Rebuilding from the (High) Ground Up

     How do you go about rebuilding an EMS department when most of the responders and even the director have suffered severe damage and displacement from their homes? That's the situation New Orleans, LA, EMS is facing six months after Hurricane Katrina devastated the city and the emergency department that serves it. Headed by Jullette Saussy, MD, whose title includes both director and medical director, N.O. EMS is a field unit system centered around a single base of operations. In such a system, all the assigned employees show up to the base before each shift and then are fielded out to locations throughout the city, based on the call volume need, as determined by system status management. The advantages of this system mean that Saussy and Deputy Director Mark Reis--both of whom had only started working in the department eight months prior to the storm--are in contact with everyone who works for them every day, and providers are close to an emergency call at any given moment. The disadvantages became apparent when flooding washed out that base, 25 of 40 vehicles, all the computers and the telecommunications systems.

     Today, Reis, spokesperson for the agency, makes a strong case that New Orleans EMS is in better shape than one might think. While frustrations are many in dealing with an ongoing disaster of this magnitude, there is also great opportunity when starting from the ground up. As one medic put it, "You don't get that many chances to start over, but that's exactly what we're getting to do."

     What they're looking at, says Reis, is an opportunity to standardize and back up communications with the rest of the emergency system, develop and integrate training practices with other public safety departments, and implement a unified vision of the Incident Command System and other organizational structures--an enviable position if it had not come at such high cost. But now, with the help of the Army Corps of Engineers and FEMA, including a $112-million loan shared with the New Orleans Fire Department, plus a sizeable Assistance to Firefighters (AFG or FIRE) Grant to set up a consolidated training center, among other things, once they're stabilized, the department is coming back strong. "We're good, we're running," says Reis. "We just have to make sure we're ready for the next hurricane season."

     While the EMS agency has recovered by leaps and bounds, there is still much to be done to prepare for that season, which is only three months away; and at press time, the Gulf of Mexico is already 10 degrees hotter than a year ago, he says. "That's bad for tropical depressions; it could be just as bad a year as it was last year for us. So, that's what we're focusing on now. We're not going to lose everything again."

     What have they accomplished, and more important, what have they learned that will help them when the next named storm hits the Crescent City?

     "The lesson learned is pretty simple," says Reis, "You go back to basics. Like most major metropolitan areas, we had a disaster plan. Obviously, that plan went out the window when we lost all communications and all ability to be mobile. How do you answer a phone call if there are no phones? Imagine all of the infrastructure that you had ever put together, all the computers, the electronics--they're gone. You just had to go out...on foot and in boats...and find people."

     Where do you start building an infrastructure? "On very high ground," says Reis.

COMMAND AND CONTROL
     First order of business is stabilizing the organization itself. "It's like establishing a family: You stabilize your hierarchy, food, water and shelter; then the rest follows," explains the deputy director. Establishing command and control is the highest ground from which you can then build.

     When the storm hit, Saussy and Reis had only barely begun to restructure this municipal department, which had previously been managed by a private contractor. Now they had to work fast. Developing a proper Incident Command System requires "extreme depth in command and control," says Reis. And that starts by creating leaders, which means creating strong relationships.

     "You have to be able to go to your line employees and say, 'You need to act like you're a supervisor today.' So we split the department into five pods: each one had a field supervisor with employees and equipment underneath them. Many of them had never been in that command role, so there was a change in dynamics."

     There weren't enough supervisors to go around for the important jobs, he explains, so line employees had to do things they'd never been asked to do before.

     "I had one medic, Cedric, whose job was doing the flight line. I told him, 'You are responsible for this: You will land all these helicopters, you will tell people where to go, what to do.' He was a part-time employee before the storm. He now had the responsibility for the entire division of landing and handling all air assets coming into our landing zone."

     The Incident Command Structure and the NIMS training they had, was critical here, says Reis. Leadership has to be structured into the team, and is task-oriented rather than person-oriented. In other words, "Whoever has on the red vest that day is in charge, it's his deal. Because even I, as deputy director, took direction from Cedric when I worked on the flight line. It was his flight line, not mine."

     That takes trust in the top, which Reis and Saussy have built by their response during and since the storm, according to at least one medic who said, if anonymously, "They're awesome."

     New Orleans EMS is now divided into five "pods of leadership": Logistics, in charge of inventory and the recovery of equipment; Communications, handling dispatch and documentation; Operations, which manages staff and runs day-to-day missions; the Special Operations Division (SOD), for everything from training to swiftwater and high-angle rescue, vehicle extrication, USAR and SWAT medics; and Finances and Human Resources (HR), taking care of the budget, billing, reimbursements, payroll, hiring and company policies. In addition, there are two liaisons, one for DHS and the other for both the city and state emergency operations centers (EOCs). All employees--paramedics and EMTs; there are no administrative staff--work in one or more of these divisions.

     Managers meet together each week along with Reis to plan ongoing developments and keep everyone in the loop.

FACILITIES
     Next order of business is finding a home, he says--a base of operations. After a month of living and working together in a make-shift base at a nursing home during and after the storm, staff were relocated to better quarters (more on that below), while operations were run out of a borrowed 40' by 40' portable building (dubbed "The White House") and parked in the Convention Center parking lot. By December, the base was moved into two 14' x 60' FEMA trailers placed under the Crescent City Connection, a nearby bridge and "the highest point in the city," according to Reis. Here they expect to stay until arrangements for a permanent facility, properly "mitigated for flood control," can be completed.

     Their dispatch center is housed, also temporarily, in another location near City Park, as part of a consolidated communications center shared with the police and fire departments, which too sustained considerable damage from Katrina in both structure and morale.

     Consolidating resources has been one of the storm's blessings. "We've been together in the same physical structure since the days after the storm," says Reis. "That's new. Now, when you have a major event, the dispatchers for all the major players are talking to each other in the same room--my guy turns and looks five feet from him and there is a police dispatcher sitting right there. No delays, no waiting for an answer--it's a more efficient system. That came out of this event."

     Police, fire and EMS comprise the public safety component of the city's Department of Homeland Security, headed by retired Marine Corps Colonel Terry Ebbert, and are now working together with the city on plans to build a Unified Command Center that will house the three departments, beyond their 9-1-1 call center, together permanently. With turf wars rendered irrelevant by disaster, it makes sense to build one public safety facility rather than duplicating their systems.

     "We have an opportunity to do it right," says Reis, which means in this case, building above the high water mark, with back-up technologies for power, communication and data storage installed.

     But, Reis is careful, if not adamant, to say that while developing technologies that are disaster-resistant is a great goal, the lesson of "back to basics" means to expect that these will fail. "It's not a matter of if, but when," he says, which means before you build anything, you need to build your relationships. A disaster is not the best time to start that process, but that's the position they found themselves in last August and September.

EQUIPMENT & SUPPLIES
     The Logistics Division has succeeded in replacing the 25 flooded vehicles with brand-new ambulances, restoring the fleet to 40. They are still two short of their original 11 sprint cars; and have only one rescue truck, down from two.

     Since uniforms were stolen during the disaster, presenting potential security issues to the citizens of New Orleans, these have been redesigned and reissued with new colors, patches and badges. Policy has changed along with them, and staff are reportedly proud to wear them now on every shift.

     Patient-care supplies have also been restored with all the basics and brand-new monitors.

     Working together, Logistics and Communications have supplied all the managers with Blackberry wireless telephones, which have cellular, instant messaging and e-mail capabilities. Staff are carrying portable radios and personal cell phones. Mobile radios are functioning in the vehicles. Still in the planning stages are satellite phones and laptops with wi-fi capability, says Reis, which proved invaluable for those agencies that had them during the storm.

COMMUNICATIONS
     The Communications Division is scheduled to get Dispatch back on line with their CAD (computer aided dispatch) system soon after print time. Until then, they have been painstakingly inputting call volume data by hand into a spreadsheet that Reis created to track it. They can then use the geographic information system (GIS) software RAMSAFE to map their calls and keep their systems status management current, so Operations can place field units where the need is greatest.

     They can also document from this data that calls are up 200% in the West Bank area, the slowest region prior to the storm, "because that's where the population is densest," says Reis. They are also tracking the return of the population as a whole in New Orleans. "They may not have power and all that," he says, "but they're sitting on their porches in the Lower 9th Ward, and they're back in Lakeview and Uptown, and they're back in New Orleans East. There are people out on their porches. What the media's portraying is not always accurate."

     Once the CAD system is in, this data will be automatically available as the calls come in.

BACK TO PAPER
     Reports are still being written on paper at this time, as the computers have not yet been replaced. Reis says this is an important lesson for everyone in the country. "Don't be foolish," he says. "Carry a box of paper reports with you. Back to basics: A pen, pencil and a piece of paper will go miles. In an all-out disaster, forget the computers. It's all going to fail. You will have to be able to find someone you know and get the information to them. Get to know them now."

     For that matter, all records are still on paper, including medical and billing. However, says Reis, the old systems were antiquated, "so all it's really done is accelerate the timeline on replacing all that; it may be a blessing." A request for proposals (RFP) will be going out for billing and records any day now, he says.

PERSONNEL
     Many, if not most, of the 130 or so full- and part-time staff lost their homes or were separated from family members during the evacuation. Twenty-one have left the organization, though Reis says with the city removing the residency requirement for workers to live in the city, he expects the hiring process to improve drastically. With new hires, the agency is working with a total of 95 full and part-time employees, down by about 20%, but call volume is down over 50%.

     All workers for the city of New Orleans were provided with housing and three meals a day on either of two cruise ships, the Ecstasy and the Sensation; families welcome. However, many of these had moved away as New Orleans schools, hospitals, jobs and other basic amenities remained few and far between.

     The department responded by adjusting the shift schedule to make it easier to travel long distances and keep family relationships intact: seven days on and seven days off. This means staff can be with their families every other week, which, while far from ideal, helps, says Bill Niemeck, EOC liaison, who was initially separated from his family. "It's better than a long commute or weekends that are too short," he says.

     All staff are scheduled to be off the ships and into homes by March 1. How that will affect families and the schedule remains to be seen.

     Healthcare support has also been provided to staff with physical screenings after the storm, and ongoing psychiatric care and stress debriefing available to anyone who wants it. "We don't think it should be mandatory," says Reis, "and it's not, but Jullette and I are committed to making sure our employees have it. Many are having issues not just with EMS, but with their families, with finances; there are so many questions to be answered. Those who've used it have found it has helped them out tremendously. "

A NEW DAY
     Like a phoenix rises renewed from the ashes, New Orleans EMS is rising from the waters, a whole new organization.

     Says Reis, "If you look at New Orleans EMS on August 28, 2005, the equipment we had, what we dressed like, what we lived in, and then fast-forward to today, it's light years apart. We've rewritten all the policy and procedures, we've got new uniforms, a new badge, a new patch, new ambulances, new truck, new stretchers and new monitors. And we started back...fresh and new, moving ahead. A completely different entity that looks wonderful, that's operating efficiently and, you know, we're going to continue to do that."