Dr. Jodie Escobedo with our medical assistant Armando Hidalgo have left today for Louisiana with a group of prominent Santa Monica physicians as part of a relief effort for Hurricane Katrina. We will be posting her daily blogs here. On her way out, she sent us this description of the group and their purpose:
"We are traveling with a NGO, Doctors and Nurses of the World, along with several other local doctors and nurses.
They cannot say where exactly we will be as plans are fluid but we will be flying in to Baton Rouge on a donated private jet. We will be the first of a series of local docs
traveling to reach the as yet untreated and to relieve the docs who have been working around the clock for the past 2 weeks. Part of our job is to get a foot hold and ground knowledge of the area so each successive rotation can build an increasingly more effective medical relief program."
All of us here at Peak Health Medical Group are honored that Dr. Escobedo was asked to be a part of this important mission, and we thank all of our patients for understanding any inconvenience this may cause with her absence. Stay tuned for more updates!
Dr. Escobedo called about 12 hours ago after finishing her first shift, working overnight at the River Center shelter outside of Baton Rouge. She was exhausted and didn't have time to write, so I'm paraphrasing our conversation on her behalf.
The first day was consumed by bureaucracy. They were initially told by FEMA authorities that they didn't need any doctors and were sent away. They knew this wasn't true, so they finally found another group - not sure which - who was able to assign them to a location. Half of the group went away - Dr. Escobedo doesn't know where, while her half was assigned to the River Center shelter. She hasn't had contact with the others in her original group since.
Somehow in this process they are told they will need certification before they can report to their assignment - or they even found this out after arriving at their assigned place. They had to trek back to Baton Rouge - wait for another meeting, so they could receive this certification letter. Finally upon making it to the assigned place with the proper paperwork, they were able to start.
And so far she has worked one shift and nobody has asked to see that piece of paper.
So the thinking goes it would be more efficient if volunteer physicians took the liberty of completing this form for themselves if they are assigned to a location to be part of the relief effort. Now it occurs to me to point out that if you do this you should actually be a physician with a prearranged assignment in Louisiana, but in this case I don't think there's much to be gained (if it could be pulled off at all) by being a volunteer doctor impostor. From Dr. Escobedo's description, it seemed all the bureaucracy accomplished was to delay her ability to start treating patients.
On the patient side, already the trauma is evident. Perhaps this illustrates it best: when a patient's oh-by-the-way moment as they walk out the door is "and did I tell you I have a brain tumor?" you know that priorities have shifted. This particular patient was more concerned about the young orphan he adopted in lieu of his missing 14-year-old. Others with chemical burns over half their bodies from three days of search and rescue efforts. (Chemical!)
It was obvious from this conversation that there is an incredible amount of work left to be done. Her team was taking over for an intensivist from Boston who was here because he knew a friend from Tulane who asked him to come down; originally he was to help at the hospital but ended up working in a shelter. There are still more evacuees arriving daily to her location.
I later found out that Dr. Escobedo was interviewed by CNN, probably when she returned to start her shift at 7pm - we don't know when it will air but we will keep watch for it!
Here is an email from Dr. Escobedo sent this morning, I think it catches us up on the situation well:
"I am at a loss for words. Last night was our second night as night shift at the River Center in Baton Rouge. Diarrhea and vomiting broke out for the second time in the last 2 weeks and the "River Center Runs" brought about 50 people through the 2 medical clinics we staffed. We sent several to the ER including a case of flash pulmonary edema and a gentleman who collapsed and was bagged by paramedics. He seemed to be having an MI. Counts as per the shelter director this am, show nearly 1900 people at a minimum. Add nearly the same number of volunteers and workers, who are all tired and stressed and often dealing with losses of their own. For the refugees' care we write little quick notes that we keep in a rudimentary charting system of manila folders by name. The volunteers and workers we treat "paperlessly". We have a collection of tables and we have nurses assess quickly and bring people back where we sit next to them and talk to them about their problem.
The stories are intense and unbelievable. At least 30% of people have no functional literacy. Medication confusion and compliance errors abound as does diarrhea and puke. The reserve guard troops equipped with their empty automatic weapons are angels. They alone withstand better complete chaos and a repeat of the superdome horror. They watch the bathrooms for us and bring us the patients who are so sick they move to the bathrooms where vomiting blood and passing out can then be done in semi-privacy and evade our volunteers and nurses who patrol the "floor" watching for sick people.
The majority of the professional staff are non-natives. California is very well represented. We have been alternating with a team from South Carolina who do the BUSY days. They are doing a bang-up job. A FNP from Northern California watches the "arena" - a second clinic near the second large floor that has ~500 of our refugees in cots and piles. We walk through the loading dock between the two areas through a massive amount of clothes, diapers, water and supplies. Upstairs a group of nurses staff an area of 12-20 people who need TLC and to be protected from the general population. Demented and handicapped patients get to keep one caregiver with them in that area.
At night it is rather quiet for me as they are sleeping. Last night Vicki Paterno hydrated a boy with a sickle cell crisis which we were able to avert for a 12 hours at least, though he and his mom were checking back in as we came "home" to "the chapel" - see http://www.thechapel.com. It is at LSU and here they house healthcare and mental health workers with cots, showers, food, and everything else from underwear to taxi service.
Pregnancy tests are not plentiful and birth control is not available for anyone. If you think sleeping on a cot in public would stop people from having sex you are wrong. We are amazingly resourceful. That is why I called and left the voicemail to ship the promo condoms we bought here. THEY ARE NOT AVAILABLE ANYWHERE.
Last night I contacted the emergency response center as I saw a couple of patients I am very suspicious of giardia. I realized that despite the fact no one was dangerously ill from the diarrhea/nausea I realized we could easily end up with 1500 people shipping out with chronic giardia all over the US or worse yet the tip of a building iceberg of emerging cholera. We had no material to collect stool samples nor guidelines from the CDC regarding appropriate public health investigation. At 2am I paged the CDC epidemiologist and never heard back. Eventually we were able to speak with a doc from the public health department of LA. They are overwhelmingly frustrated as they had surveillance measures in place when the CDC came in and informed them they would take over. Not being comfortable just hydrating and scrounging pedialyte, bananas and clean(er) sheets and cots for those who needed help, we started looking to improve the sanitation situation.
The floor was covered with puke and diarrhea and had kids walking through it in the bathrooms last night. The janitorial staff cleaned it up ASAP but still the traffic immediately assured effective distribution throughout the huge conference center. We knew the Red Cross was pushing hand sanitizer as people entered but once we started asking we realized that nearly everybody ill stated they had no personal supply available of hand sanitizer. Additionally we realized there had been no arrangements for parents to have access to clean bottles for their infants and they had been washing them in the bathroom with whatever soap they had. This was despite a few hundred new bottles on the loading dock. We started out just handing out fresh bottles and realized we would eventually run out and contacted the chapel this morning and got a volunteer to agree to pick up dirty bottles and return them then next day when she picks up more. Every parent with a toddler and below we have had to then approach and tell them to come pick up at least 4 bottles per kiddo and give us their dirty ones because we can't have the babies getting ill. This alone is a huge accomplishment.
We handed out every bottle of hand sanitizer we could find and filled up several carts with trash bags (for vomit and dirty clothes and diapers). Once we started circulating people began asking for diapers and baby wipes. It turns out they could get them from the Red Cross who were ever so slowly releasing them in packs of 3 diapers per child. The people are still coming in and many leave each day with the net an increase in population - supposedly 200 yesterday. Most people are finally getting in touch with family or friends and fleeing the center to crowd in friends and family homes. Unphased by the absolute insanity of only giving parents enough diapers for 6 hours or so we started just taking entire packs of the diapers and handing them out. Needles to say the public health doctor agreed with us when we explained that even though it was not organized and it risked some people taking a pack or two more than they needed immediately (they cannot carry more than that as they must carry everything they own) we cannot skimp on hygiene basics. Still he could do nothing to officially sanction them as the Red Cross technically "owned the mountain of diapers which we did our best to make a molehill of and get every baby easy access to clean diapers. One day shift Red Cross manager repeatedly asked Armando to move the dolly he was continually filling and handing out for the 3 hours after our 12 hour shift ended. "You need to move that its in my way" his response "YOU need to move you are in my way!"
All the professional RNs and nurses aided and abetted our wanton generosity - with the assist of the health department we got a meeting with the Red Cross shelter "manager" where we reviewed the numerous hygiene problems and gained official sanction for our baby bottle exchange program. After putting out an emergency call for hand sanitizer for a shelter with ~3000 refugees and workers at about 3am, by noon we had received 3 small cases despite sending a BLS ambulance to the Red Cross storehouse where by everyone's account they have "mountains". Hopefully by 9pm the floor will have been piece by piece mopped with dilute bleach solution, we will have chlorox wipes to clean cots, and plenty of hand sanitizer. I am really tired so I am gonna sign off as i am exhausted. I have to go sleep before i go back on duty in 6 hours. Another quality productive agency is www.prccompassion.com, also support www.thechapel.com. There is huge need here. We have to do more. slagarde1@cox.net has a huge constantly updated list of small pockets of people in acute need!"
"Last night was less busy. Armando and I "adopted" a few people and avoided crying by looking for ways to provide the basics for those who had really nothing but a cot and each other. At midnight I saw a lady in her 70's caring for 3 teenage grand nephews and as well as their 4 year old brother. She had a mild COPD exacerbation but shared that all 4 boys had asthma and they had no meds. The 13 year old also suffered from bad bipolar disease in addition to his asthma so getting those meds had been her first priority after arrival and she had accomplished that in the last 48 hours. Because of his medication he had surpassed all his brothers in size and now weighed 200 pounds at age 13 and had no pants to wear to school so he was refusing to go. She had waited to come in as unless they were asleep she really could not bring them all into our cramped little area and they would not behave long enough for her to get some help for herself. "Besides" she said "I have to call the Red Cross at 2 or 3 am anyway as that is the only time you can get through to them." The River Center is a Red Cross shelter. She is in their shelter and yet she has to be up at 2am to communicate with them. She left the "first aide" station with an uncommon and coveted cot that had the ability to lift the head up as she was asking for pillows so she could sleep because she could not lie flat. Her back was killing her so Armando set her up with one of the rare air mattresses as well. We got her spacers, albuterol and advair for each of them labelled with their names and set up in zip locks. We dug up incontinence supplies for her and the ever needed hand sanitizers and baby wipes. I took her back to the piles of donated clothes scattered all over the loading dock so she could find her boys underwear and herself a bra and something to use for Pj's. Armando saw her 4 "boys" sleeping and as they walked to her area and she shared the problem of no pants for the boys so getting them to school was difficult and she was stuck. He found not only several second hand pants to fit each of them but also brand new cool T-shirts and even several pairs of new pants hidden under a table in a box with an "x" on it as a cryptic identification for Xtra large. I helped him carry the two boxes of clothing and a brand new nebulizer and 4 boxes of albuterol solution unit doses to set amongst their things about 3am. The boys were all asleep but her bed was empty. She was no doubt on the phone trying to get red cross to help her register with FEMA so she could get temporary housing and get out of the shelter. I hope the boys went to school because she is gonna need a nap. The baby bottle recycling is slowly becoming part of the system after 48 hours. We are running low on new ones and not getting so many dirty ones. People leave the shelter every day - we encourage them to have 4 bottles per kid per day. More families enter also every day and often come with nothing or only one or two bottles. The floors only got cleaned here and there. Everyone pointed at the six horsemen of the apocalypse: FEMA, Red Cross, City Admin, Louisiana state Administrators, independent contractors, the refugees for whom this is "working out just fine." (... in Barbara Bush's words). Oh well a little is better than nothing.
When we showed up there was no additional hand sanitizer. I spoke with the dude who at least unofficially manages the piles in flux all over the loading docks. I asked him if he could help me out. 20 minutes later 8 cases of waterless hand sanitizer showed up in front of the pharmacy. Now when I walk through the floor I see many familiar faces. The rumor is when we leave they are no longer going to staff the night clinic so there will be no one to deal with the sick kids, people that can't sleep, those who have diarrhea in their beds and cannot change them. I suspect they will instead have emts sit "on call" for people who are decompensating. Despite dozens of MDs showing up at DHH headquarters they are turning them away because they do not want to staff a night clinic. All the nurses and doctors are volunteers. It costs them nothing to keep it open but probably by looking at the site tallies for number of patients seen they figure there is not enough need. They have never really looked around on their limited brief visits and seen people or imagined that even if people don't come in for medical care we have plenty to do such as reaching out to them and cleaning up the mess from the previous day let alone working to improve systems modest step by modest step. I am gonna go take a shower and see you guys soon. After sleeping a bit this pm I am gonna try to run over to Jimmy Swaggart Center and make sure they have someone to follow me and then hook up with a paramedic unit making runs into New Orleans and doing house to house visits/searches as a "freelance" ride along. Part of me is very afraid of seeing things that by all accounts look like an atomic blast hit. The other part of me, now painfully aware of the poverty hidden from my consciousness by distance and economic segragation, feels I cannot shrink from the front lines of this gigantic poopy diaper that must be changed. In areas everything below the flood line is still dead weeks after the flood. Anyone from this area knows vegetation in humid climes grows rapidly. They just started requiring waders and respirators on anyone returning to the very poor and completely flattened St Bernard Parrish. No one knows what all was spilled and the stench is unbelievable according to those who have been. Don't believe George Bush that things are getting better. The only area the authorities keep admitting the need for additional help with is morticians. That is telling. Be very afraid. Everyone who can throughout the entire nation needs to plan to spend a week or two in the next year if not more physically in the gulf somewhere. It is a third world country here for those displaced and I desperately hope this brings the horror of economic injustice home to our country. This was our generation's wake-up call. We must come to help bury the dead, assist in the healing and learn how to demand/embrace economic justice for our own sake and our fellow men. The need is immense. Our generation will be judged and defined by the long term response to this unbelievable, horrendous tragedy."
"Last night an hour before we showed up we were called and told that the night clinic was cancelled. We of course showed up anyway "to get our last paychecks" (hearty chuckle by all) and ended up treating several dozen people including at least 4 who would have required acute ER visits. When we arrived the word was out that the clinic was closing... "because we need to transition to providing long term health care access. We are making these people too dependant on us. The middle class are holed up 8 and 12 people in a house and they can't get access to health care while these people are able to walk in and they can afford to go see their doctors." Ok I did not memorize her words but that is very close and was the ah ha moment just before I got told to leave and not come back. You will be very impressed that not one curse word passed my lips. Not only has the Red Cross, OPH, EOC, FEMA and the CDC reached new heights of bureaucratic mediocrity in crisis; there is a clear underlying resentment that "these people" are in Barbara Bush's words having this "work out very well for them." To make a long long story short.
When we showed up for our shift that had been cancelled patients were waiting on us. We were told the "infirmary" on the second floor which housed a few demented and schizophrenic patients as well as a developmentally disabled boy who is bedbound had to be moved to the floor with the main population because "they do not have special needs" so we need to close the "special needs" infirmary. What are special needs you ask? No one could tell me. They admitted that the patients in the infirmary would be at risk and could not safely be placed on the "floor". The nurse manager, a very burnt-out lady, Kim Scullen RN, insisted they would be fine because they were going to move all the people out of a corner of the conference center and move all the infirmary patients there and staff it with Red Cross volunteers who would bring them their food and help them to the public restrooms across the convention center floor. We were told the medical clinic was not going to be staffed after 9am in the morning and the upstairs room had to be emptied. Since the Red Cross was going to have to staff VOLUNTEERS either way and I promised I could have volunteer nurses cover the area why not just call it a board and care room instead of special needs. She had no answer to that and fell back on because my boss says so. We took a chance last night and tried to move the patients to a temporary hospital which the ems dispatcher told us would accept them. Unfortunately they sent them back to us but the emergency disptacher agreed they could not go to the floor so at least I had an excuse to keep them in the upstairs until my shift "ended". Nurse Kim Scullen then came in this am and yelled at me telling me I had no authority to transfer patients and who did I think I was and then laid into the Red Cross RN working with me tonight. As she insulted me again and accused me of "Rabble Rousing"... I think that's a Southern way to say "talking back." I guess it was a good thing I got credentialled after all since she took my name and I expect to be forever blackballed by the Red Cross. If there is a riot or a serious disease outbreak in the River Center in Baton Rouge, we saw it coming and the bullies insisted everything was fine. I am gonna go try to catch a ride to the storm destruction area. With so many authority figures saying things are business as usual I have to see for myself."