Bradford Gray, a principal research associate in the Urban Institute's Health Policy Center, is an expert on the roles of nonprofit and for-profit organizations in health care and on racial and ethnic disparities in health care. Gray and Louisiana cardiologist Kathy Hebert assessed hospitals' response to Hurricane Katrina based on published accounts and interviews with hospital executives, public officials, trade association leaders, and others with firsthand experience. "Hospitals in Hurricane Katrina: Challenges Facing Custodial Institutions in a Disaster" draws lessons from what happened in the area's hospitals, especially the 11 flood-bound institutions.
August 7, 2006
1. How did New Orleans-area hospitals respond to Hurricane Katrina?
Except for at least one hospital west of the city that evacuated before the storm, hospitals rode out the storm. It was the flooding after Katrina that made evacuation necessary, not the hurricane itself. The area-wide loss of such essential services as power and water created the need to relocate patients, but the 11 hospitals that were surrounded by floodwater faced especially perilous challenges.
Those hospitals housed more than 1,700 patients. Most were very ill, since hospitals had discharged whatever patients they could before the storm. Hospitals also became refuges for other people. According the Louisiana Hospital Association, more than 7,600 people besides patients were in those hospitals after Katrina. These included staff, relatives of patients, and other people who simply sought the hospital's relative safety.
Conditions in the stranded hospitals in the days after the storm were almost unimaginably terrible. The buildings lost power, temperatures soared, water and sewerage systems failed, communications were sporadic, and patients' constant need for care did not cease even though the necessary equipment was no longer operable.
Bodies were stacked in stairwells in one hospital because the basement morgue was flooded. Supplies ran out. Personnel reportedly fed each other with IV fluid at one hospital. Some deaths could be attributed to these conditions, and the high number of deaths at Memorial Medical Center in New Orleans led to a criminal investigation.
The hospitals that had their own external sources of assistance were evacuated most quickly. Tulane University Hospital was accessible by helicopter, and such transportation, as well as patient placement, was arranged by HCA, its parent organization. The Veterans Affairs Hospital was reached by volunteer reservists from Arkansas who had trucks that could move through the water. But other hospitals could only wait for help to arrive and try to find sources of assistance before cell phones ran out of power. People at some hospitals feared that they had been forgotten.
It seems remarkable that the evacuation of hospitals and nursing homes was not a priority in the response to the Katrina disaster. And when the evacuation did occur, it was terribly slow because each boat or helicopter could hold only a couple of patients and round trips could take an hour or more.
2. How were you able to gather so much first-hand information?
My collaborator, Kathy Hebert, has practiced cardiology in the New Orleans area for many years and is on the Louisiana State University faculty. Her connections were helpful. Also, some people who had gone through the experience were quite eager to share their stories. We are most grateful to them.
We also found much useful information in contemporary press accounts. The Internet helped us locate first-hand accounts of experiences in hospitals during and after the storm.
Still, with an active criminal investigation under way, many people were reluctant to talk. Some simply wouldn't; others insisted that neither they nor their institution be identified.
3. What were the biggest mistakes made?
In my opinion, the hospitals should not be faulted for failing to evacuate before the storm. Neither time nor resources were available by the time that the mayor ordered an evacuation of the city. During many previous hurricanes, evacuation was never necessary, and paralyzing traffic congestion could be anticipated. But neither the hospitals nor public officials were prepared for a flood and its consequences. That was what caused the catastrophe for hospitals.
In many facilities, the location of generators and essential supplies proved to be vulnerable to flooding. The emergency department at Charity Hospital was on the first floor and flooded, so everything had to be moved up a floor. Evacuation planning hadn't considered the possibility that boats would be required.
However, the hospitals can't be held responsible for the authorities' failure to recognize that hospitals -- and nursing homes -- would face crisis conditions if power and other essential services were lost. Few public officials recognized the dire need to get outside assistance to hospitals cut off by floodwaters. Many hospitals ran short of food, water, and vital medical supplies. In some instances, assistance and supplies that the stricken hospitals had managed to arrange for themselves were diverted elsewhere by authorities before arriving at the hospital.
Many hospitals, with their crippled communications, had to do their best on their own to find ways to evacuate. Communications were so bad that the first helicopters that arrived at one of the stricken hospitals intended to deliver patients to the hospital.
4. Did acts of heroism emerge?
Many remarkable things happened as patients' needs were met in dark facilities with no running water or air conditioning. Temperatures exceeded 100 degrees. Some surgery was done under those conditions. Doctors made rounds by flashlight. Patients on respirators were kept alive by hand. Patients, including bariatric surgery patients weighing more than 500 pounds, were moved on stretchers from floor to floor in narrow staircases. But the fact that personnel stayed and worked almost endless shifts with great creativity under horrific conditions was itself heroic and should not be taken for granted.
5. What lessons have been learned?
Our paper concludes with several lessons. Hospitals and other institutions with custodial responsibility for human beings face special problems in disasters. Patients all need care, but their health status and their needs are very diverse. There are patients receiving IV medications, patients on respirators, demented patients, immobilized patients who must be moved on stretchers, wheelchair patients, newborn infants, and so forth. Evacuating a building full of such patients in small boats is extraordinarily difficult.
But there are many other lessons. Essential supplies and such infrastructure as generators should not be vulnerable to flooding in flood-prone areas. Planning by individual institutions is not adequate for area-wide disasters because of the peak load problems that arise for ambulance service and other necessities. Hospital evacuation is logistically complex and external coordination is needed, especially to find transportation and identify destination hospitals for patients. Someone with the big picture needs to be responsible for these functions.
Many types of patients have special needs that must be considered in an evacuation. Tracking systems and ongoing access to patient records are needed for transporting patients. And more thought should be given to evacuation priorities, including whether to remove the sickest first. After Katrina, hospital and rescue personnel sometimes disagreed on evacuation priorities.
And, there are other special circumstances. Security is required since hospitals have drugs. Another tough issue is whether to allow people other than caregivers to enter or remain on premises with patients. Relatives can help care for patients-and did so in the days after Katrina-but large numbers of additional people complicate the task of evacuation.
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