Disaster psychiatry in the Houston Astrodome
Lead psychiatrist tells how teams restored stability for hurricane evacuees.
Thousands of cots lined the floor while the Houston Astrodome was used to shelter hurricane evacuees.
For 2 intense weeks in September, Dr. John Burruss coordinated the psychiatric unit of the emergency medical response at the Astrodome for New Orleans residents evacuated to Houston after Hurricane Katrina. Within hours, a field hospital was built to care for thousands of people who had experienced the hurricane, then floods, then days without adequate food, water, medical care, or protection in the New Orleans Superdome.
Many evacuees suffered acute stress reactions, as might be expected, but the mental health teams encountered the unexpected as well. Dr. Burruss describes how they addressed these challenges in an interview with Dr. Lois Krahn, deputy editor of Current Psychiatry.
LK: How much notice did you have before Hurricane Katrina evacuees started to arrive in Houston?
JB: About a day. Because there was no communications infrastructure in Louisiana after the hurricane, we didn’t know who was coming until the buses from New Orleans crossed the Texas border. We had people stationed at the Sabine River calling us to say things like, “Here come 15 buses of 50 people each.”
LK: So you didn’t know ages—or medical histories—of people on the buses?
JB: We knew nothing except numbers, and even those were hit or miss.
LK: What equipment did you have on hand before the evacuees arrived?
JB: I work for Harris County Hospital District, the major provider of indigent and low-cost health care for Houston. Essentially, the district put together a field hospital amazingly fast. In the mental health area, we had 10 exam rooms, though we had to deal with limited confidentiality because the walls were plastic sheeting.
Our medical staff could not do surgery, but we had everything else. We had on-site radiology, phlebotomy, and labs to interpret results of urinalyses and blood draws.
Within the first day, CVS brought in a portable pharmacy where we could write prescriptions for essentially anything we wanted. We also used a fair number of sample medications, and we sent runners to the nearby hospital if we needed an unusual medication or something not available.
LK: At the height, how many evacuees were in your facility?
JB: Estimates are varied, but at the Astrodome complex—which was three different housing locations—we had approximately 24,000.
LK: Did you provide mental health care around the clock?
JB: When people first started arriving, it was 24/7. A huge caravan of buses dropped off maybe 4,000 people in the middle of the night, so we were very busy for the initial 72 hours. We saw 600 to 700 people for mental health needs each day for the first few days.
LK: How many psychiatrists, psychologists, and psychiatric nurse practitioners did you have on site?
JB: We had 2 to 10 psychiatrists, 2 to 4 nurses, and 20 or 30 counselors on hand at any time, more during the day than at night. We had easily a dozen or more MD psychiatrists and many more psychologists, social workers, and licensed marital and family therapists who came from outside the Houston area to volunteer.
LK: What kind of psychiatric issues did you expect before the buses arrived?
JB: We expected some distress, maybe a lot of acute stress reactions, but that’s not what we encountered. What we did encounter was a tremendous number of people with existing psychiatric diagnoses who did not have their medications and needed them. We spent most of our time in the mental health clinic replacing people’s prescriptions.
LK: Which psychiatric diagnoses came to your attention most often?
JB: The usual smorgasbord: a lot of major depression and anxiety disorders, fewer bipolar disorder and schizophrenia, but certainly plenty of those. And we had a fair number of people who were on methadone maintenance programs, so we had to figure out a rapid way to address that need.
LK: How did you manage that?
JB: We got on the phone. Luckily—because of the situation—we had pretty instant access to people at the state level to get allowances for a local methadone clinic to treat these folks. Then the local clinic agreed to help if we could get the people there. So, then we arranged transportation pretty quickly.
LK: Were many methadone patients in withdrawal when they started getting medical care?
JB: Only a couple were in obvious physical distress. We used some adjunct agents such as clonidine to help them get through the first day or so but got the system set up as soon as we could so they could get their methadone.
LK: Did you see many people more than once?
JB: Quite a few. Depending on available space, we let some people stay in our clinic overnight for observation instead of sending them to the psychiatric hospital. And we’d see them several times. We also had some folks who kept decompensating.
LK: Were many patients paranoid or decompensated because of chronic psychotic illness?
JB: No, but during the 2 weeks we were in operation we sent several to the psychiatric hospital for further care. Some had de novo psychotic breaks; they were clearly very paranoid, and the distress had gotten to them.
LK: Did you have much trouble with aggressive individuals?
JB: Not really, very little. The Houston Police Department has a crisis intervention team (CIT officers) trained to handle mental health emergencies. These officers have learned how to approach aggressive individuals with patience, reserve, and calmness. We had CIT officers in our clinic 24/7, and if somebody got worked up they helped us manage it very quickly.
LK: I can only imagine the challenges of verifying drugs and dosages for patients, trying to provide treatment that approximated what they had received in New Orleans.
JB: Fortunately, some patients had their prescription bottles. But for most we had to rely on them to tell us what they were taking. They’d come in and say, “I take Zyprexa,” or “I take Wellbutrin,” or whatever. I would say, “Well, how much do you take?” And they would say,“ I don’t know; I take the red one.” Or, “I take the white one.”
So, if they knew that much, we could get the PDR and try to figure out which one the red one was. But a lot of times we just picked a reasonable dose.
LK: What about patients who were on depot forms of antipsychotics?
JB: Same challenge; they had no idea how much their shot was. We generally tried to substitute something oral because we often didn’t know when their last shot was or they weren’t remembering very well when it was.
LK: Any suicidal patients?
JB: No, very little suicidality.
LK: Any thoughts about why?
JB: People who ended up with us were, for the most part, very grateful to be alive. They were scared as hell at the Superdome in New Orleans, not just of the storm but of what humans apparently were doing to other humans there.
When they got to us, they were grateful to be safe, sheltered, and fed.
LK: You said the numbers of evacuees with chronic psychiatric problems got your attention, but what about those who had an acute stress response?
JB: I have not seen a chart review, but I would guess that no more than 20%—maybe 25%—of the evacuees we saw for mental health assessment had acute, overwhelmed stress reactions. We would use mild tranquilizers or sedatives to help them get some rest and provide them with crisis counseling.
As I said, we had at least 20 to 30 psychologists, social workers, licensed family therapists, and nurse practitioners on site most of the time, even during the night, for people who were struggling. They would go out among the people, wearing a badge that identified them, and just wander, stop and talk to folks—be our eyes and ears.
LK: And engage people who weren’t coming forward?
JB: Well, that was a problem. We had people who didn’t want to come to the clinic, no matter what. There were not enough cots for all the people who came to the Astrodome shelter, so those who got cots early were afraid someone would take them.
So, at first, we would take medical charts and medications in a backpack and go seek them out. If they wouldn’t come to us, we would go to them.
LK: How did elderly patients with cognitive impairment handle all of this?
JB: A lot of them—even with fairly significant cognitive impairments—would just follow the crowd and blend in, and it took us a while to locate who they were. Eventually, we would realize, “This guy is not doing anything. He’s not seeking help, he’s not seeking loved ones. He just sits here.”
As the crowd lessened, we started to pick up on those people. Sometimes, they were in groups; we found 16 developmentally disabled adults from the same care home who were all together in the Astrodome with their caretakers.
LK: What’s happened to the medical records you created?
JB: Our information technology group did an amazing job and in less than 24 hours set us up so that we could create a unique Harris County Hospital District identifier number on everybody who came in.
LK: Because for writing prescriptions—including prescribing controlled medications—you need to document what happened.
JB: Absolutely. We provided medical care in the usual fashion. And if FEMA or Medicaid is going to reimburse us for anything, they will want a record of what we did.
LK: It is amazing how coordinated the response was. Had you done any emergency preparedness drills?
JB: There had been all kinds of drills with various organizations volunteering in different scenarios—a bomb, an explosion, a hurricane hitting Houston—but nothing like this. Nothing where someone said, “We’re going to bring you a huge cohort of people from somewhere else to take care of.”
We were providing disaster relief, but all of our infrastructure was intact. All our phones and everything else worked. So we could set up and man facilities on demand, at the drop of a hat. It was a very different experience than if you were doing this in a community that had suffered its own disaster.
Even so, I have to say I’ve never been as proud of the system I work for as I was at seeing how well it came together. In many ways, it was astounding.