Major Incidents

Houston Comes Through for Evacuees

Issue 11 and Volume 30.

As Louisiana’s closest neighbor undamaged by Hurricane Katrina, the state of Texas welcomed shell-shocked evacuees with typical Lone Star State hospitality, and more than 200,000 came to the city of Houston, alone. The giant operation to receive those evacuees was organized in hours. Longstanding connections and solid planning eased the daunting, logistical operation for EMS personnel.

Southeast Texas Trauma Regional Advisory Council (SETTRAC, or “the RAC,” to area EMS agencies) is a regional advisory council legislated in part to organize local systems for trauma management. Those interdepartmental agreements and relationships were vital during Katrina, when pulling together relief efforts meant knowing exactly who to call for help.

“This is the most amazing thing I have ever witnessed,” says Allen Johnson, secretary/treasurer of SETTRAC, who, as EMS group supervisor, helped coordinate agencies assisting with the evacuation. “We’ve never played together like this, before. After this is over, we’ll have a whole lot more people well-versed in incident command. We’re solving problems now that no one ever dreamed of.”

Houston-area EMS agencies were notified officially on Wednesday (two days after Katrina struck) that Houston would receive many evacuees from New Orleans. But cell phones and Blackberries were buzzing between RAC members even before the storm made landfall, setting plans in motion prior to activation.

Some of the groundwork was laid four years earlier, when Tropical Storm Allison swamped southeast Texas. Houston’s Texas Medical Center complex was inundated with floodwater and lost power, forcing patient evacuations and months-long diversions while the complex was renovated. Now New Orleans faced similar difficulties, though on a much larger scale.

“God made Allison as a dress rehearsal for Hurricane Katrina,” says Thelma Lemley, a retired RN/EMT-B whose decades-long affiliation with Houston and state of Texas EMS operations made her an invaluable resource in coordinating Katrina relief operations. She is vice chair of SETTRAC’s system administration. “There were serious mistakes made when Allison came through. But plans were made as a result, and we found ways to make things work.”

Nonetheless, it was a monumental task, balancing logistic capabilities while remaining delicate with political lines. Even in the midst of a catastrophe, no one wanted to burn bridges between jurisdictions. Issues of emergency licensure for out-of-state resources, whose protocols to use, which radio frequencies to use, splitting crews, equipment and O2 restocking issues for outlying EMS crews traveling to Houston to assist, and reimbursement of funds (especially skyrocketing fuel costs) were among hundreds of topics addressed during multiple meetings.

Reliant Park (a sports and event complex that includes the Astrodome, Center, Arena and Stadium) and George R. Brown Convention Center (GRB, in downtown Houston) were designated as shelters. Evacuees arrived in a days-long caravan of nearly 1,000 full buses, with 50–60 people per bus. Nearly 28,000 people sought refuge at Reliant and GRB alone.

Houston Fire Department dedicated personnel, ambulances and suppression equipment to manage the influx of people, many dehydrated or seriously ill after going without medications or dialysis treatments for five days. More than 15,000 arrived within 12 hours. As designated by the RAC for MCIs, Mont­gomery County Hospital District (MCHD) Com­munications Center posted over EMSystems for additional assistance, and coordinated direction of those outside units into Houston.

As evacuees were processed into the Reliant Astrodome, buses lined up in the parking lot. For 36 hours, teams of EMS and fire personnel entered each bus to triage and identify those needing medical aid. Part of Reliant Arena was transformed into a 100,000-square foot clinic by Harris County Hospital District for the thousands of evacuees who needed medical attention. A similar clinic was established at GRB by the city of Houston, Uni­versity of Texas Health Science Center and Memorial Hermann Hospital.

Ambulances from multiple agencies lined up adjacent to the Astrodome, registering with command as BLS- or ALS-capable. When the need arose, the appropriate ambulance was sent by on-site dispatch wherever needed. A unified medical command monitored each hospital’s status by computer.

At one point, clinic staff forwarded 30 patients per hour to area hospitals by ambulances. Double-loading was common. Ambulances transported more than 200 patients that first day. In an effort to conserve ambulance resources for critical patients, Harris County Precinct 1 and Houston Metro buses were used as shuttles for stable patients directly from the arriving buses to the on-site clinic.

Faced with the need to dedicate personnel for transport to EDs from Reliant, Metro balked at using its buses to transport patients across the city to hospitals. Emergency licensure of those vehicles for patient transport was easily solved, says Johnson. “The bigger issue was getting Metro to think outside the box,” he says, adding that future pre-incident planning might avert similar, bureaucratic-related issues. “I considered calling outlying communities to send (buses from senior living facilities) to use as shuttles, but it fell off the radar because our call volume ultimately went down.”

Nonetheless, obtaining enough resources to continue managing transport needs became more difficult when the call volume swelled throughout southeast Texas. Harris County’s population of 3.7 million people rose by more than 5 percent in three days. Evacuees who needed health care or prescription refills had few options but to either go to an ED (difficult when their vehicles had run out of gas and they had no money left to purchase it), or call an ambulance. Desperate for help, many called 9-1-1.

Swamped with additional calls in their own territory, HFD turned over Reliant command to Enterprise Ambulance, a private agency already contracted by Reliant Park to provide coverage at events. Enterprise and HFD had been co-commanding the Reliant incident, initially. When HFD withdrew, Enterprise narrowed its focus on coordinating dispatch, while the RAC managed EMS command.

The Houston area has 125 EMS agencies (municipal and private) and 1,200 ambulances. Few agencies share radio frequencies. When Reliant operations began on Aug. 29, personnel from HFD, Enterprise and numerous ambulance agencies on stand-by exchanged cell phone numbers to stay in touch with each other until radio communications and an accountability staff was established. Emergency personnel soon received 50 portable radios on the regional 800 mHz system, for use by ambulances that were staging and transporting patients from Reliant and GRB.

In addition to coordinating the EMS response, emergency services at Reliant and GRB worked in tandem with multiple law enforcement agencies, HFD and thousands of workers representing every relief effort imaginable. The U.S. Postal Service set up a post office, establishing a ZIP code for the newly dubbed “Reliant City.”

An estimated 2,500 hospitalized patients were transferred to Houston by multiple air medical and ground ambulances before and after Katrina’s landfall. Hundreds more arrived by C-130 aircraft at Ellington Field and were transferred to Houston area facilities. Most Houston area hospitals were filled to capacity by the time hospital evacuations from New Orleans were complete, and ED diversions were commonplace.

Dozens of agencies from throughout Texas sent ambulances and personnel to assist with the evacuations.

“Fifty ambulances from Texas were sent to Louisiana to assist with transports,” Johnson said. “With the deployment, the area EMS agencies did not have the surge capacity to manage the additional load, and that’s what drove the need to bring in outside ambulances. The [out-of-region] units made a tremendous difference.”

The RAC also was grateful for assistance from Houston EMS Medical Director David Persse, MD, and the Texas Department of State Health Services. “They were involved from the very beginning,” Johnson says. “We kept them updated on the situation, and they were active partners, helping us solve problems as they arose.”

With the assistance of the combined EMS group, a deployment schedule was developed and implemented, transitioning to a larger presence for private providers so municipal agencies could return to service in their overburdened territories. Tens of thousands of additional evacuees were sheltered in Austin, College Station, Dallas and San Antonio, creating similar challenges for those jurisdictions.

The response at Reliant went international one week later, when Cruz Roja arrived from Mexico just in time to assist a Denver-based DMAT with the latest crisis to strike evacuees. Red Cross and FEMA began handing out monetary assistance when the heat index was well above 100º, and EMS response skyrocketed as evacuees began fainting in droves while standing in the long lines.

Many evacuees who came to Houston will be staying in the area, transforming the city’s demographics and thus, its need for EMS.

“It changes daily,” Johnson says of how call volumes, types of calls and locations of calls have changed since Katrina struck. As interim CEO of MCHD, Johnson has seen similarly erratic call volumes in Montgomery County, just north of Houston. “Unpredictability (of EMS needs) hasn’t been based before on sudden increases in population. We’re no longer dealing with evacuees, but refugees. And now that they’re refugees, how does the EMS need change? When are peak times? How many trucks are needed, and where are they needed?”

Maintaining the home front in Houston was as important as sending resources to Louisiana. That cautious approach to deployment, plus an insistence from local EMS directors that area EMS personnel take downtime from relief efforts, proved invaluable within weeks, when millions of Houstonians (plus new residents still weary from Katrina) evacuated the city as Hurricane Rita approached.

“Realistically, another tragedy will occur before this one is completely done,” Johnson said on Sept. 11, less than two weeks before Hurricane Rita proved his words. “However, I have a strong belief that Texas and the Houston area will be ready to rise to meet the challenges the next disaster presents.”