on the disaster:

Face-to-face communication is essential.

With the paging system, cell phones and e-mail out of commission, Deitelzweig rounded up the hospitalists on his staff for twice-daily meetings that lasted at least 30 minutes. The meetings allowed Deitelzweig to pass on information from hospital's senior management while giving physicians a chance to discuss their concerns and bolster one another's morale.

Social workers are key to recovery.

Before Katrina, Ochsner's list of essential personnel for hurricane duty did not include social workers. Today it does.

In the days after the storm, Deitelzweig says, discharge planning became more important than ever. "You need to get people discharged, but they don't have a house, so what do you do with them?" he says. "They have no money. It's really a challenge."

Physicians must learn to triage patients for relocation.

As the severity of Katrina became clear, Ochsner physicians developed an on-the-fly protocol for determining which patients could be moved to hospitals outside New Orleans.

"It was 'who is sick enough to be triaged at the highest level and who is sick enough but probably wouldn't survive if we were to transfer them?'" Deitelzweig says.

That protocol is being fine-tuned for future storms, starting with a pre-storm evacuation plan for high-demand patients, such as pediatric neurosurgery patients, unstable cardiac patients, and people waiting for organ transplants.

Every institution must take responsibility for its own survival.

"The most key lesson we learned is that you have to be prepared to go weeks without support from the federal government because you can't rely on FEMA," Deitelzweig says, referring to the Federal Emergency Management Association.

Lessons from a FEMA team member

As others poured out of the Gulf coast, Mark Gebhart, MD, rushed in. An assistant professor of emergency medicine at Wright State University's Boonshoft School of Medicine in Dayton, Ohio, Gebhart volunteers as medical manager of a FEMA urban search and rescue team called Ohio Task Force One.

Deployed in advance of Katrina's arrival, Gebhart's unit was positioned at Meridian Naval Air Station in Mississippi, ready to begin rescue as soon as weather permitted.

"We were in place, as well as many other (FEMA) assets, beforehand," he says. "It was simply the magnitude of this whole thing that everyone saw."

After two weeks serving the Mississippi communities of Gulfport, Pass Christian and Long Beach, Gebhart came away frustrated that most physicians do not even know about National Incident Command System, established by the U.S. Department of Homeland Security for just such situations, let alone how to support the system.

His insights:

Physicians should get with the program.

"One untrained physician in a disaster is worse than 500 victims because if you don't know the system, you impede the ability to solve problems," Gebhart says.

He encourages physicians to prepare to help by enrolling in National Disaster Life Support course offered through American Medical Association or to start learning about the national incident management system on FEMA's Web site.

"Our tendency as physicians is to be in charge of situations we're in. But you cannot have every physician who arrives be in charge," he says.

Health care executives should build networks that create self-sufficiency.

Gebhart's advocacy for the National Incident Command System does not mean any individual or organization should count on the government to rescue them.

"You make a grave mistake if you count on the federal government to come bail you out," he says. "You need to prepare locally and within your state."

He encourages health care leaders to learn from first responders who have developed mutual aid pacts. Just as fire departments count on neighboring fire companies to pitch in when needed, hospitals should have written agreements with their peers--their competitors--to help one another in times of crisis.

Lessons from a flooded hospital

Dwayne Thomas, MD, CEO of the Medical Center of Louisiana at New Orleans, was trapped at University Hospital when Katrina rolled in, flooding both University and its sister institution, Charity Hospital.

[ILLUSTRATION OMITTED]

Charity, one of America's oldest and best known safety-net hospitals, was destroyed and will not re-open. University Hospital is re-opening in stages. The medical center's rebuilding plan calls for services to be dispersed throughout the city rather than consolidated in a single location.

What others can learn from Thomas' experience:

Health care providers need 800 Mhz radios.

Despite redundant systems--the medical center was equipped with land lines, cell phones, two-way radios, 800 MHz police radios, the city-wide emergency medical system radio system, a ham radio and satellite phones--lack of reliable communication equipment was a serious problem.

"The satellite phones were unreliable, and we lost all of the other communication, with the exception of those 800 MHz radios and the ham radio," Thomas says. "That was our communication with the outside world."

Survival depends on stockpiles, not supply contracts.

Because of a previous storm experience, when a panicked vendor failed to honor a contract to deliver water, Charity had nearly 14,000 gallons of drinkable water delivered at the beginning of the 2005 hurricane system.

"You need to have an accurate count of the number of employees and family members that you're going to be housing during the storm," Thomas says. "And you need to have at least a gallon of water per person, per day, stored and ready."

Similarly, a hospital should have 14 days of non-perishable food stockpiled and, if the sewer system might be damaged, enough portable toilets or five-gallon buckets--with bleach and infectious waste bags--to create a makeshift sanitation system.

CEOs must budget for a crisis.

Unlike most natural disasters, hurricanes generally come with enough warning that elective procedures are cancelled and a hospital's census is as low as possible. Meanwhile staffing expense and the costs of food, water and other supplies are much higher than normal.

"That's not something that I think everybody thinks about ahead of time, but you have to budget with regard to the lost revenue and the additional expenses," he says.

Executives should establish a disaster pay plan and publicize it.

Thomas' staff members worked 12-hour shifts, then rested for 12 hours, but they were paid round-the-clock, courtesy of an emergency pay plan that had been communicated well in advance of the storm.

"That buys you more loyalty and goodwill than you might imagine," Thomas says.

Physicians must develop a system that allows them to help one another.

Thomas wants state licensing boards to develop interstate agreements that allow emergency validation of physician licenses in times of crisis. Some physicians who arrived to help after Katrina could not do so until Charity staff members, already overwhelmed with recovery efforts, helped them arrange temporary privileges in Louisiana, a difficult task because phones and computers were not working.

"That was one of the major issues that we had to deal with as an afterthought," he says.

Lessons from a volunteer physician

Michael Basco, MD, a medical director in CIGNA's Carrollton, Texas, office, arrived in Baton Rouge on Sept. 2--four days after Katrina hit--with a van load of doctors, nurses and medical supplies.

"Before we left, we actually tried to ... get hooked up with FEMA and the local doctors," he says. "We figured out that FEMA didn't know what was going on."

His group connected with Louisiana State University physicians in Baton Rouge and helped them transform an abandoned Kmart store into a field hospital. From there, Basco, three other physicians and eight nurses headed to the New Orleans Convention Center, where they found a Texas Medical Rangers unit that needed help triaging storm victims.

"They didn't have any physicians with them, but we quickly provided the medical support," Basco says. "As they were pulling people out, we evaluated them and had them airlifted out by helicopter if they were ill."

Basco returned to Texas convinced that coordination between federal officials and health care providers willing to help should be improved.

Physicians need to be leaders in disaster-response planning.

"We need to have does up in these organizations in higher-position levels to help make these decisions," he says. "I think everybody realized that the folks within FEMA and our president even didn't have the capability to make the right decisions because they have no understanding of how to disburse medical resources."

Lessons from the hospital executive suite

Richard Guthrie Jr., MD, is medical director for Ochsner Health System's New Orleans region, which includes about 420 physicians and a 400-bed teaching hospital. The system's hurricane plan, tested many times in drills and smaller hurricanes, served the institution well, but Katrina highlighted areas that will be tightened up in future disasters.

[ILLUSTRATION OMITTED]

"Because of the unprecedented nature of the event, we had to do a lot of improvising, and we learned a lot." he says.

In times of crisis, leaders should be optimistic. And realistic.

Ochsner's senior management team met frequently with physicians, head nurses and other hospital leaders. The facts changed from one meeting to the next, but the underlying message remained the same: "We're going to get through this. We have some tough issues to deal with and some of this we're making up as we go along. But we have a great team ... and we're going to do just fine."

The significance of that confidence resonates with Guthrie nearly a year later. "That type of realistic optimism was critically important for the morale of our workforce," he says.

Hospital security means armed guards.

Ochsner managers learned this lesson in 1998, when a hurricane threat prompted nearly 4,000 people to seek shelter at the hospital. A hospital cannot carry out its medical mission if it devotes its space, food and other assets to people who need shelter.

A highly visible security force also is key to helping employees feel secure in a scary situation.

"They've got their M-16s with them, and they will secure the perimeter of our campus and they will be visible. So you do not have to worry about your safety--that's a very important message," he says.

Hospitals should go paperless--now.

With the exception of the files at one clinic, Ochsner's paper medical records survived the storm. But nearly 80 percent of the medical records staff did not return after Katrina. That marked the end of the dual system--electronic medical records and paper chart delivery--used before the storm.

"Were it not for the fact that the electronic medical records had been used for a year and a half and people were familiar with it, going paperless overnight would have not been possible," Guthrie says. "And that was essential."

Lola Butcher writes about the business of health care for several trade publications. She can be reached by e-mail in Springfield, Mo., at [e-mail].