Major Incidents, Operations

72 Hours

Issue 11 and Volume 30.

Editor’s note: LaCombe is director of the National EMS Academy, an educational partnership between Acadian Ambulance Service and South Louisiana Community College. On the Tuesday after the storm, he arrived at the Superdome, serving at a makeshift shelter and, later, at the improvised flight line for aeromedical evacuations.

Rescuers are frequently directed to be self-sufficient for the first 72 hours of operation. That fact, according to training manuals published by urban search and rescue and Disaster Medical Assistance Teams (DMATs), may be misleading to those already on the ground when disaster strikes. Catastrophic natural and man-made disasters affect those emergency responders who are on duty when the event begins with an amplified effect. Little or no opportunity exists for last-minute, advance preparations for those carrying out routine, daily response activities. Prior to Hurricane Katrina and the 9/11 attacks, few, if any, emergency responders serving in the United States had ever been trapped for days along with the patients we intended to rescue.

Supplied initially with little more than the equipment in their units, many firefighters, law enforcement officers and EMS personnel found themselves trapped in New Orleans with insufficient resources. These are my firsthand observations and tips from my experience at the New Orleans Superdome.

The incident began Sunday, Aug. 28, 2005, the day before the storm made landfall. The last 300 refugees left the Superdome on Saturday, Sept. 3, stopping the clock at approximately 168 hours, more than doubling the 72 hours of recommended self-sufficiency.

 

The Incident

Hurricane Katrina made landfall as a Category IV hurricane near New Orleans on Aug. 29 at approximately 6:10 a.m. Three days earlier, some computer models were putting New Orleans at the center of the storm, with a nearly 90% chance of a direct hit. On Aug. 28, the National Weather Service issued a bulletin predicting devastating damage to the Gulf Coast. At 10 a.m., as Katrina strengthened to a Category V storm, New Orleans Mayor Ray Nagin issued a mandatory evacuation of the city on a televised press conference. At this time, it became clear to most citizens that this was no ordinary storm.

Most residents voluntarily complied with the evacuation order. All lanes of Interstate 10 (East/West) and Interstates 55 and 59 (South/
North) flowed out of the city. An estimated 150,000 people were not able to evacuate, mainly because they didn’t have transportation.

As the storm moved closer, Mayor Nagin established several “refuges of last resort”—the largest of these being the Louisiana Superdome. Thousands of evacuees waited in lines for hours for access to the dome. Of course, few of these individuals were prepared for 72 hours of self-sufficiency.

It appears that most of the evacuees believed that they would ride out the storm in the dome and return to their homes the next day. This is evident because so many did not bring their medications or formula for their children.

The Superdome, first intended to be a short-term shelter for a few thousand evacuees, became the epicenter of suffering and controversy. It’s undetermined how many people died at the dome but certainly some did.

So much of contemporary training for weapons of mass destruction incidents emphasizes care for the injuries and syndromes of chemical, biological and explosive attacks. During Katrina, people died and suffered not from such extraordinary injuries, but from preventable (or at least manageable) conditions, such as heatstroke, dehydration, heart attack, drowning, malnutrition and prolonged exposure to the elements.

On Wednesday, Aug. 31, dozens of civilian and military aircraft initiated a massive airlift of critically ill patients. By Sept. 3, the Superdome was completely evacuated. Officials who have returned to the site must wear Tyvek coveralls and respirators for protection from potential biohazards.

 

Beyond Expectations

As with any incident, much was learned by those who provided emergency medical care in the Superdome. Consider the following factors when preparing for the next major incident:

Pre-incident planning: Designating multiple, appropriately rated shelters is critical, especially for those responders who will remain in place during the event. Public safety responders should have approved shelters assigned to their station or unit, and an accountability system to track and ensure responders’ location and safety. This system will also facilitate deployment and allocation of resources in the hours following a disaster. These individuals as well as the public need a safe haven when conditions prohibit response and evacuation. Sheltering areas for responders with large caches of medical supplies and provisions must also be adequately secured.

A second essential planning step is ensuring that responders have emergency provisions (non-perishable food and water) that will last beyond the current 72-hour window. Most crews shop for groceries at the beginning of a shift; imagine remaining on duty for 72 hours or more with only the food remaining in the refrigerator and cabinets. Areas that are prone to major disasters should consider planning for emergency caches of additional critical supplies, such as provisions for infants and children as well as the elderly.

Third, plan for and anticipate eventual communication failures as an incident escalates. In the future, public safety responders will need redundant systems that rely on basic technology for the movement of information between communications centers and responders. As part of your com­muni­cations planning, consider how you will advise both on- and off-duty personnel of the situation status, deployment orders and response information as well as provide for personal communications for responders to communicate with their families following an incident.

Expect the best from people but plan for the worst: The press reported looting, physical assaults, rapes and murders in the greater New Orleans area. Many of these alleged incidents cannot be verified; however, it was evident that tension and frustration remained high. Imagine for a moment that no one could tell you if your home or loved ones still existed. Consider the distress if you could not find your children. Picture waiting for two hours in a line for Meals Ready to Eat (MREs). Now, tell me what in that MRE packet can your two-week-old infant eat?

In my observation, people in the Superdome became highly distressed and potentially violent when three situations occurred: 1) when basic physiologic and safety needs were not met, 2) when evacuees were not given updated information on a regular basis, and 3) when social order and basic courtesy disappeared. Planning for a large incident requires strong consideration of Maslow’s Hierarchy of Needs, with an additional emphasis on disaster behavioral health.

Ensure your personal safety and comfort: Working in dark and wet conditions for a prolonged period of time is uncomfortable. Few people, including rescuers, entering the Superdome on the eve of the storm anticipated that conditions would deteriorate so quickly. As you pack for the next 24-hour shift, consider that you may have to substantially extend your tour of duty when unanticipated events or major disasters strike.

Begin with the basics: Are your shoes comfortable? Few things will slow you down more quickly than blistered and injured feet. Do you have a change of clothes? What about underwear, socks and moist towelettes for a quick field cleansing?

Next, think about safety. After employing common sense, my No. 1 and No. 2 choices are a functioning radio and flashlight. I recommend getting the smallest, brightest light you can afford. Traditional penlights are useless for anything but illuminating pupils.

Next, consider fuel. Keep a stash of energy bars in a variety of flavors. During the first few days of a major incident, you won’t be sitting down for a meal. You’ll be busy and, thus, burn an increased amount of calories. Most commercially available bars contain plenty of complex carbohydrates for sustained energy.

Finally, don’t forget the protection your uniform should provide from the elements. During Katrina, many rescuers wore the same clothing for four days or more until supplies arrived. Rescuers received serious sunburn, rash and dehydration. Is your current uniform selected more for its appearance or for functionality? Polyester has no place in disaster response, let alone a disaster in a tropical climate. Consider lightweight, 100% cotton pants with a long-sleeve T-shirt and wide-brim hat. It may not look as pressed as other materials, but you’ll increase your personal effectiveness if you’re comfortable.

 

Summary

I’m absolutely convinced that those who served in the Super­dome earned master’s level training in large-scale disaster response. Although we’ve not yet received the degree, we’ve certainly developed a healthy appreciation for pre-incident planning, group dynamics under stressful conditions and selection of personal equipment. Our next focus should be small unit medical tactics in support of large, contained crowds. Future considerations should be on incident management, logistics, communication and teamwork.