Saturday, August 29, 2009

Hurricane Katrina, Four Years Later

I laughed when I read a fellow blogger's note that she left her best stuff in the comment sections of other people's blogs, but yesterday I did this myself. I left my best writing in the comment section of the New York Times. The article, to run in the magazine section Sunday, August 30th is about the events occurring in a flooded hospital in New Orleans.

Your link to the article, "Strained by Katrina, a Hospital Faced Deadly Choices" in the August 30th New York Times.

EDITORS' SELECTIONS (what's this?)

Kansas City, MO
August 28th, 2009
7:01 pm
As a nurse and former EMT, I read this article with increasing sorrow and trepidation. You could see it coming, like an oncoming freight train. Lines were going to be crossed and things were going to happen. It's like a vise closed on them, and the thinking got narrower and narrower...

A few words about triage. There may be nine systems of triage but there are two essential ways to do triage. One way is when the most critical and close to death are treated first, then the less critical, then the "walking wounded". This is the typical form of triage in your local ED. People with gun shot wounds and heart attacks skip to the front of the line because delaying their care will cause death or permanent injury. Those with non life threatening illnesses or injuries wait. The second way to do triage is to defer care for many of those whose injuries/illnesses are life threatening and will require a lot of resources to be stabilized. Those with lesser problems are treated first. This form of triage is used when resources are limited, and the idea is to do the most good for the most people. It must be noted that you cannot use these two philosophies of triage at the same time. The next thing to know about triage is that it is very difficult. On the face of it, it may look easy, but it's not. For the triage nurse in the ED, she/he must take the data and evaluate the patient in a very short time. Mistakes are easy to make. There are courses in how to do this well and as accurately as possible.

And now a few words about D.N.R. orders: D.N.R. does not mean D.N.T.--do not treat. It means only that if the heart is to stop, the patient does not want someone jumping on their chest with CPR, does not want to have a breathing tube placed, and does not want drugs, external pacemakers or other tools of Advanced Cardiovascular Life Support applied to them. It does mean that if they have an illness that is amenable to treatment, such as an infection or a condition correctable by surgery, that they would like to have those things.

For a few of the patients in Memorial/LifeCare during Katrina a cascade of issues resulted in the awful outcome related in this article. Poor disaster planning (I now hope every hospital in the US has considered how their generators and electric systems would fair in the disasters endemic to their areas.),structural issues (two flights of stairs outside and a three foot hole to reach the helipad?) failure of evacuation, poor triage decision making, and some bad judgements and decisions during the event caused the perfect storm (pardon the expression) of failure. I particularly think of Mr. Everett, who fell victim to several kinds of failure.

I'm sure that the events surrounding Katrina have been used to change plans and improve mass casualty and disaster response. Let's hope so, so that this horrible outcome is never repeated. And talk is cheap. Don't be afraid to practice these things in drills and such.

I have trouble with what the doctor and the nurses did. I don't like it, and I suspect if I were on the scene I would be looking for another way, any other way. I'm not sure what prosecuting them would have done for anyone. Let's focus on prevention and planning, so that it never comes down to this again.

Consider the difference one working elevator would have made...

Natch, I'm pretty proud that my little opus made the editor's choice list. I always feel that when I read medical articles that the general public may not have the whole picture due to lack of information. So when I venture into comment land, I feel a need to explain in a little detail what's going on. So there's not a lot of opinion sometimes. Here's some opinion for you. I do believe that people were killed, using morphine and Versed, some because they were indeed ill, and some because they presented, to the people present an unsolvable and unpleasant problem. Serious triage mistakes were made due to confabulating Do Not Resuscitate with Do Not Treat. Not to mention that triage needs to be rethought just a little here. In addition to medical condition, resources and outcome, we almost need to add mobility. Mr. Everett would have lived if we could have gotten him down from the seventh floor. When the flood waters were creeping up and electric service was known to be in peril, that would have been the time to get this immobile but otherwise stable patient downstairs.

Now, I hear all the comments saying, "But you weren't there." Indeed I was not, and I have no perfect idea of how I would have reacted. I think, knowing myself, I would have kept busy helping patients. I do not think I would have accepted the drugging/overdose/euthanasia idea if it had been presented to me. I don't think I could have injected the cats! It's interesting to me that the doctor and nurses operated as isolated as they did. The doc took the lead, got "permission" (or at least, no resistance or command to stop), and they did it together. To me, the crucial thing lacking was forethought and planning ahead. Clearly, whatever planning and drilling were done at Memorial and in New Orleans as a whole (including the sorry performances of the local, state and federal governments) was not sufficient. Not enough. Not even close.

In 1984, the Amtrak Montrealer, which at that time, ran through Vermont, derailed in Williston after crossing over a washed out area of track. 7 people died and over 70 were injured. This was a big deal for Vermont. However, Vermont had a tradition of practicing disasters, complete with real patients, taken by real ambulances to real hospitals. Moulage, the whole thing. And debriefings afterwards. Vermont's EMS was hailed as having done a superior job at handling this mass casualty situation. Part of the credit has to go to the drills. When you practice something, the pathways can be established, bugs washed out and plans reviewed as needed.

Were circumstances in New Orleans so extraordinary that any plan would have fallen short? Maybe. But if you have a good plan, you have something to hang on to, and something to innovate from. What was the command structure at Memorial? Who was in charge? What were the goals? Who would make decisions about resources? Who could suppress rouge elements and deal with conflict? Why was the LifeCare institution not included in the Memorial plans as matter of course? (I sure hope the Kansas City version of LifeCare, Select Specialty, is included in the plans of Research Medical Center and Overland Park Regional...) Did they ever practice these things, even as an exercise around a table? These questions cannot be answered in the midst of the disaster. There's too much pressure and too much at stake. There is no substitute for preparation. You can't prepare during the situation. You must prepare beforehand. If you have good preparation, then you can innovate as things progress (or decay). You are more able to think freely and broadly. Applying this to Memorial, the solution of euthanasia does not have an appeal because there are good sound alternatives that are brought to the table. Perhaps time does not become such a pressure (clearly, the application of a time deadline by people outside the hospital influenced and hastened the decision process), because someone can stand up and say, "Give us 12 more hours. Get us some help." and it has meaning and weight.

There is no substitute in a disaster for preparation. And no substitute for practice.

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