Commentary: Hurricane Relocation Center Lessons

In late August of 2005 Hurricane Katrina slammed the Gulf Coast Area wreaking havoc in the states of Florida, Alabama, Mississippi, and Louisiana. Over 1,300 people were killed and hundreds of thousands were displaced from their homes. The media incorrectly referred to these people as "refugees," but the correct terminology is "evacuee" or "internally displaced person" (IDP). "Refugee" is a term reserved to describe those who have been displaced across international borders.

Several relocation centers were established across the United States to temporarily house the throngs of displaced persons. The State of Texas accommodated the majority of evacuees with over 5,500 being sent to San Antonio alone. Originally there were four shelters established within the city to receive these people.

This article outlines the experience of one paramedic at one relocation facility. The author understands that the operations differed from center to center as relayed in conversations with people who volunteered elsewhere. It is not the intent of this article to criticize individuals, but rather evaluate the performance of this particular center as a whole to improve future responses.

From September 5th to the 11th the National Association of Emergency Medical Services Educators (NAMESE) held its annual conference in San Antonio. Prior to my departure I received an e-mail notice that NAEMSE was looking for paramedics, EMTs, nurses, and physicians to volunteer their evenings at the relocation centers. The first step in this process was to fill out an application for a temporary certification card so that I could legally practice as a paramedic in Texas. The form was then faxed in to the Texas Department of State Health Services (DSHS). We were told that once the fax was in we were approved to practice, since DSHS was not able to get back to us to confirm temporary certification. They had set up a web site to confirm this, but the data entry was delayed to the point that no confirmation could be gained this way either. I did receive my temporary certification in October after I had returned home.

Bus transportation was arranged from the hotel to one of the four shelters. The shelter that we were sent to was an old Montgomery Ward store that was no longer in business. The outside parking lot was cordoned off with chain link fence. Fire, EMS, and police had a staging area within the parking lot with one fire engine standing by and up to five ambulances staged to transport people out if they were ill enough for hospitalization. People were wandering about and were allowed to leave the premises if they chose. A sheriff's deputy was posted at the entrance gates to monitor incoming and outgoing traffic. There was a significant law enforcement presence inside and out.

The inside was a two-story structure with escalators in the center. Fortunately, the air conditioning was functioning. Folding beds were spread out over nearly the entire first floor and about half of the second floor. There was a volunteer sign-in desk on the first floor. After signing in we were all directed upstairs. Half of the floor was sleeping area, one section was for recreation, one corner was designated as the food service area, one area was set up with a telephone bank, and another corner was for medical services.

The recreation area had blackboards all along the wall that children had drawn all over with chalk. Some kids were playing there with basketballs, and one kid was even riding a bike around. Televisions were dispersed in various sections of the first and second floors. Many people just walked around aimlessly. It was clear that a good supply of reading material or games would have gone a long way to alleviate the boredom. The public library system in San Antonio did ultimately offer a free six-month library card to anyone in the relocation centers.

The food service area seemed well organized. There were three lanes, not unlike a grocery store, that people moved along picking up items as they progressed. There were storerooms adjacent to this area with generous stockpiles of food and beverages. Volunteer food service people were staffing the area.

There were portable toilets set up outside and two restrooms on each floor. So many people were using the toilets and sinks that the conditions in the restrooms were unsanitary, to put it mildly.

The medical services area had several sections. When a person walked in they could either go straight ahead to a triage area or take a right into a make-shift pharmacy to fill their prescription drugs. Not all drugs were available, but the more common ones were stocked if possible. One man did have to be sent out via ambulance as he was feeling weak and had not taken his seizure medication for a week.

In the triage area the patient was assessed, a history was taken, and they were treated and released or treated and then taken downstairs by wheelchair to the awaiting ambulances. Most of the ambulances sat idle as very few patients were transported out. There were many over the counter (OTC) drugs given out, dressings changed, and blood sugars checked. Insulin was available for those who needed it. Vaccines were also available if needed. Vaccines in stock included tetanus and hepatitis A. They were given out haphazardly and no one could articulate the criteria for who received the vaccines.

There was a total lack of any incident management structure. We worked a shift without even knowing who was in charge. I strongly suspect that no one was. We asked many people, but could not find any such person(s). Although grossly inefficient with many volunteers looking for things to do, the necessary services were being provided. The burn out rate among volunteers was high and may have been reduced with a command structure in place. About a third of the volunteers could have carried out the same work load if some organization had been applied.

In our group there were about six nurses and sixteen paramedics. The nurses were immediately put to work triaging and treating people whereas the paramedics were relegated to posting signs, distributing food, and running small errands. The nurses in the medical area either had no idea that paramedics could perform most of the same skills (and some beyond) that they could or were not interested in learning what we could do to help. So while they were struggling in the medical section, complaining of work overload, we were sent out to perform tasks that a medically untrained person could easily have done. Some of us worked our way into helping medically, but at that point I'm sure they thought we were nurses too.

Many of the people had not been medically evaluated since leaving the hurricane-impacted areas. When I inquired about any kind of surveillance measure to monitor for lice, scabies, hepatitis, measles, diarrheal illness, etc., I was told just to send them to the medical area if I came across any. Some of my group was sent out with a bucket of medications (acetaminophen, Immodium AD ®, diphenhydramine, etc.) to go person to person and ask if they needed anything. This proved very inefficient and wasteful as almost everyone wanted some kind of medication. Since they had lost everything, there was a tendency to hoard whatever they could get. This included medications although they were supposed to take them immediately when offered. The reality was that many took the medications and walked away to add to their stash of supplies. There was also no documentation as to who was given what medication or why. The OTC drug storage area was a free for all, with volunteers just taking what they needed with no accounting or inventory system. Generously, the local Wal-Greens Drug Store just kept stocking it up when medications were depleted.

A chaplaincy group and a social worker set up camp behind the triage area. People would show up with behavioral health needs and could be referred immediately back for assistance. Burned into my memory is one man who came to the triage area who said he had been at the facility for the last few days, but that it had just sunk in that he had visited his home for the last time and worked his last day at his job. He was feeling despondent and depressed and need someone to talk to. He just looked lost.

Other medical services available included dentistry, cardiologists, and optometry. These specialized services were available on certain days and their schedules were posted.

In conclusion, there was mass chaos, as can be expected in just about any large scale incident. Many good services were being provided and food and shelter were well provided. It was, however, frustrating to see the inefficiencies and lack of organization that were also prevalent. With the proper implementation of an incident management system and thorough pre-event planning the relocation center could have performed much more efficiently and made much better use of resources. I hope the chronicle of my experience will help others learn how a situation like this may unfold in their own area and give valuable insight as to how to prepare for events of this nature in the future.

Chris G. Caulkins, MPH, FF, EMT-P, is the EMS Program Director for Century College in White Bear Lake, Minnesota. He also serves as a paramedic and firefighter for the City of Woodbury Public Safety Department.