05-SEP-A-9
STARTING UP A NEW “FIRST DAY” FROM MY NIGHT ON A MATTRESS ON THE FLOOR OF ABANDONED MEADOWCREST
HOSPITAL READY FOR THE NEWS-PROMOTED COMMUNITY
CLINICS OF OPERATION LIFELINE IN JEFFERSON PARISH
September 7, 2005
I am on the floor, quite comfortable in the A/C and lighted Room 231 with a roommate in a sleeping bag who is a surgeon form Howard County General Hospital, an affiliate of the Johns Hopkins group. I am meeting a lot of folk form around the periphery of Maryland, and camped beneath me in a big tent with a generator is the Anne Arundel County SAR team with their equipment. Adjacent to them in hat was the parking lot, filled now with big fallen trees, the large antennas and generators of the FEMA Command Post are being erected. A large group of EMT’s have come in to occupy one of the floors with which we gave them a hand n scrounging things to make the next group comfortable. We are no different in two ways than the “groups” of squatters and plunderers that had marauded through the hospital before—we are camped in the luxuries of a hospital and have plundered much of what was here, organizing it for what we will need for our clinics until the FEMA pallets are offloaded which are essentially self-contained. The issue of ownership and the legalities of “abandoned property” are to be resolved later. I think of the devastating waste as I walked through the OR’s central sterile supply room where racks of things are standing that are better stocked than nations I have visited earlier. I had set up in Sudan with whatever I could do from my duffel bag packed with sutures and had done hundreds of cases with what might be ten percent of the wasted or redundant equipment and consumables here, not to mention the stocks of open heart equipment, pump oxygenators, anesthesia deluxe machines, and all the accessory peripheral equipment left her in disarray. The kinds of monitoring and telemetry equipment alone would-be a treasure trove—of course, highly valuable only if you could count on electricity!
There was a confrontation of a surly kind earlier when our plunderers were plundered, and a group form the West Jefferson Hospital we had just decamped from yesterday came over in two raiding parties, attracted to the wish lists they might get form the notice that we were in the Meadowcrest Hospital and they might head us off in garnering up everything valuable and portable, and two teams were encountered hustling out with every kind of endoscopic and fiberoptic equipment—in short, hundreds of thousands of dollars. Our guard was alerted and threatened them to show authorization, but the standoff resulted in a hurry up evacuation to the parking lot, where it was explained that the group was let proceed unmolested since the authorization was unclear for either or our groups and we would gather what we would need for our clinics but not proceed to use it until further orders. So, we have inventoried what we have and ordered what we would need and matched the two lists, and are awaiting yet another early morning briefing to “get us all on the same page”—notwithstanding that many of the paragraphs on that page are missing and no one knows who it is that will confirm or deny what plans have been re-arranged, as they have been already several times. The one authority here at present in a “police line” are MP’s and we proceeded the Military Police, even though we are surrounded by the National Guard in a medial detail, all in full BDU’s but unarmed. We will see what evolves as we proceed today, and will set up the precedents for the large volumes of volunteers who will be following. The confusion of the fluid situation has caused more angst among the folk who expected to hit the ground and do what it is that they would be doing back home in a situation with an infrastructure in place, and infrastructure they probably had no part in creating. So, the insecurity of pulling together a system before using the system to run is a strain for some, and for me, it gives a chance to observe the “organizational learning.” Today may mark the first day of our actual operations, since we have had to make sure that no one just started random action on their own, both for the safety of the personnel and for the coordination of the “system” effort, which has a much larger multiplier than individual efforts, which may make the donor feel good, but rises only envy and anger among those who are not so lucky as to be the random contacts of the entrepreneurs.
OPENING DAY OF SCHOOL AT LINCOLN ELEMENTARY
IN JEFFERSON PARISH LOUISIANA,
FOR A WALK-IN CLINIC NO ONE HAD ANTICIPATED,
CREATING A FOOD, WATER AND ICE DISPENSING POINT
The complexities of the logistics and effort to achieve a safe and effective series of walk-in clinics at distribution points around Jefferson Parish resulted in another “Mexican Fire Drill” again today after yet another series of briefings this morning. I taped a couple of them, including the hopelessness of trying to resuscitate children who come in arresting, and if they do, a perfunctory effort should be made only to be treating the parents. Next came a brief psychiatric talk on the difference between delirium and dementia and how to recognize the person who is suicidal. The latter had to be hospitalized immediately and the others could be treated on site. We did not expect a lot of patients on the first day, but the whole system had to be invented as we went and there was no precedent to follow, so that the drill got very chaotic at first. We were finally loaded aboard the ambulance trucks (“mobile ICU’s of Cecil County MD and a few other EMS systems, and had to await our armed escort before any in the convoy could leave. The Hopkins group did not hear that message and took off, without a secure environment staked out by National Guard MP’s and as a consequence, they were shortly called back and spent the day back in the hospital organizing kits of supplies still being discovered and rummaged through in the mess left behind on the one hour notice the hospital staff had to evacuate the morning AFTER the Hurricane Katrina itself had been weathered by all patients and staff. One charge nurse discovered today was found who had said she was the head nurse on our third floor and had here uncle as a patient in the hospital on a ventilator. When they had awaited the word after the Hurricane that there would be a staff meeting at nine o’clock AM and at sight in the morning the panicked news came that the administrators had gone and the hospital had to be cleared, the thirty patients on the third floor were discharged, and the staff encouraged to flee without buttoning down, and the nurse’s uncle did not survive the transfer. Another nurse from Memorial Baptist (she actually gave her title as Cardiovascular technician) had told us that after she was evacuated from that New Orleans hospital as it closed, the Chapel was entered and thirteen bodies were discovered in it, unclear as to how many may have died before or as a result of the Hurricane, but three were on the podium covered with sheets and with an Open “Bible over them as if someone had conducted a preemptory service over them and the only ones left as the flood closed off all other records of this wistful last event in the Memorial Baptist Hospital’s Chapel.
We sat as twelve of us squeezed into the tight quarters of the Cecil County ambulance around a stretcher carrying our supplies which included several cases of water, and each of us had an MRE (Meal Ready to Eat) as well as the team kit and the individual items we might need for our aid station. We were ready to roll, with the only saving grace note being that the diesel truck had an A/C. As we waited we heard a “Hurry/Quick/ Stand Down/Wait” order to reassemble out front in the lobby area of the hospital. It was a bizarre turn of events explained as a zero tolerance for any unsecured area which had to have both a recon which cleared the secured grounds of any squatters or suspicious activity (one of the MP convoys was fired upon with a shot going through the Humvee’s windows) and the necessity of two kinds of communications systems hooked up at all times to assure we could be pulled out or a patient transferred out as needed. Our 800 Megahertz radios were tested out the eight miles form HQ that we would be convoyed, and they seemed to work as the National Guard/Regular Army in full combat gear, including body armor and helmets, radios and M-16’s never out of hand had gone out to check and clear the area. Now, it seems, that the 800 megahertz radios did not communicate with out tower here which had been put up with booster towers awaiting security for the positions where they would be erected. So, when only a few 600 megahertz radios could be located and they did not have adequate chargers to sustain them, it seemed that our twelve person team and another similar team were told to “stand down” as the others would be mobilized and moved out under armed escort which they did with us awaiting their return.
Once again, we were waiting but could not go far or start any other useful thing, since we were on standby which came only a short time later. During that time two New Orleans RN’s appeared to help our team and were added to our group, until it was realized that we had to fill out the third set of forms for the morning and name address etc each of us yet again. To my embarrassment, the New Orleans nurses were not allowed to accompany us, even though they had valuable local knowledge, since they were not under the umbrella license and liability waiver of our EMAC agreement, and they were kicked off. To say that charitably, I felt sorry they were not going with us, but the two together also had a combined weight in excess of 750 pounds—a habit that senior nurses and health care personnel seem to fall into. I said to Roy Smoot of Havre de Grace MD who is our titular “Team Leader” “It looks a little like your waiting room here!” (He is the Obesity Surgeon of the Delmarva Peninsula where he has not run short of patients for his procedure.)
Abruptly, we were called again back into the ambulance to pack our selves in and wait. This time, we actually pulled out behind the National Guard escort and fell in along the patrolled highway and under a tunnel to pass the West Jefferson Hospital where we had been the first night—then an ally, now a counter-marauder, as they came with trucks and rolled whole cartloads of supplies out the door this morning as we were “stood down.” It seemed to me that if they were “needy” so much the better that they should take them to where they might be used; but it seemed to be “greedy”, since I saw they were taking the big ticket items that are of no use during an emergency but are very high capital intensive items to be plundered. In the “Waste of War” I had written about in the huge piles of rusting military materiel I had seen in Eritrea, I bemoaned the waste of life and other consumables. But in this large military operation, there is also a great deal of waste especially as the wheel is being re-invented hourly with a lot of very high priced and specialized people sitting about kvetching about how it should be run if they were in charge. My only regret is that I cannot use the downtime for anything useful other than for observations about the “Chaos Theory” and how a new order can be brought about by an outlier who is “strange” at the e outset according to the plan, but then becomes an “attractor” as the environment changes around the new modal distribution of random events that seem to be happening at increasingly short intervals. The post-natural disaster is now leading to a large systems failure and acknowledgement that the system has to be changed to accommodate new information which is not fitting the prior paradigm or plan. This is a “test laboratory” for the “Learning Organization,” with the massive support either here or about to descend upon us the front runners giving rise to the military parable “Quantity had a Quality all its Own!”
We drove out to the Lincoln Elementary School and waited outside the locked gates before our escort could leave and before we were allowed to enter. We found out that the 800 mega Herz radios now seemed to be working despite the earlier report that they did not, and the 600 mega-Herz substitutes were NOT working. I pointed out that many of us were packing cell phones and mine turned on now for the first time in some time turned out to work—I was called by the Somaliland representative who had limoed me over to the Somaliland rally before I left to Eritrea, apologizing for interrupting my volunteer efforts and saying eh would call again in two weeks. I learned that the Audi now has a new battery. I learned that the Environmental Solutions Inc team could get in to the house today and test the floors at the tile and the cupboard baseboards since Ed and Debbie Lubers had mopped up the kitchen but had not cleaned behind the refrigerator which it was moved out in the first place with such disastrous results. (Those results are only apparent today as I appear to bear the black and blue marks of a heavy object across both thighs and the shoulders!) I do not know more about what is happening at home except that the refrigerator/freezer to have been delivered yesterday (when now I need it as my ONLY one) was not available (I did not hear if the upright freezer companion to it WAS available and WAS delivered—which would have been a handy coincidence since the frozen Omaha Steaks delivery comes today at home.) But, as soon as I hopped out of the cramped ambulance to stand in the hot and humid sun of southern Louisiana, I got the overwhelming death stench with which I am too familiar. I t turns out that a very large and very dead dog had just been removed from the curb in front of the Lincoln School exactly where the people are supposed to line up along the fence to the gated entrance. If they were hungry with some appetite before, they would not be after a while, since the smell would drive them off. I do not have to come to New Orleans to have a whiff of death—thanks to my electrically failed freezers! But, I later tired to keep them form the same odor that the Environmental Solutions Inc people are working on at Derwood by finding a bucket and mop ion the school and moping up the street of the congealed gore where the dog had lain, exactly as the same kinds of proteinaceous gore had been under all three freezer units at Derwood. The other cell phone message is that the State Farm people have received the messages and found that the Viking unit replacement will all come under the original claim,
LINCOLN ELEMENTRAY WALK-IN CLINIC
When we came into the school cafeteria, I tried to help clean up and arrange a “four quadrant team station” plan just like the similar screening clinics I have run in the Himalayas or in Haiti. The brief team meeting started off with a bang as one man in the queue out front had chest pain as he had been dehydrating in the sun. We scooped him up and brought him in, and sure enough, he had had a CABG for coronary artery heart disease five and a half years ago. We gave him nitroglycerine, Oxygen, had an IV line started and had him loaded on the stretcher and out the door within four minutes—a good triage for our team that included the Cecil County mobile ICU and its ambulance, which was now ready for him to be transferred in to the hospital that was working. Not so fast. He had to wait in the ambulance (at least in A/C and in comfortably safe monitored telemetry) awaiting the sheriff and an armed escort for the ambulance to roll out in the rocking chair position toward the hospital—a wait that took twenty times as long as his stopover with us.
I did a “recon” of the school. Lots of damage was everywhere with no electricity, of course, and a full refrigerator of milk products which I advised against opening, knowing what that had been like at Derwood. There was standing water in the halls, classrooms, and stairwells, through which we paddled to get to see if there were any facilities in the school nurses’ office—which there were not. There were poignant notes on the chalkboards from seven year old students who only knew about Hurricane Katrina as far as it had hit Florida before they left school. They may be in school now in Texas, since they certainly won’t be going to school here any time within the next year. I saw almost all the ceiling tiles fallen down on the PC’s in some class rooms and all the books and teaching materials were soaked with rain water (not Mississippi flood waters.) There were multiple poignant reminders as I went to the arts and crafts room and n the best third grade teacher’s printing my sisters had taught me before I was in school, I had printed “Walk-In Clinic: Operation Lifeline, for the People of Jefferson Parish from the Maryland Volunteer Emergency Response Services” I made up names as I went—probably to be changed by some officialdom, but it got a few people’s attentions
I then went out to see a line of old cars and pickup trucks awaiting with the passengers in each looking weary. I went down the line to check to see how many people were sick as a young woman came up in a rented red Ford Escort. She had a FEMA tag on, and later I learned she was from Washington DC’s Office of Homeland Security—abbot twelve feet from my office in GWUMC. She also told me later she had originally rented a car and the agency gave her a gold Lincoln upgrade as a luxury favor—some favor! She figured she would be car jacked immediately driving it and turned it back in after the first day. She looked to see me looking forlornly down the line of cars with nothing in hand—we were expecting a later arrival of a FEMA truck—and she took off. A few minute later she had some very good looking rations in the boot of her car. She had gone to the fire station and had taken the fireman’s’ rations, so I could give two to each car and two bottles of water. AS I did so, I noted that distributing food and water seemed what most of these people needed and after I had cleared the line of cars, only two had stayed for health care attention. They were hungry, and had no food or water, nor ice. After another hour, a big army truck came in, possibly older than I, but fully loaded with pallets of water, and cases of MRE’s. They were stacked at the gate, and a contingent of the National Guard from Arkansas were out front in full battle dress in the heat distributing the water and food to those who came for them with those who came for health care triaged by the EMS to see us.
On the subject of young men away form home with a hot sun beating done on them in battle dress as they carried the full Mae West and M-16—one of the young men collapsed, even as he had been drinking a lot and peeing well. We brought him in and put an IV in him and filled him up with several liters since he was still woozy when he sat up.
I had a 19-year old fellow who had wiped out on his bike and had a bad “road rash.” We cleaned up his multiple abrasions and since he had had his last tetanus shot about six years before, I used one of my few tetanus toxoids for him. He had what looked like skin graft donor sites, now covered with topical antibiotic dressings after the scrub to prevent “tattooing” and a peroxide irrigation.
It was a slow afternoon, but as in the “Field of Dreams” –“Build it, and they will come!” So, we will be busier now that the community knows—through my signs and the radio and the word of mouth—that we are “Open for Business.” As we convoyed back through the heavy storm damage of the blown down gas stations –only one of which I saw open with a long queue for the hand pumped gas at @2.37/gallon ($.60 cheaper then the Montgomery County from which I had come!) I looked at the enormity of the natural disaster loses and the systems it had wrecked, and the even greater enormity of the massive relief effort through FEMA and the Martial law imposed on this area of Gretna the village in Jefferson parish where I am in the Meadow crest Hospital an even bigger and much more innovative SYSTEM is needed for the Three R’s: Rescue, Relief and Reconstruction. This is a major task for the “Learning Organization” and whole new paradigms must be invented by “Strange Attractors” to come up with the new system to deal with this one. The Generals may be fighting the Last War, as I am thinking about how we may go about the next one. This may be what I am missing this weekend in the ELDP discussion about the Learning Organization. I believe I may be in the Lab while they are in the Lecture.