NEWS AND PERSPECTIVE

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Introduction

nnals News and Perspective explores topics relevanto emergency medicine, in particular those in whichur specialty interacts with the political, ethical,ociologic, legal and business spheres of our society.

w Orleans. But the bricks and mortar hospital needs come in

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anagement will be rare. By design, it will not be a‘breaking news’’ section with the latest (andndigested) developments, but instead a reflectivenvestigation of recent and emerging trends. If youave any feedback about this section, please forwardt to us at feedback@acep.org.

Discussion of specific clinical problems and their

0196-0644/$-see front matterCopyright © 2006 by the American College of Emergency Physicians.

‘CHARITY’ SUFFERS LONG: EMERGENCY MEDICINE REVIVES THE SPIRITOF CENTURIES-OLD NEW ORLEANS INSTITUTION

George FlynnSpecial Contributor to Annals News and Perspective

Nearly a year after Hurricane Katrina slammed ashore todevastate New Orleans, much of the French Quarter is againhosting visitors in the renewed revelry of Bourbon Street. Notfar away, however, are the reminders that the Crescent City isa long way from rebuilding its bedrock medical services.

The boarded-up remains of the venerable Charity Hospitalevoke the scene of the desperate last stand and delayedevacuation from the rising flood waters of the broken leveesystem late last August.

Engineers only have to eye Charity’s carcass to give theirassessments of damage, but the lingering impacts on therebuilding of basic emergency medical care is more difficult toassess, even a year after the waters receded. Asked about themany challenges encountered by emergency medicine in themonths since Katrina, emergency physician Peter M.C.DeBlieux sighed, “It continues to be [a mess].”

Charity Hospital, the state-owned hospital that shoulderedthe bulk of New Orleans’ indigent care needs since its humblebeginnings in 1736, had been the city’s only Level 1 traumacenter. To replace it, officials plan a new state medical centerwith a US Department of Veterans Affairs (VA) hospital, butuncertainties remain over the $1.2 billion in combined costsand the 5-year construction schedule.

DeBlieux took over 2 months before Katrina as theemergency medicine director of resident and facultydevelopment at the Louisiana State University’s (LSU) HealthSciences Center School of Medicine at New Orleans. Hesaid that the short term goal is to reopen a fully revitalizedemergency department (ED) in nearby University Hospital,to be phased in for completion by the summer of 2007.

“It sounds good,” he said, but adding a note of caution:“We’ll see if we’re there at that point.”

DeBlieux concedes that “we’ve been hit with every challengeimaginable” in providing emergency services in post-hurricane

tandem with the equally difficult efforts to rebound emergencymedicine and other residency programs.

Katrina cost Charity’s emergency medicine residencyprogram 10 of its 35 clinical and academic physicians. Theemergency medicine residency review committee cut thenumber of incoming resident positions from 17 to 10.

A MATCH DESPITE THE MESS“We matched those fully; no scrambling, no other

problems,” DeBlieux said. He believes the new physicianinterest in the program despite the challenges it faces heraldsa comeback. LSU-Charity Hospital’s program, established in1973 and among the oldest in the nation, is well respected inthe specialty’s community.

“They (the residency review committee) were favorablyimpressed by what our reaction was to the disaster and howwe had positioned rotations for the residents even without ourprimary care site,” DeBlieux said. By January, the programhad been offered a 3-year certification, with the next reviewscheduled for Spring 2007.

Dr. Keith Van Meter, chair of emergency medicine,promoted the opportunities in a prepared statement to medicalstudents. “We are excited about the new post-hurricane trainingopportunities, such as our relocated Level I trauma center, ourdisaster medicine experiences and our unique partnerships withmilitary medical services, to name a few.”

The decrease in emergency medicine residents for thecoming year parallels declines in other specialties. Overall,the LSU program for New Orleans has 405 residents, downfrom 518 for the prior year.

The pride of the emergency medicine staff in continuingto offer services was mixed with acknowledgment of thelong-running problems in coping with the crisis.

In announcing that the American College of EmergencyPhysicians Scientific Assembly would keep to its 7-year-old

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designation of New Orleans for the 2006 sessions, ACEP

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News and Perspective

President Frederick C. Blum, MD, said that “emergencyphysicians providing care during Hurricane Katrina were amongthe very last people to leave the city. It’s appropriate that we arenow one of the first to return.”

CRITICAL CARE IN THE AFTERMATHOf course, Charity emergency physicians never really left.

While news media attention focused on the frantic final daysfor the hospital, emergency physicians and assistants struggledin the ensuing months to keep providing carefor the hurricane victims.

DeBlieux said emergency physicians and support staff wereback to the city within hours of the evacuation of CharityHospital. They established a clinic and medical care area, led byemergency physician James Moises, MD, outside the NewOrleans Convention Center. Martial law had been declared,and law enforcement officers were warning of dangers from thefloods and marauding criminals.

“They really weren’t supposed to stay there,” DeBlieux saidof the doctors. “And yet they were there, delivering care andhelping get the people out.”

In the third week after the hurricane, the clinic outside theconvention center added a fast track area that served 75 patients aday, and combined efforts with a military combat surgical carehospital unit. The following week, the US Navy dispatched itshospital ship Comfort to the scene from Mississippi. The LSU NewOrleans Medical School emergency physicians and trauma surgeonsfrom Tulane Medical Center handled cases there for 10 days.

A TEMPEST AND A TENTAfter the departure of the Comfort, primary care delivery was

still at the urgent care facility outside the convention center. Tobroaden care, another facility was set up in the parking lotof University Hospital, DeBlieux said. The Air Force providedtents used at Army field hospitals in Iraq and Afghanistan, andportable toilets, water bladder utilities and emergency generators.

DeBlieux said the military medical equipment was good,although the tents–designed as temporary shelters until woundedsoldiers could be evacuated to real hospitals–lacked basic elementsof civilian facilities. Doctors scavenged equipment from the darkhalls of Charity and University Hospitals.

Equipment as fundamental as stretcher holders illustratedthe incompatibility. The military models lacked essential siderails to keep intoxicated or combative patients, or other fallrisks, from tumbling to the ground. “Their answer to side rails issimply pick up the litter and put it on the floor,” which wasn’ta viable option for civilian medical staff, he said. “Not all thecare providers are robust enough to go down on their kneesand deliver care at every step of the way,” DeBlieux said.“In the military, it is a different ball game.”

By the end of October, the University Hospital parking lotclinic was seeing more than 75 patients a day. The teams had addedX-ray, CT and ultrasound capabilities. With crowds of formerevacuees beginning to return to the devastated city, the parking lot

bustled with more activity than the Convention Center site.

310 Annals of Emergency Medicine

Staffing the temporary facility were residents and facultyphysicians, emergency nurses, hospital police, laboratory andradiology technicians and even dentists.“It was just really a team effort,” DeBlieux said.

Pressure was exerted beyond the basic need to treat patients,whose visits increased to 4,000 in January–about half thenumbers seen by University and Charity hospitals before thehurricane. As 2006 arrived, so did demands for the ConventionCenter clinic to be dismantled.

“There was a big press for us to leave so the ConventionCenter could get their own contractors in to prepare it for themajor conventions,” DeBlieux said. “So we began looking foralternative sites.”

Support physicians came from Florida and the Carolinas toease the workload, he said. The number of available hospitalbeds had increased to 1,700, compared to pre-Katrina’s 4,000,but February also provided more challenges with the start ofthe carnival season and Mardi Gras.

“We expanded our services to also function as kind of adrunk tank and observation unit,” DeBlieux said. “We wereable to coordinate other care with that.”

AN EMERGENCY DEPARTMENT STOREWhen they had to move from the convention center in

March, they found space for an emergency services unit insidea Lord & Taylor department store, the anchor for the formerNew Orleans Mall.

They got the certifying agencies, the Joint Commission onAccreditation of Healthcare Organizations (JCAHO) and theCenters for Medicare & Medicaid Services (CMS), to approvethe transition to the cubicle-like treatment areas.

More relief came in May, when they opened a facility formajor trauma patients in leased areas on portions of 3 floorsof the private Elmwood Hospital.

In May and June, the emergency services unit at the formerdepartment store was seeing more than 4,200 patients monthly.About 70 of them were transferred out to area hospitals, withanother 70 admitted for 1-day observation stays.

Medical centers in adjacent areas are still grappling withthe surge of patient visits from the Charity Hospital vacuum.Over the Memorial Day weekend, for example, ambulanceswere lined along the West Jefferson Medical Center for hours.Hospital officials blamed a combination of factors: staffingshortages, limited bed availability, even the collapse ofhome health care programs after the floods. Medical centeradministrators had to ask the state for some $120 million inemergency funds to underwrite the cost of the uninsured care.

“One of the frightening lessons that we learned was aboutthe assumption we’d always had that somebody from a federaland state level would step in and provide for the indigents,”DeBlieux said. He explained that indigent care encompassedmuch more than the homeless including many of the workingpoor. “They continue to fall through the cracks here, and their

needs are not being met.”

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Fears of a funding collapse have led to protests over theinitial decision to close Charity Hospital.

THE BILLION DOLLAR FIXOfficials of Louisiana and the US Department of Veterans

Affairs in June announced plans to replace Charity by buildinga $1.2 billion mega-medical complex to be completed in 2011.The VA and LSU would each operate separate downtownhospitals linked by a corridor, with projected cost savings ofabout $10 million annually by sharing some services.

A federal appropriations bill was designed to cover VA costsof about $630 million, although state funding sources remainunclear for the remainder of the project, a 350-bed teachinghospital. State officials said the money might come from federalCommunity Development Block Grant allocations or as partof the Federal Emergency Management Agency funding tocompensate the state for Hurricane Katrina.

More unique funding possibilities–one calls for privatedevelopers to build and lease the facility to the state–have beendiscussed to avoid having the costs added to Louisiana’s soaringpublic debt load.

The price tag of the replacement plan has spawnedcontinuing criticism. Critics cite a FEMA study that estimatedthat Charity could be repaired and reopened for about $24million, far less than the US Government AccountabilityOffice’s estimate of $258 million.

“After the storm, doctors, military personnel and engineersre-entered Charity, pumped out the floodwater from thebasement and cleaned and decontaminated patient care areasfor the hospital to be reopened, only to be ordered out by LSUofficials,” a joint statement by Charity’s supporters said onJune 8. “The building has been closed and guarded ever since.”

The coalition drew more attention with rallies calling for therenovation and reopening of the hospital. Among the groupsurging continued use of Charity are the Advocates for LouisianaPublic Healthcare (ALPH), People’s Hurricane Relief FundHealthcare Committee, the New Orleans chapter of the NAACPand Doctors Without Hospitals. They include physicians such asMoises, the emergency medicine specialist who helped lead theeffort to establish the first post-Hurricane Katrina medical aid area.

THE CHARITY DIASPORAWithout Charity Hospital, many patients have been

dispersed to seek care at remote locations, they argued. Theclosest chemotherapy treatments are more than an hour away,the protesters said. Louisiana, with 21% of residents uninsuredand another 20% on Medicaid, has one of the lowestpopulations with private insurance.

VA executives and the state officials denied the contentionsof critics, that the long range collaborative medical center wouldgut services to New Orleans’ indigents traditionally cared for atCharity Hospital.

Proponents of the new hospital plan pointed out thatCharity’s 70-year-old buildings have serious infrastructureproblems. Engineering studies have shown extensive disrepair

over the years, as well as damage from the floodwaters, they said.

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Donald Smithburg, an executive vice president of the LSUsystem and chief executive officer of its health care servicesdivision, outlined the concerns about the devastation at bothCharity and the nearby VA hospital. His comments came ashe pushed for the collaborative hospital center in a Marchappearance before the Committee of Veterans Affairs of theUS House of Representatives.

“Today, these facilities sit in ruins. Charity Hospital has beendeemed ‘uninhabitable and unsalvageable’ for health care byconsulting engineers, and the somewhat newer UniversityHospital (35 years old), although severely damaged and notviable in the long term, will be temporarily propped up by theend of the year as an interim solution to New Orleans’ criticalneed for health services.”

Smithburg said the planned collaboration with VA “is onepropelled by unintended opportunity” and an “enlightenedand visionary step” for the area’s medical care needs.

DeBlieux, recalling how medical teams scrambled andimprovised to provide care immediately after Katrina, hadto wonder about the findings that Charity was effectivelydestroyed by the hurricane. Asked if Charity could have beenreopened, he replied, “There’s no question.”

“Within 2 weeks after the storm, our entire residencycontingency and many of the academic faculty were back inthe building salvaging, in hopes of delivering care in thatfacility. The leadership at the state level told us to stand down.They did not think that was a salvageable enterprise. It was verydifficult (to accept).”

As of early July, the plan was to reopen portions ofUniversity Hospital, 2 blocks from Charity. In October,officials hope to have up to 150 patient care beds available,along with the existing ED and fast track. By January, thetemporary trauma care at Elmwood would be relocated toUniversity, along with two-thirds of a new ED.

KATRINA’S LESSONS LEARNEDOn the first anniversary of Katrina, one of the foremost

emergency medicine training programs reflected on the lessonsthat came not just in coping with a disaster, but with theextended recovery efforts that are continuing today and howthey might be done better.

“There is a lot of duplication of efforts,” DeBlieux said.“There’s a lot of people not being invited to the table–notintentionally, but as a result of nobody really having a graspon the big picture.”

Ultimately, he said, success during a crisis depends on“team effort.”

DeBlieux explained that “it is not just a small leadershipteam.” It is reliant on a number of individuals, from physiciansto nurses, hospital administrators, and everybody in betweenthat it takes to run health care facilities.

“It takes buy-in from everybody,” he said.

doi:10.1016/j.annemergmed.2006.07.010

Annals of Emergency Medicine 311