advance for nurse practitioners, 'dealing with disaster

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Issue Date: 9/1/2005

Dealing With Disaster

An NP describes providing care to evacuees at the New Orleans airport as a member of a Disaster MedicalAssistance Team. DMATs are organized under the Federal Emergency Management Agency, part of the U.S.Department of Homeland Security.

By Melinda "Lea" Poso, NP

[Editor’s note: The author, a Lakewood, Wash., family nurse practitioner, describes 2 weeks providing care to evacuees at the New Orleans airport as a member of a DMAT (Disaster Medical Assistance Team). DMATs,organized under the Federal Emergency Management Agency, part of the U.S. Department of Homeland Security, are deployed to provide immediate medical assistance whenever local emergency facilities become overwhelmed. There are 80 DMATs across the country. NPs interested in joining one should contact a team through a local hospital or go to the National Disaster Medical System Web site at http://www.oep-

ndms.dhhs.gov/dmat.html. ]

Hurricane Katrina will forever be one of the major events of my life. Not just one of those “fifteen minutes offame” experiences, but one that will affect how I relate to my family, patients, parish community, life in generaland my naïve relationship with God. It was a not only a personal disaster story. It was a shared disaster withfellow relief workers, military, police and even the airport cleaning personnel.

Like most others, I watched the progress of Katrina as she crossed the Caribbean. Even though Washington 1(WA-1) Disaster Medical Assistance Team (DMAT) was first up for August, I thought the National DisasterMedical System (NDMS) would probably call up the September alert teams. So, I went on with my life.

Getting the CallSaturday morning, August 27, I went to our DMAT warehouse for training. We learned we were on “alert” forKatrina. Before long, cell phones and pagers were buzzing — we were activated. By Saturday evening I was

packed and waiting for more deployment information. We later learned that we would pre-position the next day,Sunday, August 28, in Houston. My part of the team flew out of Seattle on Sunday afternoon.

Houston Hyatt was busy with several NDMS personnel wearing their FEMA-issued ID badges. We were to meetat 6:45 Monday morning for an update. Of course we watched the first news stories in the morning andthroughout the day, but we had to wait for first assessments before we could go in.

Mid-afternoon, the first team (from New Mexico) left for the Superdome. We waited through the day, meetingevery couple hours for updates. At about 6:00 p.m. we sat down and ordered dinner. Beverages were delivered… and our team leader approached: We were leaving in less than an hour. Victor, our waiter, changed ourorders to take-out while we went to gather our gear.

Entering — and Leaving — New OrleansBy 8:00 p.m. our team of five vans convoyed to Baton Rouge and then on to the Superdome. We were escorted

to the Dome, water already up to our wheel rims and our gear raised off the floor onto the seats.

Navigating through lines of emergency vehicles and semi trucks with emergency supplies, we reached ourdestination. Eerily we sat waiting for instructions. Water was on every street in the area with no power to lightthe streets or surrounding buildings.

Finally, we saw our team leader and thought we are ready to unload. Then the levee broke, and we needed to goback to Baton Rouge. It was a long, tiring trip, and we arrived at Louisiana State University mid-morningTuesday, August 30.

A Second AttemptWe left our gear in a team room in Pete Maravich Assembly Center. Then we traveled off-campus for breakfast

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and returned for a couple hours of sleep. After dinner, we learned that we would be going to the New Orleansairport with other DMAT and NDMS teams, so it was suggested we get some sleep. After a quick shower, andmomentarily drifting to sleep, we were awakened to load up. We left in a convoy of vans, SUVs and semi trucksa mile long, escorted on deserted Interstate 10 by members of the Federal Protective Service.

We arrived at the New Orleans airport about 3:00 a.m. and slept in our vehicles until 6:00 a.m. We set up ourtriage center in the middle of the ticketing area of Concourse D. Three “Western Shelters” made up our triagecategories: Green for minimal care, Yellow for immediate care and Red for urgent care. Supplies were unloaded

and tents stocked. We were much like a Casualty Collection Point in military terms. I heard from my mother thatthe news media said we were a hospital.

Our WA-1 team was assigned the night shift, and we settled into the baggage claim area for Concourse D. Ourfirst meal was the standard “Meal Ready to Eat” (MRE). Initially I forgot how to heat the beef patty. InstantCoffee was poured into cold bottled water. We had 3 hours of sleep before our first shift began.

Airport ConditionsIt was hot and humid, and the only air conditioning was a foot-wide plastic tube snaked from a generator throughone door to the ticketing area.

I’m sorry I forgot their names, but the airport cleaning ladies were angels. The bathrooms were clean andstocked with toilet paper and paper towels. We had soap and water to wash hands followed by waterless alcoholsanitizer.

We were overwhelmed in the tents treating those who needed medical attention. That first shift, I was notprepared for the sea of litters, wheel chairs and people. I was assigned to the Green tent and thought thepatients would present with quite matter-of-fact treatments for this competent family nurse practitioner. Butalthough we had triage categories, when one tent was full, the patients were sent to the next lower acuity tent.

We worked 12 hours on, 12 hours off. I worked, ate breakfast, slept, ate dinner and worked. This cycle wascontinuous until we were relieved after our last shift midnight Thursday, September 8.

For restroom breaks, initially we used the same facilities as the evacuees and patients. As I passed through thewaiting area, I touched by many patients who needed water, changing and human touch. In the restrooms Ifound myself helping patients clean up after themselves and assisting to the toilets. One time, when I began toclean the toilet seat after an unusually soiled user, one of those cleaning ladies said, “Honey, you just leave thatto me, I’ll clean it.” This woman pulled in her cart, donned gloves and began wiping and sanitizing that stall.

Heartbreaking was that initially we did not have food and water for our sea of humanity in need. We could offeronly a few remnants from our MREs. I felt we were neglecting them because we didn’t have enough people tocare for those in the waiting areas. We could only offer assurances that we could come back to help them. I don’tknow how many times I exaggerated my intention to return.

By then end of my second shift on Friday, I was exhausted and mentally drained. I was short with colleagues andcranky. I called my spiritual advisor, and we talked a long time. I shared many thoughts, concerns andfrustrations.

Finding SuppliesIt became necessary to activate the expectant category. It was very sobering to transit through the Black(Expectant) area on the second day. Many patients were so frail they probably would not survive the

transportation out of New Orleans. Most were elderly people on litters being kept comfortable by a single nurse.

I realized that we could do only so much for so many with the resources we initially had on hand. By the fifth orsixth day, we were able to retriage, and all remaining patients were air evacuated out of New Orleans.

Generally we had a single of each type of medication. Our pharmacists were great in offering suggestions. Isubstituted many medications for our patients by guessing their original prescriptions: “For my pressure I take thelittle white pill.”

I was challenged to understand a variety of accents and to translate the usual mispronounced medicationnames. Many people left home with only the clothes on their backs — they had no medications, no wallets,nothing.

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Diabetic management was a challenge because we had Novolin 70/30 and Regular insulin, but we didn’t have asupply to replace missing insulin. Our only oral diabetic medication was glyburide. Mental health medicationswere limited to a single antidepressant, a single antipsychotic, Depakote, Lithium, Haldol, Lorazepam andValium. We used a lot of injectable Haldol for a variety of patients including the wandering elderly andsituational anxious populations.

Treating PatientsMany patients came from hospitals and nursing homes. Most of the time we only had name and diagnosis, whichwas usually taped to patients’ clothing. Rarely did we have a medical chart.

One nursing home asked if they could bring their residents, and we agreed — if nursing home staff membersstayed with them. In no time the staff disappeared; the residents had been “dumped.” Other patients wereevacuees departing from the New Orleans airport.

We hydrated several patients. We wrote thousands of prescriptions. We treated and initiated IV antibiotictreatment for water contaminated cellulitis (Epoctrates ID: doxycycline, Ceph 3– ceftriaxone and gentamicin). Wehad several early labor and active labor women. One team had an NP who was a midwife — she delivered twinsin the ambulance en route to Baton Rouge.

One woman had been knifed in the back by someone in line with her. It looked superficial, but she had ahematoma. I listened to her lungs a very long time; sounded clear to me, but I was concerned about a

hemothorax. Oh, I wish I had an x-ray! After consults with two other physicians, we cleared her. She had goodlung sounds, and the depth of the wound was above the fascia. This was the first time I’d sutured since I was astudent. Initially I forgot how to tie those knots, but after a few false attempts it all came back.

“R.C.”“R.C.” was a particularly memorable patient. He was an elderly gentleman who arrived in our tent in tied into hiswheelchair. He had been given a dose of IM Haldol, but he continued to try to get out of his chair.

When I first saw him, he was in need of a change of diaper and clothes. He smelled of urine, and his diaper wassaturated. As we cut him out his shirt, I put the taped paper with his name on the arm of the wheelchair. Weprovided him with a clean gown and laid him on a litter. He drank almost all of half-liter of water in 5 minutes.Then he downed a bottle of Boost.

He rested, and I went to do the paperwork. I couldn’t find that paper. I gloved and looked through both trash

bags. Nothing. I was upset with myself. All I could remember was the Alzheimer’s diagnosis. Someonesuggested “ask him.” I asked and was elated when he responded coherently. Then, I saw a little piece of papertape on his arm with his name and nursing home.

I readied him for air transfer to a hospital for evaluation and eventual nursing home care. His litter was placedbetween a few wheelchairs. Later someone mentioned that a man was eating his diaper. R.C. was tearing apartand trying to eat his diaper. At the same time a volunteer showed and started to feed him. He eagerly took everybite she offered. Last I saw, he was receiving another injection of Haldol as they prepared to load him on theplane.

PetsHurricane was a 7-week-old puppy with paws suggesting large parents. He accompanied a gentleman who hadwater cellulites and needed hospitalization. When patients had pets, they were usually transported byambulance. But the transport person said the dog couldn’t go to the hospital, and they were told no moreanimals.

This was problematic because the owner would not leave without his pet. They were accompanied by my patientwho had sun burn with some lymphedema. I wanted to hospitalize my gent, but I could delay if the dog ownerwould let his friend care for Hurricane. Mr. Transport came back with good news: He found another hospital, andthe dog could travel in a crate. If needed, a friend would care for Hurricane.

We also had several special pet patients. Initially they were cared for by an NDMS team — Veterinary MedicalAssistance Team (VMAT) — and later by military veterinarians.

One received a transfusion. A family arrived with their family dogs — two adults and a litter. One of the adultdogs had been hit by a car and needed a transfusion. The mate was donor.

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A cat took off when the helicopter landed leaving a litter of 3-week-old kittens. They were immediately adoptedby relief workers, who faithfully bottle fed them.

By the time we left the airport, arrangements had been made for pets to be regularly retrieved for care by animalrescue groups. Several crates had notes with potential adoptive families.

Improving ConditionsThroughout the first 5 or 6 days, many more teams and evacuees arrived. So did supplies and donations.

Pharmacy companies donated samples of medications I wish I’d had available the week before. Overnight,throughout the airport cases of food and beverages appeared. Volunteers arrived and began to care for our at-risk elderly adults by feeding and offering water. They changed clothes and diapers. One church group of youngadults cleaned floors and emptied trash.

By Labor Day, September 5, we had evacuated the initial and continually arriving patients. We began to seeevacuees from the Superdome and Convention Center. The tempo gradually decreased, and we treated feweracute illnesses. Prescriptions refills continued. On my last day, September 7, in the Green tent, our shift saw 50patients while the Red and Yellow tents didn’t see anyone.

After I was relieved at midnight on Thursday, September 8, I was crying as I returned to our sleeping area. A bigsoldier offered me a shoulder and hug. It was anticlimactic to say good bye to the triage area we established atthe New Orleans airport.

During our deployment at the New Orleans airport, we transported 2,300 patients by air and ground. The airportevacuated about 20,000 shelter evacuees.

Melinda "Lea" Poso is a family nurse practitioner in Lakewood, Wash.

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