Bioethics of clinical practice change during disasters, as our staff learned when providing emergency care to Hurricane Katrina evacuees. During crises such as severe weather, terrorist acts, and epidemics, physicians can be torn between advocating for individual patients’ needs or the public good.1
As the storm’s 2-year anniversary approaches (Box),2,3 we share our experiences to help you prepare for disasters in your community and to contribute to the limited data on ethics in disaster psychiatry. This article describes 3 cases to show how mental health clinicians balanced issues such as conflict, consequences, patient rights, physician virtues, and justice when making treatment decisions in the Houston Astrodome clinic.
CASE 1: Benzodiazepines for anxiety?
Mr. R, age 23, presented to the Astrodome mental health clinic requesting “Xanax for my nerves.” He said he had been taking 6 mg/d “for years and years, and it’s the only thing that helps.” Mr. R claimed he had been without his medicines at least 48 hours.
The assessing psychiatrist found no evidence of benzodiazepine withdrawal or other psychiatric emergency. The dilemma: How to provide appropriate acute treatment of a chronic problem, without continuity of care and follow-up.
As a hurricane survivor, Mr. R experienced a traumatic event that could have exacerbated an underlying anxiety disorder. But patients’ use of and physicians’ prescription of benzodiazepines can have adverse short- and long-term consequences. Mr. R’s case highlights the conflict between establishing patient-physician trust vs enabling a patient’s suspected misuse of prescription medication.
In the Astrodome clinic: 12-hour shifts, rapid assessments
Few guidelines exist to help clinicians manage trauma patients immediately after a disaster.4,5 Until recently, debriefing was thought to help prevent posttraumatic stress disorder (PTSD), but multiple studies indicate that debriefing is not effective and may worsen psychological outcomes.6,7Hurricane Katrina struck August 29, 2005, causing more than 1,000 deaths and displacing several hundred thousand Gulf Coast residents. Nearly 25,000 New Orleans evacuees were bused to the Houston Astrodome, where the medical clinic logged 11,000 patient visits in 15 days (including more than 1,000 to the mental health clinic).2,3
I joined a mental health team that met the first evacuees, who arrived disheveled, exhausted, and hungry at 5am. Many had chronic psychiatric disorders and had lost their medications in the flood. Mental health teams from Houston and elsewhere staffed the clinic around the clock to address the patients’ issues, including schizophrenia, depression, and anxiety.
Limited resources and privacy
Patients streamed through the clinic 24 hours a day, the vinyl sheets between “exam rooms” providing a modicum of privacy. Resources were limited, and we performed assessments much more rapidly than my usual 1-hour initial evaluation. I worked 12-hour shifts for 10 days until I developed the fever (104 °F) and infectious diarrhea that spread among patients and clinic workers.
Some patients arrived requesting “little round white pills” that had quieted their hallucinations, but we had no way to retrieve records destroyed in New Orleans pharmacies. Sometimes we carried backpacks filled with medicines and made “rounds” to patients who were afraid to leave their cots for fear of losing their beds.
Missing neonate
In one case, our team helped a distressed couple find a newborn who had been evacuated from a Louisiana hospital ICU to an unknown location. After several hours, we located the baby in a Texas hospital. In appreciation, the baby’s mother returned the next day to volunteer with us.
Managing patient care during a disaster was a powerful experience. I think about the evacuees often and hope I made a difference in their new beginnings.—Jennifer E. Pate, MD
Recommended postdisaster treatment now integrates 4 elements:
- providing for basic needs (food, shelter, clothing, and safety)
- psychological first aid
- needs assessment
- psychoeducation about normal responses to disasters.8
To make its decisions, the Astrodome clinic team considered the potential problems of prescribing benzodiazepines to patients such as Mr. R:
- Large numbers of traumatized victims might visit the clinic to request benzodiazepines, addictive drugs that for many would be inappropriate and potentially harmful.
- Resources such as medications, information, and time were limited. The team could not contact each patient’s health care provider or pharmacy to verify prescription records.
- Using benzodiazepines to manage anxiety in the acute aftermath of a traumatic event is not supported by the literature.10