Nearly a year after Hurricane Katrina slammed ashore to devastate New Orleans, much of the French Quarter is again hosting visitors in the renewed revelry of Bourbon Street. Not far away, however, are the reminders that the Crescent City is a long way from rebuilding its bedrock medical services.
The boarded-up remains of the venerable Charity Hospital evoke the scene of the desperate last stand and delayed evacuation from the rising flood waters of the broken levee system late last August.
Engineers only have to eye Charity’s carcass to give their assessments of damage, but the lingering impacts on the rebuilding of basic emergency medical care is more difficult to assess, even a year after the waters receded. Asked about the many challenges encountered by emergency medicine in the months since Katrina, emergency physician Peter M.C. DeBlieux sighed, “It continues to be [a mess].”
Charity Hospital, the state-owned hospital that shouldered the bulk of New Orleans’ indigent care needs since its humble beginnings in 1736, had been the city’s only Level 1 trauma center. To replace it, officials plan a new state medical center with a US Department of Veterans Affairs (VA) hospital, but uncertainties remain over the $1.2 billion in combined costs and the 5-year construction schedule.
DeBlieux took over 2 months before Katrina as the emergency medicine director of resident and faculty development at the Louisiana State University’s (LSU) Health Sciences Center School of Medicine at New Orleans. He said that the short term goal is to reopen a fully revitalized emergency department (ED) in nearby University Hospital, to be phased in for completion by the summer of 2007.
“It sounds good,” he said, but adding a note of caution: “We’ll see if we’re there at that point.”
DeBlieux concedes that “we’ve been hit with every challenge imaginable” in providing emergency services in post-hurricane New Orleans. But the bricks and mortar hospital needs come in tandem with the equally difficult efforts to rebound emergency medicine and other residency programs.
Katrina cost Charity’s emergency medicine residency program 10 of its 35 clinical and academic physicians. The emergency medicine residency review committee cut the number of incoming resident positions from 17 to 10.
A match despite the mess
“We matched those fully; no scrambling, no other problems,” DeBlieux said. He believes the new physician interest in the program despite the challenges it faces heralds a comeback. LSU-Charity Hospital’s program, established in 1973 and among the oldest in the nation, is well respected in the specialty’s community.
“They (the residency review committee) were favorably impressed by what our reaction was to the disaster and how we had positioned rotations for the residents even without our primary care site,” DeBlieux said. By January, the program had been offered a 3-year certification, with the next review scheduled for Spring 2007.
Dr. Keith Van Meter, chair of emergency medicine, promoted the opportunities in a prepared statement to medical students. “We are excited about the new post-hurricane training opportunities, such as our relocated Level I trauma center, our disaster medicine experiences and our unique partnerships with military medical services, to name a few.”
The decrease in emergency medicine residents for the coming year parallels declines in other specialties. Overall, the LSU program for New Orleans has 405 residents, down from 518 for the prior year.
The pride of the emergency medicine staff in continuing to offer services was mixed with acknowledgment of the long-running problems in coping with the crisis.
In announcing that the American College of Emergency Physicians Scientific Assembly would keep to its 7-year-old designation of New Orleans for the 2006 sessions, ACEP President Frederick C. Blum, MD, said that “emergency physicians providing care during Hurricane Katrina were among the very last people to leave the city. It’s appropriate that we are now one of the first to return.”
Critical care in the aftermath
Of course, Charity emergency physicians never really left. While news media attention focused on the frantic final days for the hospital, emergency physicians and assistants struggled in the ensuing months to keep providing care for the hurricane victims.
DeBlieux said emergency physicians and support staff were back to the city within hours of the evacuation of Charity Hospital. They established a clinic and medical care area, led by emergency physician James Moises, MD, outside the New Orleans Convention Center. Martial law had been declared, and law enforcement officers were warning of dangers from the floods and marauding criminals.
“They really weren’t supposed to stay there,” DeBlieux said of the doctors. “And yet they were there, delivering care and helping get the people out.”
In the third week after the hurricane, the clinic outside the convention center added a fast track area that served 75 patients a day, and combined efforts with a military combat surgical care hospital unit. The following week, the US Navy dispatched its hospital ship Comfort to the scene from Mississippi. The LSU New Orleans Medical School emergency physicians and trauma surgeons from Tulane Medical Center handled cases there for 10 days.
A tempest and a tent
After the departure of the Comfort, primary care delivery was still at the urgent care facility outside the convention center. To broaden care, another facility was set up in the parking lot of University Hospital, DeBlieux said. The Air Force provided tents used at Army field hospitals in Iraq and Afghanistan, and portable toilets, water bladder utilities and emergency generators.
DeBlieux said the military medical equipment was good, although the tents–designed as temporary shelters until wounded soldiers could be evacuated to real hospitals–lacked basic elements of civilian facilities. Doctors scavenged equipment from the dark halls of Charity and University Hospitals.
Equipment as fundamental as stretcher holders illustrated the incompatibility. The military models lacked essential side rails to keep intoxicated or combative patients, or other fall risks, from tumbling to the ground. “Their answer to side rails is simply pick up the litter and put it on the floor,” which wasn’t a viable option for civilian medical staff, he said. “Not all the care providers are robust enough to go down on their knees and deliver care at every step of the way,” DeBlieux said. “In the military, it is a different ball game.”
By the end of October, the University Hospital parking lot clinic was seeing more than 75 patients a day. The teams had added X-ray, CT and ultrasound capabilities. With crowds of former evacuees beginning to return to the devastated city, the parking lot bustled with more activity than the Convention Center site.
Staffing the temporary facility were residents and faculty physicians, emergency nurses, hospital police, laboratory and radiology technicians and even dentists. “It was just really a team effort,” DeBlieux said.
Pressure was exerted beyond the basic need to treat patients, whose visits increased to 4,000 in January–about half the numbers seen by University and Charity hospitals before the hurricane. As 2006 arrived, so did demands for the Convention Center clinic to be dismantled.
“There was a big press for us to leave so the Convention Center could get their own contractors in to prepare it for the major conventions,” DeBlieux said. “So we began looking for alternative sites.”
Support physicians came from Florida and the Carolinas to ease the workload, he said. The number of available hospital beds had increased to 1,700, compared to pre-Katrina’s 4,000, but February also provided more challenges with the start of the carnival season and Mardi Gras.
“We expanded our services to also function as kind of a drunk tank and observation unit,” DeBlieux said. “We were able to coordinate other care with that.”
An emergency department store
When they had to move from the convention center in March, they found space for an emergency services unit inside a Lord & Taylor department store, the anchor for the former New Orleans Mall.
They got the certifying agencies, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS), to approve the transition to the cubicle-like treatment areas.
More relief came in May, when they opened a facility for major trauma patients in leased areas on portions of 3 floors of the private Elmwood Hospital.
In May and June, the emergency services unit at the former department store was seeing more than 4,200 patients monthly. About 70 of them were transferred out to area hospitals, with another 70 admitted for 1-day observation stays.
Medical centers in adjacent areas are still grappling with the surge of patient visits from the Charity Hospital vacuum. Over the Memorial Day weekend, for example, ambulances were lined along the West Jefferson Medical Center for hours. Hospital officials blamed a combination of factors: staffing shortages, limited bed availability, even the collapse of home health care programs after the floods. Medical center administrators had to ask the state for some $120 million in emergency funds to underwrite the cost of the uninsured care.
“One of the frightening lessons that we learned was about the assumption we’d always had that somebody from a federal and state level would step in and provide for the indigents,” DeBlieux said. He explained that indigent care encompassed much more than the homeless including many of the working poor. “They continue to fall through the cracks here, and their needs are not being met.”
Fears of a funding collapse have led to protests over the initial decision to close Charity Hospital.
The billion dollar fix
Officials of Louisiana and the US Department of Veterans Affairs in June announced plans to replace Charity by building a $1.2 billion mega-medical complex to be completed in 2011. The VA and LSU would each operate separate downtown hospitals linked by a corridor, with projected cost savings of about $10 million annually by sharing some services.
A federal appropriations bill was designed to cover VA costs of about $630 million, although state funding sources remain unclear for the remainder of the project, a 350-bed teaching hospital. State officials said the money might come from federal Community Development Block Grant allocations or as part of the Federal Emergency Management Agency funding to compensate the state for Hurricane Katrina.
More unique funding possibilities–one calls for private developers to build and lease the facility to the state–have been discussed to avoid having the costs added to Louisiana’s soaring public debt load.
The price tag of the replacement plan has spawned continuing criticism. Critics cite a FEMA study that estimated that Charity could be repaired and reopened for about $24 million, far less than the US Government Accountability Office’s estimate of $258 million.
“After the storm, doctors, military personnel and engineers re-entered Charity, pumped out the floodwater from the basement and cleaned and decontaminated patient care areas for the hospital to be reopened, only to be ordered out by LSU officials,” a joint statement by Charity’s supporters said on June 8. “The building has been closed and guarded ever since.”
The coalition drew more attention with rallies calling for the renovation and reopening of the hospital. Among the groups urging continued use of Charity are the Advocates for Louisiana Public Healthcare (ALPH), People’s Hurricane Relief Fund Healthcare Committee, the New Orleans chapter of the NAACP and Doctors Without Hospitals. They include physicians such as Moises, the emergency medicine specialist who helped lead the effort to establish the first post-Hurricane Katrina medical aid area.
The charity diaspora
Without Charity Hospital, many patients have been dispersed to seek care at remote locations, they argued. The closest chemotherapy treatments are more than an hour away, the protesters said. Louisiana, with 21% of residents uninsured and another 20% on Medicaid, has one of the lowest populations with private insurance.
VA executives and the state officials denied the contentions of critics, that the long range collaborative medical center would gut services to New Orleans’ indigents traditionally cared for at Charity Hospital.
Proponents of the new hospital plan pointed out that Charity’s 70-year-old buildings have serious infrastructure problems. Engineering studies have shown extensive disrepair over the years, as well as damage from the floodwaters, they said.
Donald Smithburg, an executive vice president of the LSU system and chief executive officer of its health care services division, outlined the concerns about the devastation at both Charity and the nearby VA hospital. His comments came as he pushed for the collaborative hospital center in a March appearance before the Committee of Veterans Affairs of the US House of Representatives.
“Today, these facilities sit in ruins. Charity Hospital has been deemed ‘uninhabitable and unsalvageable’ for health care by consulting engineers, and the somewhat newer University Hospital (35 years old), although severely damaged and not viable in the long term, will be temporarily propped up by the end of the year as an interim solution to New Orleans’ critical need for health services.”
Smithburg said the planned collaboration with VA “is one propelled by unintended opportunity” and an “enlightened and visionary step” for the area’s medical care needs.
DeBlieux, recalling how medical teams scrambled and improvised to provide care immediately after Katrina, had to wonder about the findings that Charity was effectively destroyed by the hurricane. Asked if Charity could have been reopened, he replied, “There’s no question.”
“Within 2 weeks after the storm, our entire residency contingency and many of the academic faculty were back in the building salvaging, in hopes of delivering care in that facility. The leadership at the state level told us to stand down. They did not think that was a salvageable enterprise. It was very difficult (to accept).”
As of early July, the plan was to reopen portions of University Hospital, 2 blocks from Charity. In October, officials hope to have up to 150 patient care beds available, along with the existing ED and fast track. By January, the temporary trauma care at Elmwood would be relocated to University, along with two-thirds of a new ED.
Katrina’s lessons learned
On the first anniversary of Katrina, one of the foremost emergency medicine training programs reflected on the lessons that came not just in coping with a disaster, but with the extended recovery efforts that are continuing today and how they might be done better.
“There is a lot of duplication of efforts,” DeBlieux said. “There’s a lot of people not being invited to the table–not intentionally, but as a result of nobody really having a grasp on the big picture.”
Ultimately, he said, success during a crisis depends on “team effort.”
DeBlieux explained that “it is not just a small leadership team.” It is reliant on a number of individuals, from physicians to nurses, hospital administrators, and everybody in between that it takes to run health care facilities.
“It takes buy-in from everybody,” he said.
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