Six of us, including a nurse supervisor, four logistics officer, and me – the chief pharmacist of CA-4, a Disaster Medical Assistance Team (DMAT) headquartered in San Diego, Calif. – started out for Louisiana in three 24-foot trucks early in the evening of Sunday, 28 August. We arrived at Louisiana State University (LSU) in Baton Rouge in the middle of the afternoon on Wednesday, 31 August. Because the chief medical officer present had put out a call that any and all pharmacists available were urgently needed, I reported as soon as possible to a makeshift pharmacy intake area that had been set up at the Carl Maddox Field House.
After participating in three chaotic hours of ordering and dispensing medications, I and the other members of our group left Baton Rouge and proceeded to the Louis B. Armstrong International Airport in New Orleans, arriving early in the evening on that same day. The other members of our San Diego CA-4 team – one of the first three DMAT teams deployed to the airport – had been there since the evening before.
Because there was no running water, electric power, or air conditioning available, we thought it would be prudent, for security as well as medical purposes, to keep our stockpile of medicines in the refrigerated FedEx truck that was provided to us. The outside temperature was in the mid-90s and in or close to triple digits inside the airport terminal.
We dispensed medicines out of the FedEx truck for the next 36 hours, enduring both the ear-shattering noise of the compressors and the near-freezing 40-degree temperature inside the truck. When electric power was restored, though, we quickly and happily commandeered the “New Orleans Legends Bar and Grill” inside the airport, set up a field pharmacy behind the bar, and proceeded to fill – as quickly and as safely as possible under the circumstances – the literally hundreds of orders for medications that were being thrown at us.
The other members of our initial staff at the airport, besides myself, were Susana Leung, a CA-4 pharmacist, a CA-4 pharmacy tech, and three additional pharmacists from the states of Oregon, Texas, and Washington. We were augmented several days later when five additional pharmacists, and one pharmacy tech – from the states of Florida, Massachusetts, Oregon, and Pennsylvania – reported in. The Air Force stepped up to the plate by assigning both a pharmacist and a pharmacy tech to the team.
At full strength we had 14 pharmacists (14 DMAT and one Air Force) and three technicians (two DMAT and one Air Force). We set up three shifts: 0700 to 1900; 1200 to 2400; and 1900 to 0700. In six days of 24/7 operations our DMAT teams triaged more than 23,000 patients, treated more than 2,600, and, amazingly – because we pharmacists had no pharmacy software program available that could print labels – filled over 5,500 handwritten prescriptions.
Most of the rescue victims and evacuees came from downtown New Orleans and the “parishes” (i.e., counties) surrounding the city. Patients were ferried to the airport in a 24-hour unending caravan of ambulances, buses, helicopters of all types (including Chinooks, Blackhawks, Sea Knights, Jet Rangers, and many other makes and models), and any other means of transport available. The helos, most of them loaded to the max with sick and injured evacuees, were flown by Army, Navy, Marine Corps, Coast Guard, Air Force, and Air and Army National Guard pilots and by Lifeflight pilots from area hospitals as well as a number of private pilots. Almost without exception, the choppers stayed on the ground only long enough to unload their human cargo, then took off again to rescue more people.
Many of the evacuees had been rescued from rooftops or bridges, where they had been stranded since the levees broke, or from attics in homes engulfed by floodwaters. The patients brought to the airport were carried in on litters by teams of volunteers or on airport “tugs” usually – i.e., during normal operations at the airport – used to haul food and luggage from one part of the airport to another.
Inside the terminal, our deputy commander, Thérèse Rymer, and her staff would triage the patients and separate them into four groups – green, yellow, red, and black. The patients then would be moved into the appropriately colored tents that had been set up in accordance with previously established triage protocols – green for the walking wounded; yellow for delayed; and red for immediate treatment, which are the most critical.
The black-tag patients, who were not expected to live, were transported to an “expectant” ward, in a secluded area of the terminal, where they were kept warm and comfortable; they also were ministered to by Ri Venuti, our team psychologist, Chaplain Mark Reeves, and a volunteer nurse who was not with DMAT but had offered her time and skills to administer palliative care to these dying patients. Our pharmacists filled numerous orders for morphine to keep these patients as comfortable as possible so they would not suffer during their last hours on earth.
A major problem developed, though: We were rapidly using up the caches of medicines that FEMA (Federal Emergency Management Agency) had provided the teams, and were particularly low on morphine and other pain medications. We also were out of many of the “chronic” medications that many of the patients had been taking even before the hurricane hit. The most difficult situations involved patients suffering from a spectrum of medical problems – e.g., hypertension, heart disease, diabetes, renal failure, etc. – that had been compounded and aggravated by trauma suffered during the hurricane and the immersion that followed.
To conserve what was left of our pharmaceutical caches, Charlie Valencia, (the pharmacy chief of Night Ops), and I (the pharmacy chief of Day Ops), decided to dispense just a one-day supply of pain medication, a three-day supply of chronic meds, and a full – seven to ten days – supply of antibiotics. Our hope, of course, was that the patients at the airport would quickly be transported to various hospitals in Louisiana or even out-of-state hospitals. That did not always happen, of course, so we often had to refill prescriptions written only a day or two earlier.
We made sure that we first supplied the triage area, and the tent areas, with acute-care and critical-care drugs such as Benadryl, Lidocaine, Nitroglycerin, Epinephrine, and Atropine so that all levels of triaged medical care could be met. We also circulated our formulary list – arranged alphabetically and by therapeutic – to the doctors and other medical professionals at the airport, and encouraged them to order medications only from that list (another hope that was not always fulfilled). The physicians asked us to use our own clinical judgment in making therapeutic substitutions for medications that patients had been using prior to the hurricane but that were not in our necessarily limited inventory. These clinical judgments were, in fact, being made continuously, and many of the patients at the airport benefited immensely from our efforts.
All of this helped alleviate the overall shortage of medications, but did not eliminate a rapidly worsening situation. After several days of continuous operations we were running dangerously low on all of the medications we needed, not just the pain medications. Moreover, the re-supply list we had submitted had still not been filled.
Fortunately, we were able to continue operations anyway – thanks primarily to the help provided by the Air Force’s 375th EMEDS (Expeditionary Medical System) and 57th Medical Wing stationed at Lackland Air Force Base, the U.S. Forest Service’s Southern Region Red Team, and a number of private donations. We received the urgently needed morphine and Valium less than 14 hours after ordering those medications from the Air Force while we were still struggling to convince higher authorities to allow us to use this life-saving supply chain. Remembering that CA-4 Team Commander Dr. Jake Jacoby had repeatedly emphasized the need for “redundancy, redundancy, redundancy,” I called contacts – at the Cardinal Health Inc. offices in Valencia, (Calif.) and Atlanta – to serve as a backup if FEMA could not meet our re-supply needs. They told me that Cardinal would do whatever it could to help.
That has always been the case with Cardinal. CA-4’s sponsoring hospital, the University of California San Diego Medical Center, has an active MOU (memorandum of understanding) with Cardinal under which the company supplied the medications needed for CA-4’s deployment to Guam in 2002.
One of the Cardinal representatives offered to use the company’s corporate jet to fly in critical medications, including controlled substances, from Atlanta to the New Orleans airport. While I was filling out the controlled-substance transfer protocols, I received a call, from a DEA agent, telling me the agency would take the actions needed to clear through whatever controlled substances were needed without the time-consuming paperwork. This was a particularly encouraging call after all the preceding delays.
All I now had to do was to request clearance to use this alternate supply chain – which I did. The request was denied, though – apparently (although this was not specifically given as the reason) because another supplier was being used and we were not permitted to go outside of the supply chain previously established. The denial of my request caused me extreme concern, and all I could say (silently, to myself) was “Thank God for the United States Air Force!”
Because I had received CDC (Centers for Disease Control and Prevention) training on the Strategic National Stockpile (SNS) at Anniston, Ala., three years ago, I felt confident that supplies from this valuable national asset would arrive almost immediately, as they did during the aftermath of the 9/11 terrorist attacks. I did see some ventilators arrive, after several days, in the telltale SNS containers, but the medications I had requested were nowhere to be found. It was not until four days after our initial re-supply request had been submitted, in fact – far too late, in other words – that we received what seemed to me VMI (vendor-managed inventory) medications from the SNS.
What caused the medication re-supply problems is still an unanswered question. Whether the governor of Louisiana and/or other senior officials requested an SNS 12-hour push package also is not known – or, if a request had been made, whether it had been filled, or simply ignored. I and others working the staggered shifts at the airport certainly think that the magnitude of the disaster named Katrina warranted a quick and effective departure from business-as-usual procedures.
Nonetheless – and here I think I reflect the sentiments of the entire CA-4 team – I believe we did a huge amount of good for an extraordinary number of patients, despite having to overcome some overwhelming obstacles, many of them unforeseen. The DMAT pharmacists, the other members of the DMAT CA-4 team and other DMAT teams, and U.S. Air Force personnel all performed superbly.
We also are grateful in many ways large and small for the unstinting help and support given us by the Federal Protective Service, the U.S. Air Marshals, the Customs and Borders personnel, the Army’s 82nd Airborne Division and many others, including several private-sector organizations and individual citizens, who exhibited the utmost in professionalism and personal integrity I have ever witnessed. On a personal note, I would be honored to re-deploy again, on short or no notice, with any of them during any future crisis response.
Note: The author apologizes for not being able to list, by name and job title, the names of the many CA-4 team members and others with whom he worked during the response to Hurricane Katrina. He knows they will understand.
Michael J. Sohmer
Michael J. Sohmer is the system SNF consultant pharmacist for Sharp HealthCare based out of Sharp Chula Vista in San Diego. He is a 1983 graduate of the University of Maryland School of Pharmacy at Baltimore. Sohmer is the chief pharmacist of DMAT San Diego CA-4 and the San Diego County Metropolitan Medical Strike Team (MMST), the co-director of the San Diego County Pharmacy Emergency Response Team (RxERT), and the President of Pharmacist Emergency Response Management Group, Inc. (RxERMG).