Major Incidents, Mass Casualty Incidents

Surviving the Superdome

Issue 11 and Volume 30.

It was late August, and some of the staff of the NREMT and I were attending the combined NAEMT conference and EMS Expo in New Orleans. I arrived on a hot summer day. Ray Bias, the only two-time chairman of the NREMT Board of Directors, met me at the airport. Ray works for Acadian Ambulance Service as co-director of the service’s business interests in the New Orleans area.

When I awoke on Saturday morning and turned on the TV, I heard a news reporter explain that Hurricane Katrina, what was once a Category I hurricane that had crossed south Florida with minimal damage early in the week, was gaining steam and expected to hit land right over New Orleans as a Category IV or V—a tremendously powerful hurricane, she said, capable of great destruction and death throughout south Louisiana. I don’t know what possessed me, but I decided to stay behind to help the sick and injured in New Orleans.

At the hotel that afternoon, I quickly packed a few clothes and my shaving/hygiene gear in my backpack. I telephoned Ray Bias and told him my decision. Ray thought I was nuts but welcomed the added help. He knew that as a former military guy I could remain calm, and I think he felt we would make a great team in any situation.

When Ray picked me up, we headed to the Acadian Headquarters for New Orleans, across the Mississippi River in the township of Gretna. There, I changed into an Acadian pullover shirt and listened to their leadership staff on a conference call as they prepared for the upcoming hurricane.

After 20 minutes or so, Ray and I headed for a sporting goods store where I purchased a waterproof flashlight, an inexpensive headlamp and a pair of new hiking shoes. I thought using tennis shoes to hike in chest-deep water (should that be necessary) where debris was on the ground would certainly allow nails and other sharp instruments to puncture my feet. I wanted to be prepared.

Later we returned to Ray’s apartment, had a take-out chicken dinner and watched the weather reports on TV. I could not fall asleep. The meteorologist on the local television station was begging people to evacuate. She explained that Hurricane Katrina was approaching wind speeds of over 160 mph. This storm was making waves over 60 feet high in the Gulf. She expected a storm surge of over 20–25 feet as the storm hit land. I became very concerned when she explained the levees in New Orleans were capable of holding back a storm that cre­ated surges of 15–20 feet high. Her scenario had a two-foot tide, with a 20–25 foot storm surge, added to what she guessed would be 20–30 foot waves when the storm hit land.

By this time President Bush had already declared the area an emergency so federal help could be mobilized. The mayor of New Orleans came on television and said he had direct communications with the experts in the Hurricane Center in Miami, who had told him that Hurricane Katrina was, as he described it, “the real deal” and that he and his city should brace for the worst possible outcome. The mayor encouraged residents to evacuate and explained that although the Louisiana Superdome would be used as a shelter, the people who went there would be miserable. He said, imagine 30,000 people in the dome, when after the storm, electricity would most likely be out, taking out air-conditioning and causing darkness in the dome. The mayor failed to consider the eventual flood that stopped sewage from flowing, thus overflowing every toilet in the dome. But, in my opinion, the mayor clearly informed every citizen of the city on all TV stations that staying behind in the city could result in death and, at the least, misery for every citizen.

That night I only slept about four hours between watching TV, saying prayers for safety and anticipating upcoming events. Ray and I would leave for the Superdome at 6:30 a.m. Sunday.

 

Processing Special Needs Patients

We arrived in the lower level of the Superdome at 7 a.m. on Aug. 28. Ray had served in the dome when it was used as a shelter during another storm a year earlier, so he knew where to go.

We entered the loading dock area, which was one of only two entrances from the ground level. The loading dock area was where special needs patients would be in-processed to the Superdome shelter. It was early, and I found the area staffed by one physician, Dr. Robinson; a few unidentified medical personnel, some of whom identified themselves as nurses; two resident physicians; myself; and Ray Bias. Collectively, counting nurses, doctors and clerks, 20 people were present. In addition to Ray and myself, only Steve Phillipe, seemed to have any EMS experience or responsibilities.

We were shown medical processing forms that we were told needed to be completed for every patient with special needs who came to seek shelter in the dome. When I looked at the form, I knew we were in trouble. It was too long and detailed to manage in-processing for thousands of patients in one day. But the New Orleans Department of Health insisted we use the form.

No triage station was set up, so we didn’t know in what direction to move patients through the loading dock. Ray showed me the elevator we would use to move people upstairs onto the second floor, where the special needs patients were to receive care, sleep, eat and take shelter.

Despite the fact that the Super­dome had previously been used as a shelter, no system had been established to physically move patients to where they belonged. So patients began to stack up in the loading dock area. An unorganized line was established, but by 9 a.m. there was chaos in the loading dock.

I soon learned that using the patient forms did not work. Each form took 25 minutes to complete. We were expecting a thousand or more patients, and we had four triage nurses, including myself. And they wanted each nurse’s work to be second-checked by one of the two resident physicians. I was upset and told Steve Phillipe about it. “I mean, Steve, do the math. Twenty-five minutes per patient to be seen by four nurses who are re-checked by two physicians. We’ll still have a long line of people standing outside when the hurricane reaches maximum winds.”

Within an hour, the established triage system for special needs patients was abandoned for one that Steve and I urged them to use. It entailed two categories: “can walk” and “can’t walk.” I think what sped up the decision to abandon a triage system that functioned poorly was the arrival of the Louisiana National Guard.

The Guard showed up in force at about 10 a.m. They started reporting in their own private cars, and soon came by trucks and other military vehicles. Some were security guys; others were medical. Some had no military job related to helping hurricane victims, but they were in uniform. The uniform was most important for maintenance of order.

The Guard was headed by a brigadier general and the medical corps by a full (bird) colonel nurse. Both were eager to help, but little or no direction was given to them by the New Orleans DOH. Local authorities did not take charge.

Although the Guard would prove to be the most essential element for everyone’s security, the fact that they had to move their equipment and supplies into the Superdome via the same loading dock where we were in-processing patients created a further logjam of people, trucks and forklifts. It was a mess that added more to the confusion. Who had authority over the truck ramp? The Army, New Orleans Department of Health, EMS? Was it for in-processing and moving of patients? No one knew the answers and although a self-appointed transportation officer was on scene, one was never officially identified. The loading dock remained a mess.

By noon, perhaps 500 special needs patients and their family members or caregivers had arrived. A long line extended outside, and the storm was hours away.

By now, Steve had arranged the new triage system, and New Orleans firefighters were helping place field triage tags on patients. Only red (can’t walk) and yellow (can walk) counted.

Red meant the patient was wheelchair bound or couldn’t walk 25 yards. By noon we had about 75–100 red patients and 250 or so yellow patients. We sat the walkers on chairs to wait for buses that we were told were on the way. No one was moved to the second level of the dome yet.

At that time, the Guard had trucks moving supplies of weapons (for security), bottled water and MREs (meals ready to eat) into the same loading dock, which we had full of patients. Supplies came in by the thousands—four 18-wheel truckloads of bottled water and two loads of MREs. But no one brought in standard medical supplies, such as medications for hypertension, diabetes, asthma or other chronic diseases.

In the afternoon, city buses and contracted buses started to arrive to evacuate the walking patients. They would head to Baton Rouge, and the vehicles “would return before the storm to take a second load.” We expected 10 buses. When they showed up, a system had not been established to determine which patients to transport first. With frustration, we pointed to the “walking, special needs” patients and moved them out.

The movement was complicated by the patients’ families. Each special needs patient was supposed to be accompanied by one caregiver. However, many had generations of caregivers with large “bags” of goods, including baby strollers, suitcases, chairs, large radio/stereo systems and clothing. These families and their belongings took up seats that should have been used for sick people.

Because we had no system to enforce who could and could not get on the limited buses, healthy people were also evacuated while many sick people who could walk did not find a seat.

Six to eight wheelchair buses also arrived and were quickly filled. Each bus could hold three wheelchairs. With 60 wheelchair patients on the loading dock, many would be left behind. Again, no system was identified to know which wheelchair patients should be transported first and which could wait. This disorganization was mostly due to no one knowing that the wheelchair buses were coming to the dome.

When all of the buses left town near 4 p.m., we were satisfied that we had loaded many patients and had done an effective job without leadership or an on-scene incident commander.

 

Katrina Makes Landfall

At about 6 p.m. on Sunday night, it started to rain in New Orleans. The edges of Hurricane Katrina were reaching the city. We were too busy to watch any television to know if the eye of the storm was going to pass over the city as expected. We just continued to receive patients, classify them, help them get on buses or move upstairs. I was concerned that many patients would not get to the second floor by the time the winds started to arrive.

Around 7 p.m., Acadian Ambulance found six to eight volunteer medics who were willing to drive from outlying areas to New Orleans as a group. The group was to pick up eight ambulances around the Superdome and drive them to higher and safer ground.

Throughout the day, the Super­dome had received oxygen-dependent patients. Many told me they came to the dome because that’s where they were instructed to go after calling the hurricane hotline. Unfortunately, a football stadium does not have oxygen supplies. Many of these misinformed patients needed a continuous supply of oxygen, and when I told them no oxygen was available at the dome, many of them had panic in their eyes.

Near 7 p.m., the New Orleans DOH made arrangements with Tulane University Hospital to accept approximately 40 oxygen-dependent patients. Because Acadian was the only ambulance service with drivers and moving trucks in the area, the health department commandeered the Acadian ambulances that were en route to higher ground and sent them back to the Superdome.

Ray rallied the medics, and they quickly began to load 40 wheelchair patients into ambulances and wheelchair transport vehicles. It took until after 10 p.m. to identify the patients who were going to Tulane Hospital, load them onto ambulances or wheelchair vans and transport them away from the Superdome. We also evacuated all oxygen-dependent patients [present at the time].

Then, on a strong urging and lobbying effort by Ray Bias, Acadian authorized the group to caravan out of the city despite Acadian policy to not drive ambulances in winds stronger than 45 mph. We were very happy when we were phoned by the group at 11:30 p.m. and told they had successfully made it out of the city.

Ray and I prepared to go to bed after working since before 7 a.m. It was a long day, full of confusion, improvised processes, disorganization and changes in leadership—both formal and informal. But somehow we got everything accomplished, and we went upstairs in the face of ever-increasing winds and rain. I quickly fell asleep in a dark room on the third floor in an area designated for law enforcement and medical personnel on a blow-up mattress that Ray had brought with him. Air-conditioning, water and sewage were still working.

 

Holding Pattern

On Monday, Aug. 29, we awoke about 6 a.m., hearing only slight noise. I flushed a toilet that morning that would never flush again throughout my stay in the dome.

We went down to the loading dock to find all the patients had been evacuated to either the second floor or out of New Orleans. At about 6:30 a.m., the dome went dark for less than a minute, and the reduced-level emergency lighting came on. When the lights went out, a cheer was heard from the crowd of 15,000–20,000 people. My guess is they cheered because it was finally dark in the dome. After spending the night trying to sleep sitting up in chairs with the lights on, they must have been exhausted.

By 7 a.m., the storm was blowing at about 90 mph (my guess). As an Ohioan, I had never before experienced the power of a Category V hurricane. Shock and awe, words typically used by the media in regard to bombing campaigns, help describe our reactions. Rain, best described as sheets of very thick water, rushed past at the speed of the wind. In Ohio, we have snow storms, and I’ve driven through them. When the wind would blow, snow drifts on and beside the road would join the falling flakes, producing white outs. Katrina was producing similar white-out conditions, with water moving at high speeds.

Although we never heard the exact wind speed in New Orleans, it was pounding. My guess was it moved at over 150 mph. I could tell its speed only by debris—a tree limb or larger piece of paper—that would rush past a glass door. Scary, fast and powerful, thundering noise without lightning. Nothing looked dry or undamaged.

By 11 a.m., the storm had reached its peak, but the eye of the hurricane did not pass over New Orleans. Ray and I sat on the second level in the Superdome. The remaining population who had come to the Superdome for safety sat quietly in the stadium seats.

The roof of the dome was making a shaking, dangerous sound. It was unlike the shaking of an earthquake, more like the ruffling of window blinds made of sheet metal. It would begin a ruffle sound on the northern side of the dome and carry around the circle of the dome, exiting at the southern end. It was loud—and terrifying. It wasn’t enough to make us believe the dome was going to collapse, but enough that we knew it was sustaining damage. By early afternoon, two holes appeared in the dome, and two large ventilation panels had been blown out.

Water started to pour in. At first, it was only minor, and the National Guard placed trash containers on the floor to catch the water. But as the storm continued, the roof became more damaged. By mid-afternoon, it was raining inside the Louisiana Superdome. The rain was falling straight down, uninfluenced by the wind, a soft rain similar to one we see in the spring in Ohio.

By 2 p.m., Ray and I felt brave enough to go outside. We found a door that led from the dome into the parking garage, which was part of the Superdome structure. Just opening the door took great strength, requiring nearly 100 lbs. of pressure to open.

We could feel the wind and water levels from within the parking garage. We found our way to Ray’s Acadian SUV and changed our dirty, sweaty, stinky shirts. They were gross. I then went as close to the storm as I dared travel. It just didn’t seem safe to me. The gusts nearly blew me over once even though the major strength of the storm had passed.

By 5 p.m., the storm was over. The sun was out, and the streets were covered with broken glass and debris. Sections of the Superdome roof were all over the ground. The Hyatt Hotel, right next to the Superdome, had suffered major damage. On the upper floors, only the steel superstructure remained. All of the glass and furniture had turned into debris during the storm. The New Orleans Center and every building we could see had also suffered damage. But the winds were gone and the streets were dry. Everyone was grateful for at least that.

As I looked across Poydras Street from the Superdome parking deck toward Charity Hospital, I noticed a McDonald’s restaurant that was undamaged and wondered how many days it would be before it was re-opened. The floods had not come. We had survived the wind storm. Now, I thought, all that was left was to get the electricity back on, and the people of New Orleans could start life again. How sadly I was mistaken.

That night we slept in the same area we had the previous night. The New Orleans police officers had abandoned the room. We had to use flashlights to move around. I found out the hard way that the carpet was wet when I took off my shoes and soaked my socks. Knowing I didn’t have another pair and that the humidity in the room was near 100%, I thought about working the next few days with wet socks. The air mattress Ray had brought that offered much comfort the first night had lost some of its air, so we bounced around on it as we tried to sleep. But it wasn’t hard to sleep; we were exhausted.

 

Survival Medicine

The next morning we awoke at 6 a.m., and I again went to the bathroom right down the hall. I did my morning business in the dark and discovered upon attempting to flush the toilet that it didn’t work anymore, and I knew this meant trouble. No sewage and unclean water in the city would be a problem.

We then ventured around the dome to see how people had made it through the night. We were shocked when we went outside on the plaza level and saw that the streets were submerged in water. It was up to the rooftops of the cars parked on the street on the north side of the dome and up to window level on the south side of the dome. Ray found a way to start the stalled Acadian Ambulance that was on the street, damaged from being outside during the storm, to get it to high ground.

The water was demoralizing. We had withstood a very high wind hurricane and were now faced with a flood. Water surrounded the entire dome on all four sides. We were on an island! I called my local TV station to report what was happening. After giving the report, I asked them what the temperature would be in New Orleans that day. They reported mid-90s.

I knew we would be very hot in the dome, and I was grateful that the National Guard had brought four truckloads of water inside before the storm. I visited the first aid station. Some medics, particularly Vicki Koch, Mark Gerano and Mark Guinn from Mason Township (just outside Cincinnati), had remained awake throughout the night. It was easy to recognize that they were exhausted and emotionally spent. Ray and I tried to enforce a rest schedule for the team at the aid station. I immediately took Mark to the area where Ray, Billy and I had slept and showed him the bed. I had no intention of waking him until well into the afternoon.

Back at the aid station, it was chaos. People were crowding around the door of the station seeking aid. A couple of blockades brought into the dome by the National Guard had been erected, but they were insufficient. I then traveled downstairs to talk with the lead colonel nurse from the National Guard and explained that we needed more barriers at the first aid station. After a visit a few hours later, she agreed.

We determined that we needed a place to treat patients and two observation areas. One would have cots for people who couldn’t stand up, and a second with chairs where we could watch patients. We would then use the single cot in the aid station to stabilize any patients and later transfer them to the observation area.

I waited until a National Guard major came by, and I told him our plans, requesting 10 cots and six barriers. The barriers were about 12 feet long and chest height, easy to look over and through.

I asked the major to find the barriers, and when he asked where, I said, “Look, Major, I don’t care where you find them. There are many on the football field two levels below us, and if you don’t get soldiers down on that field to bring up six or so barriers, I am going down there myself to get them!” I also told him I needed cots. I knew of many downstairs that were still folded up and not in use.

Ray and Billy took an Acadian cart, typical of the ones used to cart injured football players off the field during a game, and started down the elaborate ramp system. No electric elevators were working. About an hour later, Ray returned with the cots, which we placed in a small closet near the aid station. We didn’t set them up immediately. Many people had slept in chairs and were surely very tired and uncomfortable, and I did not want our observation area to turn into a sleep quarters.

We set up three cots and placed 10 or so chairs along the wall. The National Guard came through with the barriers, and soon we had expanded the square footage of the first aid station from a 15’ x 20’ room to that space plus a 12’ x 60’ aid station.

After fixing up the aid station, I began to talk with patients. Talking with the people who had evacuated to the Superdome and spent three days there was both a blessing and curse.

I’m a medical professional, and delivering medical care in that environment was impossible. The first aid station was not a clinic or hospital. We didn’t have a pharmacy. We had one bed. Most of the medications we had were taken off Acadian Ambulances and used for first-line emergency medical care. We didn’t have the type of medications needed for these patients. We had no idea what medications they were on, except for such statements as, “I take high blood pressure medications.” We didn’t know the name of the drug or dosage, or have any history other than what these non-medically trained patients said. All we could do was consider them all in acute crisis and evaluate them from that perspective.

By noon the day after the storm, the stink of the overflowing toilets was reaching everyone’s olfactory nerves. I’m sure you’ve seen a toilet that was unable to flush after one person had completed a bowel movement. Imagine for a second 25,000 people stranded in a football stadium where the toilets don’t flush. What were they supposed to do? I’ll tell you what they did. They had another bowel movement on top of those who had previously used the same toilet. After this had occurred many, many times, the feces had to be pushed out onto the floor. And the bathrooms started to deteriorate very quickly. Although I didn’t go into the women’s restrooms, I really felt bad for the conditions they had to face. The men’s room urinals were troughs that could hold a serious amount of urine, and they were nearly filled. What the women did remained a mystery to me, and one I did not ask questions about.

Taking care of patients was impossible, and many were in need. Many more who had not come to the Superdome prior to the storm started wading in chest-deep water to the dry land of the dome. They added to the already miserable conditions.

Of those who had evacuated to the dome prior to the storm, many had some of their medications. But as the medications ran out, the people wanted to know where they could refill them. Refill questions were especially common for those with a history of asthma.

During the storm we had used nearly all of our doses of beta-2 drugs. The day after the storm, by the time I had reorganized the aid station, we were down to less than 10 doses to provide nebulization therapy for acute asthmatics. We had to ration the doses. I remember one man, about 55–60 years old, who told me he was having an asthma attack. I listened to his chest with my stethoscope, and, sure enough, he was wheezing heavily. I asked him if he had an inhaler, and he said the one he evacuated with had run out.

Again I listened to his breath sounds, and his airways were tight. We had treated a number of children suffering asthma attacks, and I wanted to save the few doses we had left for children. I told the man our situation, and then I escorted him to a chair outside, hoping the fresh air would help him. I instructed him that if he did not feel relief to return to the aid station in two hours, and we would reassess his condition. I was praying for more doses of beta-2 drugs.

I continued to interview patients and provide advice. Exactly two hours later the man returned, and his airways were tighter and more closed than they were when he first approached the aid station. I brought him into the treatment room and asked how many doses of beta 2 we had left. Six was the answer. I told one of the medics to administer a nebulization dose to the guy, and I went back outside to interview more patients.

About 20–30 minutes later, the 55-year-old man came out of the station and stopped to thank me for letting him get his treatment. He was relaxed, and his breath sounds were clear. He was very grateful, but I warned him that it was unlikely that he would receive another treatment during the rest of the time in the dome and that he needed to take good care of himself, stay hydrated and not get excited as we awaited rescue. He walked away, but I remained worried about his eventual health.

Other asthmatic patients came to the first aid station with their medications and nebulization equipment. It took electricity to run these machines, and as far as I knew the only working electricity in the dome, beyond emergency lighting, was in the aid station. Apparently, when the dome was designed, the first aid station electricity was connected to the emergency generators located in the basement. Thank goodness for this design, because we often had two or three patients who were able to provide their own care.

Patients with hypertension were another major category we found. We had two sphygmomanometers, and they were always in use. Hypertension is a major health problem in the black population, and almost everyone stranded or who had evacuated to the dome was African American. Most did not know what their normal treated blood pressure was or the name of their medications. We took thousands of blood pressures. I knew from my nursing experience the symptoms of hypertensive crisis. We did have some doses of nitroglycerin to lower blood pressure, but these would serve only as a temporary and quick remedy. If someone had a hypertensive crisis, there would be little we could do.

Thankfully, almost everyone was dehydrated, which likely helped those with hypertension. I remember systolic blood pressures as high as 220 mmHg and diastolic blood pressures as high as 120 mmHg in others. Many had headaches, and we gave them acetaminophen or ibuprofen until our doses started running too low to help them. Then all we could do for the hypertensive patients was advise them to relax on a seat in the dome and not get excited about anything. I advised many that when they left the dome, wherever they went, a medical team would greet them and at that time they would obtain some medications to treat their condition. It was disheartening not to be able to provide care.

I used tender loving care when interviewing and treating patients. A calm voice and one of hope was what many of them were looking for. I never got upset, regardless of how demanding a few were. I talked with them about their condition and offered advice, holding their hands or placing my hand on their shoulder to show I really cared for them and their plight. I spoke slowly, using simple terms, and looked everyone in the eye.

All of this was done in an average of 60 seconds to interview, assess and dispatch each patient. It was survival medicine—too many patients and no treatments available to really help them. But I provided psychological comfort in the short time I spent with each. I maintained a pleasant attitude despite the stink coming from the toilets just down the hall. I smiled despite the situation we were all in. And, most importantly, I said to every patient, “I know this is a horrible situation we’re all in, but we’re alive and someone will soon come for us. Until then we must remain calm, eat and drink when we can, and may God bless you as we all survive this disaster.” I think using the name of the Lord and, although I’m not a priest, asking for him to bless every person I interviewed was a soothing thought to leave them with. I would then go to the next patient and continue the work.

 

Supplies Arrive; Conditions Worsen

Diabetic patients were another challenge. At first we had blood glucose monitors, but by Wednesday we had none. When a diabetic patient came forward and told me of their disease, I would immediately listen to their breath sounds. I wasn’t interested in their air passages but their respiratory rate and the smell of their breath. I never encountered any patients with Kussmaul’s respirations or fruity smelling breath. None appeared to be severely hyperglycemic.

I would ask them about how they were being treated. Some were on oral glucose, and many were taking insulin. Many had their own insulin with them, and were worried about it not being refrigerated. I, too, was concerned, but I knew the outcome would be worse if they didn’t take it, so I advised them to use it anyway and to reduce their dosage so what little they had would last until rescue.

Some had their insulin, but no hypodermic needles. At first we assisted them, but we soon ran out of needles and syringes. We then started using the needles over again after wiping them with alcohol wipes. These conditions were unreal, and we had to choose to give the medication or tell them to go away without insulin. It was depressing, and we did the best we could.

Later, we received some regular fast-acting insulin and glucometer strips from a DMAT crew. The doctor advised us how much insulin to give depending on the patient glucometer reading. We administered many doses throughout the day. It may have helped, and I never heard of any cases of diabetic ketoacidosis and never assessed any severely ill diabetics. We just told them to stay hydrated, eat small amounts of food, avoid sweets and rest until rescued.

Diapers became a problem. We had received a couple of cases of diapers, and I was reminded that they come in various sizes. It didn’t take long before we were out of correct sizes. We gave diapers that were too small to mothers along with tape to hold the ends together as they were applied. Later, when we ran out of them, mothers would come and say they had no others. All we could do was give them a stack of 4x4s and tell them to keep their children nude from the waist down. When the baby started to wet or have a bowel movement, we told them to hold them away from their bodies and then wipe them with the 4x4s. They walked away with looks of disgust.

I could only stay at the aid station on Wednesday for four to six hours before I needed a break. It was too emotionally and physically exhausting. We did get some relief when Acadian flew in fresh medics, but they too quickly became frustrated. I provided them with a briefing about survival medicine and the need to show TLC. Some started to practice as we would in the streets, placing monitors on chest pain patients and starting an IV. Soon they would abandon this regimen and realized that individual care for each patient was impossible.

We had no system to distinguish those who were really sick from those who were not. Many people said they had “heart conditions” and complained of chest pain, but after we advised them to seek fresh air they never returned. Often, I wondered how many were telling us of old conditions so that they could separate themselves from others and perhaps be the first on the buses that were rumored to be heading toward New Orleans.

Late Wednesday, we started to receive some supplies. No medications, but at least we had IVs for those severely dehydrated. We had no IV poles, so we had to tape the bags onto the wall in order to allow gravity to help. When the last sphygmomanometer broke, I had to estimate blood pressure by noting the strength of the pulse. Many patients knew this wasn’t accurate, but there was nothing else we could do.

Security was a problem. At first, right after the storm, people were generally nice. On rare occasion, a patient would try to insist we provide them care even though we had nothing to offer. All of the medics were exhausted. The National Guard stationed five airman or soldiers on 12-hour shifts to provide security. Initially, they didn’t carry weapons, but later, as the crowd became more miserable, two or three of them had M-16s strapped over their shoulders. The guardsman were very helpful. Although they had no medical training, they helped us move patients and, at times, carried those who could not walk. When a patient refused to leave the medical area, a guardsman would get very insistent with them and soon they would depart.

Some patients had mental illnesses. One man came up to me and showed me a medication I was not familiar with. The bottle was empty, and he told me he had a “nervous disorder.” I asked him if he had schizophrenia or bipolar disease, and he said he didn’t know, only a nervous disorder. I asked him what happened when he did not take his medication, and he said that within two days he would start “seeing things and acting strangely.” I could tell him only to keep the empty bottle of medication with him and to show it to a soldier when the buses arrived so that he could be evacuated on one of the first buses. He then looked at the medication and stuffed it deeply into his pocket and walked away thinking it would be his ticket to early evacuation.

An elderly lady complained of chest pain, and we applied a monitor to her and found some ST changes in her three-lead rhythm. We gave her nitroglycerin, but she continued to complain of pain. We moved her to the observation area and watched her for a couple of hours and her status didn’t change. We could do nothing. We discontinued her IV and told her to go rest in the seats of the Superdome.

Within 20 minutes she was back with the same complaint. We talked to her, but she would not leave. We became frustrated with her, and a military guardsman had to escort her to a chair in the dome. She returned. We escorted her back, and a few minutes later she was back again. Her behavior was bizarre, and we finally got her to leave permanently when a New Orleans police officer threatened to arrest her. It was demoralizing, but she was fine, and we could not provide her enough comfort.

Whenever I took a break, I would venture up to the higher levels of the Superdome to sit calmly and reflect. The dome was hot and humid. It stank. It was miserable, just as the mayor had warned everyone it would be. After a rest, I would go to the loading dock to see if the any help had arrived. Helicopters were now landing on the roof of the parking garage, and people were being moved from the dome to the basketball arena across a bridge from the plaza level.

A DMAT crew had somehow gotten into the Superdome and had set up in the basketball arena. I walked around the area to see how many patients they were caring for. I estimated 300. The DMAT was from New Mexico, and I quickly looked around to see if I knew anyone from New Mexico EMS.

Later in the day when we desperately needed supplies, I approached the team and asked to speak to the person in charge. I was directed to a physician who had his back to me. I touched him on the shoulder. He turned around and it was Dr. Mike Richards, the New Mexico EMS Medical Director.

I said, “Mike, what are you doing here?”

He replied, “Bill Brown, what the hell are you doing here?” I quickly told my story and then asked for medical supplies. They had also run out of medication, but were doing a great job in triaging patients to determine who to airlift out first. Although Mike and I are great friends, we never spoke again of anything other than patient care. There was no time for small and friendly chatting.

The helicopters were busy. Black Hawks from the Air National Guard, and helicopters from Acadian Ambulance Service and hospital programs were coming in hot, waiting a few minutes to load and leaving immediately.

Charity Hospital was closed. They were without power, and their critical patients were the first evacuated. Most were being ventilated by nurses in the critical care areas for more than 24 hours. Most, in my opinion would have been given black triage tags in a disaster situation, but they were the first to be helicoptered out of New Orleans. I questioned this logic, and I wondered why we were helicoptering out people who already were so crucially ill that they had to be on ventilators. I knew we had many dialysis patients who had gone two or three days without dialysis. I was told they could last four days before uremic poisoning would take their lives. But this was not my decision, and in America we save everyone.

I assisted with the helicopter evacuations, transporting patients from the basketball arena to the roof of the parking garage for evacuation until late at night. The operations stopped about an hour after dark. I was exhausted.

That night Ray and I returned to our sleeping room in the Superdome. By now the dome was full of people who came after the storm. Prior to the storm, the National Guard searched everyone for weapons and drugs. But after the water rose, there was no opportunity to search, and more violent people started to arrive. One national guardsman was shot in the leg, and everyone was becoming concerned about safety. Ray and I were concerned that sleeping in the dome would be dangerous, so we deflated our mattress, packed up all of our gear and headed for the Acadian supervisor car parked on the second floor of the parking deck on the opposite side of the dome.

We walked through only secure areas, and we reached his car even more exhausted. We ate peanut butter and jelly sandwiches, our choice of food for most of the time we spent in the dome. Ray offered me the back seat, and we started the engine and turned on the air-conditioner. The cool, fresh air felt like it was coming from heaven. By then my shirt and pants were covered with sweat and were filthy. I took off the wet clothes and put on a clean T-shirt, but my underwear remained soaked. We stayed in the car for 30 minutes running the air-conditioner with me turning each side toward the air trying to dry my underwear. In 30 minutes, they were dry enough to sleep in, and after drinking a bottle of water and a cold can of soda, we rolled down the windows and shut off the car to save gasoline. I told Ray that if we could, on Thursday, I felt he and I should catch a ride on one of Acadian’s helicopters to assist patients and leave the dome. He agreed.

 

Moving Out

We awoke in the hot sun of the morning on Sept. 1 around 6 a.m. Ray planned to continue to assist with helicopter evacuations, and I went to the aid station. Upon entering the dome, I noted the conditions had severely deteriorated. The smell from the bathrooms about 75 feet from the aid station was so thick I was almost overcome by fumes when I walked past.

On arrival, I told the tired medics who had stayed overnight that I planned to move the station outside. I then went to see the National Guard general and colonel. They were engaged in an impromptu meeting with the New Orleans health director. I presented a list of needed supplies. During the meeting, the health director informed me that more than 800 buses were staged outside the city, and they were planning evacuations that day as soon as they could find a safe and dry route.

That news lifted my spirits, but I still asked if we could move the aid station. They said yes, and the general said he would help me make it happen. I then asked a major for help, and he said that I should attend a 9 a.m. military briefing to ask for assistance.

I was the only civilian present at the National Guard briefing. A full colonel led the briefing, and they were talking about logistics of moving large trucks into the Superdome, the routes they would take through the water and what complications they expected. No pre-plan existed. I stayed for 15 minutes and soon realized that moving the first aid station was one of their least concerns. I left the briefing.

Acadian had now flown in a team of fresh medics and physicians. They were welcomed, and I gave them a briefing on the survival medicine we had been delivering. They, too, had difficulty dealing with this type of care. Soon they were also overwhelmed and frustrated. We were seeking a system to distinguish the sick from the non-sick, and there was none. No armbands to separate people. No way to mark them. We thought of just drawing a big X on their chests so that we could order their evacuation first when the buses arrived, but we soon realized that any person could duplicate the X marking system, and it wouldn’t work. I was concerned that as the buses arrived, the strong would overwhelm the weak and board first. Another tragedy of Hurricane Katrina would occur.

By late morning, many boxes of medical supplies had arrived and were stacked in the hall behind the barriers we had erected to expand the first aid station. We devised a plan to first move the medical supplies, then the barriers and last the first aid supplies found in the first aid room. I knew our medical personnel would need the assistance of the National Guard to move the aid station outside where we could have fresh air to treat patients. I then went back to the briefing location. I asked the colonel where we could move the first aid station, and he said, “Wherever you want.” I took that as an order.

I returned to the aid station and looked for a cart to move the medical supplies. God must have been on our side because I soon found a livery cart right outside the first aid station. I quickly loaded the cart with supplies and told one of our guardsmen to come with me to offer security when I pushed the loaded cart of medical supplies through the crowd. I asked guardsmen providing security by the doors to watch our supplies while I made two or three trips. Then I found five guardsmen and told them of my plan and asked them to come with me.

We went to the first aid station, and I assigned each guardsman and medic one barrier to move. I stationed one guardsman with a gun to guard the first aid station, and then I yelled, “On three, grab your barrier and start moving down the hall to the next entrance to the dome and then outside.” On cue, everyone grabbed a barrier, and we moved the entire first aid station outside. It was incredible teamwork.

Outside, we had fresh air, and we didn’t have patient after patient coming up demanding care. We could triage them one at a time in an area guarded by military personnel. Then, taking them into the first aid station, they could be more appropriately cared for.

I had the guard erect 10 or so cots so that we could have a larger observation and treatment area, and all of the medical supplies were placed so we knew where everything was and what supplies we had. The aid station was huge compared with what we were working with inside. I told Acadian Medical Director Dr. Ross Judice that the aid station was satisfactory, but we only had nine hours before darkness, and then we would need a generator and lights.

I tried to start a triage system for the people who lined up outside the perimeter established by the National Guard. This worked OK, but it was too far to walk for simple things like a bandage or Tylenol. I moved those first aid type supplies forward. By then, many evacuees were fainting, and many were carried like dolls, one person on each limb, to the first aid station where an IV would be started on them. Some Guardsmen helped me run a piece of parachute line over the ceiling of the cots and anchor it to the outside lights on the dome. From this line, we hung IV bags.

I was continuing to triage patients when Ray came up to me and said Richard Zuschlag, president of Acadian Ambu­lance, had requested that Ray and I leave the dome immediately. We had done enough. I told Ray that was fine, but I didn’t want to leave until the last flight out at night. He agreed, but told me to get my gear ready. I went to the supervisor car we had slept in and readied my gear for a quick exit. Then I went back to the first aid station to help.

I think I was there for about an hour when Ray drove up with my pack in one of the carts Acadian uses during football games. He said, “Bill, Richard has ordered us out. A helicopter is on the pad right now waiting to take us to Lafayette. Get on this cart right now. We’re leaving.”

I left with a tremendously empty feeling. The battle was not over. There were still so many in need. There were many friends I had met that I wanted to say thanks to for all they had done. Mike Richards, the National Guard general and the nurse who commanded the medical corps. Some of the medics who had just come to replace us, and one particular old black gentleman who sat directly across from the first aid station. I had befriended him—helped him go to the bathroom, helped him go outside—and I wanted to assure him that he would live and that he and his extended family would soon be getting on buses and out of the Superdome. I felt I had abandoned those people and couldn’t say goodbye. But Ray insisted, and the helicopter was occupying a space needed by another helicopter, so I left.

 

Lessons Learned

Ray Bias and I were the first Acadian representatives to arrive at the dome on Sunday, the day before Hurricane Katrina struck New Orleans and the Gulf Coast. And we were the last to leave on Thursday. As the helicopter took off, I saw for the first time what millions of Americans had been seeing on TV for days. The flood waters were deep and expansive. I knew the scenario and prayed for those who were left behind. I was hopeful the plans I had heard about at the Army briefing and the words of the New Orleans health director were true and that help would arrive at the Superdome before dark.

As I sat in the noise of the helicopter and talked with the pilots over the intercom, my mind wouldn’t leave the disastrous situation. Ray and I had gone days without a shower. We stank and were exhausted. We could hardly walk. We were hungry, and we wanted to go home. In Baton Rouge, I called my wife, and we cried together because I was safe and because so many still suffered.

It’s now nine days after the event, and I want to set some things straight from my point of view. I was not in the streets of New Orleans, so I won’t comment on what I don’t know. These words are honest, and, hopefully, they will be helpful to whoever reads this. First, I reflect from a medical point of view and then a personal one.

Right from the beginning on the first day before the storm hit, I quickly learned there was no incident command system in place. This was a major mistake. The New Orleans officials knew thousands of special needs patients would be coming for in-processing at the dome, and without an effective system to triage and move patients it was a mess. There was no unified command, and I never did figure out who to talk to for information or supplies.

The National Guard was essential. They had a command structure, but they didn’t know their authority. They brought in needed supplies before the storm. Without them many more would have died. The soldiers and airmen were very professional. They really cared about the citizens and special needs patients. Most importantly, they brought order.

Any incident where thousands of patients are involved must be handled by the military. They understand chain of command, and they have the supplies and ability to move them. I really don’t care about some federal law that precludes the military from taking part in federal policing or assistance with civilians. Replace that law, and give the military a greater role once the president has declared a disaster. State and local officials have their hearts in the right places, but they need military assistance.

Although police and fire are necessary at most disasters, I found the need for medical personnel to be equally great. The New Orleans Fire Department was busy rescuing patients, and had no time to treat folks at the Superdome or other shelters. EMS was required, and EMS did the job in New Orleans. The New Orleans EMS folks worked the city, and Acadian provided care at the dome. If New Orleans had not had a third service with the size and assets of Acadian Ambulance, more people would have died.

I worry about a disaster in another city that requires large support from fire and EMS when they’re in the same department. Where the assets will go and how many people will go untreated are questions all disaster planners must answer before a disaster. I fear that in a disaster situation which requires both fire and medical care that something will be left out. I hope it’s not EMS.

Stockpiles of medical supplies must be made available. The Superdome had thousands of patients who needed medications, and we didn’t have the supplies. Nor did we know how to get them to the dome. When the convention center was used as a back-up for the dome, even fewer medical personnel and supplies were available for that location. Large cities need access to the stockpiles. Their hospitals and pharmacies will also be victims of the disaster and be of little support.

It’s foolish to rely on local support after a disaster because the local support will also be consumed by the disaster. You can’t automatically count on local police, fire and EMS if they’ve evacuated with their families or are injured in the event.

Prehospital medical education should include some information on chronic disease and the long-term care of those patients. We had to provide insulin to patients. We had to ration medications. We had to make decisions that were very difficult. We had to withhold some treatments. I doubt if many medics in America could make these types of decisions by what’s in the standard national EMS education curriculum.

On a personal note, it takes great will, mental stability and spiritual strength to undergo and help after a disaster. If you’re not in good physical condition, you don’t belong at a disaster scene. If you don’t have mental toughness, you’ll have nightmares from what you’ll see. This is real. It’s horrible, and you have to be mentally tough to go through these situations. If you don’t have mental toughness—and there is nothing wrong with knowing this about yourself—do not volunteer to participate in disaster relief.

Finally, and to me most importantly, you must have a spiritual heart. I am a Christian and attend church and worship as often as I can. It’s through this faith that I was able to pass along words of encouragement to the thousands of patients I encountered. My expressions of “God bless you” were comforting to many patients for whom I had no medications or treatments. I said “God bless you” to every one of them. We were all miserable and caught in the same disaster. When I said “God bless you” to someone, the next patient I was to talk with heard me say it to the prior patient.

Using appropriate touch, looking people in the eye, showing compassion and blessing them was essential. I was non-judgmental. The people of New Orleans who evacuated to the dome were warm, caring and special. I honored them and their circumstances. I heard many sad stories, and I often wanted to cry with them. But I was there to offer care and to lift their spirits. I did the best I could under the circumstances. I will be honored someday to return to New Orleans and walk among those who suffered together at the dome.

Don’t believe everything you saw and heard on television. Only 1% of the people in the dome were troublemakers, and they got all of the media attention. The other 99% were true Americans. They may have been poor, but believe me they were brave, warm-hearted and loving while enduring the worst circumstances I have ever seen in my life.

I am one who loves misery. I endure long bike rides and climb mountains. My friend Jon Politis says we both love to suffer. But nothing was like being in the Superdome before, during and after Hurricane Katrina. It was the ultimate suffering and the blessed people of New Orleans suffered the most. May God bless them all, and may their hometown rise again to be one of America’s truly great cities.