OR WAIT null SECS
Three psychiatrists give their perspective on helping victims of one of the nation's worst natural disasters.
In times past, Louisiana psychiatrist Harold Ginzburg,M.D., J.D., M.P.H., has worked with refugees in Vietnam, Thailand and thePhilippines and evaluated the psychological health of Russian villagers livingin areas contaminated with radioactive fallout from Chernobyl. However, on Aug.28, Ginzburg himself was fleeing from the fury ofHurricane Katrina, just a day before it destroyed his home near New Orleans.
"The roof on my home is pretty badly damaged, according to the satellitephotos," Ginzburg told Psychiatric Times. One of Ginzburg'sneighbors who checked on his home in Metairie, La., described it as pretty muchdestroyed.
Yet Ginzburg, disaster chair of the AmericanPsychiatric Association's district branch in Louisiana, had no time to dwell on his ownplight. When the mandatory evacuation was issued for New Orleans and the surrounding areas, he went to the Henry S. JacobsCamp, a Jewish summer camp in Utica,Miss.
"The camp was set up as a refugee center and had the capacity [for] up to300 people. So when I got there, I became the camp doctor, working both as ageneral medical doctor as well as a psychiatrist."
He faced challenges in both roles, and it became a matter of being creative.He needed oxygen for one patient, but had no access to medical oxygen. So, hefound a welder in Uticaand got welding oxygen instead. He had to change patients' medications to whatwas available at the local pharmacy or stretch out their supply.
"Utica is avery small [population <1,000], poor community. So the pharmacist justorders medicines when people need prescription refills. He doesn't keep them instock," Ginzburg said.
After the storm struck, there was no power available and no running water atthe camp. To help prevent an infectious outbreak, Ginzburghad camp residents draw water from a nearby lake and load it into 55-gallondrums, so that people could use small trash cans filled with water to flush thecamp toilets.
The psychiatric challenges were equally daunting. Ginzburgwas faced with three sets of problems: taking care of about 35 to 40 severelydevelopmentally disabled individuals, helping those with pre-existingpsychiatric problems, and addressing the needs of the newly traumatized.
The caretakers of the developmentally disabled individuals had brought afive-day supply of medications. Since many of the disabled were prone to seizures,Ginzburg worried about keeping them cool without airconditioning.
"The staff would go on an ice hunt to Vicksburg[Miss.] or across the Mississippi River toTallulah [La.],so patients could be iced down during the night to keep them cool to preventseizures," he said.
For those who had pre-existing psychiatric problems, such as bipolardisorder, chronic depression and psychotic thought disorders, he made sure thatthey had enough medications. If not, he arranged to buy them himself from thepharmacy in Utica.
"Frankly, it was easier to buy the older medications, which were generic,until we got power back and had enough gasoline to start driving around andgetting prescriptions filled," he said. "In those instances where they neededmedication, I just went in to the pharmacist and wrote prescriptions, because Iam licensed in Mississippi."
For the newly traumatized, Ginzburg and the staffurged them to start talking about their problems, to stay physically active andto take positive action by planning their next steps. He explained to theevacuees that if they could walk and talk, they were better off than otherpeople.
"It was easy for them to see that we had more severely affected people, sowe had no psychotic breaks, we had no suicides and we had no significantacting-out, at least initially. Later on, we had some minor problems," Ginzburg said. "Basically, we got them to look at thepositive, accept the fact that they weren't going home right away, and thatthey were going to have to enroll their children locally or go to anothercommunity where their children would go to school."
Now that his responsibilities at the camp have diminished, Ginzburg is focusing on next steps as well. Staying with amedical colleague in Baton Rouge, La., Ginzburgis looking at possibly reopening his private psychiatric practice on apart-time basis.
"I have 17 patients who have called in so far from seven different states,"he said, adding that he is hoping that the other 83 will call in at some point.
Because Ginzburg worked in the Office of EmergencyPreparedness of the U.S. Public Health Service for five years before he retiredfrom the military, he is assessing future needs for Louisiana.
"I am working with the mental health component of the Louisiana HealthDepartment in Baton Rouge,helping them write grants to get more funding," he said. "We are trying tofigure out what our needs will be for psychiatrists and other kinds ofphysicians and mental health providers, starting at the time when the acutememory of Katrina goes away. We are going to be creating new communities andnew sections of towns, so outreach psychiatry and outreach mental healthworkers, school interventionists and people working with various faith-basedorganizations are going to play an important role in stabilizing thispopulation. If we can do primary prevention, we will be a lot better off."
Based on his earlier experiences in working with disaster victims, Ginzburg warned his fellow psychiatrists against overdiagnosing.
"People are entitled to have symptoms. I don't want to see them being givenpsychiatric diagnoses during a period of time when to be angry, to be upset orto be confused is a normal healthy response to being involved in a disaster,"he said. "If they become dysfunctional, then a diagnosis is appropriate. Youcan prescribe medication if they are having symptoms and emotional tumult, butlet's not overdiagnose."
Ginzburg is also treating police personnel andother first responders. Fortunately for his patients, part of his privatepractice involves evaluating and treating patients who had developedpsychiatric problems as a result of traumatic incidents, and he often workswith law enforcement officers and their families.
Since he is disaster chair for the Louisiana Psychiatric MedicalAssociation, Ginzburg was asked about his efforts toorganize psychiatric coverage in the early days after Katrina caused what Ginzburg described as the "largest involuntary migration inthe U.S.,since the Okies in the 1930s." Katrina involved adisplacement of half a million people or more.
Early on, Ginzburg contacted Joni Lee Orazlo, M.D., a child and adolescent psychiatrist, inLafayette; Jodie Holloway, M.D., a forensic and pediatric/adolescentpsychiatrist who was helping in the Lake Charles area; Dudley Stewart Jr.,M.D., a psychiatrist with a subspecialty in forensics from New Orleans, whoended up in the Astrodome; and David Post, M.D., a psychiatrist who coordinatesmental health and mental retardation services in Baton Rouge. The psychiatristscommunicated by Internet and cell phone trying to get a sense of what the needswere, provide services to evacuees and make requests for additional mentalhealth volunteers.
One of the problems they faced, Ginzburg said, isthat psychiatrists in New Orleansleft on mandatory evacuation orders, and many went outside the state.Additionally, most of the psychiatrists who remained in the western or northernparts of the state were not only unable to help with the evacuees, but wereunable to take care of their own patients, because they had their own families,as well as relatives and friends, staying with them.
Psychiatrists in Louisiana and other parts of the country able to volunteertheir help for a week or more, according to Ginzburgand Post, should send an e-mail with their name, address, phone number, statemedical license number, e-mail address and dates of availability toCAHSDfirstname.lastname@example.org.
Despite the destruction of his home and the disruption of his privatepractice, Ginzburg remains optimistic.
"I'm flexible. I'll work it out. It is a matter of taking a deep breath andsaying OK, I've got to start over," he said. "All my grandparents came from atown called Bialystock, either in Russia or Poland, depending on what year theyleft. They came here, they started all over and they didn't speak English. Sofor me to start all over is not a big deal. I speak English, I have my medicallicense and I'll get back to normal in a few months."
While Ginzburg was helping in Mississippiand Louisiana, Sally Taylor, M.D., medicaldirector of the University Hospital psychiatric emergency service in San Antonio, and Scott Zeller, M.D., chief of staff forpsychiatric emergency services at the AlamedaCounty MedicalCenter in Oakland,Calif., were helping in Texas, along with hundreds of psychiatristsand other mental health professionals.
As the Category 4 storm ravaged New Orleans,parts of Mississippi and Alabama,thousands of evacuees found shelter in Texas,with some 13,000 in San Antonio.They were distributed to two shelters at Kelley USA (a commercial developmenton the former Kelly Air Force Base) in buildings 1536 and 171; in an old LeviStrauss building; in Windsor Park Mall; and in several shelters providedthrough the Baptist church.
"Initially, we set up a mental health unit at one of the Kelly shelters, andthen sent mental health screeners to all the other sites. The screenersincluded volunteer psychologists, nurse practitioners, psychiatric socialworkers, anyone who had experience in the mental health arena," Taylor said.
A training session was provided by the Texas Department of State HealthServices (DSHS), where Steve Shon, M.D., is directorof mental health services. The screeners also distributedinformation on posttraumatic stress disorder symptoms, and told evacuees thatif they experienced such symptoms to come and see them. Psychiatrists workedround-the-clock at the mental health unit in Kelly Building 171.
"Occasionally, we had enough psychiatrists we could send them to the othershelters, but mostly they were concentrated at Kelly 171," Taylor said.
Some 25 psychiatrists volunteered to help, according to Taylor. She said part of her responsibilitywas to recruit psychiatrists to assist with the mental health clinic. A numberof the psychiatrists came from the University of TexasHealth Science Center at San Antonio (UTHSCSA) faculty, as well as some inprivate practice in San Antonioand the surrounding areas. Psychiatry residents also volunteered and oftenaccompanied faculty members. Additionally, Taylor arranged for the senior medicalstudents, who are rotating in the psychiatric emergency service, to help aspart of their rotation.
"Without exception, they have said how much they learned, and I think itwill prepare them to feel more comfortable responding to future disasterevents," she added.
From Sept. 2 to 20, news reports indicated that 1,094 evacuees received helpat the mental health clinic. By the time of the PT interview a week later, Taylor estimated thenumber was probably double that.
"At the beginning, what we were primarily seeing were people who hadpre-existing psychiatric illness, such as bipolar disorder, schizophrenia,anxiety disorders, depression and [PTSD]. Many had not had any medications fora week or so," Taylorsaid.
The psychiatrists gave them a two- or three-day supply of medication samplesdonated by local pharmaceutical company representatives, until an on-sitepharmacy was established. Taylorsaid they also had quite a few patients who were on methadone for opiatedependence or pain control.
"We set up a shuttle system to take those patients to the county methadoneclinic," she said.
Some of the more ill psychiatric patients, primarily those with bipolardisorder or schizophrenia, who just could not stabilize in the shelter weresent to area hospitals.
"We have probably seen about 10 patients in our psych ER [at University Hospital],and I would say that six or seven have needed hospitalization," Taylor said.
Taylorworries about the appearance of PTSD symptoms. She explained that "it wasn'tlike a big storm happened, some of their house was destroyed and then it wasover." For many, the trauma was ongoing. "A lot of patients told me about seeingdead bodies and seeing people die at the [New Orleans] convention center."
"I believe we will be seeing emergence of PTSD symptoms, and the questionfor us is, are we going to be able to provide the care that these patients needin our community, including the needs of children, because Texasis usually 47th or 48th in the U.S.for mental health funding," she said. She expressed the hope that federal fundswill become available to help strengthen mental health services in Texas.
(By mid-September, the Substance Abuseand Mental Health Services Administration had awarded a total of $600,000 inemergency response grants for clinical services, including pharmaceuticals, toLouisiana, Texas, Mississippi and Alabama--Ed.)
Federal help also is likely to be needed for evacuees with disabilities, Taylor added.
"We have a number of shelters who have patients with various kinds ofdisabilities, such as mental retardation, autism and Alzheimer's disease," shesaid. "I don't think at this point we have adequately come up with a system ofcare for them, and they are difficult for us to manage anyway, because of ourpoor funding in Texas.I think the Baptist church has really stepped up to the plate and has a numberof shelters for patients with special needs. They have done a very good job,but ultimately they need more support."
Asked about her own reaction to caring for the evacuees, Taylor told PT that as an emergency psychiatrist, she was used to treatingpeople who are upset, decompensated and angry.Emergency psychiatrists can tolerate a lot of affect from people, and that wasgood preparation for this experience.
"But I have never done anything like this on this large of scale," she said,adding that her learning curve was steep.
Taylor wasthankful for some earlier training she had received. Many years ago, sheexplained, she had been on a task force on psychiatric response to disasterwith Robert Ursano, M.D., who is director of theCenter for the Study of Traumatic Stress. Some of that disaster guidance came backto her. Fortuitously, she also had training just a week or two before Katrinahit with Carol North, M.D., who researched the psychological impact of the Oklahoma City bombing, aswell as other disasters. To help inform her fellow psychiatrists about workingwith disaster victims, Taylorrelied on some resources provided by Ursano, whichshe printed up and took to the mental health unit.
(Several of these resources, such as "HurricaneKatrina: Evacuee Mental Health and Care" and "Psychosocial Concerns afterHurricane Katrina-Tips for Medical Care Providers," are available fordownloading from the CSTS site <www.usuhs.mil/ psy/hurricane.html>--Ed.)
Summing up her work at the Kelly mental health unit, Taylor said, "It hasbeen one of the most moving experiences I have ever had, and without exceptionevery evacuee that I have seen has been appreciative of anything we could offerto them. I was also touched by the volunteerism of psychiatrists and othermental health professionals."
On Sept. 4, Zeller, vice president of the Western region of the AmericanAssociation of Emergency Psychiatry (AAEP), flew to Houston at the request of a colleague who wasseeking emergency psychiatry physicians to operate a psychiatric clinic forKatrina evacuees. At the beginning of September, the Astrodome housed 26,000evacuees.
"We pulled up to Reliant Arena, which is part of a huge plaza complex thatincludes the Astrodome and Reliant Stadium," Zeller said in a perspectivearticle for CNET News. "The arena is where the makeshift clinic and hospitalare housed. It's actually a pretty impressive de novo medical center. There aremetal dividers everywhere with canvas curtains separating the general-medicineclinic, surgery, infectious disease, obstetrics, pediatrics and psychiatryareas ... If you lift up the curtains for the [psychiatric] emergency room, you are in the dialysis clinic."
In an interview with PT, Zellersaid that Avrim Fishkind,M.D., president-elect of AAEP and medical director of the mental healthservices at the site, asked Jon Berlin, M.D., AAEP'spresident, and himself to help with the clinic.
"There were local psychiatrists who came in and volunteered. Some hadpsychiatric emergency room experience and some didn't. One doctor flew in allthe way from Scotland,and she was very helpful. People really wanted to help and a lot of peopleworked very hard," Zeller said.
Evacuees presenting to the mental health clinic were first screened by aregistered nurse. If they sought counseling, they were referred to onsite griefcounselors, mostly psychologists who would spend as much time as needed toprocess and work through issues. If they had psychiatric medical needs, theywere assigned to one of the psychiatrists working in the clinic.
"We were seeing as many as 100 people per day in the clinic," Zeller said.
He explained that the psychiatrists saw the same kinds of illnesses thatthey would see in a general psychiatric emergency service, except that theevacuees had just been through "one of the most incredible traumaticexperiences you can imagine."
Most of the evacuees had been without their medications for a week or so.
"Some of the pharmaceutical companies were very kind and donated samples, sowe were able to give people their medications right there in the clinic andthen write them a prescription, which they could get refilled at the pharmacythat was at the Astrodome."
Many of the Katrina survivors were suffering from symptoms of PTSD,depression and suicidal ideation, according to Zeller.
"There were a lot of people who were having a difficult time dealing withwhat they went through and their losses," Zeller said. "Some couldn't believethey were still alive, some felt really guilty that they hadn't done more fortheir family and friends. There was a lot of survivor's guilt. A recurrent lineI heard from people is 'I close my eyes, and I see dead bodies floating by.'"
"It was not an uncommon story to hear that people kept moving up in theirhouse until they were in the attic. When that started flooding, they would haveto chop a hole through their roof. There was one patient that we had where thefamily was out of food after three days of living on the roof. So he actuallyjumped back into the attic and swam down the stairs to the kitchen to get somecanned goods," Zeller recalled.
Zeller found working at the arena to be a surreal experience. For six days,he worked 16 or more hours per day at times. The huge arena was really noisyand sounded like a jet plane flying overhead, he said. People were walkingaround, and the expressions on their faces were often those of confusion anddisorientation.
"Many of the medical people started looking the same way. It seemed sodetached from anything you had experienced before," he said.
Asked about the future for the evacuees, Zeller said, "Some of the peopleare so caught up in the here and now, like how do we survive, so they are notallowing the serious psychological trauma to come out yet. But when things getmore settled, I think a lot of the survivors are going to be having a difficulttime and will really need some good psychiatric interventions. Lots of theevacuees are being distributed nationwide, so people are going to be seeingthem in every community across the country. I hope my colleagues might providesome pro bono help, at least initially."