In August 2005, the Louisiana State University (LSU)-Ochsner New Orleans Psychiatry Residency Program was displaced by Hurricane Katrina and reestablished at a number of Louisiana state hospitals. Prior articles in Academic Psychiatry have chronicled the post-Katrina stories of the LSU and Tulane departments of psychiatry (1–6). These articles underscore the struggles and resilience of the programs’ attempts to survive and recover. This article is a retrospective review of the experiences of the LSU Psychiatry Residency Program post-Katrina, with particular emphasis on the work of stabilizing and reestablishing residency infrastructure.
Some challenges can simply be addressed with good disaster preparedness, but others require a higher level of state and federal policy changes. This article will present seven concrete caveats of residency program preparedness learned from the LSU psychiatric residency director’s direct experience with the Hurricane Katrina disaster in the hope of assisting other programs to prepare for a possible disaster.
Since its beginning, the LSU department of psychiatry has played a key role in providing clinical services to indigent and underserved residents with mental illness in New Orleans. For the last 7 years, the department has partnered with Ochsner Hospital, a private hospital located in a New Orleans suburb, which continued to operate throughout Hurricane Katrina and afterward. About half of LSU’s residents rotate there at any given time. Their consistent presence ultimately played a major role in the residency’s stabilization. After the storm, the core LSU faculty and those residents not at Ochsner were relocated to state hospitals and clinics in Baton Rouge (1 hour from New Orleans), Lafayette (2 hours), and Pineville (3.5 hours). The majority of residents stayed with the program and continued to receive their education while providing clinical services in Louisiana.
Although Ochsner has had its own post-Katrina challenges, this article will focus on the LSU psychiatric residency because its main teaching hospitals and outpatient clinics were annihilated by the flood. A review of the LSU department of psychiatry faculty and residents before and after the storm is presented in Table 1.
The Evacuation and Immediate Storm Aftermath
Despite the fact that the possibility of a serious hurricane threat to New Orleans was well known, there was no clear plan for the scenario of Hurricane Katrina. The city was familiar with evacuations, but the department of psychiatry members had always returned within days and resumed their regular work schedules. The hospitals had never been flooded. In anticipation of the storm, all patients who could be safely discharged to evacuating family were, but other patients were not evacuated, and hospitals continued to operate with essential personnel.
Although fearful of the magnitude and power of the hurricane, and whether this would be the “big one,” the evacuation was routine. On the way out of town, the directors and chief residents spoke. The author had been the residency director since 2000, along with Dr. Margaret Baier, the associate director at LSU and Charity Hospital, and Dr. Dean Hickman, the associate director at Ochsner. It was an asset that the directors had worked together for a long time.
Cell phones worked well initially, and, as in the past, faculty and residents planned to be in contact by e-mail. On awakening Monday morning in various places of evacuation, it appeared that New Orleans had missed the direct hit and would once again be safe. This feeling of relief, however, was short lived, as the media began broadcasting that the levees had been breached and the city was flooding.
The department had neither anticipated nor planned for the chaos that unfolded. All usual forms of communication collapsed. Cell phones would not connect, and the medical center web site and e-mail went down. The residency director called the national paging operator, located elsewhere in the United States, and left the number of his location. Other residents, faculty, and staff, preoccupied with their immediate disaster concerns, did not. Although a national paging operator is an excellent switchboard for every resident and staff clinician during such a catastrophic collapse of communication, department members simply did not think of calling in their updated land-line numbers.
Disaster Caveat 1: Emergency Contacts
Every department should have an emergency contact list, with alternative land-line numbers outside the area. Keep the list in the car or in an evacuation kit. In addition, a national paging service can be an excellent central switchboard in a disaster. Store this number in a cell phone and safe place. After a disaster, department members should give their relocation information to the national paging operator.
Interestingly, the residents’ pagers had long-distance capacity but faculty members’ pagers did not. Because the residents were able to contact one another, they formed an Internet group and began communicating.
Disaster Caveat 2: Internet Groups
If the university server is local, consider establishing a disaster Internet group, with a name that is easy to remember, and keep the access information in an emergency kit, cell phone, PDA, or other safe place. Members can register with the group after the storm.
During the initial days of the flood, much of everyone’s time was spent attempting to get information about one’s family and house. Pieces of information began to come in that the LSU School of Medicine had relocated to Baton Rouge at the Pennington Research Center (3, 4).
Several days after the storm, the chief resident and residency director were able to finally connect by text message. Cell phones with local area codes were mostly useless, but text messaging would occasionally get through. The residency director learned of a general faculty teleconference with the dean, and from there he was able to get the department chairman’s new contact information and reach him. Charity Hospital patients had been evacuated to Central Louisiana State Hospital in Pineville, La., so the residency director went there and began contacting directors of other state hospitals and clinics to establish interim clinical training sites.
The need for well-established, prestorm relationships and agreements with other hospitals and clinics was never more evident than in this moment of crisis. Not all hospital directors were open to integrating residents and teaching faculty into their hospitals. There were many challenging talks and attempts to forge relationships between north and south Louisianans and academicians and the public sector. There were credentialing issues, new letters of agreement, contracts, rotation sites, expectations, and didactic schedules. There was no preestablished mechanism to fund new services or provide immediate housing for faculty and residents.
As the residency director was attending to these issues, he learned of the residents’ Internet group. Although he had finally been able to give the chief residents the little information that he had, he had not been able to speak to all the residents. There was unrest, as could be expected. There was no apparent state or federal funding to get physicians back into New Orleans as first responders to begin reestablishing the health care infrastructure. The School of Medicine’s plan was to integrate with the state hospitals primarily located in Baton Rouge and Lafayette, hospitals without inpatient psychiatry units. In the meantime, the department of psychiatry was working on partnerships with inpatient psychiatric facilities and clinics in Baton Rouge, Lafayette, and Pineville.
The medical school moved its main teaching and administrative campus to the Pennington Research Center in Baton Rouge, and Baton Rouge became the psychiatry department’s main teaching site. There the department established a consultation-liaison rotation at Earl K. Long Hospital and an inpatient rotation at its psychiatric hospital. Several adult residents also rotated with the LSU child psychiatry department, which had been relocated to East Louisiana State Hospital in north Baton Rouge. In addition, several LSU graduates on staff at a seven-parish regional mental health center based in Baton Rouge served as unpaid faculty supervisors and helped LSU students and residents find temporary housing, mostly in people’s homes, and integrate into the first responder clinical services that were being implemented (7).
Disaster Caveat 3: Developing Relationships
Develop and maintain key relationships with personnel from outside hospitals and clinics. Integrating trainees into clinical sites where the department has a personal relationship and, ideally, prearranged agreements, facilitates a much smoother transition.
Understandably, in the initial days following the disaster, when contact was impossible, some residents felt abandoned, neglected, and angry. Most understood the nearly impossible communication obstacles and had used the few days after the storm to address their immediate life concerns. But feelings were strong among some. Having always worked hard to respond to the needs of the residents as much as possible, it was difficult for the residency director to be perceived as abandoning or neglectful.
Yet this was the reality. The residency director was more than 3 hours away from New Orleans and isolated from Baton Rouge, where the residents and the medical school were established. In the immediate aftermath of the disaster, for the most part, faculty assignments had been made according to where everyone landed and had housing. Because the residency director was in Pineville with the displaced Charity Hospital patients and had temporary housing for himself and his family there, it became his new job location.
The level of unrest among the residents required a significant amount of managerial effort. Everyone tried to attend meetings in Baton Rouge to have as much face time as possible, but these meetings were difficult to arrange. Residents’ morale was also worsened by the hours of media coverage of a flooded city that had been abandoned.
In these meetings, straightforward acknowledgment of residents’ feelings, while also communicating the real limitations faced, seemed to work best. A lunch meeting with the chairman was especially beneficial to reassure residents that their needs were heard at all department levels.
Disaster Caveat 4: Location
The residency director should be located as close to the residency headquarters as possible and should maintain regular face-to-face contact with the residents, even if there is not more to say than “we are working hard and will have more information soon.” Frequent update e-mails are helpful, even if brief.
Classes, supervision, and administrative meetings continued by videoconferencing, but there were scheduling conflicts with competing state meetings and agencies and the system was not always reliable; often only teleconferences were possible.
Disaster Caveat 5: Videoconferencing
After a disaster, if the department is geographically separated, quality videoconferencing communication centers at the evacuation hospitals are optimal for continuity of training programs.
After Katrina, residents started to slowly settle into their new experiences, and for the most part their displacement became equivalent to an external rotation. Despite the devastation to the city and program, there were positive feelings about the contributions the department could make while temporarily integrated into other state hospitals and clinics where access-to-care problems existed before the storm.
The American Association of Directors of Psychiatric Residency Training (AADPRT) significantly facilitated getting residents settled into these new sites. Initially, the AADPRT emergency task force’s intention was to arrange temporary transfer positions for displaced residents. Within the anxious period of the unknown, many residents contacted other programs, and several were offered positions. However, it became quickly apparent to AADPRT that, given some time, the LSU and Tulane psychiatric residencies could stabilize and remain relatively intact. So the task force’s focus changed to protecting LSU and Tulane’s residencies from fragmentation. This markedly helped to give the programs time to regroup and establish a viable infrastructure. Keeping residents in Louisiana not only was imperative to meet immediate postdisaster needs but also to continue training residents to meet the future needs of the state.
Disaster Caveat 6: Resident Transfers
Following a disaster, outside training programs should initially presume that there is a moratorium on resident transfers, to help programs stabilize and recover, until residency directors and administrations can establish future needs and visions. Exceptions for individual circumstances can always be considered.
Disaster Caveat 7: Activation and Recovery Teams
Clearly assigned activation teams (members who stay during a disaster) and recovery teams (members who relieve the activation team as soon as leaders deem the area safe for them to enter) are needed before a disaster, as well as a means of keeping team plans actively in the minds of department members. Also, some type of rehearsal is important.
During Katrina it was unclear who would stay or go. In Louisiana, hurricane season affords many “live” drills. For example, in 2008 Hurricane Gustav gave New Orleans the opportunity to practice the lessons learned, and it was a much more organized experience.
By November 2005, 3-months poststorm, the LSU residency had been stabilized. The department had treated many evacuees in other hospitals and clinics in the state, and faculty and residents were ready to return home. However, there was no funding to get home. The main teaching hospitals had been flooded, and there was no movement to shore them up even as temporary facilities. First responders from other areas of the country were very much appreciated, but they were able to offer short interventions only. The Stafford Act prevented the use of disaster funds to provide longer-term treatment (8–10). Once patients received limited sessions and the counselors were gone, there were few doctors to whom to refer those needing continuing treatment. Eighty percent of the New Orleans’ psychiatrists had left the city and still not returned (11).
The delay in the psychiatry department’s return led to increasing stress and uncertainty within the context of furloughs of long-time faculty—laying off employees with the condition that their jobs could be reinstated if funding became available. As indicated in Table 1, the department had to furlough significant faculty despite the city’s desperate need for health care workers. The first return of LSU residents and faculty did not occur until one of the unflooded uptown public psychiatric hospitals opened in August 2006, a full year after the storm. All residents and staff were not back until January 2007. The inability to use disaster funds to stabilize economically and to get local health care workers back led some residency departments and private practitioners to sign employment contracts in other areas, which impaired their ability to return.
The caveats in this article are offered to assist other programs with disaster preparedness and immediate stabilization. However, if a disaster is prolonged, continued changes at the city, state, and federal levels will be required to bridge funds and quickly return health care personnel to the disaster areas to prevent the kind of decimation of health care infrastructure that New Orleans has seen.