Once a year I work as expedition physician for TCS or Starquest Expeditions. Here is my journal from one trip:
Wednesday 10 October in Beijing we split up, half to visit the Great Wall (which I saw from the plane) and my group going to Tiananmen Square, the Forbidden City and the Temple of Heaven. We ate lunch at the famous Hepingman Beijing Duck Restaurant (ask your Chinese friends, they probably know it). We drove past 12th century hutongs (only 400 neighborhoods remain). Signs are still up from October first National Day (which was celebrated for a week). Beijing still has nine million bicycles, but four million cars make traffic worse. Even the freeways and ring roads have bike lanes and bus lanes.
Thursday 11 October we took Air China to Chengdu and then Lhasa. The altitude of 11810 feet was immediately apparent. Now I can sympathize with my heart patients who must stop to catch their breath on each flight of steps. The bus to the airport passed yaks in the fields and ten army bases. We visited the SOS Children’s Village, were I had tea with yak butter. The Brahmaputra Hotel sits on the bank of a tributary (Lhasa River) of the river of the same name (and doubles as a museum of folk art). We were greeted by staff in traditional costume doing a yak dance and pacing shawls around our necks.
Friday 12 we climbed 200 steps to the top of the Potola Palace and bought a ticket for one hour to rush through where the Dalai Lama (the reincarnation of the bodhisattva of compassion Avalokitesvara) lived winters until 1959. The oldest part dates from the 7th C, but most of the thousand rooms were built after the 17th C, when the Dalai Lama became the leader of both the religion and the state. Next we watched the daily theological debate between pairs of monks at the Sera monastery. Finally we toured the most holy Jokhang temple, where worshippers were prostrating themselves, circumambulating clockwise, turning prayer wheels (clockwise) and burning votive candles of yak butter. Padma Sambahava had sited this temple where there had been a lake that represented the heart of an underground she devil who had been preventing the construction of any Buddhist temples in Tibet. He followed with temples on her arms and legs, and they stayed up. Inside, we were gasping from the lack of ventilation and fumes of incense and burning yak butter. In the street market outside, I bargained for a thangka of a wrathful Mara holding a mandala and surrounded by the eight auspicious symbols.
Saturday 13 we visited the excellent Tibet museum, then took the China Eastern flight to Xi’an.
Sunday 14 we saw the terra cotta warriors (still being excavated and reassembled), the Shaanxi Provincial Museum (archaeology through ceramics), and the Wild Goose Pagoda, where Tripitaka returned with the sutras from his Journey to the West.
Monday 15 we saw the Famen Temple. In the 2nd C Emperor Ashoka united India, converted to Buddhism, renounced violence, and distributed relics of Buddha around the world. There is still a tooth in the temple in Kandy, Sri Lanka. All of the relics in China were thought to be lost until the tower in Famen collapsed in 1981. Reconstruction excavation revealed a treasure that had been sealed underground since the 9th C. Included were four finger bones elaborately packaged. Four are fakes made of jade, but they are worshiped alongside the bone. We also visited another imperial tomb in Yangling, near the airport.
Tuesday 16 we finally boarded our Fokker 100 for Ulan Bataar. We stopped in the Shaolin Temple outside Zhengzhou. The temple is in a beautiful mountain setting, and is the home of both Zen and Kung Fu (developed by monks who were bodyguards to the emperor). The town around the temple is full of martial arts schools, and we saw thousands of boys in red uniforms drilling outdoors. We reboarded the plane and flew to Mongolia.
Wednsday 17 in Ulaanbaatar we visited Gandan, the one monastery left standing by the Communists. It has an 80 meter tall golden Buddha surrounded by prayer wheels and thousands of small statues, visually stunning. We drove to a ger (yurt) where we were greeted with salty tea and cheese and treated to displays of horsemanship. We saw a museum full of dinosaur fossils from the Gobi desert.
Thursday 18 we flew to the Three Camel Lodge in the Gobi outside Dalanzadgad. We dug dinosaur fossils, rode Bactrian two hump camels, and slept in gers. The star gazing was outstanding.
Friday 19 we flew back to Ulan Bataar, refueled in Chengdu (again) and landed in Kathmandu.
Saturday 20 I watched the sun rise over the Bodhnath Stupa and later we walked the 17th C town of Bhaktapur, where the Hindus were sacrificing goats to Shiva and putting the blood on their vehicles. We then took Druk Air to Paro. Bhutan is like Montreat NC, with fieldstone buildings, pine trees, and clean streams, but with a very different religious tradition, another mile of altitude, and the Himalayas in the background. We saw a watchtower converted into a museum and a fortress that is now half municipal building and half monastery. The monks were as young as five, and larking around the holy places.
The national costume is a plaid bathrobe. I saw the Paro valley rice cop being harvested, archery practice, and hundreds of stray dogs.
Sunday 21 we climbed to almost 10,000 feet to the Tiger’s Nest Monastery, along with local pilgrims, because it was a holy day, and sat with the monks chanting om mane padme hum 108 times.
Monday 22 we flew back to Kathmandu to reboard our charter jet. I took a picture of Mount Everest just as the Red Sox won the pennant. We continued to Bhopal, where our guide told us her personal experiences with arranged marriage and the disaster the night of 2 December 1984 when the Union Carbide plant leaked methyl isocyanate gas and 9000 people died in four hours. We saw the stupa and column erected in Sanchi by Ashoka in the 3rd C BC. It is a Muslim neighborhood now.
Tuesday 23 we were late getting to the airport because of another religious festival (India has 60 a year) this time Dussehra, when a statue of Durga, consort of Shiva (aka Parvarti, Uma, Kali) is carried in a grand parade and submerged in the lake. We eventually flew to Bodh Gaya where Buddha achieved enlightenment and now there are temples from all Buddhist countries, and a descendant of the tree he sat under. That evening in Varanasi, we went to the Buddhist temple to pick up twenty pedicabs, which zoomed us through the dense commercial streets to the river bank where fourteen priests were performing the evening salutation to the river with the lights and music of a rock concert. We boarded two boats to watch the ceremony from the river, then visited the riverside crematorium. (Hindus come to Varanasi to die.) We ended the evening with an elegant dinner at the Raja Ghat.
Wednesday 24 we returned to the Ganges at 5:30am to see morning ablutions. We visited the deer park at Sarnath where Buddha preached his first sermon. Ashok’s stupa still stands, but not his column, and the monastery is a ruin. There is still a deer park, and a Jain temple. We flew to Siem Reap, a new airport with lots of new hotels, closer to Angkor Wat than the capital of Cambodia, Phnom Penh.
Thursday 25 as the Red Sox won the first game of the World Series, we rode elephants around the Bayon temple, built in the 12th C by Jayavarman VII. It is covered by huge faces of Jayavarman VII that are also called Buddhas because he too was a reincarnation of of the bodhisattva of compassion Avalokitesvara. We crawled through Ta Prohm, which is still covered in banyan, kapok and cardamom trees and popular for shooting movies. In the afternoon, we explored the less reconstructed and less crowded ruin at Preah Kahn and finished up at Angkor Wat (built by an earlier king) as it began to rain.
Friday 26 we flew to Danang. We visited a museum of sculpture of the Cham kingdom, who were Hindu Malay people who ruled the middle section of Vietnam in the 12th C. (It was a Cham invasion that caused Angkor to be evacuated. Angor Wat was the best preserved temple because Buddhist monks stayed behind after the government moved permanently to Penom Penh.) I stayed behind at the hotel to tend to a patient and missed the tour of Hoi Au. (We finally got our first traveler’s diarrhea. Blame it on India.) With the extra two hours, I got a haircut, and waded in the Pacific at China Beach.
Saturday 27 we drove to three hours through beautiful scenery to Hue. At the Tu Hieu Pagoda (home of Tich Nhat Hanh) we joined the noon chant and walking meditation. At the Kinh Tein Pagoda, we heard a talk from the abbot and ate lunch. I came back early to check up on patients.
Sunday 28 we flew to Luang Prabang. On the drive in to the hotel, we visited the village of weavers and the ethnology museum. In the afternoon, we took a boat up the Mekong River to see the Buddha statues in the Tam Ting Caves and joined the monks chanting at dusk at the Wat Xieng Thong monastery.
Monday 29 we flew to Macau and refueled as the Red Sox won the World Series. We flew to Osaka and drove to Kyoto.
Tuesday 30 we saw the Todaiji Temple, which was overrun with tame deer and Japanese school groups. It is the largest wooden structure in the world, built in the 8th C and rebuilt twice again when it burned, and containing the largest Buddha in Japan. There we ran into a TCS Around the World group with Leader Lynn Turner and lecturer Wayne Ranney, whom I knew from Jewels of the Indian Ocean in 2005. Their physician was Stephanie Roseborough from my own group! We saw them again at the nearby Shinto Kusaga Shrine. After lunch we visited the Yakushiji Temple, also from the 8th C, with a pagoda and an ancient university. We saw a just-completed set of paintings commemorating Triptaka’s Journey to the West, although they call him Sanjo Ginjo here.
Wednesday 31 we walked next door to the 13th C Sanjyusangendo Temple, with its one thousand Buddha statues. We rode the bus to the 17th C Nijyojo Castle, home of the samurai shoguns who ruled until they abdicated to the emperor after Commodore Perry and the opening of Japan in the 18th C. The “nightingale” floor was designed to squeak when walked upon, and the room screens were painted with beautiful tigers and nature scenes and gold leaf. We continued to the 14th C Kinkukuji Temple. We couldn’t go inside the Golden Pavilion (covered with gold leaf and the subject of a Yukio Mishiima novel based on the monk who burned it down) but the grounds were lovely. After lunch we walked around the Jishoji Temple, its Ginkaku Silver Pavilion and the tea house where the tea ceremony originated. We finally left the crowds of school groups at the Nanzenji Sanmom Gate and finished in the serenity of the Hojo Zen Garden.
Thursday 1 November I spent the morning in the Kyoto National Museum. That evening I flew home. Over the Pacific, I rendered medical assistance to a passenger, telling the pilot we did not need to divert, but should have paramedics meet the plane in San Francisco. UA gave me 10,000 miles.
Monday, April 27, 2009
St Gabriel Morgue 2005
I volunteer with a federal disaster medical assistance team, which meant that I was a government employee for two weeks after Hurricane Katrina. Here is my journal of that experience:
Sunday 4 September Lucy dropped me at Logan airport at in IMSuRT uniform for a 0930 press conference. We flew Delta to Houston in three groups that afternoon (we couldn't fly together on a day's notice). In the Atlanta and Houston airports, we kept running into Red Cross and armed service personnel also involved in disaster relief, and all the cable news coverage was about the humanitarian disaster in the wake of Hurricane Katrina (the death of Chief Justice Renquist received only brief notice). Among the news, we learned of three Disaster Medical Assistance Teams that had responded immediately, only to wander, searching for victims, repeatedly redeployed, and running out of gas (those reports turned out to be only part of the story). We slept in a Sheraton in Houston (empty because conventions were cancelled and evacuees were camping in the Astrodome). Tomorrow we plan to drive to Baton Rouge to meet up with NY-1 and NY-4 and establish a temporary hospital.
IMSuRT is using the Incident Command Structure developed by a group of laid off Boeing engineers twenty years ago on a federal grant, which we use for our disaster drills at the hospital (and which I wish FEMA were better at). ICS uses a military command and control structure with strict communication up and orders down a rigid pre-defined pyramidal hierarchy. It is inappropriate for the operations of rostered teams in stable environments, like daily operations in the ED and even our clinic in the second week of this deployment, but it is the solution for the confusion and delay that marked the first week of FEMA's response to Hurricane Katrina.
Under ICS, IMSuRT has an Incident Commander and Deputy, and during initial deployment, I do nothing independantly without informing them, and spend most of my time following their orders. Under them, the Safety Officer has veto power over all operations, and makes sure we keep drinking bottled water and slathering on sunscreen and insect repellant. Under them come chiefs of Operations, Planning, Finance, and Logistics, with pre-defined responsibilities. From hour to hour, I get assigned to move boxes, drive vans, guard luggage, cover sick call, design forms, run errands, et cetera.
Labor Day Monday we rented ten SUVs and drove to Baton Rouge as a convoy. On I-10 we saw other convoys: trucks loaded with empty gas cans, Texas buses headed west, police from Texas and California, and enough supplies to set up a small city from Fort Hood's First Cavalry (Fred's Division from WWII) all headed east with us. Every hundred miles or so, we drove through a swarm of love bugs mating in midair, splatting and specking the windshield.
When we arrived at the staging area at LSU, there were already six DMATs there, and we watched Tennessee, Arizona, and New York metropolitan get their assignments and deploy. Ken Iserson was with AZ-1 and went to St Bernard parish. We talked to others: California, Oklahoma and New Mexico had followed Katrina and been pre-positioned in the Superdome, along with plenty of food and water, but had to flee out the back door when the National Guard surrounded them, the water rose, and the riots began. NM-1 are in Baton Rouge now, part of an excellent medical service in two sports arenas, along with plenty of irregular volunteers. Rebecca may meet some of them later in the search and rescue team.
We learned another problem of pre-positioning assistance for natural disasters, which is not knowing right away exactly where you are needed. The NM, CA and OK DMATs came in before the hurricane, but still wound up in the wrong place at the wrong time unable to handle the Superdome riots. Now that hospitals in New Orleans and the Gulf Coast are coming back on line, attention is turning from the DMATs to the DMORTs mortuary service and the VMATs veterinary service. Those services as well as Fire, Police, Parks and FBI are here with us in the LSU gym. Two other buildings are dedicated to animal evacuees, and the lawns are full of people walking displaced dogs.
Tuesday 6 September classes begin at LSU and lines are long at the bookstore. I had fifteen minutes, which was enough to browse the entire literature section and buy three novels. Our trucks have arrived. Dysentery has broken out in the evacuees and caregivers, but a blog from the Astrodome said it was the same Norwalk virus that runs through cruise ships. There are reports however of four deaths from Vibrio vulnificans cellulitis. We were tasked with developing a system for evaluating injuries and exposures in relief workers being demobilized, and updating their tetanus and hepatitis boosters. Much depends on how fast the water goes down and infrastructure services are restored.
Wednesday 7 we repacked our trucks and distributed additional supplies, including helmets, goggles and sleeping bags. I emailed Lucy to FedEx our cell phone, because we are using them to stay in touch. It's not bad sleeping on the floor in the University Recreation building, but heightened security keeps me confined to the building except when we all together walk to the Student Union for meals. Sue Briggs has been promoted to Medical Officer for the Management Support Team in Baton Rouge.
Thursday 8 before the phone arrived, we formed a six person strike force headed to the Louisiana School for the Deaf to screen and out process demobilized DMAT teams, looking for injuries and exposures, updating immunizations, planning PTSD follow up, et cetera. Suddenly we were rerouted to St Gabriel, the site of the great morgue, for what will probably be our job until September 18, providing medical care for the mortuary workers. We toured the site that is set up to decontaminate, identify, autopsy, and prepare for burial up to 40,000 human remains, and is now running 24 hours a day in assembly line fashion. The identification process involves state of the art fingerprinting, dental and body x rays and DNA testing. There is a front page story in today's USA Today that describes it well.
We met some of the 200 members of three DMORTs who will be our primary responsibility and most of the 50 DMORT WMD members who are in charge of the decontamination, and toured the morgue (which is set up inside a third of a functioning warehouse and resembles the quarantine scene in the movie ET). They photograph, catalogue clothing and possessions, perform cursory forensic exams (but not full autopsies except where required), take 18 dental x rays with a futuristic hand held digital CRT, collect fingerprints for the FBI to scan, take DNA samples and plain x rays in a two hour assembly line. One tracker accompanies each body and collects the documents. They really do use yellow toe tags with serial numbers. The processed remains go back in a refigerated truck. No embalming here. Most of the DMORT are middle aged morticians who volunteer to do this.
Also here are FBI forensic units, Forest Service, and the catering, laundry and shower trucks that usually support teams fighting forest fires. Bird's Baths can provide 30 hot showers at a time, and still smells of wood smoke. North Slope Catering hands everyone 3000 calories a day, even if you ask for smaller portions. This tent city has been improvised over the last few days. Two more forensic dentists just arrived at midnight, and I helped them find a place to sleep. New tents are going up soon for more sleeping space. Forty bodies (human remains or HR) were processed today.
Every morning and evening at 6:45 there is a group meeting that starts with the pledge of allegiance to the flag and ends with orders to hug the person on your left. I carry a walkie talkie even when in the shower, and five hundred people say "Hi Doc" when they pass me. The facility was originally an elementary school (our chairs are stencilled "Iberville Head Start"). The front offices were converted to be the city hall for St Gabriel. The morgue itself is a third of a still-active warehouse. Jason is the chief of our strike team (or is it a task force). He's a firefighter with considerable HazMat experience. Jacquie, an ED nurse from the Beth Israel Deaconess, is deputy, and in charge of all the stupid FEMA paperwork. She made a call schedule so we can cover the clinic 24h, but put me on permanent call with no shift assignments. I drop by about twenty times a day, especially when I ancipitate it will be busy around 6am and 6pm when 12h shifts change in the morge, and I nap in the afternoons.
I bunk with Joe White, the physician for the DMORT WMD, which is a sort of elite unit of experienced DMORT members with special hazardous materials training and equipment, and has trained four times a year since it was founded post 9/11. Dr Joe was one of my students at Georgetown, graduating in 1981, now in family practice on Long Island. He was a SCUBA diver, then got involved in hyperbaric medicine for the bends, then assisted divers recovering remains from the TWA crash, joined a DMORT, helped at 9/11, and was recruited to WMD, the only DMORT that really needs a clinician. He has developed an occupational health approach to his team, keeping medical records, and taking vital signs before and after they work inside the morgue, where the heat index tops 120, so workers get seriously dehydrated, overheated and hypertensive. There's lots of heat exhaustion, heat cramps, prickly heat, athlete's foot and blisters inside the impervious personal protective equipment they have to wear in the morgue, and, despite the PPEs, they can be exposed to infections and toxins for us to diagnose and treat.
Friday 9 there were no remains brought from New Orleans all day. The collection of bodies was contracted out to Kenyon, a British firm that ordinarily hires the same people who are already working at St Gabriel. The Army Airborne units who provide martial law are marking bodies, and we process them. Before we arrived, some of the DMORT guys made a foray into New Orleans to pick up some HR, but it was a fiasco, with misdirection, structurally unsound buildings, no police or medical backup, and two hazmat exposures not handled well. One guy was splashed in the face with the dirty water and later turned up at the dinner table without washing. We heard the stories of the guys who went to the nursing home where 30 people drowned. They killed two snakes on the front porch, and waded through a foot of mud.
The WMD guys, with their own permanent physician, have immunizations up to date, and vital signs (temperature, pulse, blood pressure and weight) recorded going in and coming out of shifts in PPEs in the heat, all all recorded in a FilemakerPro database. (At the Brigham, the procedure is also to take vital signs before and after wearing our class C Tyvek suits.) The other groups have none of this, but we are rapidly bringing them up to the same standard. In one week we have converted an abandoned kindergarden classroom beside the entrance to the morgue into a decent occupational health clinic, using the supplies we brought or picked up along the way.
Michael Brown, the appointed head of FEMA, was today transferred back to Washington, and the Coast Guard Admiral Thad Allen put in charge of the Katrina disaster made recovery of bodies from New Orleans top priority. This is a classic case of bureaucratic delayed over reaction, because there is no urgency other than public relations. As they say in the DMORT, "Dead is dead." We have been ordered to return to the field to collect HR again, and we will, but only if we can do so in a safe fashion. At the group meeting tonight Dr Joe told everyone the first priority was getting ourselves back safe and healthy. After midnight, two trucks brought another 40 remains, and the night shift was busy again.
Saturday 10 four strike groups of about 16 each set out for the two hour drive to New Orleans, planning to fan out from the Superdome, follow the Airborne to the easiest sites (like hospitals) and fetch four refrigerated trucks of remains. We checked vital signs on all and sent them out with the first aid supplies we have acquired from anywhere along the way here. During the day, I took care of the sick and injured from the grounds crew and caterers. By 9pm, all four groups had returned. Two teams were late for their rendez vous so the Airborne troops left and they spent all day sitting in the parking lot. They did however see President Bush and Admiral Allen helicopter in for a visit. All these futile sorties suggest that there are few more remains, but the priority of our leadership remains acting busy in response to continuing photographs of cadavers in the news media. The strike groups will go out earlier tomorrow, at 5am, which means I'll have to get up at 3:30am to help take vital signs on all 68.
Sunday 9/11 marks the midpoint of our two week deployment. All of IMSuRT are on assignments: six still processing demobilized volunteers in Baton Rouge, twelve at W Jefferson Hospital (including the pediatricians), and the remaining twenty (including the orthopedic surgeons) with two other DMATs cooling their heels at the New Orleans Airport, which has now evacuated patients and is resuming commercial flights. I met Vickers, a Louisiana mortician who lost his home and and business in the hurricane, and now lives and works at the St Gabriel morgue. Tomorrow is his 65th birthday. There were few emergency patients here today, but a big rush when the strike teams returned after 9pm with more remains, enough to resume 24h morgue operations. The camp tried to hold an ice cream social tonight, but the ice cream melted too fast. Every room has an ice chest full of Gatorade and bottled water. Local black prison release guys hired by the Forest Service replenish coolers and maintain buildings and grounds. They are extremely polite.
Monday 12 Operations decided to eliminate the two hour commute, and send strike forces out to New Orleans for the next three days, spending two nights in the cruise ship the evacuees refused to board. Volunteers have begun showing up for "medical debriefing" for demobilization, so I made up a procedure we can all follow. Work included bodies we brought out of a hospital and one girl partly eaten by animals. We had our first heat exhaustion case: a middle-aged mortician decontaminating bodies felt lightheaded. We stripped him out of PPE and brought him by wheelchair to the clinic, where he lay in front of a fan and we spritzed him with water and gave him two liters of intravenous saline. In two hours, his vital signs were back to normal (an instant patient – just add water).
Tuesday 13 The weather just gets more hot and humid, so we have reduced shifts in PPE to 45 minutes.
Public Health is starting up a vaccination clinic. Coast Guard is fixing the internet connection. Amy continues coming to the clinic every day for minor complaints, routine health care and parenting she gets nowhere else. She left home in Oregon five years ago, at age 16, and has lived in a tent ever since with North Slope Catering, traveling from forest fire to forest fire. Nurse Shiela says she's like the patients she sees at the MGH ED who've run off with the circus. Amy sits in the clinic air conditioning for a few hours each day and asks about nursing school. Today's batch of remains were very decomposed and the whole camp stinks. Vaseline on the upper lip mitigates the smell of decomposing bodies. Three of us escaped to a cajun restaurant for dinner.
Wednesday 14 Very hot and humid. Operations becoming routine. People beginning to rotate back home because their two weeks are up. Joe and some of the WMD leaders visited the operations in New Orleans. Contact with Lucy has been limited to a couple of e mails and a couple of faxes, because I forgot our cell phone, her CRT screen died, and Camp Omigosh blocks long distance. Tonight I figured out how to put a call on the Visa card, we got to talk for the first time in ten days and my mood has soared.
Thursday 15 So hot and humid there were two cases of heat exhaustion and we're going to have to suspend operations in the afternoon and work at night. Little red ants are everywhere, we spray daily for mosquitoes, there are lizards and a wasp nest in my room and an alligator in our graywater dump. DMORT workers come out of the morgue and into the medical unit for vital signs limping and smelling of death, but the next morning are eager to go back. Had a visit from the under secretary of health. We had two minutes and made a good impression. Tonight we heard a rumor we will demobilize back to Baton Rouge in the morning. President Bush gave a speech from New Orleans outlining the federal recovery plan.
I am glad I lugged my laptop here, because we do have shaky intermittant and often slow internet access, and dozens of people depend on my laptop to keep up with their e mail. The computer however will never be the same again. All these users slow it down with trash files, little red ants crawl into the ports, and the case is speckled from insect repellant.
Friday 16 Red Cross chaplains are turning up in numbers. In the field, they say a short prayer over each body before it is transported here: "We give thanks for this person's life. We give thanks that this person was found. We give thanks for the persons that found them. We ask that they may be made whole in God's arms. And that they know peace." Jason visits New Orleans. We have a case of heat cramps and shut down morgue operations at 3pm due to heat and humidity. One pathologist we sent out because of her blood pressure – it turned out she was being worked up at home for a not-yet-diagnosed mass on her pancreas when she was called up, and in retrospect never should have come. She said it was boring sitting around Camp Omigosh anyway, because the only action was in the morgue. We didn't travel today after all – now the rumor is we fly Sunday. Whatever. Big thunderstorm at night.
Saturday 17 Morgue operations began at 6:30, creating a bottleneck in the clinic, then were suspended at 1:00 due to heat and humidity. The second air conditioning unit is in place, but still cannot keep up. The GE guys have tent pods for long term storage of remains that stay at forty degrees, but they are sealed tight. The federal government has bought land six miles away and set up more refrigerated storage pods for bodies. DMAT strike teams from TN and SC arrive to relieve us. We arrange their billets and orientation, then we are off to the Louisiana School for the Deaf in Baton rouge for demobilization with the same DMATS that arrived with us two weeks ago. We did each other's medical clearance and each had a two minute mental health interview. Eighteen of us jumped into the nine rental vehicles and drove them five hours back to Enterprise Rentals at the Bush Intercontinental Airport in Houston, where they will be issued to fresh DMAT volunteers in the morning. We slept at the airport Marriott with wake up calls for 3:30.
Sunday 18 Airborne at 5:20am to Atlanta to Boston. I imagine in the future people will ask me "Where were you for Hurricane Katrina?" I worked at the St Gabriel morgue." (long silence) "So, how about those Red Sox?"
Sunday 4 September Lucy dropped me at Logan airport at in IMSuRT uniform for a 0930 press conference. We flew Delta to Houston in three groups that afternoon (we couldn't fly together on a day's notice). In the Atlanta and Houston airports, we kept running into Red Cross and armed service personnel also involved in disaster relief, and all the cable news coverage was about the humanitarian disaster in the wake of Hurricane Katrina (the death of Chief Justice Renquist received only brief notice). Among the news, we learned of three Disaster Medical Assistance Teams that had responded immediately, only to wander, searching for victims, repeatedly redeployed, and running out of gas (those reports turned out to be only part of the story). We slept in a Sheraton in Houston (empty because conventions were cancelled and evacuees were camping in the Astrodome). Tomorrow we plan to drive to Baton Rouge to meet up with NY-1 and NY-4 and establish a temporary hospital.
IMSuRT is using the Incident Command Structure developed by a group of laid off Boeing engineers twenty years ago on a federal grant, which we use for our disaster drills at the hospital (and which I wish FEMA were better at). ICS uses a military command and control structure with strict communication up and orders down a rigid pre-defined pyramidal hierarchy. It is inappropriate for the operations of rostered teams in stable environments, like daily operations in the ED and even our clinic in the second week of this deployment, but it is the solution for the confusion and delay that marked the first week of FEMA's response to Hurricane Katrina.
Under ICS, IMSuRT has an Incident Commander and Deputy, and during initial deployment, I do nothing independantly without informing them, and spend most of my time following their orders. Under them, the Safety Officer has veto power over all operations, and makes sure we keep drinking bottled water and slathering on sunscreen and insect repellant. Under them come chiefs of Operations, Planning, Finance, and Logistics, with pre-defined responsibilities. From hour to hour, I get assigned to move boxes, drive vans, guard luggage, cover sick call, design forms, run errands, et cetera.
Labor Day Monday we rented ten SUVs and drove to Baton Rouge as a convoy. On I-10 we saw other convoys: trucks loaded with empty gas cans, Texas buses headed west, police from Texas and California, and enough supplies to set up a small city from Fort Hood's First Cavalry (Fred's Division from WWII) all headed east with us. Every hundred miles or so, we drove through a swarm of love bugs mating in midair, splatting and specking the windshield.
When we arrived at the staging area at LSU, there were already six DMATs there, and we watched Tennessee, Arizona, and New York metropolitan get their assignments and deploy. Ken Iserson was with AZ-1 and went to St Bernard parish. We talked to others: California, Oklahoma and New Mexico had followed Katrina and been pre-positioned in the Superdome, along with plenty of food and water, but had to flee out the back door when the National Guard surrounded them, the water rose, and the riots began. NM-1 are in Baton Rouge now, part of an excellent medical service in two sports arenas, along with plenty of irregular volunteers. Rebecca may meet some of them later in the search and rescue team.
We learned another problem of pre-positioning assistance for natural disasters, which is not knowing right away exactly where you are needed. The NM, CA and OK DMATs came in before the hurricane, but still wound up in the wrong place at the wrong time unable to handle the Superdome riots. Now that hospitals in New Orleans and the Gulf Coast are coming back on line, attention is turning from the DMATs to the DMORTs mortuary service and the VMATs veterinary service. Those services as well as Fire, Police, Parks and FBI are here with us in the LSU gym. Two other buildings are dedicated to animal evacuees, and the lawns are full of people walking displaced dogs.
Tuesday 6 September classes begin at LSU and lines are long at the bookstore. I had fifteen minutes, which was enough to browse the entire literature section and buy three novels. Our trucks have arrived. Dysentery has broken out in the evacuees and caregivers, but a blog from the Astrodome said it was the same Norwalk virus that runs through cruise ships. There are reports however of four deaths from Vibrio vulnificans cellulitis. We were tasked with developing a system for evaluating injuries and exposures in relief workers being demobilized, and updating their tetanus and hepatitis boosters. Much depends on how fast the water goes down and infrastructure services are restored.
Wednesday 7 we repacked our trucks and distributed additional supplies, including helmets, goggles and sleeping bags. I emailed Lucy to FedEx our cell phone, because we are using them to stay in touch. It's not bad sleeping on the floor in the University Recreation building, but heightened security keeps me confined to the building except when we all together walk to the Student Union for meals. Sue Briggs has been promoted to Medical Officer for the Management Support Team in Baton Rouge.
Thursday 8 before the phone arrived, we formed a six person strike force headed to the Louisiana School for the Deaf to screen and out process demobilized DMAT teams, looking for injuries and exposures, updating immunizations, planning PTSD follow up, et cetera. Suddenly we were rerouted to St Gabriel, the site of the great morgue, for what will probably be our job until September 18, providing medical care for the mortuary workers. We toured the site that is set up to decontaminate, identify, autopsy, and prepare for burial up to 40,000 human remains, and is now running 24 hours a day in assembly line fashion. The identification process involves state of the art fingerprinting, dental and body x rays and DNA testing. There is a front page story in today's USA Today that describes it well.
We met some of the 200 members of three DMORTs who will be our primary responsibility and most of the 50 DMORT WMD members who are in charge of the decontamination, and toured the morgue (which is set up inside a third of a functioning warehouse and resembles the quarantine scene in the movie ET). They photograph, catalogue clothing and possessions, perform cursory forensic exams (but not full autopsies except where required), take 18 dental x rays with a futuristic hand held digital CRT, collect fingerprints for the FBI to scan, take DNA samples and plain x rays in a two hour assembly line. One tracker accompanies each body and collects the documents. They really do use yellow toe tags with serial numbers. The processed remains go back in a refigerated truck. No embalming here. Most of the DMORT are middle aged morticians who volunteer to do this.
Also here are FBI forensic units, Forest Service, and the catering, laundry and shower trucks that usually support teams fighting forest fires. Bird's Baths can provide 30 hot showers at a time, and still smells of wood smoke. North Slope Catering hands everyone 3000 calories a day, even if you ask for smaller portions. This tent city has been improvised over the last few days. Two more forensic dentists just arrived at midnight, and I helped them find a place to sleep. New tents are going up soon for more sleeping space. Forty bodies (human remains or HR) were processed today.
Every morning and evening at 6:45 there is a group meeting that starts with the pledge of allegiance to the flag and ends with orders to hug the person on your left. I carry a walkie talkie even when in the shower, and five hundred people say "Hi Doc" when they pass me. The facility was originally an elementary school (our chairs are stencilled "Iberville Head Start"). The front offices were converted to be the city hall for St Gabriel. The morgue itself is a third of a still-active warehouse. Jason is the chief of our strike team (or is it a task force). He's a firefighter with considerable HazMat experience. Jacquie, an ED nurse from the Beth Israel Deaconess, is deputy, and in charge of all the stupid FEMA paperwork. She made a call schedule so we can cover the clinic 24h, but put me on permanent call with no shift assignments. I drop by about twenty times a day, especially when I ancipitate it will be busy around 6am and 6pm when 12h shifts change in the morge, and I nap in the afternoons.
I bunk with Joe White, the physician for the DMORT WMD, which is a sort of elite unit of experienced DMORT members with special hazardous materials training and equipment, and has trained four times a year since it was founded post 9/11. Dr Joe was one of my students at Georgetown, graduating in 1981, now in family practice on Long Island. He was a SCUBA diver, then got involved in hyperbaric medicine for the bends, then assisted divers recovering remains from the TWA crash, joined a DMORT, helped at 9/11, and was recruited to WMD, the only DMORT that really needs a clinician. He has developed an occupational health approach to his team, keeping medical records, and taking vital signs before and after they work inside the morgue, where the heat index tops 120, so workers get seriously dehydrated, overheated and hypertensive. There's lots of heat exhaustion, heat cramps, prickly heat, athlete's foot and blisters inside the impervious personal protective equipment they have to wear in the morgue, and, despite the PPEs, they can be exposed to infections and toxins for us to diagnose and treat.
Friday 9 there were no remains brought from New Orleans all day. The collection of bodies was contracted out to Kenyon, a British firm that ordinarily hires the same people who are already working at St Gabriel. The Army Airborne units who provide martial law are marking bodies, and we process them. Before we arrived, some of the DMORT guys made a foray into New Orleans to pick up some HR, but it was a fiasco, with misdirection, structurally unsound buildings, no police or medical backup, and two hazmat exposures not handled well. One guy was splashed in the face with the dirty water and later turned up at the dinner table without washing. We heard the stories of the guys who went to the nursing home where 30 people drowned. They killed two snakes on the front porch, and waded through a foot of mud.
The WMD guys, with their own permanent physician, have immunizations up to date, and vital signs (temperature, pulse, blood pressure and weight) recorded going in and coming out of shifts in PPEs in the heat, all all recorded in a FilemakerPro database. (At the Brigham, the procedure is also to take vital signs before and after wearing our class C Tyvek suits.) The other groups have none of this, but we are rapidly bringing them up to the same standard. In one week we have converted an abandoned kindergarden classroom beside the entrance to the morgue into a decent occupational health clinic, using the supplies we brought or picked up along the way.
Michael Brown, the appointed head of FEMA, was today transferred back to Washington, and the Coast Guard Admiral Thad Allen put in charge of the Katrina disaster made recovery of bodies from New Orleans top priority. This is a classic case of bureaucratic delayed over reaction, because there is no urgency other than public relations. As they say in the DMORT, "Dead is dead." We have been ordered to return to the field to collect HR again, and we will, but only if we can do so in a safe fashion. At the group meeting tonight Dr Joe told everyone the first priority was getting ourselves back safe and healthy. After midnight, two trucks brought another 40 remains, and the night shift was busy again.
Saturday 10 four strike groups of about 16 each set out for the two hour drive to New Orleans, planning to fan out from the Superdome, follow the Airborne to the easiest sites (like hospitals) and fetch four refrigerated trucks of remains. We checked vital signs on all and sent them out with the first aid supplies we have acquired from anywhere along the way here. During the day, I took care of the sick and injured from the grounds crew and caterers. By 9pm, all four groups had returned. Two teams were late for their rendez vous so the Airborne troops left and they spent all day sitting in the parking lot. They did however see President Bush and Admiral Allen helicopter in for a visit. All these futile sorties suggest that there are few more remains, but the priority of our leadership remains acting busy in response to continuing photographs of cadavers in the news media. The strike groups will go out earlier tomorrow, at 5am, which means I'll have to get up at 3:30am to help take vital signs on all 68.
Sunday 9/11 marks the midpoint of our two week deployment. All of IMSuRT are on assignments: six still processing demobilized volunteers in Baton Rouge, twelve at W Jefferson Hospital (including the pediatricians), and the remaining twenty (including the orthopedic surgeons) with two other DMATs cooling their heels at the New Orleans Airport, which has now evacuated patients and is resuming commercial flights. I met Vickers, a Louisiana mortician who lost his home and and business in the hurricane, and now lives and works at the St Gabriel morgue. Tomorrow is his 65th birthday. There were few emergency patients here today, but a big rush when the strike teams returned after 9pm with more remains, enough to resume 24h morgue operations. The camp tried to hold an ice cream social tonight, but the ice cream melted too fast. Every room has an ice chest full of Gatorade and bottled water. Local black prison release guys hired by the Forest Service replenish coolers and maintain buildings and grounds. They are extremely polite.
Monday 12 Operations decided to eliminate the two hour commute, and send strike forces out to New Orleans for the next three days, spending two nights in the cruise ship the evacuees refused to board. Volunteers have begun showing up for "medical debriefing" for demobilization, so I made up a procedure we can all follow. Work included bodies we brought out of a hospital and one girl partly eaten by animals. We had our first heat exhaustion case: a middle-aged mortician decontaminating bodies felt lightheaded. We stripped him out of PPE and brought him by wheelchair to the clinic, where he lay in front of a fan and we spritzed him with water and gave him two liters of intravenous saline. In two hours, his vital signs were back to normal (an instant patient – just add water).
Tuesday 13 The weather just gets more hot and humid, so we have reduced shifts in PPE to 45 minutes.
Public Health is starting up a vaccination clinic. Coast Guard is fixing the internet connection. Amy continues coming to the clinic every day for minor complaints, routine health care and parenting she gets nowhere else. She left home in Oregon five years ago, at age 16, and has lived in a tent ever since with North Slope Catering, traveling from forest fire to forest fire. Nurse Shiela says she's like the patients she sees at the MGH ED who've run off with the circus. Amy sits in the clinic air conditioning for a few hours each day and asks about nursing school. Today's batch of remains were very decomposed and the whole camp stinks. Vaseline on the upper lip mitigates the smell of decomposing bodies. Three of us escaped to a cajun restaurant for dinner.
Wednesday 14 Very hot and humid. Operations becoming routine. People beginning to rotate back home because their two weeks are up. Joe and some of the WMD leaders visited the operations in New Orleans. Contact with Lucy has been limited to a couple of e mails and a couple of faxes, because I forgot our cell phone, her CRT screen died, and Camp Omigosh blocks long distance. Tonight I figured out how to put a call on the Visa card, we got to talk for the first time in ten days and my mood has soared.
Thursday 15 So hot and humid there were two cases of heat exhaustion and we're going to have to suspend operations in the afternoon and work at night. Little red ants are everywhere, we spray daily for mosquitoes, there are lizards and a wasp nest in my room and an alligator in our graywater dump. DMORT workers come out of the morgue and into the medical unit for vital signs limping and smelling of death, but the next morning are eager to go back. Had a visit from the under secretary of health. We had two minutes and made a good impression. Tonight we heard a rumor we will demobilize back to Baton Rouge in the morning. President Bush gave a speech from New Orleans outlining the federal recovery plan.
I am glad I lugged my laptop here, because we do have shaky intermittant and often slow internet access, and dozens of people depend on my laptop to keep up with their e mail. The computer however will never be the same again. All these users slow it down with trash files, little red ants crawl into the ports, and the case is speckled from insect repellant.
Friday 16 Red Cross chaplains are turning up in numbers. In the field, they say a short prayer over each body before it is transported here: "We give thanks for this person's life. We give thanks that this person was found. We give thanks for the persons that found them. We ask that they may be made whole in God's arms. And that they know peace." Jason visits New Orleans. We have a case of heat cramps and shut down morgue operations at 3pm due to heat and humidity. One pathologist we sent out because of her blood pressure – it turned out she was being worked up at home for a not-yet-diagnosed mass on her pancreas when she was called up, and in retrospect never should have come. She said it was boring sitting around Camp Omigosh anyway, because the only action was in the morgue. We didn't travel today after all – now the rumor is we fly Sunday. Whatever. Big thunderstorm at night.
Saturday 17 Morgue operations began at 6:30, creating a bottleneck in the clinic, then were suspended at 1:00 due to heat and humidity. The second air conditioning unit is in place, but still cannot keep up. The GE guys have tent pods for long term storage of remains that stay at forty degrees, but they are sealed tight. The federal government has bought land six miles away and set up more refrigerated storage pods for bodies. DMAT strike teams from TN and SC arrive to relieve us. We arrange their billets and orientation, then we are off to the Louisiana School for the Deaf in Baton rouge for demobilization with the same DMATS that arrived with us two weeks ago. We did each other's medical clearance and each had a two minute mental health interview. Eighteen of us jumped into the nine rental vehicles and drove them five hours back to Enterprise Rentals at the Bush Intercontinental Airport in Houston, where they will be issued to fresh DMAT volunteers in the morning. We slept at the airport Marriott with wake up calls for 3:30.
Sunday 18 Airborne at 5:20am to Atlanta to Boston. I imagine in the future people will ask me "Where were you for Hurricane Katrina?" I worked at the St Gabriel morgue." (long silence) "So, how about those Red Sox?"
Common Simple Emergencies
In 1980 I was on the Emergency Medicine faculty at Georgetown University Hospital with Phil Buttaravoli, who was the second physician to train in EM (I was about the 100th). I helped him write a book that covered conditions that were not yet in other texts, which is still for sale as "Minor Emergencies" (I dropped out as co-author this last edition). A html version that is 10 years out of date is still available at http://www.ncemi.org/cse/contents.htm
Subscribe to:
Posts (Atom)
