What Would You Have Done?
The Aftermath
The aftermath of a disaster can be worse than the event itself. Following Hurricane Katrina many physicians and healthcare workers were homeless, jobless, and faced financial ruin overnight. Among physicians there were many suicides, depression, and posttraumatic stress disorder (PTSD), which also was found in other first responders and the public. Of 912 police officers in New Orleans, 26% reported symptoms of depression and 19% reported PTSD. In 2007, PTSD was diagnosed in more than 38% of patients reporting to an emergency department in New Orleans, which is 10 times the prevalence in the general population. Researchers found that the incidence of mental illness worsened over time. Two years after the storm, PTSD increased to 20.9% (from 14.9%), the incidence of serious mental illness rose to 14.0%, suicide ideation rose from 2.8% to 6.4%, and creation of suicide plans rose from 1% to 5%. These increases were due to secondary stressors. An additional challenge was the lack of mental health resources. Eighty-nine percent of psychiatrists left the greater New Orleans area, when people were most in need.
Missing Pieces
Despite the improvements in disaster planning since Hurricane Katrina, missing pieces persist. There is no standard triage protocol universally accepted in the United States for mass-casualty events. "Standard" triage is not applicable to chronically/critically ill patients housed in shelters during disasters, and there is no triage system to provide reliable distinction among similar patients. To date, there is no legal standard of care for treating patients during a mass-casualty event; however, it is hoped that following disaster protocols will provide some protection to healthcare workers.
All healthcare personnel who work during disasters need legal protection, particularly those who live and work in the disaster-affected area. Most laws protect volunteers, government officials, federal employees, and the military and they are provided civil immunity. Many nurses and physicians faced civil suits following Hurricane Katrina, when patients died while waiting for evacuation, a process over which they had no control. The government officials who were responsible for the failures following the storm were not sued because they were granted civil immunity. Only the individuals who stayed and cared for patients were sued, but those who left their patients without care, were not. It is obvious that there are many gaps in legal protection. These events, in addition to criminal charges filed, led to the formation in 2008 of the Committee for Disaster Medicine Reform. Louisiana was the first state to pass model disaster legislation into law that protects healthcare workers (not institutions) during a declaration of disaster. These laws do not protect against intentional acts or willful misconduct.
Solution
Although it may not be possible to plan for the unimaginable, most ethical and legal conflicts can be avoided with disaster training and familiarity with disaster plans. The author recommends that there be hands-on disaster drills that include both medical and ethical decision making. During a real event, professionals must make consistent judgments and decisions based on the plan, regardless of their own emotions and beliefs and drills may help alleviate this situation. Nurse Terri Edens reported that it was the repeated disaster drills for a tornado scenario that allowed the team of healthcare professionals at St John's Regional Medical Center in Joplin, Missouri to evacuate the hospital in only 90 minutes, when a tornado struck on May 22, 2011. Disaster plans also should include onsite mental health support for healthcare workers; no one is immune from the effects of trauma. Some healthcare providers did not return to work at St John's after the tornado and many did not return to work after Hurricane Katrina because of the severe trauma they endured.
To maximize patient outcomes, training should be mandatory for all medical students and residents as part of their education. The National Disaster Life Support Foundation of the AMA provides core, basic, and advanced disaster life support courses. The author also recommends that disaster training be mandatory for all practicing clinicians and other healthcare workers to obtain hospital privileges. It would be most beneficial if all hospital employees were required to undergo some form of disaster medicine training as part of orientation and that the institution's disaster plan is discussed in detail. After all, no one knows where he or she will be when disaster strikes.
Transparency
The medical system that collapsed in Hurricane Katrina brought to light the difficult decisions facing healthcare providers. It is important for the public to understand the limitations of the medical system during disasters and for them to have fair input regarding to whom the limited resources should be given. This will ensure public trust and confidence in the fairness of these critical medical decisions. The magnitude of destruction and human suffering caused by Hurricane Katrina was unprecedented, but it gives the people responsible for making the disaster plans a clear vision of what is possible.