Presidents and Disasters

Some have given President Barack Obama some grief for not going to the tornado scene in Joplin right away. He also got some mild push back for not going to Alabama until a number of days had passed. Those with memories will remember that President G.W.Bush got it six ways to Sunday about merely "flying over" New Orleans in the earliest days of recovery after hurricane Katrina. So, should the POTUS go to disaster areas? If so, when?

Now, I view this more from the point of the first responder. I could give a care about the "optics" of a situation. I think that President Bush was 100% right in his call to not go on the ground too soon after Katrina. I think President Obama hit just the right time in Alabama, after the majority, if not all, of rescue and recovery was completed, but before too much clean up had happened. He could do all of it: be a consoling presence, show leadership and get the really cool pictures in the rubble, without being disruptive to what was going on.

So here are my parameters: The visit must not complicate the lives of the fire service, EMS, or law enforcement at all. The president should be as "self contained" as possible--bringing as much of his own logistics as he can. Saving of life and property must always be the first priority; if a president's visit will slow that, it needs to wait. There are other ways to show that you care--videos, radio addresses, statements in speeches, etc. etc.--that can be used until a ground presence is not a major hindrance. People do appreciate the president coming by, I think that is true, but it must not take resources from the immediate task at hand.

We in Missouri will welcome Mr. Obama when he comes--currently scheduled for Sunday. It might be sooner if conditions in Missouri can tolerate it and the president has to return from Europe early due to the volcanic ash cloud's affects on air travel.

Addendum: I left this post and I was pretty satisfied with it. And then I wasn't. So I am adding this and modifying the last paragraph, which had suffered from an invasion of partisan snark. Because I am not going to pick at any president politically for how he handles going into disaster sites. Or not going, as the case may be. People who pick at this topic are incredibly inconsistent: Republicans defend Bush for not rushing to New Orleans, yet rake Obama over the coals for not going to Missouri. I am thinking you are better off sticking to general principles, and judging according to those principles, applying criticism evenly, regardless of political labels. Using disasters for political gain is incredibly distasteful to me. It is not a time to trot out nasty partisan politics--it is a time to pull together and help those who need help, both now and in the long term.

Katrina: Five Years Later

I experienced Katrina most vividly through the stalwart reporting of Dan Verbeck, Entercom radio station KMBZ's fabulous street reporter who retired in 2008 (though not completely; he can now be heard on public radio station KCUR.) He was lent to WWL, Entercom's station in NOLA to do reporting and help man the critical radio station during the disaster. He would report in to KMBZ by phone as part of his days in NOLA, giving us in Kansas City a very inside view of what New Orleans was like in those days.

As you remember, Katrina hit New Orleans Monday, August 29th 2005 with its wind and rain, towards the evening hours. Mr. Verbeck reported on what the wind sounded like, and what it felt like as the hurricane passed by. As morning came the next day, Tuesday, Mr. Verbeck came on and was the first to report that the city was flooding from the broken levies. I still remember the tone of his voice as he reported the flooding, the water inundating everything in the lowest parts of New Orleans. He was the one that reinforced for me the fact that if the levies had held up, Katrina would be remembered for the way it devastated the Mississippi coast, rather than what happened in New Orleans. He reported on the initially only sparsely flooded streets in the immediate aftermath of the storm, and then, as official and unofficial reports of levy breaks and flooding waters came into the radio station, came on to let the world know that the bowl of NOLA would be filled with water.

Aaron Barnhart interviewed Mr. Verbeck shortly after the hurricane. Here's a link to his blog entry, which includes a link to the MP3 of the interview. It is "must listen" stuff, the stuff of history. As were the original reports--I do hope they have been preserved somewhere--I believe those reports were some of the best reporting I heard or saw from New Orleans in those difficult days.

Image: photo of Mr. Verbeck, from a google search.

Art: David Bates' Vivid Katrina Work at Kemper Museum

I had never heard of painter David Bates before, but I noted his striking paintings pictured in the Sunday edition of the Kansas City Star and was intrigued by them. I was further intrigued to read about him in the article that accompanied the images. He is based in Dallas, and educated at Southern Methodist University, but loves New Orleans, and has been going to that city for 25 years, painting its natural aspects.

"Lady in a Black Dress" David Bates

When Katrina hit, he was unable to go and personally see the scenes in the city, so working from news reports, he began to paint his impressions of the visuals and the emotions of the people. He worked on this series for two years, painting his last Katrina themed work in 2007. The works have been shown here and there, but the Kemper Museum of Contemporary Art will have 80% of the works on exhibit.

"Elysian Fields Avenue" David Bates

As you can see, he's a modernist, but a realistic painter and one painting a theme or narrative. I like the quote pulled by The Star from this New York Times article. "David Bates is having a perfectly interesting career without any attention from the New York art establishment, thank you very much." (I suppose he's not weird and hip enough for most in the NY art scene.)

Details: Kemper Museum of Contemporary Art is at 4420 Warwick Boulevard in Kansas City Missouri. Hours are Tues-Thurs 10-4, Fri-Sat 10-9, Sun 11-5. Admission and parking are free. On the web at www.kemperart.org. Bates' exhibit starts May 21 and ends August 22. I plan on going; the pictures of the paintings I have seen in the paper and on line are powerful and vivid.

Links of note: Kansas City Star: Paintings of David Bates are a vivid chronicle of Hurricane Katrina. Arthur Roger Gallery in New Orleans, Bates' home Gallery.

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.

293.
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.