Naval Air Station, Meridian, Mississippi, is usually a noisy place, a jet training site for the navy where jets streak in at all hours. About a three-hour drive inland from the Gulf of Mexico and relatively unscathed by Hurricane Katrina, it was designated in late August as a staging area for federal disaster supplies, storing hundreds of trailers full of emergency supplies, from generators to bottles of water. On September 10, only two days after they'd arrived, I observed a team of 78 officers from the United States
Public Health Service (USPHS) Commissioned Corps already caring for evacuees in a maintenance hangar suddenly transformed into a 362-bed federal medical contingency shelter (FMCS). These shelters can best be described as intermediate care or transitional care facilities for individuals with chronic health care needs-people who require oxygen, for example, or the elderly and disabled.
Commander Dan Cline, BSN, RN, the chief nurse, said the facility was created almost overnight from a "hospital in a box," a new prototype of mobile medical unit that "essentially contains everything needed for a hospital except the walls." Staff included nurses, physicians, nurse practitioners, physician assistants, and pharmacists-all USPHS officers deployed from various parts of the country. According to Cline, after setting up the actual facility, they had to establish procedures for admitting and assessing evacuees and "resolving issues related to roles." For example, there were two issues that needed to be clarified with other team members: who would triage patients (nurses) and how patients would receive their medications (patients would self-medicate except with narcotics).
In this shelter, among the 25 initial evacuees (all from Louisiana) were an elderly woman who was diabetic and also receiving oxygen because of lung disease; six members of a family spanning three generations, including a grandmother with terminal liver cancer; and a young woman who had asthma and diabetes and no medications. According to Cline, they were expecting another 30 clients to arrive any moment, most of whom would be coming from temporary shelters and would stay at this facility until there were more definitive plans for their care (for example, placement in a nursing home outside the disaster area or with relatives). There was a calm, quiet atmosphere, much like that of a hospital: low voices, small clusters of conversation, families sitting together. Outside the hangar, airmen walked briskly, talked a bit louder, and life seemed a bit more normal.
Teams sent to disaster sites normally stay for about two weeks, though that can change. The stress of deployment varies with the setting, the staffing, the needs of the patients, and the quarters. Here, like the evacuees, the staff slept on cots in one large room; there was little privacy. Showers and air conditioning, available thanks to Herculean efforts by their navy hosts, made a big difference.
When there is a public health emergency requiring a federal response, lights burn long into the night in a glass office building in Rockville, Maryland. The parking garage remains full. I couldn't help notice the boxes of Club crackers and snacks and coffee-helpful for the 12- and 14-hour days many were working, explained captain Angela Martinelli, DNSc, RN, CNOR. Here, the Office of Force Readiness and Deployment, the division of the USPHS that is responsible for sending teams of health professionals to respond to disasters, coordinates its part of the National Response Plan (see "The National Response Plan," page 26).
With the realization that more manpower over a long period would be required, on August 31, USPHS captain Carol Romano, PhD, RN, FAAN, and colleague commander Renee Joskow, DDS, MPH, were given the task of setting up a call-in and online system for civilian health care professionals to volunteer their services. By September 8 their registry had fielded 15,000 calls and logged 130,000 visitors to the Web site. On September 16, they deactivated the registry-they had registered more than 34,000 volunteers in the database. "For the first time, we have an infrastructure in place for capturing health professional volunteers," said Romano, who normally works in the department of clinical research informatics at the National Institutes of Health.
"This is the largest USPHS response ever mounted," Martinelli told me. She, along with colleague John Mallos, BSN, RN, lieutenant commander, is a response coordinator. Mallos explained that they began their planning about a week before Hurricane Katrina made landfall on August 29. That included having one team "ready and on the ground," so on August 28 they sent a 38-member team of public health officers to Louisiana State University in Baton Rouge to set up a 250-bed mobile hospital. By September 12, they had deployed more than 1,000 public health officers to Louisiana, Mississippi, Texas, and Washington, DC, to provide health care and mortuary services, to assess the status of hospitals and nursing homes in the disaster area, and to act as liaisons with other agencies such as the American Red Cross.
Though a nongovernmental organization, the American Red Cross is the primary organization within the National Response Plan for coordinating "mass care resources," meaning the sheltering and feeding of people affected by the disaster. They place RNs in their shelters to evaluate evacuees for health needs; those who do need health care are usually transferred to an FMCS. Dee Yeater, BA, RN, senior associate for disaster preparedness and response, reports that there were "over 400 nurses on the ground" in the disaster areas, plus many other relief workers. (By September 27, there had been 2.8 million overnight stays in 902 shelters across 25 states, and more than 160,000 Red Cross workers had participated.) The Red Cross also began planning their response needs about a week before the hurricane was due, she said, explaining that their predictions all showed that anything greater than a category two hurricane could result in vast destruction of New Orleans caused by flooding from breached levees. They opened disaster headquarters in Baton Rouge and Montgomery, Alabama.
When I asked about any plans they might have made to use the New Orleans Superdome as a shelter, Nancy McKelvey, MSN, RN, the chief nurse for the Red Cross, explained that the organization did not have any people there. "The city of New Orleans and the state requested that we not set up any shelters in the city so people wouldn't stay and would evacuate the city." She added that she couldn't recall anyone ever requesting that before.
Among the poorest states in the nation, Louisiana, Mississippi, and Alabama have a large proportion of citizens living below the poverty lin e or without insurance. These are the ones who as a rule go without-without education, without health care, without the ability to access resources for a variety of reasons, from illiteracy to ignorance of how the system works to just being too old and too sick. These citizens constitute the majority of the people who, without access to transportation out of the city, took refuge in the Superdome. When they were rescued from there, most were transported to other states, from Texas to Tennessee. These host states and local communities have been grappling with the federal government to get aid to provide care and housing for thousands of such uninsured, jobless people.
It's hard not to wonder how many of the evacuees will develop posttraumatic stress disorder and depression, or how many people with mental illness will be unable to cope because they have been without medication. And what about those who require constant monitoring and medication, such as people with AIDS and cancer or those who need dialysis? How many of the fragile elderly will survive this sudden displacement to unfamiliar locations?
The massive scope of the disaster and the sheer size of the response that would be required were quickly apparent. When I asked the assistant surgeon general Rear Admiral John Babb of the USPHS about whether the biggest challenges had come in the early days or would arrive later, he said, without hesitation, "Later, no doubt, because of the sustained effort and resources it will require. In New Orleans, the environmental hazards may take months to years to resolve completely. Making the water system potable will take months because of contamination with sewage and oil and chemicals." He added that the mental health effects on the entire region would be huge-not only because of the event itself, but also from the loss of homes, jobs, and community.
The ongoing challenge of this unprecedented disaster response will be sustaining the effort for what is projected to be a significant and long-term need-most of these responders fulfill critical roles in their normal duties and most agencies, public and private alike, are already dealing with tight staffing because of the nursing shortage. The health care volunteers in Captain Romano's database and those of the Red Cross may very well be needed to cope with the aftereffects of Katrina, and not just in the disaster areas, but in the communities where the evacuees now find themselves.
And as I write, more storms are brewing in the Caribbean.