DOI: 10.1148/radiol.2422060716
(Radiology 2007;242:334-337.)
© RSNA, 2007
Weathering the Storm: Maintaining an Operational Radiology Department at Ochsner Medical Center throughout Hurricane Katrina1
Thomas E. Heffernan, IV, MD,
Srinesh Alle, MD and
Charles C. Matthews, MD
1 From the Department of Radiology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121. Received April 24, 2006; revision requested June 20; revision received July 10; final version accepted September 1.
Address correspondence to T.E.H. (e-mail: theffernan{at}ochsner.org).
Hurricane Katrina was a storm of superlatives. The costliest storm in American history brought unprecedented devastation to New Orleans, Louisiana, and the Gulf Coast, and the region will struggle for years to recover. Ochsner Medical Center and its Department of Radiology were at the center of this disaster. The unique experience of this department during this time has served to better prepare it for future disasters. Radiology departments around the country may learn from our experience in developing and improving procedures for emergency situations.
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STORM PREPARATION
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Ochsner Medical Center is a regional tertiary care hospital. At the time of Hurricane Katrina, the hospital had 478 beds and employed over 600 physicians. The radiology department employed 19 physicians and performed approximately 250 000 examinations annually. In preparation for the storm, every department at Ochsner Medical Center created an essential personnel list—that of a minimum number of people who would be able to run their respective departments. These essential personnel were to remain in house until the emergency situation had passed. The family members of these personnel were not permitted inside the facility, as space would not allow it. There has been a call for only essential personnel several times before at Ochsner, most recently in 2004 with the near miss of Hurricane Ivan.
As the forecast tracks for Hurricane Katrina became clear, the decision to implement an essential-personnel-only protocol was made on August 27, 2005—36 hours before the landfall of the storm. Essential personnel, designated team A, were instructed to report to the hospital on the morning of August 28 and were expected to be relieved by a new team, designated team B, in a couple of days, after the storm had passed. Not anticipating the magnitude of the imminent disaster, most essential personnel brought clothes, food, and water for only a couple of days.
The radiology department's essential personnel were three staff physicians, four residents, administrators, 10 technologists, an interventional nurse, two film librarians, and a transcriptionist. Most imaging and interventional services, with the exception of nuclear medicine and mammography, were provided by this small group of staff members. The three staff physicians were selected for their combined ability to interpret images from all modalities. The four radiology residents included two senior and two junior residents. As a group, the residents were selected to interpret all imaging studies, with staff performing final interpretations. The radiology technologists consisted of two sonographers, two computed tomography (CT) technologists, one magnetic resonance (MR) technologist, one interventional technologist, and four general radiography technologists. Administrative support staff members also were present to ensure continued department function.
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KATRINA ARRIVES
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A mandatory evacuation of New Orleans was implemented on Sunday, August 28, 2005. Surprisingly, the emergency department was operating at a relatively normal volume. Patients were coming in with a spectrum of complaints not unlike those encountered on a normal day. The radiology department was functioning as usual. As the outer bands of Katrina darkened the late afternoon sky, the volume of studies requested by the emergency department dropped precipitously.
Everyone in the department was closely monitoring the track of the storm. There was an intradepartmental meeting that night, in which logistical issues were discussed. In anticipation of the loss of power, the equipment that could be operated by using backup power was clarified. According to prior planning, one CT scanner, an MR imager, two ultrasonography (US) units, an interventional suite, and the picture archiving and communication system (PACS) were expected to be operational with use of backup power.
Hurricane Katrina made landfall as a category 3 storm just east of New Orleans on the morning of August 29, 2005. That day, the radiology department and the hospital in general were not busy. As Katrina's winds battered New Orleans, the radiology department staff hoped that the worst would miss New Orleans. After the storm passed later that day, several of the team A residents took a walk down some of the streets surrounding the hospital. There was severe wind damage, including downed trees and power lines, as well as missing roofs. Although initial images were frightening, it seemed that the city had survived.
Words cannot adequately express the emotions felt by those who watched from a safe distance. Evacuated members of the radiology department watched intently from a multitude of locations around the country. Evacuees prepared in a manner similar to the preparations made by essential personnel who had stayed at the hospital, grabbing a few critical items from home and expecting to return in a day or two. However, it was soon reported that several key levee failures were slowly drowning much of the city. The sites of the flooding were initially unclear, but residents assumed the worst; New Orleans would be flooded for weeks, and recovery would be difficult, if possible at all. Everyone's thoughts went out to those who remained at Ochsner.
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IMMEDIATE EFFECTS
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The hospital switched over to generator power as Katrina made landfall. However, when the generator power came online, the angiography suite was nonfunctional. Although the PACS servers and the MR unit were operating with backup power, the air conditioning units in the facilities housing them were not. As a result, the servers overheated, and the PACS system crashed. The magnets were unable to be kept cool and had to be quenched. The dictation system also crashed. In the end, the only operational equipment included a CT scanner, digital film units, and US equipment. Radiographs were printed from the digital units, CT scans were interpreted on the control monitor, and US images were read from the units themselves. The radiology information system was still functioning, and work orders were able to be generated. Dictation was performed by using a backup Windows-based recorder, which would be uploaded into the main dictation system in the future.
Hurricane Katrina knocked out much of the city's communication infrastructure. Basic land telephone lines, mobile phones, and a great number of pagers were rendered useless. The only forms of communication that worked were internal short-range pagers, short-range mobile hospital phones, and e-mail systems. With the loss of communication in the city came the loss of information. There was access to satellite television, and employees were able to witness the dramatic events that were unfolding in the city. However, numerous rumors about conditions in the city spread throughout the hospital. The lack of information and uncertainty about the future definitely affected morale. Safety was a concern, with reports of widespread looting. Also, it was unclear how long team A would have to stay at Ochsner.
With the rest of the radiology department scattered throughout the country, communication was of the utmost importance. E-mail became the method of choice for intradepartmental communication. Despite the initial loss of phone lines, e-mail communication was maintained in the immediate aftermath of Katrina. Ochsner was able to keep e-mail and Internet access because its T3 line connecting to a backup site in Baton Rouge, Louisiana, still worked. This enabled direct contact with team A and gave reassurance to all residents that their colleagues were safe. On August 29, 2005, the first of a series of e-mails was sent to the residents with the intention of making sure that everyone had evacuated, was safe, and could provide a current contact number. One of the many unexpected problems caused by Katrina was a near total loss of wireless communication. Mobile phones were rendered almost useless, being usable only far outside the affected region. Thus, a current contact number was important. The first e-mail message led to a nearly complete response and paved the way for future resident e-mails, as well as e-mails between radiology staff members. By September 1, Ochsner had dedicated phone lines running and further communication was possible. It became clear that Ochsner Medical Center not only had weathered the storm but also was functioning at a remarkably high level.
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RELIEF TEAMS
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Maintenance of communication was a key element in the formation of relief teams. The on-site staff and residents had been working and living at Ochsner, often under great duress, since August 28, 2005. The initial plan to relieve team A after 2 days could not be implemented owing to the widespread damage and evacuations. Plans were immediately initiated to provide relief for team A on September 2. Additionally, in light of the massive scale of Katrina and the lengthy mandatory evacuations issued by local governments, a plan to rotate relief teams was formed to ensure adequate staff and resident coverage of the radiology department for the foreseeable future.
Team B consisted of three residents and three staff members. These personnel also were selected to ensure efficient coverage of all imaging modalities within the radiology department. On September 1, 2005, members of team B were notified of their status and asked to report to Baton Rouge the following day. Baton Rouge was the location of Ochsner Health Center-Bluebonnet, a regional outpatient care center that had become the effective staging area for relief efforts to the main campus in New Orleans. A chartered bus met the relief team, and the journey to the main campus began under police escort.
Along a route traveled so many times before, the landscape had changed. A sense of trepidation grew as fallen trees became larger and more numerous. Signs were mangled everywhere. With the exception of many military vehicles, the highways were almost empty. The most surreal marker of the devastation that lay ahead was a digital road sign—the same type of sign used on highways nationwide indicating construction zones—that read simply, "New Orleans Closed."
Crossing the Mississippi River, residents obtained their first glimpse of Ochsner Medical Center. It looked remarkably unchanged in contrast to the surrounding area. Nearby streets, littered with fallen trees, were inaccessible. Stores were smashed and in some cases burned to the ground. Fortunately, the flooding seen elsewhere had spared Ochsner Medical Center, which lies on the east bank of the Mississippi River, a full 6 feet above sea level. Although brief flooding occurred with the heavy rains brought by Katrina, no water from levee breaks reached the surrounding area. Additionally, the concerns about looting were alleviated by the arrival 2 days after hurricane landfall of National Guard soldiers to stand watch.
As each 6-day shift ended, a new team of relief workers arrived in the radiology department. Team B was relieved by team C, and this pattern would continue until team F, the last group to work under the hurricane conditions, arrived. On most relief rotations, three residents and three staff members covered the entire department. After the first three relief cycles, transportation improved, and many were able to drive their own vehicles to Ochsner.
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WORKING CONDITIONS
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Initially, the four radiology residents on team A divided each day into four 6-hour shifts, with 18 hours of rest after a shift was completed. Responsibilities were very similar to those of a normal overnight call. The resident covered preliminary readings for all CT examinations, performed all fluoroscopic studies, and helped staff members perform any interventional procedures requested. Staff radiologists read all hospital radiographs and US images and reviewed all of the residents' work in CT and fluoroscopy cases after the preliminary readings.
Although the volume of patients was not as high as that before the storm, there was a demographic shift in the patient population. With the flooding of many local hospitals, including Charity Hospital, the major trauma center for the area, Ochsner began to see more patients who had suffered trauma from the storm and the ensuing mayhem in the city. Additionally, many patients with chronic medical conditions who had taken up residence in the Superdome as a shelter of last resort were treated at Ochsner.
When team B arrived on September 2, 2005, the radiology department had one CT scanner, full US capability, three interventional suites, and full radiography and portable radiography capability. On September 5, a mobile MR unit arrived and the first MR examination after the hurricane was performed. Nuclear medicine procedures were unavailable, as radiopharmaceutical agents could not be delivered. Clearly, the department was able to provide needed services despite the difficult conditions.
Team B was fortunate that emergency power had restored full PACS capability with a fully functional dictation system. Therefore, the reading and reporting of imaging studies were unchanged from normal operations. Initially, the workload was light. Approximately 10 CT examinations, five US examinations, and 100 radiographic examinations were performed each day. Fluoroscopic and interventional examinations were sparse, although four or five in each modality were performed each week. The patient population consisted of relief workers and local residents who had refused or were unable to evacuate. These examination rates increased rapidly as ensuing relief teams arrived.
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LIVING CONDITIONS
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Initially, living conditions were dramatically changed. The most noticeable difference was the lack of air conditioning and running water. As a result, it was very hot inside the hospital and there were limited bathing options. Part of the disaster plan included a ground well that had been completed several years previously. This eased, but did not eliminate, the lack of running water. This was not a major concern, however, because there was plenty of bottled drinking water, which the hospital had stored prior to the storm. Although conditions during the immediate poststorm period were less than pleasant, they were far better than those that others had to endure in the hospitals across the city that were flooded.
Fatigue was a constant problem among team A members despite their shift-based work schedule. It was hard to sleep because of sweating from the heat. There were horrific smells throughout the hospital. There was no place to take a shower to get clean and refreshed. Meals consisted of one can of food and a bottle of water. By the time team B arrived, conditions had markedly improved. For radiology, three call rooms were available to the residents. Air conditioning was functioning in most of the hospital, including all of the radiology department and the call rooms. Cold water was now available from the hospital well, and showers were a nice luxury. Power, including telephone lines and the Internet, was available. It was very easy to keep in touch with friends and family who were understandably concerned.
The food service improved as relief items arrived. Three meals were provided daily in the cafeteria. Two meals were usually sandwiches or a cold item. However, supper was a hot meal and was always appreciated. On Labor Day, fresh watermelon was even provided to help make the day feel a little more like a holiday. Most residents brought a good supply of snacks, drinks, and comfort food, as well.
When not working a shift, many residents had time to make short trips to their homes. The opportunity to rip up wet carpet and clean out refrigerators was not missed. Unfortunately, several residents and staff members did lose their homes to flooding. Some were also victims of looting. However, there was great peace of mind for many who discovered that their homes were intact.
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RETURN TO FULL FUNCTIONALITY
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On October 3, 2005, the radiology department at Ochsner returned to full functionality, as a full complement of staff members and residents reported for duty. The decision to return to full functionality was based on a number of factors: First, the Orleans and Jefferson parishes were officially reopened to residents. As people returned home, medical care was a necessity. Ochsner Medical Center, as one of three fully functional hospitals in the metropolitan area, was ready to fulfill these needs.
Before October 3, the radiology department had been tracking the increase in imaging examinations as the relief effort continued. These data were used to project the number of examinations that would be performed in the near future in an effort to determine when full staffing would be most prudent (Figure). Of note, satellite clinics resumed general radiologic operations on September 12, mammography on September 26, and nuclear medicine on September 28. By late September, it was evident that full staffing would soon be required, as the department had reached nearly half of its pre-Katrina examination volume. On October 3, the first day of full staff and resident coverage, 621 radiologic examinations—over two-thirds the normal volume—were performed. By late November, the radiology department work volume had essentially returned to pre-Katrina levels.
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Line graph shows weekly radiology examination volume by modality after the storm. Lines for hospital and satellite areas represent radiographic examinations performed at Ochsner Medical Center and local clinics, respectively.
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Also of note, the teaching aspect of the residency program did not suffer. The relief work allowed residents to have broader exposure to modalities that they normally would not have been exposed to until later in their residency. Staff and resident teaching conferences resumed in October, and most multidisciplinary conferences resumed that month as well.
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LESSONS LEARNED
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The radiology department at Ochsner Medical Center is in a unique position. Residents and businesses in New Orleans have experienced numerous hurricane evacuations in the past. These evacuations have allowed the medical center to develop and fine tune a disaster preparedness plan over the years. This plan was put to the ultimate test during Hurricane Katrina. Despite some shortcomings, the department was able to provide continuous service to Ochsner Medical Center throughout this crisis. The lessons learned during this catastrophic event may be of help to other radiology departments around the country. Other disasters, both natural and man-made, have occurred and will continue to occur.
First and foremost, it is intuitive that a disaster preparedness plan should be discussed and planned in advance of any threats. There is never enough warning prior to such an event. Having in place a well-designed plan that can be activated when necessary is essential. Selecting the appropriate personnel to maintain the department is a critical aspect of this plan. These personnel should include staff physicians, residents, and technologists, as well as support personnel to operate systems critical to the department. A plan for relief of these personnel is also essential. Additionally, a radiology department has unique needs for power and water that need to be considered. Backup power should be available for essential equipment and reading stations. Radiology departments should consider performing a trial power outage to ensure that the backup power works as planned. Water for air conditioning and to directly cool computer systems is critical in this era of PACS and digital imaging. Contingency protocols for printing images if computer systems fail should also be available. Consideration of how reports will be provided to clinicians is also essential, because this is a major responsibility of any radiology department.
The Ochsner Medical Center Department of Radiology hopes that the experience it gained during Hurricane Katrina will help better prepare its staff for the inevitable next hurricane. Multiple steps have been taken at our institution to ensure that the difficulties encountered during this crisis will not interrupt services during future hurricanes. Additional backup generators have been installed in areas to protect them from possible flooding. Another important change has been the initiation of a hospital command center with satellite phone and communication services to coordinate hospital care and ensure that Ochsner remains in contact with the outside world throughout such an event. We hope that other radiology departments can learn from our experiences and formulate their own disaster preparedness plans.
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ACKNOWLEDGMENTS
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The authors thank all members of the radiology department at Ochsner Medical Center for their courageous efforts during and after Hurricane Katrina.
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STORM PREPARATION
KATRINA ARRIVES
