Emergency Psychiatry in Houston: Caring for Victims of the Katrina Catastrophe

I arrived too late to meet Bill Clinton, but just in time for the dysentery.

So I was told as our car approached the Houston Astrodome, which at the time was lodging 26,000 evacuees from Hurricane Katrina. The politicians had already come for their sound bites and left. But swarms of desperate people remained, many in dire need of medical care.

Two miles from the stadium, we started to see them. Groups of teens and young adults were everywhere: walking in the middle of busy traffic, sitting and talking on highway medians, cowering in parking lots. Some waved as we drove by.

We went through a labyrinth of parking lot checkpoints and finally reached a small basketball arena across from the Dome. Inside, we found a makeshift medical center. There were metal dividers everywhere, with canvas curtains separating the general medicine, surgery, infectious disease, and pediatrics areas. There was even a dental clinic.

Everything was relatively cheek by jowl. If you lifted up the curtains for the psychiatry area, you were in the dialysis booth. Pediatrics shared drapes with surgery.

A large room was identified merely as “quarantine.” It already hosted at least 50 occupied cots. People had started getting dysentery, marked by diarrhea and vomiting. At the time, no one knew what was causing the infection.

Just past the isolation tent was a cordoned-off area with a narrow entrance. A cardboard sign on a pylon had “Mental Health” scrawled in magic marker. There was a line of people waiting patiently to enter. I went inside and met the staff.

I was introduced to a large multidisciplinary team: nurses, social workers, therapists, psychiatrists. Everyone had a weary half-smile. They were grateful for the extra help, as the numbers had been overwhelming.

We would see dozens of patients during the long shift. Almost everyone had an unsettled gaze. They had been through so much. Most had spent the preceding few days in the chaos of the Superdome or the New Orleans Convention Center, surrounded by catastrophe and fear.

A good number had been rescued off of roofs, overpasses, any high ground. Their stories could make your jaw drop. So many of them had seen death right next to them, in some cases even floating by. Their pain was palpable as they spoke.

But mostly, somehow, they were compensating. They primarily came for medical care. Some wanted to talk, others just wanted a refill and maybe would talk about it all some other day.

Many had not had their psychiatric medications since the storm hit. It was taking all their strength to keep going. It is difficult enough to have a serious mental illness. Being without medications during a cataclysmic experience had to be overwhelming.

For some, the medication stoppage led to psychotic exacerbations, with symptoms ranging from paranoia (“more bad storms are coming”) to distressing auditory hallucinations that commanded, “Run away.” The most frequent symptom was profound disorganization, with patients not really knowing where they were or what to do next. Several of them insisted they lived nearby. Fortunately, we had plenty of drug samples and an onsite pharmacy.

It was important to get people what they needed quickly. This wasn’t easy for some of the psychiatrists. It really wasn’t their fault. They were used to 50-minute interviews and scheduled appointments, so treating five new patients in an hour had to be a bit much. Those whose regular job was emergency psychiatry stepped up to cover the load.

From as far away as Scotland, emergency psychiatrists had come to help the evacuees. Rapid assessment, treatment, and disposition are the bread-and-butter of emergency psychiatrists. They would ask pointed questions—“What is happening now?” “What can we do to help?” “What are the names of your meds?”—and act on the answers. This allowed them to rapidly triage needs, work fast, and see multiple patients simultaneously. It is not a skill set applicable to many psychiatric disciplines, but very useful in crises, and in Houston.

So many of the people had multiple needs, be they medical, psychiatric, or social. Symptoms could be treated, but a supervised living facility might be necessary. During blood sugar stabilization, someone might need a consult about panic symptoms, while another staffer was trying to locate family members. Staff ran around frenetically, doing whatever was necessary, and rarely took breaks.

With so much work, the hours flew past. It got difficult to know what time of day it was, especially when working 18 or 24 hours in a row. The clinic had poor fluorescent lighting and no windows. Its warehouse setting magnified every noise and there was a constant cacophony. All this led to a general disorientation, a fuzziness in your head. The only way to overcome it was to remember how much people needed your help and to refocus.

Sometimes we provided consultation on patients inside the Astrodome proper. The massive indoor football field was jammed with folding cots. Thousands of people were aimlessly wandering between the cots. Kids ran by screaming and giggling, unaware that anything was the matter. Policemen surrounded the Astrodome floor. They wore masks because they were concerned about infections.

We were all worried about infections. Only three porta-potties were available for all medical workers; a can of spray disinfectant was nearby for before each use. And there was only one set of sinks for the entire clinic building, a good distance away. So we all used dry alcohol solutions to wash our hands between patients.

After several days we learned the cause of the dysentery—a virus—and that it was immune to the alcohol wash. It was fortunate that the quarantine was working and the infection had not spread.

Other good news came over the next few days. Places were being found for many of the evacuees, and the Astrodome began to empty out. In just a week, the head count had dropped to below 5,000. With less patient demand, the clinics condensed to skeleton staffing. Soon the volunteers were hugging and thanking each other and heading for the airport.

After our plane took off, I could see the Astrodome out of the window. For a minute, I wasn’t sure I had really been there. Losing an entire major city, moving its inhabitants hundreds of miles away, finding a way to care for them, all in a few days’ time. It all seemed surreal.

For many nights after returning home I dreamed I was still at the Astrodome. The dreams would last all night and I would wake up exhausted, my pillow cold and damp. In the dreams the clinic would be saturated with sobbing people, clutching teddy bears, photographs, even pieces of their former homes. I would cry too, for no matter how much we tried to help, we couldn’t make things the way they were before.