Sunday, October 09, 2005
The Whole Blog from Start to Finish !
This blog concerns my two week stint in Louisiana as a disaster psychiatrist. I have consolidated all my entries into this single one to enable readers to read my diary from beginning to end.
9/19/05 What I Expect to Encounter in Katrina's Wake
I suspect that the burden of untreated addictive illness is quite substantial in poor states such as Louisiana and Mississipi, and I imagine that the cataclysmic flooding of New Orleans precipitated acute withdrawal syndromes in tens of thousands of addicts and alcoholics who have fanned out all over the Gulf Coast and Southeast. Cut off from their usual channels of drug procurement and the meager resources that fund their habits, I anticipate that I will encounter a great deal of distress and drug-seeking behavior in large numbers of desperate people. Does this crisis represent an opportunity for help to reach many who have been untouched by our haphazard healthcare system? Or has the flood and resultant dislocation simply worsened an unmanageable societal problem to the point where the pot is getting ready to boil over? These are questions that I hope to begin answering when I arrive in Louisiana the day after tomorrow.
9/20/05 A Reassuring Illusion is Ruptured
All set to fly into Lake Charles, Louisiana in about 24 hours, I just got word that Hurricane Rita may be heading to the area that I was intended to serve. All psyched up and ready to roll, I am somewhat disappointed that these plans are being scrapped. Perhaps I will be redeployed elsewhere - that remains unclear. When I take a deep breath I realize that the unpredictability of the weather and its impact on the usual course of human events is what this entire enterprise is about. This sudden disruption of my mission to help out is a miniscule and trivial example of how nature and God have their way with the facade of orderliness that structures much of modern life in the Western world. I suspect that my attraction to the chaotic lives of addicts and the mentally ill may have something to do with a need to reassure myself that order can always be made to prevail over chaos. Although this thought sustains me, Katrina (and maybe Rita) expose it as a reassuring illusion.
9/20/05 Destination: Houma
The powers that be have redirected me to Houma, Louisiana, which looks to be about 30 miles or so from the Big Easy. I will be flying into New Orleans via Detroit. I am relieved that the entire initiative is not being stalled by Rita - I imagine that the possibility of a new storm will aggravate the PTSD symptoms of many refugees. To be continued...........
9/20/05 Ya Gotta Believe
The National Hurricane Center's website indicates that Rita is on track to steer clear of Southeastern Louisiana, where I am headed. Nonetheless, her strengthening and looming presence have caused some to question the wisdom of the journey that begins in a few short hours. I have faith in my wits and good judgment, and I believe that my presence will be positive, reassuring and of benefit to many as this traumatizing aftershock approaches. To paraphrase fans of the '64 Mets: Ya Gotta Believe.
9/21/05 Some Initial Observations
- Extensive wetlands were visible as we approached the airport. Piecemeal houses stood in the midst of these wetlands, indicating that they were previously surrounded by dry land.
- Soldiers in camouflage uniforms with loaded M-16s slung over their shoulders patrolled the grounds of the airport. It was not at all clear why this was necessary. This was reminiscent of airport scenes in Israel and Colombia.
- The airport had the feel of a ghost town. Very few people, very little activity. The shops in the terminal were all closed.
- Some battered and dazed looking people, a few covered in blankets, were to be found in the terminal. Others were battling the car rental agent to overlook their credit limits so as to rent them a vehicle. The jolly woman who drove me to Alamo let me know that she had "lost everything" - she was glad to have a job and told me that being grumpy with the public wasn't going to change anything.
- Although a great deal of the mess on the ground outside of New Orleans has been cleaned up, signs of the devastation abound: tangled gas stations, downed trees, absent roofs, etc.
- Radio talk focuses on Rita, and on the dire situation in several of the parishes. Bankrupt parishes are laying off government workers because they have run out of funds and promised assistance has yet to materialize.
- Large numbers of displaced persons are here in Houma. I saw some rummaging through trash in an apparent effort to begin reconstituting their households.
- My initial impression of the relief efforts, which I will be plugged into in earnest tomorrow, is that they are disorganized and uncoordinated. Louisiana mental health services, the Red Cross and FEMA have not yet figured out how to work together.
To be continued..........
9/21/05 A Few Relevant Hyperlinks
Click here to read about the initiative that brought me to Louisiana. The training video on this site can be viewed by all; it's an effective and straightforward overview of disaster mental health intervention.
My launching point is a Louisiana Office of Mental Health in Houma .
My abode is Audrey George's so-called Little Cajun Mansion Bed and Breakfast , a humble Houma dwelling that proves the adage that "mansions are in the mind of the marketer."
9/22/05 In the Beginning......
Last night the other members of my team found their way to our shared residence. One or two additional team members may be coming in today, if the Rita situation does not necessitate a change in plans. Our team consists of a pastoral counselor/minister from Oklahoma, a psychologist from Chicago, and a counselor from Oklahoma who got in her car and drove 16 hours to get here. This morning we got together at the state mental health office and viewed a useful online training video (you can get there from http://www.wcikatrinahelp.com ). I was then deployed to a mental health center in dire need of a psychiatrist at Morgan City in St. Mary's Parish. Enroute, I listened on the radio as a hurricane warning was being declared for this parish. Five minutes later my cell phone rang and I was directed to turn around - St. Mary's Parish was being evacuated. Now I am sitting at the Terrabone Parish Mental Health Center in Houma, filling in for the local psychiatrist who decided to take the afternoon off to evacuate his family - many people around here are not taking any chances and are preparing for the worst. The approaching specter of this latest storm is reawakening the worst fears of many.
When I am not seeing patients I find that debriefing staff is a good use of my time. One young therapist told me about her 3 weeks of double shifts in one of the nearby Special Needs shelters that was housing evacuees. She was particularly frustrated that one of her clients who was in the middle of a chemotherapy trial for recurrent breast cancer was not deemed "acute enough" to qualify for expedited medical care. She is also very concerned that many of the "somewhat stabilized" evacuees are being re-evacuated to other locales because of Rita.
Despite the tension brought on by the looming menace of Rita, people down here good-spirited, relaxed and calm. Many have a profound sense of gratitude and thankfulness that "it could have been much worse" and they are counting their blessings.
9/22/05 A Brief Comment on Comments......
I have reconfigured this blog to allow anyone who wants to to comment on my postings. Please feel free to do so, while respecting my anonymity. Whenever a comment is posted, I will automatically receive a notification email. The clinic where I am currently sitting has decided to shut down tomorrow. I can only guess what my next assignment will be.
9/22/05 To Evacuate or Not to Evacuate, that........
This afternoon at the Terrebonne Mental Health Clinic patients and staff alike began to speak of evacuating this area to move inland, distancing themselves from the approaching storm. The governor has advised everybody below the intracoastal waterway to evacuate; the center of Houma sits a few miles above the intracoastal. Everyone from Morgan City to the Texas border was also advised to evacuate; Morgan City is about 35 miles to our West. Some of the staff at the clinic were annoyed that they were not sent home early to get out of town. They were ambivalent enough about whether or not to evacuate that they based their decision not to do so on the fact that the roads would be clogged and it would take 5-10 hours to get anywhere.
The Georges, whose home we are staying in, were not about to move. They were confident of the safety of their home (complete with backup generator), and reassured by the predictions for the eye of the storm to hit land far from here (about 200 miles down the Gulf Coast). Our group of visiting mental health "angels" (the government's term, not mine) debated whether or not we should move ourselves to one of the inland disaster centers. Although there was a bit of trepidation about Rita, our main reason to relocate would have been to situate ourselves at sites that were receiving large numbers of evacuees in order to be of assistance. As things here are as loosely organized as the products of a pre-colonoscopy prep, the decision about where we would go and what we would do was left entirely to us. After concluding that it made more sense to follow the storm rather than to precede it, we decided to pay a visit to the Terrebonne Civic Center, which some 400 Katrina evacuees still call their home.
The shelter at the Civic Center has been organized by and is run by the citizens of Houma (the main city in Terrebonne parish). Some 3000 Katrina evacuees have moved through this shelter; all who could be placed with friends and family have moved on -the remaining folks have nowhere else to go. This entirely volunteer operation was incredibly impressive; in addtion to providing living quarters they have stockpiled clothes, games and medical supplies, and have created ad hoc social services, employment services, a Cajun kitchen, a pharmacy, a medical clinic, and an isolation unit. Today, the mood of the clientele was tense - the approaching storm was pushing all their most sensitive buttons. Some of the most traumatized residents, fearing an imminent deluge, had to be talked out of moving their belongings to the top row of the bleachers. The staff we spoke to were heartened by our unannounced arrival, and had a great need to tell us their stories.
I myself will be going to back to the Civic Center first thing in the morning. I was the first psychiatrist to set foot in this shelter since Katrina, and their general MD, provided by the Red Cross, completed her tour of duty today. I will stay there Friday night and all day Saturday, joined at various times by my colleagues. I plan to make my next entry on Saturday, after dark.
9/24/05 Genuine Inspiration
About an hour ago I returned to my home base (Audrey's Little Cajun Mansion) following a taxing and inspiring 36 hour shift at the the largest Terrebonne Parish shelter. Following Katrina, a large shelter was established in the local civic center here in Houma and a much smaller shelter in the Houma Baptist Church. Yesterday, as Rita passed to our South and and the coast was now downwind, water began moving into the many bayous and up over the levees that connect them. Although many of the local folk in the lower half of the parish had already evacuated, some had not. The flooding was extensive and severe. One local nurse found her car and home suddently inundated by 4 feet of water. At 6:30 this morning a school bus containing 30 detainees from the local juvenile detention center pulled up to the Civic Center. The juvenile facility was taking on water and the local authorities scrambled to create an impromptu lock-up until they could figure out what to do with these teenage boys and girls. I believe that most of them were released to the custody of their parents. Overnight, 3 additional shelters were designated here in Houma and filled to capacity.
Although a couple of other doctors passed through the facility during my tour of duty, my decision to stay there overnight effectively placed me on call, bringing back the anxiety-provoking days of going it alone at a 300 bed psychiatric facility. Many medical cobwebs were cleared as I encountered diabetes, lupus, pneumonia, a mysterious rash, and a possible case of appendicitis. Try as I did to do my shrink thing, the needs of the clients kept pulling me back into more of a primary care/family medicine role. Thankfully, there was no need for me to dust off surgical skills that never existed in the first place!
Friday was a very tense time in the shelter for the New Orleans evacuees. Rita's winds and rains were all too reminiscent of Katrina. People wept and grimaced as live TV coverage showed new breaches in the levees and renewed flooding in the 9th Ward. Many people here have chosen to remain in a Southeastern Louisiana shelter instead of relocating to Texas or elsewhere in the hope that they could get home sooner and salvage whatever there was to salvage; their last hopes and dreams were being submerged and subverted by the latest turn of events. By midday today, it seemed that their discouragement was giving way to a more sober and realistic assessment of their situation. Some began to acknowledge that it was finally time to move on; this repetition of history was painfully therapeutic.
With the backdrop of a new storm and new floods in New Orleans, many survivors continued working on processing the multitude of traumas and losses that they experienced in such a short time. Several I spoke to fled waters that were rising so rapidly that there was little time to do anything more than frantically poke a hole in the roof and climb up out of harm's way. Various necessities - food, water, dentures and medications - were left behind in the scramble for safety. Many residents of the shelter are just getting comfortable enough to recount their harrowing tales of desperation and salvation.
The profound faith of these survivors is inspiring. One older woman sits all day at a table, bobbing back and forth (Jews refer to this as davenning), praising God and literally singing the blues. Many people have succeeded in attributing cosmic significance to their ordeal: one woman views it as a message from God that we need to be more humble; another is beginning to see it as God's way of moving her and her children to a more congenial and safe environment (now that she realizes that the schools here in Houma are better than those in New Orleans, she has decided to stay and is beginning to hunt for an apartment here). When a Christian Rock Band came to perform yesterday, the spirited participation of several hundred evacuees concealed the gravity of their many losses.
What It's Like to Live in a Shelter
Living in a large auditorium with hundreds of people is very, very challenging. It's noisy. Nobody is really in charge. The rules are unclear and inconsistently enforced. Physical intimacy is almost out of the question. Noisy bands of little kids collide with unruly droves of hormonally stoked adolescents. Showers and meals are available according to schedule, not as needed. In spite of this all, the resilience and indomitability of the human spirit shines through. The evacuees' ability to start anew after such a severe and abrupt series of losses is genuinely inspiring.
9/26/05 Sunday Miscellanea
What follows is a rather quick summary of Sunday in Houma, Louisiana, the day after a few thousand people in this Parish left their homes when the local bayous overflowed and flooded the lowlying sections.
Rock of Ages Baptist Church - Pastor Smith and his congregation invoked absolute faith in God and joyful worship as the antidote to all the trials and tribulations that continue to befall the people of Southern Louisiana. The strengthening of belief in the face of crisis is wondrous to behold.
Battle Fatigue - The staff of the Houma Civic Center decided against taking in the new crop of local evacuees; they were accomodated in 4 new local shelters. In fact, one particulary weary fellow asked me, only half-jokingly, what I thought would happen if we simply locked the shelter when everybody was out and told them it was closed. Similarly, a few Red Cross volunteers and local police have been making comments about the clientele that are less than compassionate and sympathetic. One of the shelter residents poignantly told me that he was fed up with being treated like an incarcerated criminal by the law enforcement staff. With our fresh energy and enthusiasm, our group of mental health do-gooders has continued to take small initiatives to improve the atmosphere in the shelter: we brought in an organ, have organized a daily news bulletin, changed offensive signage ("feeding times" instead of "meal times"), and recommended getting clocks and calendars up on the walls of the 2 enormous windowless rooms that are the home of several hundred people.
The New Orleans Diaspora - Hurricane Katrina has rent asunder the fabric of tens of thousands of functional, close, extended family systems. One angry woman I spoke with yesterday described to me how her children and grandchildren, previously all residing in the same New Orleans neighborhood, were now situated in 4 locations in 3 states. She has yet to locate some of her siblings. In addition to dealing with the heartache of not being able to go home and the indignity of accepting handouts, she was clearly stymied by the near impossibility of reuniting her family anytime in the near future.
Prescription Drug Dilemmas - How do people with lost insurance cards fill prescriptions after a hurricane? The answer is, "with great difficulty." The ad hoc sample pharmacy at the shelter is winding down and closing. A couple of local pharmacies who have been filling prescriptions with the hope of someday receiving reimbursement are beginning to worry that if they are not paid for their humanitarian largesse that they will go out of business. One of these pharmacies took on water yesterday and was closed. The large national chains were under strict orders to do things by the book, and they were disinclined to fill scripts with Red Cross vouchers that had been photocopied without the customary purchase order numbers on them. One veteran I saw yesterday evening had 6 heavy-duty prescription drugs washed away in the local flood, and after calling around he and I decided that he would just have to tough it out until this morning, despite the possibility of a very uncomfortable night.
Down the Bayou - The local Cajun fisherman and shrimpers who were deluged by Rita's storm surge are a colorful and unique group of people. Those who live something of a hand-to-mouth existence landed in the local shelters, some barefoot and sullied by flood waters. The more functional families simply evacuated in their RVs to the Civic Center parking lot. In a future posting I hope to expand my observations on these colorful folk.
9/26/05 History Repeating Itself (& It Hurts)
The most noteworthy event of the day involved the consolidation of the many shelters in Terrebonne Parish. The 4 ad hoc shelters that sprouted up over the weekend in several local schools were rather summarily closed in anticipation of school reopening tomorrow. Those evacuees who could not return home were bussed to the Terrebonne Civic Center, to join a few hundred Katrina evacuees from New Orleans who remain there. The Cajun folk from "down the bayou" were not the least bit happy about being moved. They had staked their claims in a variety of choice spots in the cafeterias, gyms and hallways, and the order to pack up their things and climb onto waiting school busses was all too reminiscent of their hasty flight from the floodwaters. Unfortunately, their relocation to the Houma Civic Center necessitated the institution of a parallel process that forced the New Orleans evacuees to vacate an entire auditorium and to crowd into half as much space.
A friend of mine in Florida once purchased the home next door to her rental house. Until today I never really understood her comment that this move next door was the most difficult move of her entire life. These Katrina evacuees had regained some small measure of stability and predictability by staking their claim to a specific area of floor space in Auditorium B. Family groups and neighborhoods were able to stay together; new friendships and relationships with evacuees in nearby beds had taken root. With very little notice, a declaration to vacate Auditorium B was made, and the population of Auditorium A was doubled in the course of an hour. The abrupt and unexpected evacuation of a roomful of survivors was sadly and eerily reminiscent of their recent exile by Katrina. Some people broke down, others cursed angrily. Some carried out the order dutifully, exuding a sense of futility, powerlessness and resignation.
Our mental health team patrolled the floors, striking up conversations with as many people as possible. For some, the opportunity to unburden themselves and to have their raw feelings validated seemed enormously beneficial. Within a couple of hours of the latest round of relocation and crowding, the mood in Auditorium A had changed for the better, a shift that was fostered by LSU's hoped-for trouncing of Tennessee.
9/27/05 Nooks & Crannies
Since yesterday my day job has been to treat adults in the St. Mary Mental Health Center located in Morgan City, LA., about 30 miles West of Houma which is 60 miles West of New Orleans. The center here has been without a psychiatrist for the last several weeks, and the town's only Family Practicioner has also left practice. The clinic's staff and hundreds of patients are counting on this Yankee shrink to work wonders in less than 2 weeks. Although I am already beginning to prepare them for my imminent departure, their here-and-now focus is to have me put out fires and eat through the lengthy backlog.
Before getting started I wondered to what extent my work in this center would be connected to the recent natural disasters. I figured that at the very least my presence here would remove some of the pressure on an overtaxed public health system. And I knew that coming on board would provide relief and respite to staff members who have been doubly burdened by the pressures of serving a demanding and restive patient population while at the same time managing their own hurricane-related challenges. What I did not realize until I started seeing patients was the extent to which the floodwaters had reached into the nooks and crannies of so many lives.
I saw 14 clinic patients today, and at least 9 of them presented with hurricane- related difficulties. A few examples (purposefully disguised to maintain confidentiality) follow:
A patient from a pain clinic in New Orleans whose psychiatric problems have worsened in the absence of treatment for severe chronic pain; a puzzling middle-aged man with a progressive confusional state that has progressed since he evacuated his home outside New Orleans; an elderly woman whose depression and anxiety crescendoed while she fled Rita and got caught in mammoth traffic jams; a young woman with major mental illness and a history of non-compliance who travelled 75 miles for her monthly injection because the mental health center in her inundated town will be closed until the end of October; and, a construction worker overwhelmed (to the point of high anxiety and sleeplessness) by the volume of work-to-be-done and the demands of additional on-the-job responsibilities.
Clearly, natural disasters take their toll in a variety of subtle and unexpected ways that cannot be readily discerned in helicopter flyovers.
9/28/05 The Practice of Psychiatry on Planet Louisiana
After evaluating a confused and catatonic patient who should have had her brain scanned more than a year ago to rule out tumors, atrophy and the like, I mentioned to one of the nurses in the St. Mary Mental Health Clinic that working here was a lot like working in a third world country. She immediately quipped, "Welcome to Planet Louisiana."
The culture on this planet is foreign to me and I am attempting to adapt to it as fast as I can. Here are some of the unique practices that I have observed:
Item: The local parish jail relies heavily on the services of the mental health center. Prisoners with jump suits, handcuffs and leg shackles are routinely brought in by the local sheriff for casual, unscheduled psychiatric look-sees. The doctor's opinion may determine whether the prisoner stays in jail or goes to an inpatient psych bed to serve out his sentence in a somewhat more therapeutic environment.
Item: Louisianans who care to may present an affidavit to the parish coroner attesting that somebody they know is in need of immediate emergency mental health care. If the coroner approves the request for a protective custody order, the sheriff rounds up the named individual, and delivers him or her to a locked seclusion room in the good old parish mental health center. It then falls on the psychiatrist to determine whether or not the individual in custody is in need of involuntary treatment in a locked facility. As one can well imagine, mean-spirited people can make the lives of their enemies miserable by having them rounded up and evaluated. Today's case at SMMHC involved a conflict between ex-spouses, the New Orleans treatment records of the so-called "identified patient" having been rendered inaccessible by Katrina.
Item: I now have a clear and visceral understanding of the term "dirt poor." One after the other, individuals with hard-luck stories, absent incomes, and longstanding histories of abuse, abandonment and victimization, parade in and out of my office. The lucky ones have government-subsidized health benefits and meager disability incomes, although most do not. They live harsh, impoverished hand-to-mouth existences with no visible means of support whatsoever. Many seem to cycle between the streets, the jails and the mental health system.
Item: Prescription drug coverage is a joke down here. The absence of benefits shapes the care or lack thereof of hundreds of thousands of poor folk. Sadly, Katrina evacuees who lost their Medicaid cards have been squeezed and soaked, jerked around and turned away, by all of the major national pharmacy chains. A few of the remaining independent pharmacies have treated them with compassion, demonstrating a high degree of morality that may end up being to their fiscal detriment.
Item: It seems as though virtually everybody who has ever experienced a delusional thought or an auditory hallucination in Southern Louisiana has been deemed schizophrenic. The extent of diagnostic imprecision is appalling, and the long-term overuse of antipsychotic medications extremely unfortunate. Crack-induced paranoia, hallucinations due to alcohol withdrawal, and the psychotic symptoms that sometimes accompany episodes of mania or major depression do not require decades of treatment with powerful and potentially toxic major tranquilizers. It appears as though large numbers of psychopharmacological cripples have been created by fuzzy thinking.
Item: Here in Lousiana, doctors are treated with a level of respect, deference and near deification that I find to be both novel and quaint. On the other hand, the notions of "patient-centered care" and "consumer-driven healthcare" seem to be foreign and unfamiliar.
In tomorrow's post, I hope to update you on the gradual reopening of New Orleans and the impact this is having on the evacuees in our local shelter.
9/30/05 Telepsychiatry, the Governor, the Vietnamese Shrimpers & Imminent Death
In between patients, I spent much of Thursday fantasizing about the creation of a long-term telepsychiatric linkage between the over-abundant psychiatrists who reside in relatively glutted Northeastern academic strongholds like Boston and New York and the understaffed mental health clinics of underserved rural areas like Morgan City, Louisiana. Like many dreams, this one may not be realized. Nonetheless, I will discuss it in earnest with the powers that be in the Louisiana Office of Mental Health, to see where it might lead. In the words of Theodore Herzl: "If you will it, it is no dream."
"SHE DIDN'T EVEN MENTION THE LEVEES!"
When I arrived at the shelter in Houma yesterday afternoon, a previously non-existent stage was sitting in front of the Civic Center. A local television personality had organized a "Time for Action" rally to send Governor Kathleen Babineaux Blanco the message that Southern Louisiana needed the government's help. Prior to the governor's arrival, the rally's organizer instructed the large and restive crowd to, "Treat the governor with respect. After all, we're going to be on national television." A short time later, a State Police helicopter carrying the governor landed on the lawn next to McDonald's. Ms. Blanco is no Rudolph Giuliani, nor would she have made it as Head Cheerleader. She smiled and waved and uttered a few scripted platitudes about the proud people of her state and their determination to rebuild. Audrey Babineaux George, the proprietress of my bed and breakfast and the governor's cousin, told me later on that she grabbed the governor in the course of the rally and told her, "You didn't even mention the levees. You need to mention the levees. You've got to let the people know that you plan to rebuild and strengthen the levees." Audrey was very pleased that her cousin uttered the word "levee" at least seven or eight times in the ensuing five minutes. This bird's eye view of the political process in action was quite enlightening!
THE VIETNAMESE SHRIMPERS
Large numbers of Vietnamese shrimpers and their families have settled here in Southern Louisiana, and both hurricanes have damaged the homes of some of these new immigrants. These modest, quiet people have come to the United States to improve their lot, and their single-minded determination to create opportunity for their children is palpable. Whilst many of the children of the New Orleans urban poor and the hardscrabble Cajuns from "down the bayou" run amok in the free-for-all atmosphere of an emergency shelter that is gradually taking on the trappings of a long-term refugee camp, the children of the shrimpers sit quietly on their bedrolls, reading schoolbooks and doing their homework. Motivation (informed by faith, family cohesiveness, cultural attitudes and life experience) to transcend the oppressiveness of one's current circumstance may be the single most important variable in determining whether or not one manages to move up and out.
"I'M GOING TO DIE TODAY."
Burnout is unavoidable to some of the shelter staff; the burden of suffering, dysfunction and confusion that surrounds us is too much for some to bear. One of the workers at the shelter has stopped sleeping and is gradually descending into the realm of magical thinking, believing that his death is imminent. We need to look after ourselves and each other; I am keeping close tabs on this gentleman in order to get him the help that he needs. On Saturday teams comprised of mental health professionals, medical staff and clergy will be accompanying several busloads of evacuees back to their neighborhoods in New Orleans. We must take care to screen the fitness and stability of those who are meant to support Katrina's victims at a time of tremendous emotional stress and strain.
9/30/05 The Potential Value of Electronic Medical Records
Three of my clinic patients today were Katrina evacuees who had relocated themselves to Morgan City. Each of them was plugged into the New Orleans area community mental health system prior to the storm. Thanks to the hurricane their mental health centers are closed, their clinicians have joined the amorphous New Orleans diaspora, and their paper medical records are unavailable. All 3 of these chronic patients ran out of medication earlier this month and were experiencing recurrent symptoms of a significant mental disorder. In order to figure out how to help them, I had to rely on the verbal reports of seriously impaired individuals. How much easier my task would have been if their records had been available to me electronically!
I used the word "Potential" in the title of this posting because yesterday I encountered a similar situation with a patient who had been receiving treatment for a major mental disorder in the New Orleans Veterans Administration Hospital. "Oh boy," I thought, "I should be able to locate an electronic record in the VA system." Multiple phone calls later, I discovered something that I already new: A system is only as good as its weakest link. I made a number of phone calls to various VA Sites and functionaries, and after multiple phone menu mazes that led into voice mail cul-de-sacs, I hung up in disgust and decided to do what I have been doing best for the past week: Flying by the seat of my pants and winging it.
10/1/05 The City of New Orleans
Today I escorted a mini-busload of evacuees back to New Orleans. The purpose of their visit was to see what, if anything, could be salvaged, and to retrieve a few keepsakes and documents. With the turn of a key, we expected some hopes to abruptly evaporate and many fears to be confirmed. The presence of mental health professionals "on the scene" was intended to assist and support the evacuees in beginning to seriously reckon with the saddening and sobering reality of deepening loss, disruption and disclocation.
As much of this story has been covered by the media, I will attempt to be brief here. The visit literally brought all of us "ad nauseum." The stench is unbearable, especially on the first floors of homes that took on significant amounts of water. Three of the six homes we entered were particularly nauseating. Rotting food adds to the disgusting aroma of mildew and mold. In the residential neighborhoods we visited, the toxic waters have killed all plant life up to the water line (some tall bushes have retained a green pate). The lush palette of the tropics has given way to a pallid grey-brown hue, the same sickening color that coats the thousands of automobiles left behind. The city is littered with boats that sit aground in the most unlikely places. Mounds of detritus are everywhere; running shoes (which apparently float) and decaying food dot the landscape. The wide-eyed human forms one encounters appear as ghostly apparitions in a most unlikely and incongruous urban netherworld.
En route to New Orleans, two of the single men in the group appeared to be particularly composed and emotionally well=prepared for the expected upset. They fared least well. One of them was appalled and enraged to discover that in spite of the absence of water damage, his apartment had been gutted and rendered permanently uninhabitable by a vicious combination of wind and looting. The other man had lived in a once tidy neighborhood of low-lying homes that were flush to the ground. The breach in the local canal spared nothing, destroying this tradesman's tools in an outdoor shed. Shaken by the sudden realization that he now lacked the means to begin to support himself, he could only shake his head.
Upon returning to the shelter in Houma, we spread the word as to the conditions back in the city. Each day a few more shelter residents make contact with neighbors and friends who have surveyed the wreckage. I stood with one toothless gentleman as his girlfriend spoke on the phone with her son as he sifted through their things back in the city. They had escaped with their lives as rapidly rising flood waters necessitated a hasty flight to the attic and a frantic, successful effort to poke a hole in the ceiling in order to gain safety on the roof. Unfortunately, this gentleman's one request could not be accomodated: his girlfriend's son was unable to locate the dentures that he had left behind in his haste. Although the price of regaining one's dignity may not be very high, in these unique conditions it cannot always be paid.
10/2/05 Lafitte, Lafourche, Madewood & Putrefaction
Since arriving here on September 21, today was our first day of relative leisure. Our Mental Health Response Team learned more about Cajun history and culture at the Wetlands Acadian Cultural Center of the Jean Lafitte National Historical Park and Preserve in Thibodaux. We then proceeded to take a pleasant boat ride up Bayou Lafourche, a previously major distributary of the Mississippi that was blocked in 1904, much to the detriment of the Southern Louisiana watershed and ecosystem.
We landed our craft at Madewood Plantation, a dramatic piece of antebellum Greek Revival Architecture cum luxury B&B. If you're ever in the neighborhood, Madewood is a totally convincing and memorable reminder of the way of life that spawned the War Between the States. While touring this painstakingly restored mansion I could not help but take note that the kitchen help were of one color, whereas the tour guide and office staff were of the other. Throughout my visit I have made contradictory observations about race relations: whereas blacks and whites down here appear to coexist in closer proximity and with more comfort and intimacy than in the North, racist attitudes displayed by whites and deferential behavior exhibited by blacks are much more apparent.
Today's tour guide helped us to understand some of the historical forces that gave rise to the Cajun folk "down on the Bayou." When the French settled the choice land on the banks of bayous like Lafourche, local Indian Tribes moved further downstream, into the swamp country. When the English came along they coveted the lands occupied by the French, and these Accadians or Cajuns were themselves displaced downstream into the lower-lying swamp land closer to the mouths of the bayous. There they were left in relative isolation, able to maintain an almost medieval French dialect and their unique folkways. Several of Hurricane Rita's refugees in the Houma Civic Center are elderly Cajuns who do not speak English. Their children, now middle-aged, speak both Cajun and a distinctive French-accented English. Some of their grandchildren speak relatively little French. I hope to learn a lot more about this accelerated process of assimilation when I sink my teeth into Bayou Farewell by Mike Tidwell.
After speeding back to Jean Lafitte from Madewood ahead of a thunderstorm, we drove into the French Quarter of New Orleans. Although untouched by floodwaters, Katrina's impact on the power grid, the sewage system, and garbage collection has endured. The French Quarter stinks of decaying food; the stench is pervasive and inescapable. Most establishments remain locked; a small number are in the process of sprucing themselves up; a mere handful of businesses are open. It will be quite some time before New Orleans reclaims her glory.
10/3/05 Connecting Some Dots & A Hiatus
On my way into New Orleans the other day somebody mentioned that the sections of the city closest to the Mississippi River fared the best during the hurricanes. I noted as much yesterday, when we drove alongside the river, beneath the water level, protected by the massive levees that obscure the Mississippi from view. Actually, these massive levees are part of the problem, which I can begin to explain with the information I am learning from Bayou Farewell. My reading is helping me to understand why Southern Louisiana is such an endangered region of the United States.
Massive rivers like the Mississippi are meant to overflow from time to time. They are also meant to distribute their riches to distributaries like Bayou Lafourche. One of a river's greatest riches is silt. When a river floods, both water and silt overflow its banks. The silt builds up and replenishes the soil of the swamps, flood plains and barrier islands. The way things are currently engineered, the mighty Mississippi is delivering almost all of its water and silt directly into the Gulf of Mexico. It no longer feeds the bayous as it once did, so the land in the bayou country is currently disappearing at a rate of 40 acres or more per day. And it no longer overflows over the Mississippi Delta either, so silt that could replenish and restore the disappearing barrier islands is being wasted.
The erosion of the coastal land mass and the disappearance of the barrier islands expose the population of Southern Louisiana to the full brunt of these tropical storms. The existence of a border zone of swampland and silt-enriched barrier islands is a natural form of protection. Overdevelopment, in conjunction with engineering initiatives that upset the natural course of events, are direct precursors of the devastation caused by the two storms.
I have also gained some appreciation as to how the flooding caused by Rita in Terrebonne Parish is connected to Hurricane Katrina. Katrina's storm surges softened and weakened the levees in Terrebonne parish just enough so that Rita's storm surges caused them to breach. Although Terrabone did not receive the brunt of either storm, it received a one-two knockout combination in the space of a month, and this combined effect was just enough to cause breaches in the levees and severe flooding. As mentioned above, if the local bayous had sufficient water flow and silting to bulk up the swampland, the storm surges of Katrina and Rita might have been mitigated to the point where the levees would have held.
As I think about the efforts underway to rebuild New Orleans and the shattered lives of its residents, it strikes me that our society will be throwing away "good money after bad" unless and until we improve the systems for managing rivers, wetlands and erosion.
For reasons that I do not have the time or inclination to explain, I won't be blogging for the next 52 hours. I intend to post something on Wednesday evening, before preparing for my trip home on Thursday.
10/6/05 Thoughts As I Prepare to Depart
I am leaving Louisiana in just a few hours. Before I came here I envisioned a humanitarian mission wherein I would help victims of a powerful storm. Over the course of this sojourn I have realized that the victimization of this state's citizens has a long and glorious history, and that the devastation wrought by the two recent hurricanes stemmed from greed, ignorance and an arrogant, devil-may-care-attitude towards this fragile environment and its vulnerable ecosystem.
People down here are lovely: consistently warm, friendly and polite (I have heard the two words "Yes, Sir!" more times in 15 days and in the previous 1000 weeks). They do not take themselves or their lives too seriously, and their expectations are, at times, alarmingly low. It is almost heartbreaking how they savor the crumbs that are thrown their way.
Just the other day I caught myself imploring a young man to "get out of this state if you possibly can." I was shocked and saddened by his story that a high school guidance counselor had advised him to drop out of school after a hospitalization because "it will be too much trouble for you to make up the work that you missed." He followed this counsel, and over the subsequent two years he has gone from being an honors student to an underemployed, minimum wage flunkee who can look forward to a life of underachievement and subsistence. A society that does not give its talented young people a chance to shine is in serious trouble.
Misguidance and mismanagement appear to be the coin of the realm in these parts. The other day at Madewood Plantation I was disturbed, although not surprised, to learn that FEMA functionaries were being housed in this luxurious B&B. South Louisiana is abuzz with thousands of folks who are being funded by the Red Cross and various branches of the Federal Government; much of the time they work at cross purposes and get in each other's way while nearly 50,000 storm evacuees continue to languish in shelters, making little progress in securing adequate housing.
For this region of the country to recover, we need visionary leadership, much hard work, sacrifice and an organized and concerted effort to address the fundamental socioeconomic and environmental infrastructure problems that underly the toll taken by these two storms. And while Southern Louisiana is sinking, our tax money is supporting gourmet meals and happy hours on plantations. When will we ever learn?
10/6/05 Coastal Lousiana Needs Rehab Now
On the plane ride home I read a visionary New Yorker article by John McPhee from 1987. I then proceeded to write the following OpEd piece. Perhaps I will succeed in having it published:
A few weeks ago the American Society of Addiction Medicine sent an urgent email to its membership asking for doctors to volunteer for two week tours of duty in Southeast Louisiana. Ostensibly, drug and alcohol-dependent New Orleaneans needed our help in the wake of Hurricane Katrina. I answered the call and soon found myself doing rounds in a crowded shelter of evacuees in the bayou town of Houma, some 35 miles west of New Orleans.
I quickly learned that the infrastructure of the region’s marginal healthcare and social service systems had sustained nearly as much damage as the gutted homes of New Orleans’ Ninth Ward. Despite the rustiness of my general medical skills (I’m a mid-career psychiatrist), I found myself assessing patients with asthma, diabetes, chest pain and lupus, along with those who have lost their Medicaid cards and alongside those with drug withdrawal, hallucinations, insomnia and flashbacks.
When Rita hit and the local bayous flooded, our shelter’s population doubled overnight. Bearing witness to this second wave of evacuations concretized for me the sogginess and vulnerability of the very land beneath my feet, and helped me begin to realize that coastal Louisiana resembles an end-stage alcoholic. This dying region of our country is like a red-nosed, middle-aged guy with early cirrhosis of the liver who cannot bear to give up his poison, despite a mounting awareness that it is gradually killing him.
Most hard core smokers, alcoholics and addicts have known for years that their addiction is doing them in. Nonetheless, they continue using their substance of choice because they enjoy the buzz, abhor the discomfort of stopping, and deny or minimize the possibility that they will be afflicted with a life-threatening complication. “What, me worry? I’ll quit tomorrow.” In a similar vein, our society has been ravaging the Louisiana coastline for decades, knowing full well that our neglect of the environment would expose New Orleans and its environs to catastrophic damage in the event of a direct hit.
Addicted to the commercial need for an unchanging man-made lower Mississippi basin, we have destroyed barrier islands and coastal wetlands by allowing the Army Corps of Engineers to flush billions of tons of valuable sediment off the end of the continental shelf, out into the Gulf of Mexico. Hooked on the money and power of Big Oil, we have encouraged and enabled the sinking of coastal Louisiana by sucking large volumes of petroleum out of the Gulf, and we have promoted the salinization and death of freshwater marshes by dredging waterways for pipeline construction and maintenance (once dredged, these channels expand themselves geometrically).
High on the drugs of profit and growth, we have ignored the fact that our laissez-faire, let-the-good-times-roll policies have eliminated one-third of the buffer zone that protects us from the ravages of storms like Katrina and Rita. It is time for us to awaken from our stupor, and to institute sweeping environmental reforms that will arrest and then reverse the deleterious processes that have taken such a toll on the people of coastal Louisiana.