PHS Katrina Response: Baton Rouge Deployment

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PHS Katrina Response Baton Rouge Deployment
V. 23 Sep 2005
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PHS Katrina ResponseBaton Rouge Deployment,
Alpha team

• CAPT Charles McGarvey, PT Deployment
• Chief, Physical Therapy Dept, NIH Clinical Center
• CDR Sarah Linde-Feucht, MD Medical operation
• Center for Orphan Products Development, FDA
• CAPT Martha OLone, RN Staffing and services
• Center for Devices and Radiologic Health, FDA
• CDR Shirley Lee-Lecher, MD Infectious disease
  issues
• Vaccine Clinical Research Center, Walter Reed
  Army Medical Ctr
• CDR Jeasmine Aizvera, MSW Mental health issues
• Social Work Dept, NIH Clinical Center
• CDR Jeffrey Kopp, MD Nephrology, hospital
  assessment
• Kidney Disease Section, NIDDK, NIH

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Sunday 28 Sept 2005, in the Gulf of Mexico
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PHS Katrina Deployment Team 1 Deployed Aug 28 -
Sep 9 Leadership

• CAPT Charles McGarvey, NIH, Team leader
• CDR Bill Greim, CDC, Deputy Team Leader
• CDR Sarah Linde-Feucht, FDA, Lead Medical Officer
• CAPT Martha OLone, FDA, Lead Nurse
• LCDR Connie Jung, FDA, Lead Pharmacist
• LCDR Camille Hawkins, DCCOS, Lead of Others (EHO,
  MHP,PA)
• LCDR Doug Hanley, CDC, Logistics
• LT Todd Raziano, OSOPHS, Logistics

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PHS Katrina Alpha Team (37)
Environ Health Officers Nurses Physicians
CDR Bill Greim LCDR Carma Ayala CDR Sarah Atanasoff
LCDR Doug Hanley CDR Linda Jo Belsito CAPT Vito Caserta
LCDR Molly Patton LCDR Alicia Bradford CDR Christine Casey
LT Nicole Chamberlain CDR David Kim
Pharmacists LT Scott Colburn CDR Jeffrey Kopp
LT Kojo Awuah CDR Anette Debisette CDR Charlie lee
LCDR Connie Jung LCDR Eileen Falzini CDR Shirley Lee-Lecher
LT Ben Danso LCDR Patty Garzone CDR Sarah Linde-Feucht
CDR Valerie Jensen LT Martin Hamilton CAPT David Sniadack
LT William Pierce LTJG Josh Hardin
Mental Health LCDR Chuck Kerns Logistics
LCDR Jeasmine Aizvera LCDR Bernetta Lane LT Todd Raziano
CAPT Armen Thoumaian CAPT Martha OLone
Physician Assistant CDR Terry Porter Physical Therapy
LCDR Camille Hawkins LCDR Vickie Scott-Lewis CAPT Charles McGarvey
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Mission

• Travel to Meridian, MS - field hospital
  augmentation in Superdome
• Changed to travel to Jackson, MS - field hospital
  augmentation in Baton Rouge
• Additional missions
• Staff augmentation for shelters
• Hospital needs assessments throughout 8 parishes
• Epidemiologic surveillance in shelters
• Physical and mental health screening of first
  responders

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• Sun 8/28
• 1300 Email from ADM John Babb
• 1700 muster at Dulles
• 1900 flight to Jackson, MS

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From the Hilton Hotel, Jackson, Mon 8/29
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Muster in the Hilton
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Planning for hospital augmentation/Med Ops

• Three 8-hr rotations of physicians/nurses/pharmaci
  sts
• Smaller musters between category teams to review
  skill sets and preferences
• Review of logistics for travel to Baton Rouge and
  additional supplies

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USPHS CC Baton Rouge

• Aug 28 Alpha team of 37 officers deploys to
  Jackson, MS
• Aug 30 Team deploys to Baton Rouge to provide
  support to a 200 bed field hospital at LSU Pete
  Maravich Assembly Center (PMAC)
• Aug 31 ESF-8 desk at State Emergency Operations
  Center, staffed by Secretarys Emergency Response
  Team (SERT)
• Sep 1 2nd PHS CC team of 85 officers (CDR Dobbs)
  arrives in Port Allen to support evolving
  mission - medical support of Carl Maddox
  Fieldhouse and Belmont Hotel
• Sep 2-4 3rd USPHS CC team of 140 officers (CAPT
  Vito Caserta) arrives at England Industrial Air
  Park, Alexandria, LA - ultimately supports State
  special needs shelters in Alexandria (28
  officers) and Lafayette (22 officers)
• Sep 4 Parish Hospital Assessment team deployed
• Sept 4-6 Officers deploy to New Orleans, under
  CAPT Vince Berkeley
• Sep 7 Elements of 3rd USPHS team deploy to Baton
  Rouge - 20 four-person teams were tasked with
  shelter assessments and syndromic surveillance

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Port Allen
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LSU Peter Maravich Assembly Center(PMAC)
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PMAC just after PHS team arrived
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Evolution of PMAC organization

• Tues 8/30 PHS physician volunteers
• Set up as medical facility
• Patients begin arriving
• Late Wed 8/31 IMERT arrives, later augmented and
  then replaced by New Mexico DMAT
• Throughout its lifetime (8/30-9/7) PMAC provided
  an extended triage function, with an average
  patient stay of 6 hours

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PMAC medical operations
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PMAC Organizational Structure

• Director, Dr. Thomas,
• LA State Dept of Health and Hospitals

DHHS Theater Commander ADM Craig Vanderwagen
Incident Commander Dr. Gerry Monnier
Medical Director Dr. Chris Trevino
Mental Health
IMERT 8/31-9/7 (51) NM DMAT 9/1-9/9 (35)
PHS Team (37)
Nursing Ops
Physician Ops
Admin Ops
LogisticsOps
Triage Pt care Team leads
Volunteer staffing Pt tracking/records Disposition
Transportation Environmental health Clinical
laboratory Radiology Comfort care
Communication Facilities Pharmacy Supplies
Triage Pt flow Team leads
PHS participation
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Patient Flow and triage

• Arrivals helicopter, ambulance, bus - 2000
  patients/d
• First helicopter arrived 8/30 2300 on the Bernie
  Moore Track Stadium
• Generally alerts for many patients and fewer
  actually arrived
• Triage
• RED urgent medical needs ? transfer to hospital
  (Baton Rouge General or Lady of the Lake
  Hospital) or admit to PMAC
• YELLOW non-urgent medical needs ? admit to PMAC
  or Carl Maddox fieldhouse or other special needs
  shelters
• GREEN no medical needs ? transfer to general
  population shelters
• BLACK not expected to survive ? comfort care

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Courtesy of Washington Post
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Triage area
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Triage yellow or green waiting area
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Triage
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Corridor into the hospital floor
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PMAC Layout
Main Triage
Vol Staffing
Command Ctr

• Initially
• PMAC red, yellow
• Fieldhouse yellow, green
• Later
• PMAC Red, high yellow
• Fieldhouse, low yellow, green

Ped
Yellow
Transp
Red
Dispo
Staffing
ICU
Trauma
Helo Triage
Pharm
Lab
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30 seconds of PMAC in action
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PMAC logistics and administrative operations

• PHS Officers
• Volunteer coordination
• Logistics
• Laboratory
• Pharmacy
• Information system
• Summary

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Volunteers

• Medical physicians, physician assistants,
  nurses, pharmacists, respiratory therapists,
  X-ray technicians, social workers, mental health
  professionals
• Non-medical LSU college students, countless
  others
• Scheduling
• Credentialing - hospital ID or state license and
  (eventually) website confirmation
• Potential liability - an issue for the future

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Volunteer scheduling board
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Nurses
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Nurse
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Licensed Nursing Assistant
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Non-medical volunteers
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LSU Student volunteers distributing meals
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Clinical laboratory

• Bedside glucometers, urine dipsticks
• Service laboratory send out 0800-1700
• Added Lady of the Lake Hospital evenings
• CBC, PT/PTT, Chem 7, limited enzymes - no
  cultures
• Added radiology capability

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Radiology
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Security
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Logistics

• Strategic National Stockpile (CDC)
• 12 hr push packages, first arrived 8/30
• Specific orders
• IMERT and New Mexico DMAT

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Donated supplies
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Supply desk
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Supply desk
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Pharmacy

• Initial supplies from SNS
• Supplementation from
• - local distributor (Morris Dickson) purchased
  through LA Office of Public Health
• - donations from local physicians
• Final formulary listed gt500 meds
• gt5000 prescriptions for PMAC alone
• Initially dispensed 3 days of medication to
  conserve supplies ? later 7 days ? finally 30
  days
• Provided support for clinics and shelters, first
  responder immunizations, and field assessment
  teams
• Local commercial pharmacy program 1 week refill
  free
• Louisiana state program 4 weeks of medication
  free

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Receiving
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Storage
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Information System

• Triage/care form

• 8/30 Louisiana state required demographic
  information, limited surveillance
• Entered into Excel
• 9/2 Added more clinical information
• Converted to Access database
• Diagnosis and disposition not entered initially
  into database, complicating responses to family
  questions

Demographics Chief Complaint VS HPI Major Med
Prob Med PE Course Discharge
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SG Carmona, Secretary Leavitt (Sun 4 Sep)
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PMAC Evaluations

• Michael Leavitt, Secretary DHHS I thought I
  would see people suffering from stress, but
  there's a sense of calmness among the workers.
  It's heartening. It's testament to the level of
  caring and compassion among the health
  professionals.
• Surgeon General Richard Carmona Truly
  extraordinary and humbling to me. The volunteers
  are extraordinary.

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PMAC in the headlines
Health workers say they were ready for Katrina By
Maggie Fox, Health and Science Correspondent
Reuters Tuesday, September 6, 2005 1224 PM
Improvising to Replace Services for Many
Thousands Washington Post, Sept 4, 2005
With military precision, patients were designated
red for most severe, yellow for serious and green
for walking wounded. By Monday afternoon, 3,500
patients had passed through the arena and more
than 1,400 prescriptions had been filled, said
Capt. Charles McGarvey.
USPHS Capt. Charles McGarvey has been at an aid
center set up at Louisiana State University in
Baton Rouge with a 38-member team since just
before Katrina hit last Monday. "We have been
pretty much at it ever since, with 12-hour
shifts," he said. Another 82 officers have since
arrived at the makeshift clinic at LSU's
basketball stadium and auditorium.
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PMAC summary

• Triaged 15,000 pts and admitted 6000 patients in
  9 days
• Census peaked about Sept 4-6 and then declined as
  evacuee numbers declined - closed Sept 7
• At least 2 people died (CVA with herniation,
  sepsis)
• One baby was born (in a locker room)
• Fats Domino was evacuated from New Orleans 9th
  ward to the PMAC
• Common diagnoses
• - acute exacerbation of chronic diseases (HBP,
  diabetes, COPD, CHF, psychiatric)
• - needs medications, dialysis or oxygen
• - minor trauma
• - acute mental health needs

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Observations about PMAC

• Flexibility required due to constant evolution of
  mission
• Need to augment and integrate into a State-run
  facility with changing emergency team partners
• Professional manpower was generally adequate,
  organization was critical and a key role for PHS
• Communication poor few land-lines, few
  computers, cell phones worked only outside the
  PMAC and not consistently, radios not useful for
  inter-facility communication
• Shelter beds initially in short supply
• Transportation for discharged patients was a
  major difficulty

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IMERT, DMAT and PHS Officers, together, after
PMAC closed Sept 7
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Katrina and mental health needs
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Mental Health Provider Role in the PMAC

• Stress debriefing for PHS staff
• Group
• individual
• Stress debriefing for first responders/other
  staff
• Crisis intervention for patients and families
• Assistance locating family members/loved ones

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Mental Health Staffing

• Two representatives from the LA State Office of
  Mental Health led the effort to provide services
  to evacuees and other staff in the PMAC
• Leaders from the Capitol Area Human Services
  District (local community mental health) were in
  charge of MH service provision at the Fieldhouse
  brought 2 psychiatrists and close to 15 MH
  staff
• Initially little coordination between the two
  programs

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Mental Health Staffing in the PMAC

• By the end of the first full day of PMAC
  operation, multiple mental health volunteers had
  shown up but there was no central place to
  identify, organize, or coordinate them
• Medical staff searching for mental health
  providers in moments of crisis
• Need for psychiatrists
• Formulary with limited psychotropic meds

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Mental Health Staffing in the PMAC

• Clash in agendas between MH volunteers who wished
  to focus on discharge, social service resource
  needs and those present to provide counseling
  support and psychiatric intervention
• LA State Department of Social Services on site at
  both the PMAC the Fieldhouse. Somewhat
  involved in resource finding (shelters,
  transportation) though their stated goal was to
  compile a database of all evacuees who had come
  through the PMAC Fieldhouse

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Coordinating MH resources

• MH volunteers scheduled for 8hr shifts,
  coordinated by state OMH
• Central MH Table set up to improve access to MH
  volunteers
• MH volunteers proactively assigned to different
  areas of the PMAC
• Private areas identified to provide group or
  individual counseling/debriefing

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Coordinating MH resources

• Psychiatrist volunteers shared between PMAC
  Fieldhouse for 24hr coverage
• Additional meds obtained through National
  Stockpile
• Identify MH/SW volunteers who want to assist with
  discharge planning resource finding utilize
  them appropriately

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Transport desk Discharge Desk Physician Ops Dr.
Gregory
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Discharge Planning

• Flow of patients into PMAC required intense high
  speed discharge planning
• Creating coordinating a discharge process was
  essential
• Intake/Triage sheet used to document discharge
  instructions
• Routed discharge sheets to a central area

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Discharge Planning

• Required a minimum of 14 people to make it work
  around the clock
• 4 RNs/SWs to identify and coordinate discharges
  to general shelters, special needs shelters,
  hospitals, nursing homes, and other care settings
• 1 EMT coordinating all ambulance arrangements
• 1 DSS volunteer to identify transportation
  resources
• 1 support person to develop and maintain a
  spreadsheet of patients discharged specifying
  facility/shelter name
• Facilitate family reunification

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Challenges

• Making time to provide stress debriefing to
  healthcare volunteers
• Groups held at change of shift
• One on one
• Offered groups at standing times throughout the
  day
• Provide additional debriefing after deployment
  ends
• Coordination!!!

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Katrina and infectious disease issues
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EMERGENCY RESPONSE

• Participated in assistance with assessment of
  800-1000 firefighters and police departing and
  arriving to New Orleans, LA
• Assisted with provision of supplies, medications,
  tetanus toxoid for immunizations
• Provided CDC immunization recommendations
• Mental health providers assisted local physicians
  with assessments
• Provided DOD physical examination forms for
  standardized intake evaluation

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INFECTIOUS DISEASE ISSUES

• Immunizations CDC recommendations
• Standard Adult Immunizations
• Tetanus and diphtheria toxoids (Td)
• Pneumococcal polysaccharide vaccine (PPV) for gt
  65 yrs/high risk
• Influenza vaccine
• Crowded Group Settings
• Influenza
• Varicella
• MMR
• Hepatitis A
• Diarrheal diseases
• Vaccination against typhoid and cholera are not
  recommended
• Rabies
• Rabies vaccine should only be used for
  post-exposure prophylaxis after an animal bite or
  bat exposure

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INFECTIOUS DISEASE ISSUES

• Gastroenteritis Cases
• LSU Pete Marovich Center, Baton Rouge, LA, 10
  cases 7 Sept.
• Lamar Dixon Convention Center Shelter, Gonzales,
  LA 10 cases 2-5 Sept.
• Control Measures to Prevent the Spread of
  Diarrheal Diseases
• General measures for all staff and evacuation
  center residents
• Wash hands regularly with soap and water or
  alcohol hand gels.
• Maintain a clean living environment and good
  personal hygiene
• Measures for sick persons
• Ask sick persons about the type and frequency of
  symptoms (including whether they have fever or
  bloody diarrhea).
• Separate sick persons from other residents until
  24 hours after diarrhea and vomiting stop. If
  possible, put them in a separate room or,
  alternatively, place sick people in a separate
  section of the evacuation center away from
  evacuation center residents who are not sick.
• Designate toilets for use only by persons who are
  sick.
• Provide residents with plastic bags (e.g., small
  bathroom trash can liners) to contain vomit and
  to dispose of diapers.

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CDC Health Advisory Distributed via Health Alert
Network
(September 7, 2005) To date, seven people, in the
area affected by Hurricane Katrina, have been
reported to be ill from the bacterial disease,
Vibrio vulnificus. Four have died. The first
cases were reported by the Mississippi Department
of Health. V. vulnificus can cause an infection
of the skin when open wounds are exposed to warm
seawater. Infection with V. vulnificus is a
serious health threat that predominantly affects
persons with an underlying illness or a
compromised immune system, and especially affects
persons with liver disease. Persons who develop
wound infections generally do so following
contamination of a pre-existing wound or through
an injury acquired while exposed to warm coastal
waters where the V. vulnificus organism is
growing.
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CDC Health Advisory Distributed via Health Alert
Network

• Antibiotic therapy
• Doxycycline and ceftazidime IV/IM.
• A single agent fluoroquinolone e.g.,
  levofloxacin, ciprofloxacin or gatifloxacin, may
  be as effective.
• Necrotic tissue should be debrided severe cases
  may require fasciotomy or limb amputation.

Characteristic skin lesions of Vibrio vulnificus
infection and morphotype of the microorganism. A)
Gangrenous change with hemorrhagic bullae over
the leg in a 75-year-old patient with liver
cirrhosis in whom septic shock and V. vulnificus
bacteremia developed. B) V. vulnificus bacteremia
developed 1 day after a fish bone injury on the
fourth finger of the left hand (arrow) in a
45-year-old patient with uremia. C) Gram-negative
curved bacilli (arrowhead) isolated from a blood
sample of the 45-year-old patient with uremia.
http//www.cdc.gov/ncidod/eid/vol10no8/04-0047-G2.
htm
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OUTREACH TO HEALTHCARE CENTERS

• Established a daily communication link to
  disseminate CDC recommendations and other Katrina
  related healthcare information to hospital
  directors, staff physicians and other healthcare
  providers
• Ongoing communication from State of Louisiana to
  healthcare centers resulting from this
  coordination

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Katrina and ESRD
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End-stage renal disease (ESRD) in Louisiana

• Louisiana has part of a 6-state kidney disease
  belt with highest US ESRD rates
• Possible factors African-American population,
  obesity, diabetes, other?

Prevalent dialysis rates, per million population,
2002, USRDS data
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Entity African-American population
USA 12
Louisiana 32
New Orleans city 67
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Katrina and ESRD

• Metropolitan New Orleans 45 dialysis clinics
  serving 2403 patients closed due to the
  hurricane
• Unprecedented closure of dialysis units
  throughout a major city
• PMAC received 50 patients/d who had not received
  dialysis in up to 10 days
• 700 dialysis came to Baton Rouge (adding to the
  800 patients on dialysis there)
• As of 9/16, 260 pts remain in Baton Rouge, the
  others having returned to New Orleans

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Katrina and ESRD

• Provided solutions for peritoneal dialysis
  patients to resume dialysis in the PMAC
• Baton Rouge nephrologists and Fresenius and Renal
  Care Group dialysis units
• - brought in multiple mobile hemodialysis units,
  dialysis nurses and technicians, patient
  transport bus
• - arranged for temporary housing for staff
• - social workers arranged for shelters and
  transportation for patients

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Parish Hospital Assessment
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8 Parishes
Phone call from St Bernard Parish Sat Sep 3

• Washington
• St Tammany
• St Bernard
• Plaquemines
• Jefferson
• St Charles
• LaFourche
• Terrebonne

Orleans Parish all 22 hospitals closed
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Data for Orleans Parish are provided separately
by Team New Orleans
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New Mission

• Rapid evaluation hospitals and (when possible)
  clinics in 8 parishes, using multidisciplinary
  teams
• Parameters
• Facilities, staff, staff housing
• Utilities power, phone, water
• Medication, consumables, mortuary needs
• Timeline Sun Sep 3 - Wed Sep 7
• 41 hospitals 3 not accessible, 34 visited, 4
  phone interviews

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Clinic in office building in Chalmette, St
Bernard Parish
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Police
National Guard
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Makeshift ambulance in Chalmette
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Mississippi Dock, St Bernard Parish
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Triage clinic, St Bernard
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St Bernard Response

• Sun (9/4) assessment, recommended DMAT and DMORT
• Mon helicopter delivery of 200 lbs of medicine
  (inc insulin, tetanus toxoid) and supplies
• Tues Arizona DMAT (30 member team) arrived

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Wyoming National Guard Blackhawk
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Private Corporate Bell
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Slidell Urgent Care Center
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• Washington Parish
• Franklington Riverside Medical Center
• Bogalusa LSU Health Sciences Center, Clinic

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Wind damage, Washington Parish
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Washington Parish

• Tues 9/6 EOC meeting _at_ 4pm Parish president, 5
  mayors, state senator, state representative,
  police chief, fire chief, school superintendent,
  public health nurse, prison warden, LA National
  Guard, Army National Guard, Corps of Engineers,
  FEMA, American Red Cross
• Issues security, communication, oxygen,
  rebuilding county
• Responses already happening
• - more troops
• -oxygen
• - semitrailer of medications from PhRMA

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Washington Parish

• Parish public health nurse, Kathy Willis What
  do we need? I have no idea. We need a needs
  assessment.
• Clinic and housing projects outreach team, under
  leadership of PHN, beginning Wed 9/7
• 1) PHS 6 member team (MD, NP, RN) to do outreach
  and establish clinic
• 2) Partners in Health, 15 member team from
  Florida
• 3) Georgia Army Medical Reserve unit
• 4) Living Water Church, Robert Smith

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Functional status
All 38 surveyed hospitals Open 26 (within New
Orleans City Ochsner Clinic, West Jefferson,
East Jefferson) Closed 12
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Bed capacity
Before Katrina After Katrina (at survey)
8 parishes 4719 2839 (60)
8 parishes Orleans parish 8762 2839 (32)
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Staffing needs

• 12 closed hospitals
• Likely all these will have
• staffing needs prior to reopening
• 26 open hospitals
• 8 request staff augmentation
• 8 request assistance with staff housing

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Utilities at time of survey(26 functioning
hospitals)
Utility Intact Compromised
Power 15 11
Telephone 14 12
Water 17 9
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Major recommendations

• Stand up closed hospitals
• 1 DMAT
• 1 DMORT
• 7 hospitals staffing augmentation
  (possible DMAT)
• 6 hospitals staff housing
• Restore utilities to affected hospitals

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Evaluation and follow-up of hospital assessment

• Mission identified critical needs of hospitals
• Mission should have been carried out earlier
  (beginning on day 2 instead of day 6)
• Duplication of efforts
• Unclear at this point how adequately all needs
  have been met
• Project extension (PHS teams 2 and 3)
• Public Health Clinics data from Regional Public
  Health Administrators
• Community Health Centers data from the
  Louisiana Primary Care Association

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Epidemiology team
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Number of Evacuees in Shelters, by Parish,
Louisiana September 2005
Source NY Times, 9/13/05
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General and Special Needs Shelter Assessments
September 8-12
Objective Evaluate 300 general and special
needs shelters for clinical, pharmaceutical,
environmental/sanitation/hygiene, and mental
health needs to provide needed support in coming
weeks/months
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Partnership for Shelter Assessments

• USPHS
• State of Louisiana
• Centers for Disease Control and Prevention
• American Red Cross
• Harvard University
• Johns Hopkins University

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Shelter Assessment Instrument

• Identifying and contact data
• Resident capacity, census and demographics
• Existing information management
• Health Capacity
• Availability of clinics, hospitals, health
  professionals
• Staff/volunteer planning/scheduling
• Isolation procedures
• Syndromic surveillance summary
• Diseases of epidemic potential
• Mental health psychological problems
• Injury, Chronic Disease, Other
• Deaths

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Shelter Assessment Instrument

• Medical equipment pharmaceutical availability
  and recent needs
• Environmental Health
• Facilities
• Water Food
• Hygiene, sanitation waste
• Injury prevention
• Vector control
• Safety code compliance
• Chemical hazards
• Summary sheet

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Shelter Assessment Implementation

• 24 USPHS/ARC field teams consisting of
• Physician/PA/epidemiologist
• Nurse
• Environmental Health Officer
• Pharmacist
• Mental Health Officer

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Preliminary Assessment Findingsand Actions Taken

1. 225 assessments from 9/08-9/12
2. Found 50 additional unreported shelters
3. Supplies, personnel, technical assistance were
   immediately directed to shelters with immediate
   needs planning started for long-term needs
4. Assessment also used to initiate or reinforce
   syndromic surveillance system in shelters

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Syndromic Surveillance in General and Special
Needs Shelters
Objective Immediately identify potential
outbreaks of communicable diseases and monitor
the burden of clinical care at shelters and their
capacity to effectively care for residents
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Partnership for Syndromic Surveillance in Shelters

• USPHS
• State of Louisiana
• Centers for Disease Control Prevention
• American Red Cross
• Harvard University
• Johns Hopkins University

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Syndromic Surveillance Instrument
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Syndromic Surveillance Implementation

• Conducted in parallel with exisiting surveillance
  systems adminstered by State/Regional/Local
  health departments
• USPHS and ARC staff contacted individual shelters
  to explain need and methods
• Shelter assessment teams provided brief
  surveillance orientation/reminders and
  troubleshooting
• Zero reporting by shelters through FAX or phone
• Surveillance data communicated daily to Louisiana
  State Office of Public Health Epidemiology
  Department for follow up (e.g., investigations)
• USPHS assists with outbreak investigations as
  requested

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Outbreak Investigations
Objective To rapidly confirm if reported
outbreaks are occurring (with special focus on
general and special needs shelters), determine
their etiology and magnitude, and implement the
best method for control
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Line Listing of Gastroenteritis Cases at Lamar
Dixon Shelter, Gonzales, LA Sept 2005
Pt Section Sxs Sex Age DONSET DOA DOA-DONSET
1 15 d F 75 9/2 DK
2 14 d F 55 9/2 DK
3 7 v F DK 9/3 8/30 5 days
4 12 d M DK 9/3 8/30 5 days
5 14 v,d F 49 9/3 DK
6 12 v,d F 18 9/3 8/27 8 days
7 10 v F DK 9/3 DK
8 10 v F DK 9/3 8/30 5 days
9 16 v M 7 9/4 DK
10 11 v F DK 9/5 DK
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Epidemic Curve of Lamar Dixon Convention Center
Shelter Gastroenteritis Outbreak, Gonzales, LA,
September 2005
9/01
9/02
9/03
9/04
9/05
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Spot Map of Gastroenteritis Cases, Lamar Dixon
Convention Shelter, Gonzales, LA September 2005
Reefer Trucks
14
9
10
11
15
13
12
16
Nurses station
9/2
9/3
9/3
9/2
9/4
9/5
Admin
9/3
9/3
9/3
Registration Desk
Latrines
Entrance
Exit
9/3
1
3
2
4
5
6
7
8
Food prep and serve
Mens Room
Womens Room
Kitchen Cleaning Area
Gastroenteritis case
Garbage
147
Outbreak Recommendations

• If possible, move latrines and garbage at least
  300 feet from food preparation handling area
  AND
• Use screening material to enclose food
  preparation and handling areas
• Ensure adequate refrigeration in reefer trucks
• Ensure that staff wash hands frequently,
  especially after using the latrines
• Remove standing water from containers
• Continue surveillance with special vigilance for
  gastroenteritis, using standard case definitions
• Isolate residents with diseases of epidemic
  potential

148
Summary and Conclusions
149
Summary of lessons learned

• Flexibility required due to constant evolution of
  mission
• Need to augment and integrate into State-run
  missions with changing emergency team partners
• Professional manpower was generally adequate,
  organization was critical and a key role for PHS
• Communication poor few land-lines, few
  computers, cell phones worked only outside the
  PMAC and not consistently, radios not useful for
  inter-facility communication
• Shelter beds initially in short supply
• Transportation for discharged patients was a
  major difficulty

150
Thoughts for Future Disasters General

• Improve radio communication network, shared among
  all responders
• Develop legal framework for federal lead in
  massive/multi-state disasters and for
  participation of federal military assets in law
  enforcement
• Move DMATs back to HHS - strengthen PHS DMAT
• Develop simple, robust electronic record system,
  with data input from laptops and PDAs into
  theater-wide database ? evacuee tracking
• Pre-designate network of disaster shelters
• Pre-evacuate population
• Pre-deploy personnel, pharmaceuticals, supplies

151
Thoughts for Future DisastersSpecifics

• Provide better communication tools to DMATs and
  field hospitals
• Establish disaster patient flow sheet
• Establish hospital, clinic, shelter evaluation
  and needs assessment instrument
• Establish syndromic surveillance instrument
• Develop standard environmental health and medical
  recommendations for shelter management
• Stay flexible!

152
Packing for deployment

• Pack so that you can carry/roll your bag moderate
  distances
• Sleeping bag, travel pillow, ear plugs (for
  sleeping, helicopter), casual clothes, BDU, 2
  sets khaki uniforms
• Insect repellent, sunscreen, sunglasses, hand
  sanitizer, shower shoes, towel, baby wipes
  (helpful when showers unavailable), small
  flashlight
• Drivers license, agency or PHS photo ID, copy of
  professional license, business cards, dog tags
• Notebooks, pens, Sharpie, calendar, new address
  book (many new names and numbers)
• Stethoscope, BP cuff, first aid kit, pen light,
  ACLS algorithm, references (Washington manual,
  Sanford)
• Government Visa card, cash
• Cell phone, charger, car charger
• Inexpensive digital camera, pocket calculator,
  memory stick
• Blackberry (helpful but probably not available
  for all)

153
Some guidelines for disaster responders

• Be aware of your surroundings. Be safe. Ask for
  security if needed. Buddy system (minimum team of
  2).
• Stay flexible. Operation Gumby. Prepare for new
  mission every 24-48 hr.
• Integrate, augment, help out - much of what you
  do may be distinct from your professional
  training.
• If you are too physically or emotionally
  exhausted for a task, say so. Dont feel guilty.
• Take care of each other. Encourage rest, food,
  fluids.
• Recognize signs of stress in yourself and
  teammates. Take advantage of mental health
  professionals in the field and on your return.
• Exercise.
• Call home frequently (assuming phones are
  available).

154
Appreciation

• We wish to recognized and thank
• All PHS Officers who deployed for Hurricane
  Katrina
• The Office of Secretary (DHHS), Office of
  Surgeon General, and Operating Divisions
• All medical and non-medical volunteers that we
  worked side by side with in the PMAC, Fieldhouse,
  and elsewhere
• The helicopter, ambulance and bus teams
• The police, fire and military units
• The volunteers who fed and lodged thousands of
  care-givers
• Above all, we wish to salute the dignity,
  resiliency, and courage of the people of the Gulf
  Coast region, who rose to the occasion and
  demonstrated true heroism in the face of this
  disaster.s

155
Photo Credits

• CDR Sarah Atasonoff, MD
• LCDR Carma Ayala, RN
• LCDR Connie Jung, RPh, PhD
• CDR Jeffrey Kopp, MD
• Acadian Ambulance Company
• Louisiana State University
• Washington Post
• LSU Daily Reveille