What If It Happens Here? Preparation Is the Key to Surviving Catastrophes Texas Medicine Magazine Cover Story May 2006 By Erin Prather Associate Editor
Last year's back-to-back natural disasters known as Katrina and Rita tested emergency preparation and response in Texas like never before. As areas ravaged by the storms continue to rebuild, a new hurricane season officially starts June 1, and Texas is right now in the middle of the spring severe weather season. In fact, some of the worst tornadoes in the state's history occurred in May – Lubbock and Waco come to mind – and there is no guarantee an F5 twister won't come calling on your doorstep.
Despite the successes in handling last year's largest hurricanes, Texas physicians must be prepared for future catastrophes, whether they're natural or man made.
Kenneth Mattox, MD, professor of surgery at Baylor College of Medicine and chief of staff/chief of surgery at Ben Taub General Hospital in Houston, sees another very busy hurricane season encroaching on the state.
"The Gulf of Mexico did not cool down. Texans can anticipate an equal number or more tropical storms and hurricanes in comparison to last season," he said. "Every Texas physician must be prepared to assume a leadership position, which was demonstrated by many during Katrina and Rita."
The governor's Division of Emergency Management says Texas leads the nation in tornadoes and flash floods, and is second only to Florida in hurricanes. Tropical storms can do as much damage as hurricanes, as Houston discovered in 2001 when Tropical Storm Allison dumped 37 inches of rain and caused $5 billion in damage to the Texas Medical Center and other areas of Harris County.
Quick Action Required
History confirms that a disaster's greatest damage occurs within its first hours. Dr. Mattox says any community facing a disaster is on its own during the initial 48 hours. As cochair of the medical effort at Katrina Clinic, he witnessed firsthand the necessity of structured leadership for disaster management. (See "Angels of the Storm," November 2005 Texas Medicine.)
"If you have your infrastructure, as we did in Houston, you have lots of options. If you lose that infrastructure, like New Orleans, it's a totally different story in relation to leadership, communication, and rallying individuals to make decisions," he said.
Houston's success, he maintains, was due to the local Joint Incident Command (JIC) station. All agencies involved with the city's largest shelters were required to work through the command station, which had a military management style, and adhere to its emergency-operating plan.
"There must be a collaborative, integrated network of government, private, and academic resources within a community. Outside involvement, even by federal agencies, should be coordinated through the JIC. Local, state, regional, and national political agendas should be kept out of the JIC. It's important that operations and logistics be driven only by the specific needs of the disaster."
Edward M. Racht, MD, medical director of Austin's Emergency Medical Services, agrees that the hurricanes demonstrated the importance of collaboration. He says disasters are too large for any one entity to manage; he credits the City of Austin's Emergency Operations Center with being the brain behind Austin's disaster management.
"Physicians may not understand what to do immediately in a large-scale event, but they should know how to find out that information quickly," he said. "For example, I can't tell you what specific actions at a specific time in a specific place we would take if a tornado ripped through Austin, because every large-scale event is dynamic. I can tell you how I would find out what to do. The Emergency Operations Center would be activated, and the Travis County Medical Society [TCMS] would start coordinating the physician response. TCMS has a preplanned paging alert system to notify physicians of what actions to take."
Volunteers
The February Journal of Family Practice says volunteer physicians are most effective in a disaster if they understand the importance of reestablishing the needed infrastructure, they arrive on scene as part of an organized response, and they have been trained in disaster medicine and public health.
But while volunteers are necessary to treat a large number of patients, Dr. Mattox stresses that a system must be in place to use them effectively. He warns against "disaster voyeurs" and explains that coordinating volunteers, donated supplies, and outside government agencies is a continuing challenge at all disaster sites.
"Those in charge have to be careful of people who are just looking. This is especially important when dealing with medical professionals. If someone arrives and says, 'I'm a doctor,' or 'I'm a nurse,' there needs to be a mechanism to ascertain they are licensed and credentialed. In Houston we turned away 200 because we could not authenticate that they were doctors and nurses. It turned out a majority of them were not licensed, did not have an MD."
Dr. Racht says although physicians are key in large-scale disasters, few are trained to function during such events.
"Most physicians, when they hear their hospital is conducting a disaster drill, will do everything they can to avoid getting sucked into the drill that day. It's time we accept our roles in disasters and know the necessary information to participate efficiently. The rest of the health care community is looking at us to be prepared and ready."
Physicians who are interested in disaster preparation can join the Texas Medical Rangers (TMR). The rangers, cosponsored by The University of Texas Health Science Center at San Antonio and other state-supported health science centers, are chartered by the governor. They help public health authorities respond to contagious diseases and other threats to public health, including bioterrorism. In March 2003, Gov. Rick Perry made TMR part of the Texas Military Forces under the Texas adjutant general.
To join TMR, go online to www.texasmedicalrangers.com or call (866) 835-8936 for more information.
Additionally, the American Medical Association's National Disaster Life Support (NDLS) helps health professionals prepare for large-scale, catastrophic events, including terrorist attacks, explosions, fires, and natural disasters such as hurricanes, floods, and infectious disease outbreaks. To view and register for NDLS courses, visit the NDLS Foundation Web site at www.bdls.com.
Better Evacuation Planning
Last October, in the wake of Hurricane Rita, Governor Perry appointed a 14-member Task Force on Evacuation, Transportation, and Logistics. The task force defines people with special needs as "those who cannot take care of themselves during an evacuation."
Although it recommended that local officials identify and document special-needs populations in their jurisdictions, the task force acknowledged that those patients and their caregivers must plan ahead so they have ample medicine and supplies during the evacuation and after they reach their destination or shelter.
David Persse, MD, Houston's emergency medical services director, is concerned about the value of a special-needs registry as there is no proven way to identify all such persons in a community. He also worries that people may interpret the registry as a guarantee they will be evacuated.
"An individual might wait to evacuate because his or her name is on a list. That's dangerous because the volume is too great. There is no way the government can provide transportation for everyone during an impending hurricane. In Houston, we're telling listed individuals that they need to take responsibility and have a personal evacuation plan. We're providing them with assets and references."
In late March, Governor Perry issued an executive order requiring state officials to develop more detailed hurricane evacuation plans, including a plan for opening major highways to one-way outbound traffic as storms bear down on the Texas coast.
State officials are trying to prevent a recurrence of the chaos that ensued during the evacuation of the Houston area as Hurricane Rita approached in September. Some 60 people, including 23 nursing home patients, died along jammed highways.
"Our goal is to learn from the lessons that Hurricane Rita taught us and make Texans safer in future mass evacuations," the governor said. "These directives focus on saving lives and reducing the vulnerability of Texans – particularly those least able to fend for themselves."
Besides directing state officials to devise a plan for one-way traffic, or contraflow, the order asks the Texas Department of Transportation to find a way to provide fuel for evacuees. Additionally, the order directs the state's emergency management division to create a computer database of people with special needs so officials will know who needs help evacuating and where they live. The division also must work with school districts and universities to find buses to use in evacuations.
A Feb. 14 report by the task force said fuel shortages along evacuation routes caused hundreds of motorists to be stranded, and many could not exit roadways for fuel, food, medical care, or personal hygiene for long periods of time.
Though severe problems occurred during the Rita evacuation, Dr. Persse maintains that evacuating too many Houstonians was better than if thousands had hunkered down in their homes to face the hurricane.
"It's the lesser of two evils. I'd rather people move than stay and experience something like New Orleans. Tropical storms and hurricanes are unpredictable. There's no perfect answer."
Harried Hospitals
Harris County Medical Society President Diana L. Fite, MD, says Houston's emergency departments were hit hard during the Rita evacuation.
"People were dropping off elders at emergency rooms while trying to leave the area. They knew travel conditions were difficult. Other families had members on respirators and were scared the power would go out at their homes. They came to hospitals asking if the ventilators could be hooked up there. Emergency rooms became full and couldn't provide care for everyday emergencies. It was a dangerous situation," she said.
"Alternative shelters must be considered," Dr. Mattox said. "Rather than transporting the very sick and frail from Houston to Dallas, it might be better to erect a shelter 20 or 30 miles away in an empty hotel or gymnasium. During Rita, ambulances would bring nursing home elders to emergency rooms instead of making the 24-hour trip to Dallas. The elders weren't sick and didn't need emergency care, but the drivers didn't want to spend 24 hours going up, nine hours coming back, and be out of service. It's understandable, but hospitals need to be protected from becoming shelters."
Dr. Mattox also points out that hospitals should prepare for being isolated and should have redundant communications systems, including walkie-talkies. He says satellite telephones were unreliable in New Orleans, which was unfortunate, as many considered the technology dependable.
Dr. Persse says it's impossible to know what might occur in a disaster. Although plans should be based on first reports, physicians must keep in mind that the situation could change in an instant – sometimes for the worst.
"Until something is actually occurring, it's all rumor. But you need to make plans, then plan ahead if things take a turn for the worst. It's a different but necessary mindset in disaster situations. In Houston we received information, deciphered how it could be worse, then made contingency plans."
Physicians interviewed by Texas Medicine consider it a blessing that Houston did not take the brunt of Katrina's or Rita's wrath. Yet each acknowledged it is only a matter time before Texas has its own hurricane or other natural disaster.
Erin Prather is associate editor of Texas Medicine. She can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at erin.prather@texmed.org.
SIDEBAR 1
When Rescuers Needed Rescuing
As the magnitude of the Katrina disaster became known, many Beaumont-area physicians and other health care professionals volunteered to go to New Orleans and Biloxi to help where they could. Little did they know another storm was brewing that would put their own families, homes, and offices in harm's way.
Allergist William A. Fawcett IV, MD, was one of the physicians impacted by Hurricane Rita. Strong winds ripped the ceiling off his four-story office building, causing water damage to his practice on the third floor.
Dr. Fawcett says although his staff members had not drilled specifically for a mandatory evacuation, they had discussed what would occur during emergencies and the types of weather that affect the Beaumont area. He notes that fire could destroy a practice anywhere and stresses the importance of backing up business records.
"It's imperative that business records be moved to a safe place," he said. "Access to that information is going to have a big impact on when you're up and running. We anticipated the worst and covered all records in plastic. Other people in the building lost everything because they didn't take such precautions."
Michael W. Bungo, MD, vice dean for clinical affairs at Baylor College of Medicine, believes an electronic medical records system can preserve records during a disaster. He says physicians can attempt to protect paper records, but they can be lost forever in a storm surge from a hurricane or tropical storm, a flash flood, a tornado, or fire.
Besides saving much of their computer and medical equipment by covering them in plastic and moving everything off the floor, Dr. Fawcett and his staff had a backup generator to provide power for icing down perishable medical supplies. But they couldn't save the office supplies and furniture.
"The most difficult thing we've had to deal with is the insurance company," he said. "My wife is a lawyer; her specialty is insurance coverage. We thought the practice had great policies, but it's been tedious to follow up with the claims. While I recommend physicians get a business interruption policy, working with my company has been ridiculously difficult. At this time, I still haven't received a dime."
The Texas Medical Association's Physicians Benevolent Fund raised $225,000 to help physicians in Hardin, Tyler, Jasper, Newton, Jefferson, Liberty, Chambers, and Orange counties rebuild their practices. Grants were available to physicians whose practices incurred uninsured or nonreimbursable damages that interrupted the delivery of medical care and who could not receive adequate funding from other sources. At press time, grants totaling $187,500 had been awarded to 67 physicians in 31 practices.
And, the TMA Board of Trustees waived membership dues for physicians in any of the affected counties.
Dr. Fawcett says his practice attempted to reestablish contact with patients after reopening. A Beaumont radio station announced when physician practices resumed operating and when a practice had to relocate. Dr. Fawcett's building was gutted, and it will be months before he can return. He emphasizes that after Rita, his main priority was to have the practice up and running. Now relocated temporarily to a different Beaumont office building, he continues to provide care for his patients as they return.
What should you do to prepare for a disaster?
The January/February 2002 issue of the Texas Medical Liability Trust's newsletter, The Reporter, says the fist step in preventing disasters and minimizing risks involves planning.
"Physicians are owners and operators of small businesses and, as such, need a plan to deal with disasters that may disrupt or shut down business. It has been estimated that approximately 25 percent of small businesses that shut down due to a disaster never reopen. Even though you may be a solo practitioner, a simple disaster plan is important," it said.
The article also says emergency plans for any practice are unique because of the certain needs of practices. Disaster experts recommend 10 ways to ready yourself and your practice to deal with an emergency before an emergency strikes. According to the Jan. 1 Southern California Physician, you should:
Conduct a risk assessment of all potential hazards or emergencies for your practice and develop a disaster plan based on that information. Include emergency escape procedures, procedures to account for all employees and visitors, and procedures for reporting emergencies to local authorities. Practice the plan with your office staff.
Back up medical records or critical data frequently throughout the day. Keep copies of data at a remote site or online. Use Internet-based services such as www.EZbackup.com, which can back up files from a computer every 24 hours.
Keep a current phone list for all office staff members and provide a copy to key staff. If you have a voice-mail system at your office, designate one remote number on which you can record messages for employees and give all employees the number.
Buy three days worth of food and water supplies for yourself and your staff. Choose nonperishable food items such as canned meals, fruits, and vegetables, and granola or energy bars. A small water purifier is recommended as well, in case of water contamination.
Put together a disaster workplace kit of essential items your practice will need in an emergency, such as a flashlight with extra batteries, a battery-powered radio, nonprescription medications, blankets, plastic garbage bags, and a manual can opener.
Be on the alert for any diseases reportable to the local health department, such as West Nile virus or avian flu. If you see a patient with an unusual symptom or disease, report those cases as well to prevent the spread of a potential communicable disease.
Review information on biological agents, such as anthrax and smallpox. Know about symptoms and treatment. Identify resources for reliable and up-to-date information on biological agents, such as Web sites of local health departments and the U.S. Centers for Disease Control and Prevention. TMA has placed a Bioterrorism Toolkit on the TMA Web site. It includes physician protocols on the diagnosis, reporting, etiology, and management of anthrax, botulism, smallpox, and plague, and one-page reproducible patient handouts on each disease. You can find it under Physician Resources on the Public Health and Science page.
In case of an epidemic or communicable disease outbreak, you should have plenty of personal protective equipment, such as masks, gloves, and goggles. Initiate purchasing plans with supply vendors and distributors for protective equipment and other medical supplies to avoid running out.
Have first-aid kits and wound care supplies available. During a disaster, patients who don't require immediate care may be triaged to your practice. These patients typically suffer from orthopedic and soft-tissue injuries that are handled easily by first-aid kits and wound care supplies such as casts and splints.
Adopt a family disaster plan. The American Red Cross has developed an online family disaster plan (www.redcross.org/services/disaster) that you can use to maintain communication with your family during an emergency. Discuss possible hazards, and practice your plan with your family to ensure your individual preparedness.
Disaster and emergency experts say physicians shouldn't stop with these 10 items. Physicians should stay educated on disaster and emergency procedures by taking courses offered by the state and various medical organizations.
