Shelter from the storm: ICPs — a voice of reason in a mind-numbing disaster

Shelter from the storm: ICPs — a voice of reason in a mind-numbing disaster

These people are not pariahs.’

An infection control professional, attorney, and Louisiana native, Julie Savoy, BSN, RN, JD, brings a unique perspective to the horror that was Hurricane Katrina. But first and foremost, in the chaotic first days of the disaster aftermath in New Orleans, she was just another worried relative trying to reach loved ones and offer shelter from the storm.

Her aunt and uncle, both 79, had lived in New Orleans for 55 years. Savoy’s mother urged her brother and his wife to leave, but having weathered two previous hurricanes, they decided to hunker down and face Katrina. Foolhardy in hindsight, their decision actually didn’t look that bad shortly after the massive storm made landfall and passed through the area. The house still was standing, high and dry.

"About 9 a.m. Monday morning (Aug. 28), my uncle called to say they had lost power but the house was fine and it looks like the worst is over," says Savoy, an attorney at Gachassin Law Firm in Lafayette, LA.

"Then he said, The water is starting to come up fast in the streets; let me go.’ And that was the last we heard of them. They were in the area where the Industrial Canal levee broke. We didn’t hear from them until Wednesday, a little over 48 hours later, when my uncle called to say they had arrived at a shelter in Baton Rouge," Savoy adds.

What happened in the interim was straight out of the newscasts of house floods, attic sanctuaries, and rooftop rescues. Sometimes, it is difficult to appreciate the forces of nature except through direct experience. Savoy’s uncle for one, said before the storm that the wood was so hard in his sturdy old house it was difficult to even hammer a nail into it. "He said the force of that flood water just knocked the baseboards off the walls," Savoy says. "That was pretty impressive to me. They got up in the attic and lived up for there for two days."

The house took on 5 feet of water in about 20 minutes, but the attic remained dry and the resourceful couple managed to save some food and water. "They were never in real danger of drowning," Savoy notes. "It was just surviving until they could get rescued."

A next-door neighbor flagged down a helicopter from his rooftop, and when the rescue team picked him up, they left a crew member to check on Savoy’s aunt and uncle. "My uncle felt good about that because he knew they would come back to get that crew member," she adds. "The chopper came back and lowered the basket for my aunt. My uncle had to carry her out of the attic and get her in the basket."

Savoy’s mother went to Baton Rouge to find her kin at a shelter, but was told they had already been triaged and dispatched out to an unknown location within the city. After hours of searching, she found them and took them back to her home in Lafayette that night. "This is her only family; she was definitely going to get to them," Savoy continues. "I think a small part of her wanted to give her brother a piece of her mind about not evacuating."

There would be plenty of time for admonitions, but first the stubborn uncle was taken to a clinic. It seems the flood-soaked attic ladder broke out from under him on one the trips up and down for supplies. "It splintered and ripped up his legs," Savoy explains.

"The minute I heard that, that’s when my infection control mind kicked in. The first thing I thought of was Vibrio vulnificus. He already had some cellulitis setting in, but it wasn’t Vibrio. We got him a tetanus shot and an antibiotic. Luckily, it resolved," she adds.

ICP’s instincts on target

Savoy’s instincts were right on target, as the Centers for Disease Control and Prevention (CDC) has identified at least 22 cases of Vibrio — including five that were fatal.

The infection typically is acquired through shellfish consumption but can be acquired directly from water contact via open wounds. V. vulnificus does not spread from person to person.

It primarily is a threat to the immune-compromised, capable of causing acute illness within one to three days of exposure.

The incubation period can be as long as seven days for some cases. Signs and symptoms included fever, swelling and redness of skin on arms or legs, blood-tinged blisters, low blood pressure, and shock.

"If you are in contaminated water and you have cuts or abrasions or some sort of break in the skin, the bugs get in and establish a local infection that may not be very prominent," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University in Nashville, TN.

"It may not create a whole lot of pus, but then it gets into the bloodstream, and that’s very likely what happened with these cases," he explains.

The situation was exacerbated considerably when the national broadcast media began describing the infections as "cholera-like," which was inevitably shortened simply to cholera: a nasty, potentially fatal enteric infection that has rarely appeared in industrialized nations for more than a century. The symptoms of cholera are profuse watery diarrhea, vomiting, cramps, and low-grade fever.

"This, of course, was nonsense. It was Vibrio vulnificus," says Schaffner, who asked the media department at his hospital to call the television network and report the error.

The confusion apparently began because the pathogen is something of a second cousin to cholera’s etiologic agent: Vibrio cholerae, he explains.

As counterintuitive as it seems, the widespread perception of imminent disease outbreaks following hurricanes is not well founded in science. For example, decaying bodies create very little risk for major disease outbreaks, particularly from agents not already endemic to the geographic area.

"Disasters do not bring in new infectious agents," Schaffner says. "They just expose people to the agents that were already there. Outbreaks of infectious diseases are not common after floods or, for that matter, after volcano eruptions. We are always worried about it, but they are not. That’s just a fact. We can take some comfort in that."

That said, there will be some very real infection control concerns in the weeks and months ahead. ICPs warning about outbreaks in the crowded shelter conditions found they were being heard — for a change — loud and clear.

"It was amazing to me to see the physicians talk first and foremost about their concerns about disease control," Savoy says. "It’s gratifying for me to see that. They get it. Even though in the hospital setting, day to day, the ICPs have their struggles with compliance."

An outbreak of Norovirus, the bane of cruise ships, hit evacuees gathered in Houston’s Astrodome. Some 700 people were treated, with 40 placed in isolation cohorts to contain the virus.

"After Norovirus, I would worry about the enteroviruses echo and coxsackie because these are the viruses that go around in the summer time," Schaffner notes. "There is, undoubtedly, hepatitis A in the sewers of New Orleans, and so there was some exposure. Everybody is concerned about that, and indeed the CDC is now recommending that people who are in congregate settings get hepatitis A vaccine."

Respiratory infections remain a concern, particularly with the 2005-2006 influenza flu season looming. The CDC has recommended that evacuees be designated as a priority group to receive influenza vaccinations.

"Those recommendations will become more important as we move from the acute phase of this to the chronic phase," Schaffner explains. "Because we are going to be having evacuees living in congregate settings for a considerable period of time, there is no doubt as we move into the influenza season, every one of those people should be vaccinated."

In addition, all manner of existing infectious conditions and ongoing chronic disease problems are going to have to be addressed for the evacuees. "One of the scariest ones for me is that there are 190 active tuberculosis patients under surveillance from Orleans parish that can’t be found," Savoy says. "The biggest concern from here on out is meeting the chronic medical needs — getting those TB patients found and getting them back on their meds."

Don’t be mesmerized by the hype’

In the meantime, evacuees are reporting to emergency departments and being hospitalized for all manner of illnesses. Schaffner urges that ICPs insist standard protocols for incoming patients are applied, even though infection fears, both legitimate and absurd, have been whipped into a frenzy.

"Use standard routine infection control practices for all of the usual indications," he emphasizes. "Standard precautions with isolation indications as usual. These people are not pariahs. We don’t have to do anything unusual. If these evacuees come to your institution, treat them in the standard way. Don’t be mesmerized by the hype that’s on TV. The little bit extra they will probably have to do is provide education and reassurance to their colleagues in the hospital. They may have unreasonable anxieties."

If nothing else, one infectious disease threat may prepare us for the next. For example, common sense respiratory etiquette precautions adopted during the global SARS outbreak still are in effect at the emergency department and waiting areas at RHD Memorial Hospital in Dallas. "We never really removed respiratory etiquette," says Patti Grant, RN, BSN, MS, CIC, director of infection control. "We still have the respiratory etiquette in place, and anything else would be covered by standard precautions."

Thus, even as thousands of evacuees came into the Dallas-Forth Worth area, Grant was confident that her routine infection control measures would hold the day. "Not being in a flood area or an area that was geographically hit by Katrina, our emergency room situation is more in control here," she says. "We do get patients every day, some of them coming from the shelters, some who have relocated with friends and family."

However, one key difference is that the health department asked city hospitals to switch to active surveillance, routinely reporting each morning the type of conditions being seen in both routine patients and evacuees.

"Pretty much from Sept. 1 forward, we went from passive to active surveillance," she says. "Every day, by 10 in the morning, there are two forms that need to be faxed into the county. They are not just gathering information on victims of Katrina, but they are also wanting real-time reporting of things we normally only report once a week."

The concern is palpable, but thus far infectious disease problems have been minimal. "We have been very fortunate here," Grant says. "It was odd to listen to the news as everything was transpiring and hear words like cholera and typhoid almost instantaneously. I was very proud to be a member of a profession that immediately jumped on that and said, Wait a minute; these diseases are not even endemic to our area. They are not going to just pop up out of the middle of nowhere.’"

The nightmare stories

As an employee of a Tenet hospital, the chain that owns five hospitals in New Orleans, Grant spent some volunteer hours working the phone lines and talking to beleaguered health care workers from that hospital and other facilities.

"I can’t believe the stories I have heard," she says. "I worked several volunteer hours on the Tenet health line for the employees. People just really want to talk. One called me from a Wal-Mart. It looks like most health care workers truly tried to evacuate as many people as they could."

Savoy adds, "The stories I hear coming out of those [swamped hospitals] are just horrific: Having to let patients go because they couldn’t continue to bag [manually ventilate] them. You can only continue to do that for so long. It is very difficult on the staff. The nurses and staff were starting IVs on each other to rehydrate themselves because they didn’t have food and water," she notes.

While full-blown investigations and newly formed commissions will work to uncover what went wrong and why, Savoy says essentially the hospitals were not prepared for the levees to break.

"They fully expected the buildings themselves to withstand the storms, and they had their emergency provisions," she says. "I think people forget that this was really two separate catastrophic events. The flood that occurred on Monday night was not anticipated. It completely blocked off access to those facilities — the generators were flooding out and then they ended up without power. That was something that was never planned for."

The liability claims, medical malpractice, and wrongful death suits eventually will hit like a second storm surge, she says. "I don’t think juries are going to be very forgiving of facilities that may not have had adequate plans to address the issue," Savoy adds. "But I think individual providers who did the best they could within the circumstances will probably fare better in terms of liability."

Those are arguments for a later day; for now, the stories of the first chaotic days of the aftermath still resonate. ICPs were frantically e-mailing and calling one another to find out if their colleagues in the stricken areas were all right, Grant recalls. "When one of us heard from one of our ICP comrades, we shared the word. The scariest thing was knowing not only was their hospital being hit, but [fearing] their personal loss."

And what of Savoy’s aunt and uncle who so fiercely resisted leaving their beloved New Orleans? "They bought a car and a house here," she adds. "They’re not going back."