Dr. Karen DeSalvo
Dr. Karen DeSalvo was able to compare the extent of preparedness among the three New Orleans hospitals with which she is affiliated: Tulane, Charity, and the Veterans’ Administration (VA) hospitals:
"We work at three hospitals, and I would say their degree of preparedness varied remarkably. And from a cultural standpoint, Tulane Hospital seemed the most prepared, which was surprising to me. I was expecting the VA to be more prepared, but they appeared to be fairly unprepared. And obviously the Charity University system was pretty unprepared."
"If you were to actually look without talking to people, what is said is essentially true, that all of the hospitals followed their hurricane plan. The disconnect is they did not have any planning, and nobody knew the plans existed. For example, Charity University, the plan was for them to evacuate in place, be the last hospital evacuated in the city. And so, hence, that’s what happened. But no one told them that, so they thought they had been abandoned. But the state thought they were following the plan . . . "
"The biggest issue was that we were not prepared for a flood. We knew what to do for a hurricane, but we did not know what to do for a flood. Specifically, for example, the helivac site is at the Superdome and to get there was impossible, essentially, without boats. None of the hospitals were outfitted with the helipad, thinking they could use the streets to transport patients. So there was not a lot of thinking through the issues. The staff was not prepared with . . . the right supplies and the right training. We did not have our families set up right, so we brought people with us, and pets . . . "
"Unfortunately, the scenario was the same hospital to hospital. What was different for HCA’s hospital – Tulane Hospital – was that they behaved more like the military does. They knew that the objective was to keep people safe and then get them out, and so they continually changed what they did as an organization to adapt. And they did not have to go through as many levels of bureaucracy as probably the VA, and they had some structure and they had money, which was a big deal, because they were able to marshal that multi-billion dollar corporation to bring in transportation and satellite phones and security to protect the place."
"One of the other things that was so critical for Tulane Hospital – VA, too, probably – was we had armed security. We had really good security, and I think that gave a lot more peace of mind to the people who were staying and working there. I think there was less fear and chaos as there might have been in other hospitals in the area because people felt protected."
Dr. DeSalvo described the impact of Hurricane Katrina on the Tulane School of Medicine:
"We eventually had lay-offs in December of ’05. We laid off about a third of the faculty across the board in the School of Medicine, which continues to be one of the worst things that I ever experienced as a manager. (long pause). The reason that they did that was because there was no population and they had no revenue coming in. And academic medical centers are largely funded by, not only clinical workers, but for this medical school, most of our funding comes from our teaching contracts with the VA and Charity. So with Charity closed and that type of revenue shut off, and the VA wanted to move all of its doctors to other states temporarily until they could reopen – and so some doctors that we had left rather than do that. We lost a chunk of our revenue. . . "
"But we’ve been lucky here. We had our facilities, and essentially we were back in our med school building by March of ’06. Without internet and consistent temperature, but we were back. And there was hardly anyone there, frankly; but by July, the med students came back and that’s when they got the issues with the temperature worked out and internet going. So we’ve been in a building longer than other medical schools, so it’s been easier for us. And we moved here where we are now in August or September of 07."
In comparing three different hospitals with which she was affiliated, Dr. DeSalvo referred to a military mindset that was unique to Tulane Hospital:
"What was different for HCA’s hospital – Tulane Hospital – was that they behaved more like the military does. They knew that the objective was to keep people safe and then get them out, and so they continually changed what they did as an organization to adapt. And they didn’t have to go through as many levels of bureaucracy as probably the VA, and they had some structure and they had money, which was a big deal, because they were able to marshal that multi-billion dollar corporation to bring in transportation and satellite phones and security to protect the place. . . ."
"The only folks who seem to not have a dog in the hunt and be unbiased were the military. And there’s still some stuff we’ve got to work out with the military. But I found them to be very flexible on the ground and very agreeable to working with us. They come with enormous intellectual capacity and a lot of experience. They come with a lot of supplies, and they can assess situations because they’re not looking to be in it for the long haul. And they don’t have a dog in the hunt, is the expression. So when they left right before Rita . . . things got a little chaotic after that. We were in a lot better shape when we had the commander running the meetings versus "Okay, now who from the community is going to run the meetings?" And then, of course, you know how that goes. It was like dissension and chaos. Everyone wants to be in charge because they think they’re going to get the most marbles."
In addition to the organization and resources of the military, Dr. DeSalvo also noted the impact of the presence of armed security at Tulane:
"One of the other things that was so critical for Tulane Hospital – VA, too, probably – was we had armed security. We had really good security, and I think that gave a lot more peace of mind to the people who were staying and working there. I think there was less fear and chaos as there might have been in other hospitals in the area because people felt protected."
When asked why Tulane was armed, Dr. DeSalvo replied:
"Security is a high priority for a university generally. It’s the university’s police, not the hospital’s police. So I don’t think it was so much the hospital’s thinking; it was the school’s. And we had gone to a firearm – loaded firearm - system as the VA had and other systems don’t all have that in their security guards. So maybe that has . . . something to do with the fact that it’s university security which probably tends to be a little higher than just a simple hospital which may just have some security guards to deal with people that are coming in. . . . We had stepped up security in the months before Katrina at Tulane Hospital because of the continuing closure of University Hospital and Charity – they were on diversion a lot because of finances. So we were seeing a lot of patients come in who were not the typical kind of patients we had seen at Tulane…a lot more people with severe mental illness who were volatile. Or maybe people who had gunshot wounds, so gang-related violence. Different kinds of stuff that made the hospital and the security more concerned; so they had just stepped up a lot of that stuff before the storm, and I think it was luck. . . "
Dr. DeSalvo summarized the concern of many medical professionals in the following quote:
"It seems to me that physicians have been severely handicapped in the post Katrina policy environment because we have not had a unified voice to speak with. The state medical society only represents, I think, a third of doctors in Louisiana, and that’s insufficient. And so if nothing else at the State level, we need to have a serious dialogue about why that is and how we can have some kind of umbrella organization at the least to represent all physicians. . . Consumers don’t have a good organization either for that matter and [they] need an [advocate]."
Dr. Karen DeSalvo, Chief of General Internal Medicine and Geriatrics at Tulane School of Medicine, advocates for implementing neighborhood primary care clinics in New Orleans as a means of addressing the medical needs of the underserved:
"We had and probably still have an unbelievable opportunity to rethink and re-do health care . . . We’ve defined a health care system; we have a blue print. It doesn’t give addresses for clinics, but it certainly says "Here is how we think it is affordable to pay for primary care, give everybody access to a medical home, it is affordable to expand health information technology in the end we will save money." We had too many hospital beds before; let’s do a better job of taking care of those people to keep them out and when they are there to be more efficient; we don’t need quite so many when we go back online and we should give people more choice and access to care."
Dr. DeSalvo worked with Tulane medical residents to establish Tulane University Community Health Center at Covenant House as a primary care facility in the wake of Hurricane Katrina. They see approximately 900 patients a month, and the clinic provides consistent care for approximately 6200 patients. She is a recipient of a primary care stabilization grant from the U.S. Department of Health and Human Services and funding from the Qatar Katrina Fund to build upon that work and describes the status of the existing clinics as follows:
"The network of neighborhood clinics are all funded right now in large part by the Primary Care Access Stabilization grant which is the $100 million the community received as the result of the testimony to Congress. That money is going to run out in 2010, so we are working together to develop a structure and funding for long term sustainability. In order for us to meet the obligations of that grant, and to expand access to primary care for those in need, we are forming an organization that will allow us to share services and become more efficient. It doesn’t make any sense for a clinic with one or two doctors to hire a nurse call service, when really we could all share a call. Very, very basic stuff like that and by the end of 2010, if there aren’t changes in financing for healthcare, most of the clinics will close, including mine at Covenant House, because there is currently no sustainability mechanism."
"It used to be that most of those people got their care in some way or another in an emergency room. If you look on the website for the Charity system you’ll see that that didn’t decrease but our ability to do outpatient care there really did. We were understaffed and typically just had resident clinics. There were some exceptions like the Your Family Doctor clinic, which is a place that I worked for seven years. I also saw my own patients at Charity one-on-one. But when you have five doctors doing that, it’s a pretty small dent for the 250,000 who need care. So it’s going to take a consortium to provide neighborhood-based primary care for people. The community is working as quickly as it can to build new sites, build up the sites that are there and all of this is just a means to help each other. It’s also a leap of faith though because if we don’t make some investment in primary care as a State, a Federal Government, a community, then they will die and we’ll go back to an old system where people had to basically use the emergency room for primary care."
The institutionalization of neighborhood primary care clinics is but one way of easing the growing crisis in medical care in the greater New Orleans area. Yet connecting individuals to a localized system of comprehensive medical care and social service provision promises to increase the physical and psychosocial wellbeing of the underserved of New Orleans. In addition, the establishment of these clinics may provide the impetus for systemic environmental change in the surrounding areas:
"For most things, it’s hard to get people to go to the doctor no matter what it is, and the idea of the primary care environment is that there is a level of trust that develops between patients and their providers so that they are more comfortable being screened for issues. One of the things we’ve learned at Covenant House in particular is that for men who typically don’t receive healthcare, the risks are high. Half of our patient population at Covenant House is male, which is high for a clinic. The reason it’s so high we think is because we do allow for same day access and so we end up seeing men who come in for a cough or a back pain or something else. We check their blood pressure and do basic assessment. By doing health risk assessments on everybody who comes through, we’re able to identify chronic disease or gaps in their preventive care and deal with those on site, so rather than just being an emergency room or an urgent care centre where they’re seen for just their back pain. We really take a comprehensive approach to them when they come in and then they stay part of our patient grouping. We can do this without going into the community and doing specific outreach or doing health fairs, which we also do. By having these neighborhood based clinics you have a chance to identify people before they get sick."
"We . . . have fulltime mental health providers and do screenings for patients who come in. And most of the clinics that are involved in this network either have on-site mental health services or have a referral system. I think that the organization which we call 504 Health Net is a mixture of primary care and mental health providers which I think speaks to how important we think it is that we all work together."
Dr. DeSalvo also underscored the importance of building community awareness and support in order for the clinics to take root at the community level:
"I think what’s been missing for us to really get leverage is consumer support, so people will read about it in the paper or sort of hear about it. It took a good 20 years in places like Boston to build these neighborhood centers, getting them dotting the landscape and having people accustomed to them so that they’re now just as . . . much a part of the social fabric as having a post office in your neighborhood is. So you just wouldn’t anticipate something different, not a Post Office just for poor people . . . you have a Post Office and its purpose is that everybody uses it. It’s the same kind of idea. We just need to get over the context in Louisiana that neighborhood clinics are for the poor. They’re for everyone."
In response to a question about the security of patients and staff, Dr. DeSalvo described efforts to safeguard their welfare:
"Pretty much all health care facilities in the New Orleans area have on-site security if you think about it; so we always have security in health care, and I’m guessing that is because of narcotics and what not. These clinics do use security . . . I do pay attention to the safety needs of my staff going to and from [work] and the patients going to and from[the building]. It is one of the reasons we are not open past 7:00. We always have security on site. What it does not help, is people walking from parking [lots] or the bus [stop]. We are actually looking to move our location to one that is more directly on the bus lines and that has parking right in front, so that it is safer for people to come and go. . . . We just have got to do it and . . . the community will get better around it."
Perhaps the following quote from Dr. DeSalvo captures the depth of commitment to identifying creative yet effective and affordable solutions to the overwhelming medical challenges facing the greater New Orleans area post-Katrina:
"For me personally, well I think it is sad that the greatest natural disaster in the history of my country could not lead to really significant change. . . We had and probably still have an unbelievable opportunity to rethink and re-do health care. . . We’ve defined a health care system; we have a blue print. It doesn’t give addresses for clinics, but it certainly says "Here is how we think it is affordable to pay for primary care, give everybody access to a medical home. It is affordable to expand health information technology. In the end we will save money."
Dr. DeSalvo described the need for revising the credentialing procedures of the Louisiana State Board of Medical Examiners:
"The biggest problem I’m having right now – and again, not in their purview but something they can influence – is physician credentials. It’s a huge problem."
"There’s no emergency privileges system for doctors who are applying for a license. . . These doctors that I’m bringing in for the summer – for example, 3 of them are from out of state. They turned in their paperwork in March – excuse me, they turned in their fingerprints in March – which is one of the steps in the process. And they just found out two weeks ago that their fingerprints are smudged. And they have to start over, so I’ve lost 2 – 2 ½ months time. And they’re not going to have their license when I’m ready for them to start in July. So I have a ready provider; I have the money; I have the need. But [I cannot hire them until fingerprints are cleared]. . ."
"So, in other words, like for these guys, they’re in good standing. They should get a temporary license until their full license goes through but there’s no mechanism for that in the state. And Rob promised me a year ago that these bugs are going to get worked out because we’ve been having them for a while. And when I found this out – I’m all on fire – we’re writing a memo - I’m going to have to go to the Governor’s Office to get this worked out. It’s in his ability to deal with the Board – they need to create a new category. Especially with as many doctors as we are trying to hire. I think they can’t keep up with all the influx."
However, there also needs to be a well-defined and accessible system for notifying those who will be responsible for carrying out the disaster/recovery plan. Dr. DeSalvo recommended a unique physician number to be used in conjunction with text messaging to alert medical professionals of an emergency and where and how their skills and expertise can best be utilized.
"I ought to have a unique physician number . . . and they should have my phone number and I should get a text message. If an emergency happens, tell me what corner to show up on, who to look for, so I can report to duty. And I still don’t know why we don’t have that. We have an informal thing that we do with the city and the other community health providers so we know what corner to show up on. But if something happens . . . there ought to be some master plan so somebody can tell me . . . what to do."