The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences

The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences Read the attached article and address the bullet items listed below: ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS 1.Summarize the problems that DMAT experienced when staging at the airport. 2.Explain the protocols, treatment, and improvisation user. 3.Summarized the problems that the airport faced. 4.Describe the patient flow and staging process and associated problems. 5.Summarize the problems with the triage and treatment process. 6.What are your impressions? – Requirements Use Article 1 Page single space mass_medical_ DMR Lessons Learned Mass Medical Evacuation: Hurricane Katrina and Nursing Experiences at the New Orleans Airport Kelly R. Klein, MD, and Nanci E. Nagel, BSN, CCRN Hurricane Katrina, a category 4 storm, struck the U.S. Gulf states in late August, 2005, resulting in the most costly and second most deadly natural disaster in recent United States history. The storm and subsequent flooding due to levee failure necessitated the evacuation of 80% of the city of New Orleans’ 484,674 residents. Most of the city’s hospitals and other health care resources were destroyed or inoperable. The hurricane devastated many communities, stranding people in hospitals, shelters, homes, and nursing homes. Nurses and other health care providers deployed to New Orleans to provide medical assistance experienced substantial challenges in making triage and treatment decisions for patients whose numbers far exceeded supplies and personnel. This article describes the experiences and solutions of nurses and other personnel from 3 Disaster Medical Assistance Teams assigned to the New Orleans airport responsible for perhaps the most massive patient assessment, stabilization, and evacuation operation in U.S. history. As the frequency of disasters continues to rise, it is imperative that the nursing profession realize its value in the disaster arena and continually take leadership roles. Kelly R. Klein is Assistant Professor, Section of EMS Homeland Security and Disaster Medicine, UT Southwestern Medical Center, Department of Surgery, Dallas, Tex. Nanci E. Nagel is the Training Officer, Texas-4 Disaster Medical Assistance Team, Parkland Health and Hospital System, Hurst, Tex. Reprint requests: Kelly R. Klein, MD, Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8579. E-mail: Kelly.Klein@utsouthwestern. edu Disaster Manage Response 2007;5:56-61. 1540-2487/$32.00 Copyright Ó 2007 by the The Emergency Nurses Association. doi:10.1016/j.dmr.2007.03.001 56 Disaster Management & Response/Klein and Nagel D uring any disaster affecting the health of the general population or the medical community, nurses often are unsung leaders, playing key roles during the response effort. Because of their education, nurses are well suited to the operational leadership positions during a disaster. In addition, nurses are well suited to address the psychosocial and medical treatment aspects of both the patients and the medical team with which they work.1,2 Interestingly, however, although nurses routinely have risen to their leadership calling, emergency preparedness core competencies for nurses only recently have been developed by Gebbie and Qureshi.3 The only other formalized design for disaster nurse leadership was published in 1984 by Demi and Miles,4 in which they outlined 3 major phases of disaster and the pivotal roles played by nursing in leadership positions: (1) pre-impact ( planning prior to the event); (2) impact (onset of the event and rescue efforts); and (3) post-impact (recovery). The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences Prior to Hurricane Katrina, there has not been a catastrophic disaster in the United States that resulted in an entire city’s evacuation. When the New Orleans levees failed and massive flooding ensued, there had never been a catastrophic disaster where a whole city had to be evacuated due to the total collapse of government and support infrastructure.5 Although many citizens left the city prior to the hurricane’s landfall, when the hurricane was over, an estimated 250,000 people were left stranded in shelters, hospitals, and private homes without potable water, communication, and electricity. Many of these people were elderly, disabled, or economically challenged. According to data from the St Gabriel parish morgue, 80% of the estimated dead from Hurricane Katrina came from New Orleans, 71% of the deceased were older than 60 years, and 47% were older than 75 years.6 The federal plan for disasters identifies evacuation as one of the National Disaster Medical System (NDMS) functions. The Federal Emergency Management Agency (FEMA) decided early on that the main evacuation site for the city of New Orleans was the Louis Armstrong International Airport (MSY). Less than 48 hours after Hurricane Katrina made landfall, FEMA sent 3 Disaster Medical Assistance Teams (DMATs) to the airport to provide initial care and Volume 5, Number 2 DMR evacuation assistance for the incoming citizens. While initial intelligence reports were very vague, the DMATs were told to expect approximately 2500 evacuees a day arriving at MSY by helicopter. Although the precise number of evacuees is not documented, the U.S. Department of Transportation (2005) reported air evacuation of more than 24,000 people from MSY, the largest mass medical removal effort in recent history.7 Nurses provided the backbone of the initial DMAT disaster response. Limited research has been published regarding the roles and involvement of the nursing profession in disaster and evacuation. This case report describes on-site disaster management at the MSY and the tremendous efforts of DMAT nurses and other health care personnel deployed there. Additionally, at the end of each subheading, when appropriate, a short problems list pertaining to that topic is described. Background Disaster response is the purview of local and state governments. When local and state resources are overwhelmed, the state governor requests federal aid. Federal assets are released once a ‘‘declaration of disaster’’ is issued by the President of the United States.8,9 One of the federal assets that may be deployed are DMATs, locally sponsored medical units that are federalized during times of crisis.10 There are approximately 49 teams in the United States (including Alaska and Hawaii). Teams are categorized according to their designated levels of preparedness (see Table 1). Level 1 and 2 teams deploy with 30 to 35 members within 6 hours of activation by the federal government. The team is supplied with medical, pharmaceutical, and logistical supplies and equipment capable of providing emergency care for 250 patients a day and for 72 hours without resupply. A fully deployed team staffs 15 general positions under the following categories: Medical (nurses, doctors, and paramedics), Logistics, Communication, and Administration (see Table 2). DMATs operate under the incident command structure designated by the National Incident Management System.The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences 8,9 Hurricane Disaster Operations at the New Orleans’ International Airport Seventy-two hours after Hurricane Katrina’s landfall, MSY was designated as the primary evacuation site for New Orleans. FEMA assigned 3 DMATs to set up and staff the site until more, if any, assistance would be needed. Intelligence information from the New Orleans hospitals and shelters was scant at best, but it was understood by FEMA that the MSY DMATs should prepare to receive 2000 to 2500 patients per day. To experienced DMAT members, there was an obvious discrepancy between DMAT supplies, personnel, and the number of projected patients; in short, they were going to be overwhelmed. Initial Problem List Encountered by DMAT at the Airport 1. The number of expected patients exceeded 10fold the amount of medical supplies on hand. 2. An evacuation plan for patients or DMAT members was nonexistent. 3. Medical, pharmaceutical, and logistical inventories were incomplete; there were less than 2 complete supply caches among the 3 teams. 4. Accurate intelligence and communications with New Orleans and with the FEMA/NDMS Table 1. NDMS DMAT team designations, levels 1e4 Team Type I II III IV General Mission Triage and treat up to 250 patients a day for up to 72 hours without resupply Triage and treat up to 250 patients a day for up to 72 hours without resupply Augment or supplement type I and II team within this team’s or local area Personnel may be used to supplement other teams Deployment Personnel Numbers Able to roster within 4 hours a full 35-person roster. Able to deploy within 6 hours Able to roster within 6 hours a full 35-person roster. Able to deploy within 12 hours Able to roster 75% of a team within 12 hours. After activation, deployment ready within 24 hours Does not meet minimal deployable team requirements Team Numbers Team roster O 105 deployable members Team roster O 89 deployable members Team roster O 49 deployable team personnel Less than team type III )Data from Federal Emergency Management Agency. Typed Resource Definitions: Health and Medical Resources. May 31, 2005. FEMA 508-5. April-June 2007 Disaster Management & Response/Klein and Nagel 57 DMR Table 2. Core DMAT positions for deployment Position Team leader Administrative/finance Logistics Medical officer Pharmacist Pharmacy technician Supervisory nurse specialist Staff nurse Advanced practitioner (NP/PA) Safety officer Paramedic Equipment specialist Communications officer Administrative assistant Number 2 1 1 3 1 1 2 6 4 1 4 1 2 1 NP, Nurse practitioner; PA, physician assistant. command area were strained and practically nonexistent. Protocols, Treatment, and Improvisation Upon arrival at the MSY, and prior to the start of the air evacuation of New Orleans’ Superdome, Convention Center, and various local hospitals, the 3 DMAT teams’ commanders (2 physicians and 1 nurse/paramedic) and their operations chiefs (3 nurses) surveyed the airport for an appropriate staging and treatment area. During the initial survey, it was discovered that medical operations were being provided by 2 airport firefighters staffing a first-aid station for the 250 people already stranded at the airport. The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences Despite limited emergency electricity, which ran some lights and 3 large fans, the airport was hot and musty, smelled of mold, and was devoid of any potable water. DMAT members were instructed not to share the teams’ own small water cache with evacuees because it was unclear when resupply of potable water would occur. One of the first medical tasks was to set up the evacuee treatment area. The departure/ticketing area was selected because there was ambient light from a giant skylight, a controlled entrance and exit, and an airport departure drop-off ramp outside the door to facilitate evacuee movement. As with any disaster, DMATs must improvise and continually change plans to accommodate any situation. For instance, rather than offload pharmaceuticals, the pharmacy truck was parked just outside the departure/treatment area; the pharmaceuticals were secured and were refrigerated as long as the trucks had fuel. Another example of improvisation was the placement of the medical tents. Normally, these tents are set up freestanding outside in a parking lot or field. At MSY, the only outside location to set up the tents 58 Disaster Management & Response/Klein and Nagel was on the tarmac where the helicopters would be landing. Additionally, the outside temperature was higher than 100 F, with humidity equally as high. To overcome these obstacles, the medical tents were set up inside the airport terminal. To take advantage of the light provided by the skylight, the tents were erected without their roofs to allow ambient light to enter and illuminate the work area. The tents were designated per normal triage categories: Immediate (red), Delayed (yellow), and Minor (green). The internal configuration of each treatment tent was determined by the nurses staffing those areas. Problems facing team commanders and their operations chiefs included the lack of personnel, limited medical and sanitation supplies, lack of communication, no higher level of medical care immediately available, unclear plans for resupply, and lack of congruent evacuation plans for the many New Orleans citizens expected to arrive at the airport. Given the gravity of the situation, 2 options for medical management were discussed. Option one, based on the premise that the large influx of patients would quickly overwhelm DMAT resources, dictated that only basic life-saving medical care would be performed, with the mission directed at facilitating evacuation of patients to areas around the United States not already overwhelmed by a disaster (evacuation is described within NDMS protocols and the National Response Plan guidelines and is the responsibility of Department of Defense). Option two utilized a more traditional DMAT approach, which is to set up a field hospital and provide the highest level of care possible depending on the medical cache available at that time, with the transfer of the sicker patients to higher level of care when transportation and facilities became available. The second option was adopted, and the teams were divided into 3 working areas: team 1 and 2 in the medical care tent area and team 3 staffing the patient/evacuee staging area and flight-line operations. For the next 72 hours, when an onslaught of federal personnel assistance arrived, DMAT staff worked nonstop with local firefighters, National Guard and reserve military units, performing flight-line operations, medical treatment, and comfort care for the evacuees of New Orleans’ hospitals, nursing homes, and shelters. Airport Problem List 1. Patients were being evacuated to but not evacuated from the MSY airport. The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences This occurred despite the fact that NDMS and the National Response Plan provides for massive evacuation of civilian population by the Department of Defense. 2. No potable water or food was available for the evacuees. Volume 5, Number 2 DMR 3. A field hospital with ICU capabilities was set up with finite supplies and no mechanism in place for resupply. 4. Communication with DMAT coordinators in Baton Rouge was nonexistent. Patient Flow and Staging For the first 12 hours of operations, evacuees needing treatment and staging for transport came to the ‘‘treatment area’’ in the upper level departure concourse. By the next morning, a staging area was set up next to the tarmac in the ‘‘baggage claim area.’’ Evacuees and patients arrived not only by helicopter but also began arriving by local ambulances from the surrounding areas. As critical patients were offloaded from helicopters, they were transported 3 at a time in a van upstairs to the treatment areas. The early morning of the second day, the onslaught of helicopters was overwhelming. Nonambulatory patients in the staging areas and in the treatment areas were triaged as immediate, delayed, and expectant. The expectant patients were placed in a separate area away from the din. Once the electricity was reinstated, they were moved to a separate concourse that was airconditioned, quiet, and staffed by clergy and volunteers. As previously mentioned, the volume of evacuees arriving quickly overwhelmed the ability to quickly transport nonambulatory patients to the upstairs area. Accordingly, the DMAT operating the flight line offloading helicopters split and staffed the lower level at arrival/baggage claim, making this a patient holding area. Team members here were rotated outside as often as possible. At the height of the evacuation, DMAT members, local firefighters, and National Guard members offloaded a helicopter every minute and a half, transferring the nonambulatory and their family members by stretchers and wheelchairs to a staging area down in ‘‘baggage claim.’’ Eventually, because of a lack of basic medical and sanitary supplies, the human smell in the staging became intolerable. . DMAT members offloaded a helicopter every minute and a half . It was in this area that the feeling of hopelessness was felt and expressed by all, including relief workers and evacuees. Fortunately, after 72 hours of unrelenting work, the 4 overwhelmed primary DMAT personnel, nurses, who were working tirelessly in the baggage claim area, were relieved by a fresh DMAT, which delivered much-needed water and food to all persons in the staging area. Additionally, this relief team reassessed, retriaged and, with the help of April-June 2007 volunteers, documented the 400 or so patients in this area in preparation for their eventual evacuation. Patient Flow and Staging Problems 1. There were too few rescuers for the number of patients in the staging area. 2. There was no easy way to move sick patients from the tarmac/staging area to the medical tents. 3. Personal hygiene items, for example, handwashing capability, toilet facilities, and urinals, were lacking. 4. Because of the smell and sheer number of patients there, the baggage claim area was the last to be relieved when DMAT relief finally began to arrive. The Citadel Mass Medical Evacuation Hurricane Katrina & Nursing Experiences New Challenges With Triage and Treatment Triage, from the French meaning ‘‘to sort,’’ was developed during the Napoleonic wars to determine the treatment priority for wounded soldiers, based on the nature and urgency of injuries, treatment resources, and transportation resources. The guiding principle was that it was more important to treat as many people as possible based on the resources at hand and provide the greatest good for the greatest number of people. In most disaster situations today, however, patients who are critically ill are availed of all available personnel and equipment. Generally, resources are reallocated to make sure that these patients receive the care they need to optimize their chance for survival.11 .The overwhelming majority of patients had chronic medical conditions; they were not trauma patients and did not fit traditional triage algorithms. All DMATs are trained in triage. Traditional triage themes such as START, MASS, Seiko, Manchester, and SORT, for example, are based on trauma situations and assume that there are enough resources for treatment and transportation of all patients to a higher level of care. The difficultly in New Orleans stemmed from the fact that the overwhelming majority of patients had chronic medical conditions; they were not trauma patients and did not fit traditional triage algorithms. There were severely dehydrated or were endstage dialysis patients who had not undergone dialysis for 10 days. Many evacuees had been without their chronic medications and were hypertensive or Disaster Management & Response/Klein and Nagel 59 DMR hyperglycemic. Those from nursing homes or acutecare facilities came without charts or identification. Many of the hospitals sent patients to the MSY who had just had surgery and were emergently intubated or with tracheostomies, all requiring ventilator support. There was a lack of ventilators, oxygen, and respiratory therapists. Despite the shortage of oxygen, patients were intubated and advanced care was performed in the hope that evacuation would come quickly and patients could be transported to a higher level of care. Many of the hospitals sent patients . who had just had surgery and were emergently intubated or with tracheostomies, all requiring ventilator support. There was a lack of ventilators, oxygen, and respiratory therapists. Supplies rapidly were exhausted, including triage tags, urinals, clean gowns, gloves, and other basic items necessary for adequate care. Supplies rapidly were exhausted, including triage tags, urinals, clean gowns, gloves, and other basic items necessary for adequate care. Initially, there were not enough personnel to keep accurate records, so data regarding the actual numbers treated, those who died, or those sent to expectant care are unavailable. It was estimated that at one time there were 400 people in the staging area and almost twice that amount in the upstairs treatment and holding area, all managed by fewer than 100 medical personnel. This uncharted experience brought new challenges to triage and treatment in an austere environment. Problem List for Triage and Treatment 1. The majority of patients at MSY were medical patients, so they did not fit into the traditional trauma triage scheme. 2. Patients were treated as if they were in a tertiary hospital or that there was transportation avai … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10