Lessons from Hurricane Andrew
By Rick Eyerdam
Comes now the Haboob
In mid-afternoon on Thursday, Aug. 13, a fluffy cloud looked down upon the desolate slums of Khartoum, Sudan, offering a fleeting moment of blessed shade. Once out upon the vast African veldt the cloud took a deep breath, caught on with Haboob and went tumbling westward across Africa's midsection. The atmospheric pressure within the cloud dropped slowly as the convection and winds slowly grew, sending a roiling column of warm air and water molecules soaring up near the stratosphere then plunging back down again.
The natives call the wind Haboob; the wind that forms a powerful current propelling the storm clouds ever westward toward the Atlantic. By August 14 the cloud from Khartoum had become a storm pelting the western Senegal with winds and rain. Inspired by the rotation of the planet earth beneath it, the storm slowly began to spin as it slid onto the warm waters off the West African coast. It was late August, already the middle of the hurricane season and not one tropical disturbance had achieved the properties -- sustained winds of 39 miles-an- hour, low pressure and a definite rotation-- to earn a proper name.
On the satellite maps of the National Hurricane Center, 4,000 miles to the west in Coral Gables, Florida, sometime during the day on August 16, the storm that would become history's most costly natural disaster was casually recorded as TD 3 -- tropical depression number three.
August 16 was a Sunday, a day when the weather service allows itself to reduce forces and ease up the tension, as long as there are no threats on the distant horizon. TD-3 was followed only through satellite observation on August 16. And so, when the first reconnaissance flight entered the wall of TD-3 early Monday morning, the one-day lapse in close hand surveillance brought a surprise. By 8:00 a.m. August 17, Andrew had earned his name; the western hemisphere's first tropical storm of 1992.
As is the protocol when a tropical storm is on the map, the Hurricane Center began daily, 7:30 a.m. conferences during which the overnight data is assimilated and the reports of the reconnaissance flights are promptly evaluated.
By the morning of August 19, Andrew had spun its way across 15 degrees of longitude heading, generally, west/northwest on a traditional course that could, eventually, threaten the Dominican Republic. But the 8:00 a.m. flight into Andrew on the nineteenth of August found a surprise. Instead of a slowly growing tropical storm it found an air mass in disarray, battered by a rival weather system on its way to England. The center was not well defined. The forward motion seemed to have slowed and the sustained wind speed was down. To hopeful observers, Andrew seemed to be on the verge of dying.
Limited in its ability to survey the entire storm by its slow and low flying propeller driven aircraft, the Hurricane Center nevertheless determined that Andrew had been decapitated by the more powerful weather system that was heading northeast. The P3 Orion and C-130 aircraft that are used as hurricane hunters are too slow to cover much area and restricted in their ability to fly above the storm at altitudes between six miles and 10 miles, where jet aircraft can easily maneuver. Although the planes could not fly high enough to make a positive determination, the forecasters decided the England-bound weather system had trimmed the tops from Andrew's storm clouds, dramatically reducing its ability to generate energy. From the data on steering currents that the hurricane hunter aircraft was able to gather, it seemed Andrew would ultimately blow itself out in a northeasterly swing away from the mainland, repelled, eventually, by the Bermuda high. In truth, as it turned out, Andrew was merely catching its breath.
As Andrew wobbled on a more northerly course, its winds diminishing, a decision was made not to fly into the storm until Friday. Once again Andrew surprised the weather aviators who arrived with the dawn of Aug. 21. Andrew had traveled less than 15 degrees latitude and about the same distance of longitude. Sitting virtually still for several hours, the storm had conserved its energy while drawing strength from the warm ocean currents; redefined itself. When the surveillance aircraft arrived the morning of August 21, Andrew was in motion again, organized and showing every sign of growth to hurricane status
At the National Hurricane Center in Coral Gables, Director, Dr. Robert Sheets poured over the masses of data transmitted by the plane and weather satellites. Andrew had indeed grown stronger, its pressure gradient deepening. The slow moving planes had detected significant changes in pressure and velocity. But, subtle changes were harder to register. And the comparative data that was missing because there had been no direct observations and measurements on Thursday made calculations of a predicted course all the more difficult. It would take more information than the 8:00 a.m. Friday flight to accurately predict how rapidly the growth would occur or what direction the storm would take. Nevertheless, the State of Florida EOC was opened on Thursday with four staff members working on computer models. Representatives of the Federal Emergency Management Agency ( FEMA) visited the state office in Tallahassee to check on the preliminaries. At that time, Andrew seemed to be on a north by northwest course that would probably take it into the Middle Atlantic States in the next five or six days at its current course and speed. Hurricane watches are posted a minimum of 36 hours before a storm can possibly strike the target area. Warnings usually go up 24 hours in advance of a predicted landfall. There were days left for preparation, if all went as it seemed.
During his regular session with emergency preparedness officials Friday, August 21, Sheets recalls, he told his counterparts that he had decided that Andrew posed no immediate threat to Florida, the Bahamas or the US mainland over the weekend.
"Have a nice weekend, I told them. But I added, to cover myself, that they better check back with me on Sunday, just in case." The state Division of Emergency Management took the Hurricane Center at it word. And when Kate Hale, the Dade County EOC director contacted her counterparts in Tallahassee they told her not to worry and to have a nice weekend as they planned to do with their first-ever division picnic.
A second opinion
Florida Power and Light Company is one of several corporations and agencies that conduct their own meteorological analysis and come to their own conclusions, often different or earlier than the National Weather Service. With an area of vulnerability extending from Jacksonville to South Dade and including several nuclear reactors, FP&L has decided to look at the foul weather picture on a larger scale. According to Robert Marshall, the FP&L vice president in charge of power distribution, it was clear to FP&L on Thursday that the storm would hit in Florida somewhere that FP&L provided power.
The need for rapid deployment of linemen is as critical immediately after a storm as the need for emergency medical personnel. It was clear that some area of Florida would be affected and it was known that mobilization would take time. But FP&L and the other power companies of the Southeast had established a protocol whose underlying premise was the agreement that no one would be criticized for crying wolf. When it came to preparedness, it is better to have the help and not need it, than to need it and not have it, the power companies had agreed. So they began to prepare to repair hurricane damage four days before they could possibly be needed.
Hospitals and health care delivery systems, on the other hand, wait until a Hurricane Watch is issued before they institute emergency plans. They wait until a Hurricane Warning to act. And this means they can have no more than 24 hours to execute those plans. As we will see later, they have not established relationships with hospitals at remote distances as the power companies have, in case the devastation is wide spread. Hospitals rely on the next hospital, figuratively just down the street, as if a powerful storm would spare one and take the other. Their plans are based on the false supposition that the hospital will survive without being victimized and will only have to cope with casualties from beyond the hospital community. The plans anticipate an extraordinary patient load and some logistical inconvenience for a few days after the storm. They do not contemplate a total lack of power, water, and staff reinforcements. They have not planned to be victims of a storm, only to care for the victims.
Not so the power company. On Thursday the call went out from Florida Power and Light to other states that are members of the power companies' mutual aid agreement. They immediately began to rearrange their schedules, stockpile repair material and assemble the men and women who would be needed to repair the damage and replace the front line FP&L crews in the critical days immediately after a storm. On Saturday morning, Aug. 22, the FP&L emergency control center was opened in downtown Miami and the company's five helicopters were sent for shelter to five hangers at Tamiami Airport. They would be needed for damage assessment after the storm. On Aug. 22 South Dade seemed the safest place to store them.
The Bermuda high way
Dr. Sheets admits what happened late Friday took him completely by surprise. Heading north by west, Andrew bumped into the Bermuda high, a large high-pressure cell centered over the island of Bermuda . When the Bermuda high is in place, it serves either to push weak storms toward the North Atlantic or to propel powerful storms in a more westerly direction, aiming them, in effect, at Central and South Florida. When Andrew bumped into the Bermuda high it made a hard left along the 25th degree line of longitude that pierces the heart of the Bahamas and Key Largo. The hard left suggested a turn for the worst. The turn caught Sheets' attention and raised the prospect, at that moment, that the storm could strike Islamorada in the Florida Keys. Sheets followed the Andrew data as it was collected Aug. 21, worried that he had lost a precious forecasting edge.
By the end of the day Friday, it was clear Andrew was picking up speed as it picked up power. Sheets said he knew that he had lost a good deal of preparation time when the storm turned more to the westerly direction. The bad part was that the unexpected two miles-per-hour acceleration in forward speed cut 24 hours from his forecast time. Soon it would be time to say the awful words and issue a hurricane watch to someone.
Sheets was not yet ready to make public the call for a watch or warning zone with the storm at this distance, on a Friday night. But he wanted the key officials to know that a watch was coming soon, and a warning would probably follow.
Sheets explains that the cost of implementing a hurricane watch is measured in tens of millions of dollars to each effected community, not counting lost tourist revenue and spoiled vacations. The storm track projections late Friday put the storm anywhere from Cuba to Charlotte, South Carolina. There was only one place the storm could come ashore and one place it would depart. And it made no sense to put an area as large as the entire cost of Florida, Georgia and South Carolina on the costly course of hurricane watch.
The Bulls Eye forms
The target area was narrowed dramatically when the first flight rendezvoused with Andrew Saturday morning, Aug. 22. When the weather service plane arrived at latitude 26. 2 and longitude 67.9, 800 miles east of Miami, Andrew was already a minimal hurricane moving at a remarkable 17 miles an hour. There was then little question the storm would strike somewhere on the Florida peninsula.
Just to get a first hand opinion, Dade Emergency Manager, Kate Hale, stopped by the Coral Gables office of the Hurricane Center that Saturday morning. Sheets confided in her that things looked pretty grim for South Florida. Hale took the advice seriously and began calling in her staff for a 6 p.m. meeting at the Office of Emergency Management bunker in South West Dade County.
In his Puerto Rico hotel room, meteorologist Frank Marks began to plot the course of Hurricane Andrew. He had just arrived on a flight from Miami, specifically to intercept Andrew. His specialty is measuring storms using airborne Doppler radar, so he was looking forward to flying into Andrew. But Marks would later confess to newspaper reporters that he was certain, as early as Saturday morning, the storm would strike South Florida. It could go nowhere else, he calculated, because of the directional pressure exerted by the Bermuda high.
Back in Miami, Sheets confronted the age-old problem. To forecast a landfall in South Florida meant hundreds of millions of dollars in costs for Dade, Broward and Palm Beach counties. The track into South Florida also would mean warnings for Fort Myers, a watch as far north as Tampa and watches along a wide area of the Gulf Coast.
At 11:00 am Saturday, the Hurricane Center announced : "Andrew continues to strengthen." Three hours later, with the storm 655 miles east of Miami, it still was not time to make the official call.
"The westward movement is expected to continue through Sunday, increasing the threat to South and Central Florida. Interests in that area should closely monitor advisories on this hurricane," it said. But the official emergency network got a different message and not a minute too soon. In Tallahassee, based on the Friday advisories, the state EOC staff went ahead with their planned departmental picnic that was held at a park 12 miles from the nearest phone. In mid-afternoon a courier was dispatched to find the staff and warn them that the storm was headed for South Florida with increasing speed. Leaving families and picnic baskets behind, the state EOC staff rushed back to the capital. The 27 participating state agencies, the power companies and Southern Bell were called to the EOC and operations began in earnest on Saturday night.
At 5:45 p.m., just in time for prime time newscasts, Sheets decided he could wait no longer. Hurricane watch flags-- a black square in a red background-- were hoisted from Titusville to Key West. Sheets said that at that moment, 36 hours before the ultimate landfall, the odds were highest-- 20 percent-- that Andrew would come ashore along the Dade and Broward county line. The odds got lower by a few percentage points every 20 miles north and south of the Dade/Broward county line. The chance of Andrew riding into South Dade and missing the metropolitan areas of Miami Beach and Miami was pretty slim; about 16 out of 100 when the hurricane watch went up.
Stated another way, only 36 hours before South Dade was raked with 170 mile-per-hour winds, suffering $16 billion in damage, its residents were told there was an 84 percent chance the storm would not strike them at all. Fortunately, the area of watch was correct in its scope, including the area from the Florida Keys northward to Cape Kennedy.
Another fortunate occurrence was the professionalism of Randle-Eastern Ambulance. Beginning Saturday morning, the Randle staff reviewed its list of the adult congregate living facilities (ACLFs), nursing homes and other health care facilities for which it had been assigned evacuation responsibilities by the Dade EOC. Ventilator patients, cardiac monitor patients and IV patients were first priority and many were taken to Palm Beach despite the time it took to make the 140-mile round-trip drive. Randle called each facility on the list in order to determine if the population had changed or if any other extraordinary changes had occurred since the list was made. For many of the ACLF's this was their only notification that an evacuation could be imminent.
"We were planning ahead on Saturday because we knew that if it hit, it would be on a Sunday when management was not around," Ken Randle explained. "We were able to contact the heads of the facilities at their homes. The only problem we had was that the longer you wait, the harder it gets. As it turned out, some of our cars arrived at the facilities unannounced to determine what the needs were."
Among the facilities Randle-Eastern evacuated at the end of the day was Mercy Hospital. "We were still taking people out of there at eight or nine at night, the night before the storm. To my knowledge the facilities that we knew about, whether we had contracts with them or not, we went there. It was better to find a place empty than to go there and find someone still in a bed. When we were done we put an ambulance and a fire truck, at least, at every shelter," he said.
When it became clear a big storm was on the horizon, the state EOC became jammed with politicians, agency heads and a Supreme Court justice, none of who had been involved in any of the preliminary emergency planning sessions that had been attended by the designated staff representatives. So, instead of a trained and disciplined professional staff preparing for the impending disaster, the agency heads and politicians took over, moving the decision making process from the EOC to the governor's conference room and eliminating the trained EOC agency representatives from the critical process of decision making and inter-agency communications.
Later, a local newspaper would lambaste Metro-Dade Mayor Steve Clark for staying at home and leaving the job of hurricane evacuation and recovery to the professionals. As Hurricane Andrew targeted South Florida, the state's emergency professionals were wishing all the politicians would simply stay at home. Thirty-six hours before Andrew, and the process was already starting to unravel at the points of most critical importance.
The 36-hour alarm clock
Emergency agencies, relief agencies and health care agencies in South Florida, like those in most other hurricane-prone areas, do not begin formal preparations for a severe storm until they hear the gong. When all goes well, the alarm, the Hurricane Watch, sounds as long as 36 hours before actual landfall. At this point most hospitals begin to begin their Hurricane plans. Most other medical facilities go to alert and locate their key staff members. All of them begin to make contact with the Emergency Management offices in their area. But little else that involves extra staffing and additional expenditure is done until a Hurricane Warning is issued. Most of the time the alarm is sounded at least 24 hours before the first effects of the storm are expected to arrive. Because of liability issues, the EOCs, as a matter of policy, do not order a mandatory evacuation until the Hurricane Warning flags fly.
For the individual home owner, the typical citizen, 24 hours is enough time to prepare the home, to shop and secure those emergency supplies not already on hand. But the evidence shows that it is rarely enough time to prepare all the components of the health care delivery system for a major disaster such as a third magnitude hurricane.
In South Florida, along the projected path of Hurricane Andrew at the moment of Hurricane Watch, for example, there were 308 adult congregate living facilities and 91 hospitals. At least 1,700 individuals with special needs had asked Dade County to evacuate them to a shelter. Another 6,000 residents of Miami Beach, most of them elderly, would need assistance in evacuation. Four hospitals were located near enough to the ocean to make wave damage, storm surge or flooding a potential hazard. The hospitals facing a forced evacuation for a Level C- third magnitude- storm included Miami Heart Institute North and South, Mt. Sinai Hospital and South Shore Hospital. Hospitals facing forced evacuation at the next higher storm level, Level D, evacuation were Victoria Hospital and Mercy Hospital.
Those hospitals that would be ordered to evacuate under the broadest evacuation order, Level E, included Grant Center, Harbor View Hospital, Aventura Hospital and Health Center and South Miami Hospital at Homestead. Literally dozens of adult congregate living facilities were built in the flood plain or along the shore. Also at risk were pharmacies, ambulatory clinics, physician's offices, HMOs and rehabilitative centers that numbered in the hundreds.
The demands on the health care community for the evacuation of facilities and the relocation of patients far exceeded its ability to respond, despite statutory requirements that hurricane plans include specific plans to take care of special needs individuals at home and in medical facilities
At one time, in 1979, the Dade evacuation plan put Miami Beach's elderly in a shelter at the Greater Miami Convention Center, rather than moving them inland. The convention hall was filled with 6,000 mostly frail and elderly that year with virtually no medical assistance.
Florida state law requires that all hospitals institute and follow a hurricane plan. It requires the same of nursing homes. And, because of the 1979 debacle, Florida law required thereafter that special needs individuals be offered the opportunity to be listed on a registry so they could be contacted and evacuated to shelter after a hurricane warning is sounded.
According to Alan Clive, the Civil Right Program Manager for FEMA, Dade County registered 1,700 special needs patients in 1992. Clive said that Kate Hale, the Dade emergency management coordinator, estimated the number of special needs clients in the county who could have used help at 10,000. Others have put the number at 50,000 using standard measures of disability. Aging groups note that 380,000 Dade residents are over the age of 60. Many of them were, at the time of Andrew, frail enough to need help.
What this means for the future of special needs evacuation is critical. Assuming the elderly population survives at existing mortality rates, Dade will have at least 150,000 frail elderly in less than ten years. And with the growing popularity of coastal cities as retirement havens, the problems of evacuating frail elderly multiply with each passing year along the sunny counties of Florida, the Gulf Coast and the Southeast coast of the United States.
According to the experts, had the entire resources of the emergency medical transportation network been employed to transport to shelters or hospitals everyone in the hurricane watch area who could meet some criteria for special needs, the effort could have taken a week. But no one, under the current method of planning, enjoys the luxury of time to implement an elaborate plan, or the luxury of clear roads to travel and low stress participants. Everyone in the health care network waits for the Hurricane Watch to begin staging and everyone waits until the Warning to begin action.
Worse yet, this two-day window of opportunity inevitably occurs at the exact time the rest of the community is involved in its own chaos of preparations; taxing every aspect of the infrastructure, slowing traffic, reducing the availability of all manpower at the moment it is needed most and making intense, competing demands on stressed emergency personnel. The result is a highly inefficient collision of priorities.
The Collision of priorities
The evacuation of special needs individuals to shelters was a high priority, reinforced by state law, designed to get the frail elderly, ventilator patients, dialysis patients, blind, retarded and psychiatric patients relocated out of the storm's path to places where they were not only safe from wind and water but able to receive the constant attention many of them needed. At the same time, three hospitals on Miami Beach and one in Miami were ordered to be totally evacuated of patients who were too sick to be sent home. These hospitals did not evacuate voluntarily and, in at least one case, waited until the last minute before obeying the order to depart.
Likewise hundreds of nursing home patients were housed in evacuation areas while hundreds more who relied on life support equipment which needed dependable power were also schedule for evacuation, but not until the announcement of a mandatory evacuation after the announcement of the Hurricane Warning.
Many of the ACLFs, nursing homes and hospitals had made arrangements with Medi-Car or Randle Eastern Ambulance to bring their patients to shelter or move them to another hospital. Others relied on a system of school buses and Metro-Dade Transit bus transportation that had been established by and was directed by Dade County's Office of Emergency Management. If health care facilities had begun their evacuation at the Hurricane Watch or earlier, they might have been able to retain some control over the process and the transportation vendors. As it turned out, according to Sara Grim, president of the South Florida Hospital Association, 1,500 hospital patients were successfully evacuated but another 500 could not be evacuated due to an inadequate supply of transportation resources.
Michele Baker is now the Emergency Management Director for Pasco County Florida. Until the 1993 season she had spent seven years as the Dade County Hurricane Coordinator working for Kate Hale. She was responsible for the special needs component during Hurricane Andrew and her story is one of pulling success from the jaws of defeat.
"In 1979, when Hurricane David threatened Miami," she recalled. "Dade County evacuated 6,000 frail, medically needy elderly people in the convention center with absolutely no staff to help them."
The Florida legislature reacted to this nightmare by passing the bill that required emergency management organizations at the county level to voluntarily register anyone who needs assistance in order to evacuate. Registration is not required by the truly needy nor is there a provision to eliminate those who can help themselves. The county is not required to perform any outreach, to keep complete records or to have a program in place to support the effort. No money is provided by the state to pay for the registry or the transportation, Baker said.
For the first six years there was no plan for special needs individuals. Their names were kept in a file box on file cards, according to Baker, the former hurricane coordinator at the Dade County OEM. "The plan was, I guess, that if a hurricane came I would go out and take the file box and pick them up."
As the elderly became more activist, concurrent with the development of elderly affairs programs and centers on aging at the universities, a dialogue was begun at Florida International University to collect information on special needs by, in Baker's words, "pilfering other data bases and programs."
As the system was developed, registration of special needs individuals was done through self-addressed stamped envelopes included in information packets that county officials would hand out whenever they spoke on hurricane preparedness. Others were distributed through health care providers such as home health agencies. The notices were also included, once a year, in Florida Power and Light bills.
Baker suggests that the registration information submitted by special needs individuals ought to always include whether the special needs individual is coming to the shelter with a caregiver or other people.
"On several occasions, when we went to pick people up, we ended up with eight of them: someone who was sick and did not have a car and the rest of the family along for the ride," Baker recalls.
She said the registration information also should include a signature of the individual to be evacuated, since well-meaning neighbors or relatives could sign up a special needs individual who is not aware of the program, creating a controversy.
Baker said there is a continual controversy over the request that the patient's physician to fill out a section of the registry. One problem is that some people do not meet the requirements for special needs and their doctors might say so. Others do not wish to spend the money for a doctor visit. Others do not want anyone knowing the severity of their disability for fear they will become victims of robbery or worse should the file become public.
Baker said the effort to gain more information is actually a ruse. "We really cannot require them to provide anything more than their name or their address. Anything else we get is gravy," she said. "If they fall for it and the doctor fills it out, we have better information."
In Dade County, the special needs evacuation program was not on the county's priority list for data base development. Baker and the emergency planners wrote an R-base program of their own and manually entered the list, which was continually updated but was not culled for deaths. It was purged once a year. If people continued to respond each year they remained in the file. If they missed three consecutive years, for whatever reason, they were dropped from the service. The notice that was sent in the third year after the special needs person failed to respond, included a warning that they would be dropped if no response was forthcoming, according to Baker. This was designed to scare people into responding.
Likewise, she said, she developed a release form to be signed by special needs registrants who decided they do not want to go to a shelter. To frighten the citizen into submitting to the evacuation they raised the specter of being killed and the notification of the next of kin.
"As they learned in Hurricane Camille, asking people for their next of kin is often sufficient to scare them into doing what is right," she said.
In Broward County, as a matter of county policy, however, the neediest among the special needs patients are barred from the special needs shelters.
As reflected in the Hollywood Memorial Hospital emergency plan, the eligibility requirements for the county's three special emergency shelters precluded:
1. Patients who are not ambulatory.
2. Wheelchair patients who cannot transfer from wheelchair to bed or toilet without assistance.
3. Patients that require 24- hour electrical power for their treatment modality.
4. Patients who are incontinent of stool or urine.
5. Patients who have advanced Alzheimer’s not accompanied by caregiver or companion.
6. Patients with early Alzheimer's, not accompanied by caregiver or companion.
7. Patients who are confused and not oriented to their own identity.
8. Patients who are psychotic/schizophrenic.
The shelters were allowed to accept only:
1. Persons who need assistance to administer their own injectable medications.
2. Persons who need assistance with ostomy management and catheters.
3. Persons with minimal restrictions in performing activities of daily living (Needs little or no supervision from medical personnel).
4. Persons who require minimal monitoring of an unstable medical condition.
5. Persons who need intermittent use of oxygen.
The Mercy Dilemma
One hospital that thoroughly planned for the evacuation was Mercy Hospital, a 512 bed acute care hospital built on the shores of Biscayne Bay along a low lying section of South Miami Avenue, just north and east of the commercial heart of Coconut Grove. The Mercy Hospital emergency plan, approved in 1990, is predicated on the amount of flooding the hospital is expected to endure, even though the hospital is in a mandatory evacuation zone because it is on low ground, virtually at the water's edge.
The Mercy Hospital hurricane plan assumes that the hospital will be flooded in all storm scenarios and it establishes different protocols for various water depths. The plan assumes that the Mercy Professional Building and Mercy Outpatient Center will be inaccessible by car for 24 hours and without water for 48 hours at a minimum. Tenants in the office building are expected to secure their own offices then leave the area until the waters recede.
The plan for the hospital building contemplated a partial evacuation of the building and a total evacuation of the first floor in a minimal storm. Beyond that, the emergency plan for Mercy is a plan of total evacuation. The hospital integrated its emergency plan so that each and every service and staff member would know what was expected at every stage of the process from pre-storm stockpiling through post-storm insurance settlements.
With a patient population of 240 the morning of Saturday, August 22, Mercy hospital president Ed Rosasco-- the only hospital official empowered to order an evacuation under the Mercy plan--decided there was no need to wait for the weatherman's warning to evacuate the potential storm surge area. Those patients who could be sent home were discharged. The others were to be disbursed among 11 other hospitals in the area.
In 1990, Mercy Hospital had established a contract for evacuation transportation with Medi-Car Systems of Miami, one of two primary medical transport contractors for Metro Dade County. The agreement said that after Medi-Car completed its contractual responsibilities for evacuating patients residing in county-operated facilities it would take care of Mercy's needs, "by assigning all other available vehicles to the facility."
In addition, Medi-Car agreed to assign an employee as coordinator of transportation. It agreed to transport not only the patient but the patient's wheelchair or walker and other personal necessities. It agreed to bill Mercy for the service at the customary rates. Mercy agreed to pay within 30 days.
Mercy also agreed to put identification bracelets on each patient that also indicated their shelter destination. No provision was written in the contract for communicating the level of care that the individual patients needed. Nor was there a legal agreement to assure that the Medi-Car staff would transmit critical information to the staff at the receiving hospital about the patient's history and medication needs. There were no provisions for what the driver should do if the designated hospital was filled to capacity, closed or unwilling to take the patient. There was no discussion of liability in the contract.
In October of 1990, Mercy had established a contractual relationship with six hospitals in the area to accept patients in the event of an emergency.
Each of the six contracts is identical in content. They represent a model contract for other facilities that might find themselves in a similar situation.
1. The affected facility (sending facility) shall notify the other facility (receiving facility) of the disaster and its intent to act upon this agreement prior to implementing any transfers, and
2. The receiving facility shall indicate the number of patient beds available for the receipt of such transferred patients and identify the type of patients that can be accommodated (i.e. intensive care, obstetrics, etc.) and
3. Prior to transferring a patient, the transferring facility must receive confirmation from the receiving facility that it can, in fact, accept the patient, and
4. It shall be the responsibility of the transferring facility to arrange and provide for transport of a patient to the receiving facility and to provide, if necessary, proper medical support during transport, and
5. The medical record (medical and financial/demographic) will accompany each transferred patient at the time of transfer, and
6. It shall be the responsibility of the sending facility to endeavor to meet the staffing needs of the receiving facility to the extent requested by the receiving facility for the proper care of the transferred patient, and
7. In the event the attending physician of a transferred patient is not on the medical staff of the receiving facility, and in the event said physician wishes to continue attending to his patient at the receiving facility, the receiving facility agrees to the patient's third party and personal payments, and
8. In the event the transferred patient's attending physician does not desire or otherwise is not able to obtain such emergency temporary privileges, the receiving facility shall arrange for the assignment of an appropriate physician to the patient, and
9. Patient valuables of any transferred patient that have been placed in the sending facility's safe prior to the transfer shall remain there not withstanding the transfer of the patient. Patient valuables on the possession of the patient at the time of transfer shall be the responsibility of the patient and/or the sending facility, and
10. Transferred patients will be returned to the sending facility as soon as it is able to provide for their care subject to the patient's medical condition permitting. It shall be the responsibility of the sending facility to provide transport for the return of such patients, and
11. The sending facility will assume financial responsibility for any non-insured patients who are transferred as the result of this agreement and shall be responsible, within 30 days of receipt and of a statement from the receiving facility, for paying such bills, and
12. For insured patients, the receiving facility agrees to accept the patient's third party and personal payments, and
13. In the event the transferred patient is a HMO or other contractually provided patient whose carrier does not recognize the receiving facility, thereby refusing to tender payment, the sending facility will be financially responsible to the receiving facility for the cost of the patient's care and treatment. Each facility agrees to honor the other's contractually negotiated rates for patients so transferred, and
14. This agreement shall be effective as of the date indicated and shall remain effective for an indefinite period of time. Either party may terminate this agreement without cause upon giving not less than 30 days prior written notice, providing that any patient still in the receiving facility at the time of termination shall continue to be classified as a transferred patient under this agreement as if the agreement were still in force, and
15. It is further agreed between the parties that transfer shall be limited by the receiving facility's ability to provide care for such inpatients and that the agreement does not supersede either facility's rights and obligations under COBRA, OBRA, and/or Florida Statutes and Rules and Regulations regarding patient dumping.
Mercy made identical arrangements with AMI Kendall Regional Medical Center, Doctor's Hospital, North Gables Hospital, Coral Gables Hospital, South Miami Hospital and Parkway Regional Medical Center.
Regardless of the facilities' plans, when the warning is sounded in Dade County and most other counties, the County emergency planners take control of the ambulances and dispatch them according to their priorities. Sometimes it works better than others.
The 24-hour alarm clock
The telephone bank, the most critical component of the Dade County Emergency Operations Center (EOC) was designed to fail. A dozen different emergency functions including a two-line computer notifier system for special needs citizens, communications and dispatch for police, dispatch for fire rescue and the National Guard, rumor control and the 911 system for Dade County were all on the same rotary phone switches, according to former Dade Hurricane Coordinator Michele Baker.
As soon as the Hurricane Watch was posted at 5:45 p.m. on Saturday, Aug. 22, the volume of incoming calls jammed the lines and the phones did not stop ringing for the next week. As a result of the failure to plan for the volume of calls, for the first few critical days of operation: the day before the storm and two days after; it was impossible to make an outgoing call without several failed attempts. The volume of incoming calls also caused the switch to roll over and crash the 911 system, Baker recalls. As we will see later, the poorly planned phone system meant that no one could call into the Emergency Operations Center to report on needs, to request assistance or to find out where to go with critically needed supplies and volunteers after the storm.
"You could not get an outgoing call out of the Dade County EOC for three or four days unless you were persistent and kept dialing over and over again," Baker recalled.
The descent into disorder at the EOC began on Friday, the day before the Watch. On that day, relying on information provided by the Hurricane Center, the Dade EOC called all the key department heads and agency contacts and told them to monitor the storm. They were told the storm might arrive the next week and there might have to be some evacuations. The implication was strong that they would not be called into action over the weekend. But on Saturday morning when Kate Hale visited the National Hurricane Center in Coral Gables she was told that things looked pretty grim. The storm had picked up speed and power and was heading for South Florida.
Hale decided not to wait for a Hurricane Watch to assemble her staff and summoned them to the EOC. Most of them arrived before 6 p.m. Saturday just in time to hear that a Hurricane Watch had been posted for the area.
Baker recalls the moment. "When the watch went up, the phones went nuts, so there was no ability for any of us to do the kind of build-up that we all had in our plans; the kind of time that we expect to have those first few minutes to get organized and to make our notifications. The storm just picked up speed too fast."
Instead of staying overnight and getting caught up on the preliminaries, most of the EOC staff went home to get sleep and prepare their own families. Baker worked through the night printing out the schedules and routes for the Metro Dade Transportation Department bus drivers and for the ambulances and Dade County School District buses that would be used in the evacuation of special needs patients and other citizens.
Metro Transit personnel arrived at 3 a.m. Sunday morning to get their routes and instructions and begin the process of evacuation. Baker had printed out the list of people in need of evacuation based on the assumption that the storm would reach Category 5, even though Andrew had been a Category 3 storm when she began the process. But, by the time the list was finished, the storm had grown to Category 4 strength, so the evacuation level E, maximum evacuation plan, was the correct protocol.
If Baker had not stayed, or if she had printed a list for evacuation based only on a Category 3 storm, the evacuation process would have been set back by four or five hours and probably never completed. As it was, bus drivers were still picking up elderly individuals and carrying them down stairs from their apartments and condos at 12:30 a.m., with the wind whistling around them and sand blowing in their faces, two hours before the hurricane winds arrived.
At 3 p.m. the afternoon before the storm, 12 hours before local winds reached hurricane speed, only 10 percent of the special needs individuals had been transported. The Metro buses, that had been detailed to carry wheel chair patients, could carry only two or three patients in chairs at a time. Special transportation services were so overwhelmed with their regular clients they were unable to help. And the school board buses with special lifts for wheel chair patients were late arriving and early to leave.
When the school board transportation officials were notified that they would be needed, they had no system to notify other school board officials who would then mobilize the drivers. Because it was a weekend and no one had home numbers, the transportation administrator at the school board was not notified until 1 p.m., Sunday, four hours after the Hurricane Warning. The first school board bus did not arrive until 2:30 p.m. Florida Department of Transportation employees and those of several businesses that must react to an impending storm, have organized to eliminate this problem of notification. This is a lesson that might he learned by all agencies involved in massing before and after a storm.
DOT employees are told where they are to be and when, well in advance. They are assigned a vehicle and a task, so that there is no need for anyone in management to contact them to get them started on their important tasks. They also know how long they are expected to work and where they are supposed to report during work and once their tour of duty is completed. Not so the school bus drivers. They did not show up until they were told to show up and they were not told how long they were expected to work.
Around 7 p.m., with thousands yet to be evacuated, the school bus drivers decided it was too dangerous to work and went home leaving the Metro buses and the ambulances to finish the evacuation.
"The Metro bus drivers went so far beyond the call of duty," Baker raved. "Their responsibility was to merely go to the curb and stop and wait. But they did much more. They drove, they stopped. Where the power had gone out, they climbed the stairs and carried people and their baggage down. They picked up people in stretchers and just laid them on the floor. What these guys did was just incredible. They didn't have to do it, but they did," Baker recalls.
At Mercy Hospital, despite all the pre-planning for evacuation, things were not going as smoothly as planned. Medi-Car, the ambulance service that had contracted with Mercy to evacuate its advanced life support patients, was inundated with requests for transport from its various clients and beyond. The demands quickly exceeded the ability to respond, so Medi-Car dispatchers set their own priorities based on efficiency and the distances to be traveled. This left Mercy at the mercy of chance when it came to the timing of its evacuation.
Carlos Blanco, a manager at Medi-Car who was on duty at the time of the evacuation, recalls, "Dade County did not take command of our vehicles. We set the priorities for the use of our vehicles by location and how many patients they had and we did our evacuation following that priority. We tried to get everything on the beach and on the coast out first, and from there we tried to work inland. We did not have actual contracts other than Mercy. The ones who called us at the time were the ones we evacuated. Everybody that called us, we did evacuate. We started at five in the morning and didn't finish until midnight on the day of the storm. They went everywhere. You name it they went there, mostly other hospitals and other nursing homes. Some went to hospitals up in Broward. It was a crazy time. Every vehicle we have, 28 units, was involved in it. If there was a call for an ambulance at the time we would pull one of the vehicles off the evacuation to handle it."
He continued, "If there was one thing we learned it was that evacuations have to start earlier. It did not really make any difference if anyone had a contract at that time. Those people we did a lot of business with, we tried to accommodate them more rapidly. It gets to a point where contracts really don't count. The bottom line was we didn't care who you were, we were going to move it."
The movement of patients among the hospitals was complicated because those hospitals that had formal arrangements with some hospitals to take their patients were also asked to take patients from hospitals where they had no formal agreement to accept patients.
The arrangements that had been made with other hospitals to take patients in case of evacuation did not anticipate the demand that would be place on them to take patients from facilities that had been ordered to evacuate. Accommodations were found for the final four Mercy patients at Deering Hospital in South Dade at 6 p.m. Sunday, just hours before the winds began to blow. As it turned out, those patients were in for the times of their lives.
As the storm approached the Florida peninsula, the reports from Bahamas were chilling. The wind was clocked at 150 miles an hour, sustained, at 2 p.m. Sunday afternoon. In Miami the wind was still a breeze and a fiercely hot sun beat down on those making last minute modifications to their homes and places of work.
At the region's 79 movable bridges, Florida Department of Transportation crews stood by awaiting orders to lock them down, preventing passage by boats and facilitating evacuation. State law says that all bridges under the control of the DOT get locked down when the wind reaches 39 miles an hour. But the law does not say where the wind must reach 39 miles an hour. State law does not say how long the wind must blow 39 miles and hour. Nor does it say who decides that the wind has reached the required level or who makes the announcement.
In the mean time, the bridges over which a massive evacuation was being conducted, opened and shut on the demand of hundreds of boaters attempting to move their craft to safety.
Since Andrew was a smaller diameter storm than usual, its 39 miles per winds did not arrive until the storm was almost on top of Florida. Since the winds did not reach 39 miles an hour as expected, the evacuation of the coastal areas was hampered by the constant raising of the bridges to allow pleasure craft to venture inland for protection.
Meanwhile, 517,000 residents from the Keys, the mandatory evacuation zones and residents who recognized they did not feel safe at home, clogged the mainland highway system. No one expected the volume of traffic nor the amount of impedance automatic tollbooths might cause. Traffic backed up for miles while families that were fleeing for their lives fumble for quarters at the toll plazas and fumed that the state could be so stupid and greedy. It took a televised complaint from the local weatherman for the state to realize that taking tolls along the Turnpike system meant risking the lives of thousands of evacuees. Long after the decision should have been made, the tollbooths were opened for unfettered passage.
At 7 p.m. no one was officially allowed across the causeways onto Miami Beach. This meant that the thousands of elderly residents who remained in their condominiums, unwilling or unable to evacuate, could not be reached by their children or friends and the only hope was an official evacuation vehicle.
Since the phones had jammed at the EOC immediately after the hurricane watch was sounded, the EOC was not able to make phone calls and warn special needs individuals to pack and eat a meal and await further notice. Likewise, when the evacuation order came at 9 a.m. on Sunday, the EOC was not able to notify special needs patients that someone would be coming within six hours, as prescribed in the plan.
Fire drill and rescue
The Metro Dade Fire Department and its rescue component went on alert, like the other government agencies, when the watch was sounded at 5:40 p.m. on Saturday, August 22. Metro Fire and Rescue is the heart of the emergency medical system in Dade County since it serves all of unincorporated Dade and 22 incorporated municipalities with 1,400 uniformed personnel from 40 stations. It is an experienced unit that includes a special team of urban rescue workers who have flown around the world to locate and treat the injured in the aftermath of natural disasters.
Fire rescue's communication system links its fleet of vehicles to the area's hospitals through the Medcom radio network with eight dedicated radio frequencies. On most occasions, basic life support transports are hired out to commercial ambulance companies including Randle Eastern Ambulance and Medi-Car. Advance life support missions are handled exclusively by Fire Rescue's 30 ground rescue units and two Bell 412 choppers.
Unlike the Metro police, Metro Fire took down its tallest antennas before the storm and operated with shorter transmission units. After the storm, the masts were reinstalled along with portable repeaters at strategic locations to complete a fairly resilient communications network. Unfortunately, no other agency had equipment to tap the fire and rescue bands.
The unionized firemen had developed strict and clear-cut rules about who comes and who goes when a hurricane watch turns into a warning. The strengths and weakness of these specific policies are worth considering by other groups.
The MFD after action report tells the story as only an official fire department report can.
"Upon announcement of the Hurricane Watch, all essential MDFD personnel were placed on standby status, and as stated earlier, were expected to take immediate steps to secure their property and family.
"Upon announcement of a Hurricane Warning, the normal complement of on-duty operations personnel will be augmented by the immediate past shift. Unless otherwise instructed, on-coming personnel are expected to report to their duty station within one hour after the Hurricane Warning is announced. On-duty personnel will be relieved of duty by the reporting immediate past shift in order to secure their property and family prior to reporting back to duty. Employees are expected to return to their duty stations within 4 hours.
"Since the warning occurred right at shift change (7:00 a.m.), it was difficult to determine who was the 'immediate past shift'. The off-going shift (immediate past shift) had not had the opportunity to secure their property and families. This led to many more people than planned needing to be off to secure personal business," the report admits.
The bad timing aside, the firemen have learned over the years that they get more out of their personnel if they plan for each and everyone to be at home to prepare the home prior to the storm, and if they schedule time to return home as soon as possible after the storm.
At Florida Power and Light, the employees are also assured that someone in the system will attempt to locate the families of the men on duty. They are assured that housing will be provided if needed and loans will be available on demand. This dramatically reduces the stress on the first wave of emergency repairmen and is an excellent policy for health care personnel who must be on duty immediately before, during and after a storm.
No way out
At 7:30 p.m. Fort Lauderdale International Airport closed. At 9:30 p.m. Miami International Airport closed. The two closures stranded hundreds of tourists who had been forced out of their hotel rooms as most of the beachfront hotels decided to heed the evacuation order.
At the Fontainebleau Hotel, for example, the majority of the guests were European. Few spoke enough English to understand what to do or where to go when the instructions were broadcast. Few paid attention to the darkening weather forecasts until the hotel told them they must leave and should not expect to find rooms south of Orlando.
At the Fontainebleau the guests ultimately were forced from their rooms and told the location of hurricane shelters. Many fled to the airport in the vain attempt to catch a flight anywhere. And most of them weathered the blow at the airport.
Hearing-impaired loose touch
The deaf and hearing impaired were worse off than the non-English speaking Europeans.
The Federal Communications Commission requires that all emergency information be provided over television in the form of a "crawler," a written message to accompany any voice message and pictures. The crawler moves across the bottom of the screen to inform the hearing impaired of what is happening and what to do when a broadcast is not closed-captioned and no one is available to sign.
Tyrone Kennedy, the founder of the Deaf Services agency in Dade County, recalls that the system worked well until the Hurricane Watch was changed to a Hurricane Warning. At that moment his 30,000 clients who relied entirely on signing or closed captioning were spread throughout Dade County. And an equal number in Broward and Palm Beach counties were also left to wonder if they were going to be targets of the worst part of the storm and if they were expected to evacuate.
At the moment of greatest need, the television stations stopped using the crawler because the emergency messages were too long, complicated and varied to be reduced to writing.
"Once it changed from the watch to a warning we lost it all. The deaf population had no knowledge of what was going on. They missed out completely," Kennedy recalled.
"When the warning came, we went into action at Deaf Services. We called the National Hurricane Center to ask them where the interpreter should go, because the interpreter always goes to the National Hurricane Center to be there when the news media comes in, so they can show the interpreter along with the announcements of the impending hurricane. That did not happen." Kennedy recalls.
"We called and I did not get through. When I did, they said they did not need one, if they did they would call me back. I never got the call.
"I proceeded then to call all the television stations, because we had a plan to send the interpreters to the stations to meet with a designated person who would bring them into the newsroom where the announcements would be made. None of the television stations were receptive to bringing an interpreter in. It was just a complete failure in trying to get the deaf and the hearing impaired informed. When we finally got through to Channel 10, they said to go ahead and send an interpreter. We sent an interpreter. That was about 10 p.m. that night. By the time those people who would have relied on this information, if it came sooner, found (the station and got the information) by then it was too late. The stores were all empty. There were no supplies left," Kennedy said.
He said that after the storm the power breakdown made it impossible to contact the deaf by phone, since their TTY machines required electricity. The battery back up is good for a few hours unless you use the printer. In that case their life is substantially shorter. He said, "So we learned, at least, not to use the printers."
Kennedy said deaf services then capitalized on telephone technology to solve their communications problems. He forwarded all the calls to deaf services to an apartment in North Dade where power remained.
After the storm, the only method of gaining information about clients in the devastated area was to send staff and volunteers to their last known address. There was no way to call them without power. Southern Bell provided a supply of batteries to replace those that had been expended in the individual TTY units and the field workers exchanged spent batteries for new ones.
Since the storm, the deaf community has discussed the effectiveness of closed captioning in the emergency environment and is now recommending that all emergency messages be sent in open captioning, as written messages visible to all, at the bottom of television screens, at regularly scheduled intervals.
By 10 p.m. most of the shelters in South Florida were filled to overflowing and there was still little tangible indication of the power of the storm that was brewing on the horizon. The fearful winds did not begin until midnight. By that time, the limited order that had prevailed, dissolved in the deepening gale.
Mental patients without essential psychotropic drugs or the trained professionals to manage them were dropped in the midst of families hiding from the storm. Elderly who had not been moved from their beds in years were loaded on buses and dumped at hospitals, nursing homes and shelters.
Mark Lichtman, a director at the Miami Jewish Home for the Aging reports that one of his biggest problems came from members of the South Florida Jewish Community with elderly parents living at home or without assistance. Many of them drove up to the already overcrowded home and, without an advance warning, dumped their elderly relatives as they raced out of town or for shelter.
But the professional nurses who had been hired to help the needy during the storm showed just as little concern for their responsibilities. Baker, the Dade Hurricane Coordinator recalls, "Our responsibility was to make the arrangements for the staff. I want to tell you, we failed. It was not the fault of the Red Cross. It was ours."
"We had a program where we were supposed to have public health nurses at three of the major shelters where we were to bring special needs people," Baker said. "And Dade County had six contracts with private nursing companies to activate to bring in nurses and LPNs.
"We activated the contract. Two of the contract nurses responded and said they would come in. Only one showed up. None of the public health nurses showed up. That left us with about 1,100 on special needs registry and 6,000 people from Miami Beach who were all frail elderly. We had in the neighborhood of 10,0000 people in the shelters who had special needs and all we had to provide help for them was a paramedic and two EMTs (at each shelter) in most cases.
"But those guys are not trained in hand holding, diaper changing and geriatric medicine, and they were totally overwhelmed with this task of baby-sitting and they were under-utilized because they could not be out doing search and rescue," Baker recalled.
The net effect of the failure of the public health nurses and paid private duty nurses to respond as promised was that the EMTs had no relief for two full days. The shift that helped in the shelters during the storm was compelled to remain at their stations at the shelters the day after the storm when they might have been able to relieve their brothers who were cutting their way through the rubble looking for the dead and treating the survivors.
Baker said, "We had one whole shift (of EMT personnel) in the shelters, a third of our guys, that was inaccessible to us so that the guys who worked all night and were toast had no relief."
There he blows
At 4 a.m., the entire power grid serving South Florida collapsed, plunging four million people into darkness, cutting most off from the assurance of television. Above the Redlands Golf Course off Krome Ave., just north of Homestead, the Channel 6 television broadcasting tower was taking a beating. It was 1,500 feet tall and installed with the latest in safety procedures. It was a key communication link between the Keys, South Dade and the rest of the world. At least a dozen telephone and radio relay stations were installed on the tower.
At around 4:30 a.m., when the units of the Metro Dade County Police Department were ordered to take secure shelter, the mighty tower began to bow in the wind.
At 4:55 a.m. the eye wall reached land just south of Key Biscayne not far from Mercy Hospital.. At 4:57 a gust that might have been as high as 178 mph raked the Hurricane Center building near 40th street off Dixie Highway in Coral Gables, two miles north of South Miami Hospital, one mile east of Doctors Hospital and two miles west of Mercy Hospital. The Center's hurricane-proof radar antenna was blown off the top of the building by the gust, leaving the hurricane center virtually blind and deaf. Its rooftop wind speed measuring devices were also destroyed but remained in place with a final reading of 164 miles-an-hour.
At 5 a.m., as Andrew's eye wall approached landfall in farther south Dade the South Florida Water Management district officers who were monitoring their water level gauges in South Dade got a real surprise. They were remotely monitoring the gauges from the safety of a West Palm Beach bunker, a hundred miles north. One of the remote monitors records the outflow of water from the flood control canal opening into South Biscayne Bay near Saga Bay.
As Andrew surged ashore, the power of the low pressure in advance of eye wall was clearly visible. With the eye wall minutes away, the canal depth read an incredible 2 feet below sea level on the gauges.
For days prior to the storm, the canals had been wide open to handle the expected flooding and each showed levels at or above sea level. But the last gasp of Andrew before it came ashore had sucked the water from the bay and the canal and piled it up somewhere offshore against the rushing seas.
A few minutes later the storm surge rose to 19 feet and plunged forward at break neck speed. It picked up the 114-foot long, 210-ton freighter, Seaward Explorer, just off Elliot Key, snapped the hawser that held the Seaward Explorer to its storm anchor, submerged Elliot Key and transported the freighter across Elliot Key.
Gathering speed, the wave and the freighter crossed Biscayne Bay and smashed ashore, the water covering everything that did not stand taller than 25 feet. The Seaward Explorer came to rest 200 yards from the shore in South Dade, 500 feet from Old Cutler Road, just west of the radically shifting canal floodgate. The crew had no idea the ship was not still miles at sea until the surge receded, leaving it and them, high and dry.
At the height of the storm, the massive Channel 6 television tower could stand it no more. It's three inches in diameter cable snapped with a retort like a mortar round exploding, and it toppled to the ground, deafening an area 350 square miles in size as its ensemble of antennae crunched to the ground.
Metro Police regional chief Ben Como remembers that a few of his men in each of the four districts south of SW. 8 Street remained on patrol until 4:30 a.m., when they were officially told to take cover. Others had sought out a "secure place" somewhat sooner. Como said the problem was that no one knew which buildings would be secure against Andrew. Most agreed that the aluminum hangars at Tamiami Airport would be secure. And so, most Metro aircraft were stashed in hangars at the regional airport.
A platoon of Metro police looking for a secure building in South Dade selected a location also popular with building inspectors; the Don Carter Bowling Palace, off U.S. 1 in far South Dade. At about 4:45 a.m., the roof began to leak water, then air, and then wind. As the storm entered the alley, the threat of total collapse was imminent, and the police officers spent a terrifying hour hiding beneath the pool tables as the bowling palace crashed around them.
Things did not fair much better at the regional police and fire rescue headquarters in Cutler Ridge, according to Como. His office was destroyed and with it, his communications. The explosive decompression in the regional library next door blew off the roof and sent books careening in the wind to be found 40 miles away. Actually, the chances are that the books found 40 miles away had been checked out from the library and lost by distant bookworms struck by the storm. Such is the stuff of urban legends.
When the Channel 6 television tower buckled, Como was left with no radio. He had several cellular phones. But they were battery powered at best and useless in the jammed airwaves caused by the collapse of the Channel 6 tower and several relay stations.
Como, with four districts to control, with 1,100 men to move, with incredibly important emergency information to dispense, was left with one radio frequency that, unfortunately, matched no other nearby law enforcement station or agency.
Como tells the story, "Pre-hurricane we had a staff meeting and decided we needed at least 60 percent of our staff should be made available for the storm. That was accomplished.
"Our normal radio communications system went down and we immediately go to the phones and find out that does not work. So we immediately go to the radiophones. When the Channel 6 tower went down that knocked out our communications. The only communications we had that was generic between all the agencies, was an emergency frequency, what we referred to as Channel B. Keep in mind that I had four districts and three were directly effected. I had to make calls to handle every one from Bird Road south. It was terrible. Once you got south of Kendall, the phone systems were shot, so no one could call in. We had the one generic phone that went to the Cutler Ridge station.
"As soon as the storm passed, we had to be back on what was left of the streets to identify the emergency routes and clear them if they were blocked. We had to communicate this to our officers in the field. A lot of people had to be transported to hospitals right after the storm. Then there was a need to do damage assessment, a critical need to keep control of the streets. I needed to determine the extent of curfew, when and where it would be. Communication was paramount and I had one line," he said.
Como said he made a point of arresting 149 people in the first two hours after the storm, putting them in jail, then using the media to advertise that arrests were being made and suspects were being jailed for looting.
Como said, "Several of the things we had done in the past will have to be corrected in the future. One is a correction in the terminology, for law enforcement to find themselves a facility that is secure. No one in law enforcement has taken the time to define what is a secure facility. We quickly found that out when almost a platoon of officers selected Don Carter Bowling Alley as a secured structure. They quickly found out that it was not secure when they had to spend a couple of hours beneath the pool tables and we lost a couple of vehicles at that location.
"We did disburse our aircraft to Tamiami and they were crushed. So that left us also in a problem to try and acquire aircraft. Bell helicopter provided us loaners pretty quickly and they became extremely essential in order to find out what happened down south, because they were the only way to transport ourselves."
Como speaks of the storm with veneration. "Andrew provided an awakening to the degree of power Mother Nature has. No degree of planning could have planned for anything as devastating as this."
That is exactly the way they felt at Baptist Hospital.
A Baptism under fire
Baptist Hospital is a large and quite successful private institution whose history is deeply intertwined with the upscale community it serves. Millionaire developer Arthur Vining Davis-- whose initials became the source of the name Arvida- sought to develop his vast holdings among the groves and swamp of South Dade.
When he heard of plans to build a private hospital near Jackson Memorial Hospital, he contacted the physicians who were organizing the effort and offered to build them a hospital in the undeveloped South Dade savanna, along and with a fine access road. He promised them lots of new patients from the residential development he hoped to build along Kendall Drive. His "magnet" hospital became Baptist Hospital. As Davis predicted, the hospital prospered as the Kendall area became a major bedroom community surrounded by planned developments, apartments and condominiums.
Baptist is far enough inland to have no fear of storm surge. And it is not far enough east to worry too much about flooding from the shallow water table that underlies the reclaimed swamp. As Hurricane Andrew approached, Baptist was committed to stay open and take care of its clientele.
Baptist, like most other successful institutions, was deeply involved in marketing its oby/gyn services and birthing suites. The staff knew what most growing hospitals know; women make the health care decisions. And women will stay with the hospital where they have a happy birth.
There has been a baby boom among the affluent of South Florida with an unusually high percentage of the first time mothers around 40 years of age and able to afford pampering beyond the needs or the means of their younger sisters. Baptist had hundreds of these patients who were faced with a real problem with the approach of Andrew.
The falling barometric pressure of an approaching tropical storm will often induce labor in third trimester women, causing premature births and other complications. Those conditions are difficult enough for a young mother and another story entirely for the aging first time mother.
Beyond its maternity operation, much of the surgery done at Baptist Hospital is elective. And elective surgery is rarely scheduled for weekends. On Saturday evening when the television reported a good chance the storm would hit Miami, Baptist vice president Lee Huntley contacted the Baptist switchboard and told the operators to notify all department heads and managers that there would be a hurricane preparedness meeting the next day at eleven in the morning.
Huntley recognized the possibility that no one would be able to reach the hospital or leave for several hours after the storm, so he ordered two shifts to report by midnight, one to sleep through the storm and the other to work. It never occurred to him or any of the hospital administrators at other South Dade hospitals that most of their staff would be required to remain on duty without relief for 36 hours or that 500 of the hospital's 3,200 employees would go home after the winds blew past to find that they had no home left in which to rest after the grueling tour of duty. Nor could they have guessed that 1,500 employees would have endured devastation just short of total destruction.
Baptist made arrangements with emergency physicians and specialists including obstetricians, surgeons, cardiologists, a neurosurgeon and anesthesiologists to leave their families at home and stay at the hospital during the hurricane.
"Everyone made their phone calls, then went home to prepare their homes as best they could. The scenario was, you said good-bye to your family, then you came back to work. It was a very hard thing to do," Huntley recalled.
Pregnant women who were patients at Baptist were contacted by the doctors and told to spend the storm on campus. Some had friends who were pregnant who were not patients at Baptists. At the same time, on the radio, Jackson Memorial Hospital, the region's only public hospital was calling in its indigent mothers to be, raising the awareness among all pregnant women in the area.
So many pregnant women showed up at Baptist in the hours before the storm that they filled the auditorium, then spilled into the hallways, then filled the offices of the Joslin Diabetics Clinic. Families of women in need were also reluctantly allowed to stay, creating space, nutrition, waste disposal, sanitation and liability problems.
"No woman was turned away from Baptist Hospital prior to the storm," Huntley recalled.
Baptist was not the only hospital with a baby boom. Jackson Memorial Hospital is the primary public hospital in a region serving more than a million individuals, many of them refugees and immigrants with a tendency toward fecundity. Jackson and its clinics provide the majority of the pre-natal and ob/gyn resources for the multiplying multitude. As such, Jackson was confronted with the problems of concerned pregnant women in substantial numbers.
These women were notified over the regions rock, reggae, rap and rhythm stations to plan a stay at Jackson for the time the storm would be in the area, if they either were within three weeks of their due date or if they were in the Jackson Ob clinic program and had been told to come to the hospital.
For the most part, they were told to leave their other children, friends, mothers, husbands and boyfriends at home. But few heeded the message. The air conditioned and seemingly invincible halls of Jackson seemed a much nicer place to weather a storm than cracker box apartments, shabby shacks and crowded homes. And so, as Jackson's staff and physicians scrambled to park their boats, spare sports cars and mobile homes in the relative safety of the county lots around Jackson, the indigent flocked to Jackson in every manner of transportation both public and private. Jackson's plan had called for housing some OB families in Jackson Towers. But this plan never materialized.
Jackson's hurricane plan was long on delegation. Supervisors were given the responsibility to determine the staff that would be adequate for the emergency and to schedule them. Food was provided, under the plan, "at prevailing prices" until otherwise authorized by the command post. Only physicians and nurses authorized in advance by the command post were allowed to order delivered food from the cafeteria. All others were required to eat in the cafeteria. Ob patients who were told to report to the hospital were expected to either bring food or pay.
Jackson, like most other hospitals, waits for the hurricane warning bell to begin preparations in earnest. Staffers were scheduled in three shifts: those requested for duty before the storm hit, those scheduled to work during the storm and those scheduled to work after the storm. Employees scheduled to work before and during the storm were required to be in attendance before the storm. They were not allowed to bring family to the facility except with prior approval or if they could not get to a designated shelter on time.
Those who would relieve the hospital staff members who were working before and during the storm were advised to arrive at work two hours after the storm passed or as soon as possible thereafter. The Jackson plan called for the employees of the Metro Dade Transit Authority, the Jackson Outpatient Transportation Department, security and the material management department to find their way to their buses and then find their way to several strategic landmarks to pick up Jackson employees needing a ride to work. All this was done as if the storm would hit everyone but employees of Jackson, as if the roads would remain open countywide and the destruction would not affect the staff. As it turned out, approximately 2,400 of Jackson's 7,000 employees lived in the damaged area. Most of them suffered some storm damage while 500 were left homeless. Therefore, fewer Jackson employees than expected made it to work by eight o' clock Monday morning as ordered.
At 3:30 a.m., as sustained winds exceeded 50 miles an hour, the incident manager for Metro Dade Fire Department ordered his men and women to stop responding to new calls. Units on call were ordered to report to the nearest fire station to wait out the storm. Once the order was given, all the 911 dispatcher could do was log a call, take the name, address and phone number and promise help once the storm passed. At some stations, however, the "no response" order was ignored. There are several acts of heroism that will never be known because they involved the violation of a direct order. But we know a battalion chief who went out in the gale to check a report of a fire on the seventh floor of a North Miami Beach high rise. We also know about 22-year old Elaida Vargas who had come to Miami to have her baby, because the poor can have babies free in America and it was safer than her native Dominican Republic. At 3 a.m. she called for emergency medical assistance. Her head was pounding with pain, she complained, and she could not stand it.
For almost an hour, the EMT crew tried to reach Elaida. But the storm's winds made passage impossible and the crew was recalled. She died at 9:30 a.m. having survived the storm, killed by a cerebral hemorrhage. Her unborn baby also died.
At 4:22, with hurricane winds howling in the background, emergency medical personnel assigned to the communications center successfully helped a desperate father deliver a baby over the phone.
At 4:27 a.m. all of South Florida went dark.
Then things really got bad.
All across South Florida, as the winds reached their peak velocity, hospitals and shelters were learning a difficult lesson in construction. Virtually all the commercial buildings in South Florida keep their central air-conditioning units or cooling towers on the roof. This is also the preferred location for emergency water supplies and communications equipment. The roof location is preferred over ground level for aesthetics and to avoid water damage from heavy rain and standing water.
Andrew was not a wet hurricane. But it was intensely windy. And so, all across South Dade in the path of the 140 mph winds, air conditioning units and antennas became projectiles, not unlike the hurricane-proof radar that blew off the top of the building that housed the National Hurricane Center.
Virtually every place on a roof where an air conditioning unit was attached, a gaping hole was left behind, exposing the facilities to torrential rains and devastating winds. The rains poured in and filled the ceilings, then the walls, ending the usefulness of all electrical and communications equipment located in the walls then turned elevators into wells and stairs into waterfalls.
Most hospitals did not board up or otherwise protect their windows above the first floor. Even before the holes ripped in their roofs, gusts of wind projected objects through many windows opening up the rooms where patients and caregivers were huddled. With every breach the hospital personnel and their patients were forced to retreat deeper and deeper into their facilities. With the power gone, the retreat was into darkness and a damp fierce heat. Maintaining septic conditions was impossible as the damp, wind driven debris invaded every corner.
At Baptist Hospital they had been building a new facility for the Miami Vascular Institute on the floor above the primary surgical unit. The new construction ripped apart as the winds peaked, opening holes in the roof of the surgery section, filling the ceiling with water. One of the few areas of this hospital without windows, the surgery staff retreated to one tiny room with no power, no fans, no running water, no air conditioning and no sanitation to conduct its business.
At Deering Hospital there was no formal plan for a direct hit from a hurricane. When the hospital was called Coral Reef Hospital, the previous administration had developed a basic hurricane plan appropriate for one small and struggling hospital. Deering, the name the Columbia Hospital Corporation gave Coral Reef, was fast becoming the flagship of the Columbia hospital fleet in South Florida. But Columbia was new to the scene with a unique structure of physician ownership. Its administrators had demonstrated their skill at jump-starting failing hospitals around the country. They were not veterans of diagnosing tropical weather.
As Hurricane Andrew moved closer, the Columbia regional officers acted on the earlier predictions that the storm would come ashore north of its actual landfall. Patients from the Columbia Hospitals on Miami Beach: Miami Heart Institute and Miami Beach Community Hospital and from Victoria Hospital were transported to Deering Hospital in far South Dade instead of evacuating to Columbia's University Hospital in Broward County.
Columbia also informed the staff that they were allowed to come with their families and seek shelter at Deering. By the time the storm arrived, Deering's 153 beds were filled to capacity with patients from within its system and beyond, and its meeting rooms and offices were clogged with staff relatives.
Tony Degina, at that time the chief operating officer, recalls, "The last patients we took were four from Mercy Hospital. They got here around six in the evening. Everyone was calm and settled in. "
Degina said the hospital had not boarded up the windows on its second floor patient rooms because it was not considered necessary. Because hospital accreditation officials want all patients to have a window in order to stay in contact with the normal cycle of time, all hospitals place patient rooms around the exterior where they are the most vulnerable to the adverse effects of storms. The accreditation criterion does not, as yet, require that patient windows be fixed with storm shutters.
Deering's reserve generator was stored in a ground-level bunker and powered by natural gas. One of the maintenance men had produced a box containing a hundred flashlights and offered to distribute them. Degina said he felt that there was very little chance they would need the flashlights with the gas-powered generator. Degina said he said he did not want to cause concern among the patients and staff and, therefore, said that the flashlight should remain in storage.
"When they finally decided that the storm was going to come ashore right at us, I found that maintenance man and told him that we better not take any chances, that we better distribute the flash lights. As it turned out, they probably saved some of our lives," he said.
Mary Maxine Keesling,. R.N., was serving as clinical coordinator in two of the units at Deering the night of Andrew. She recalls the succession of events.
"Between ten and eleven that night we saw the rain increase and the tall palms beginning to bend in the wind," she begins. The growing wail of the storm was visible as long as there was power. Deering, the shelter selected for three hospitals and their staff, had not even boarded the ground floor windows.
"Each time the power flickered it set off all the alarms and buzzers associated with critical care nursing. I told the nurses on duty to prepare ambu-bags for the ventilator patients," she recalled.
"Between twelve thirty and one in the morning, the window-locking devices began to pop open and pound closed. About the time the generator stopped working, the window in the room of a ventilator patient exploded, taking the window and frame apart and sending debris flying into the room. It was time to move our patients to the hall. Those who could sit up were placed in chairs. Others who could not sit up were secured to their beds with sheets.
"The staff formed teams of three to work each ventilator patient - one to pump, one to back up the pumper and one to be a runner. Volunteer pumpers came from all over the hospital."
Degina said he expected the small windows in the patient rooms to withstand the storm.
"We moved the patient nearest the window next to the other patient in our two person rooms and pulled the cloth divider. We figure that if the windows broke, the cloth would at least prevent the patients from being hit by flying glass," he said.
As it turned out, the assumption was hopelessly naive. The windows, all of them, buckled in their aluminum frames and imploded. The rooms became unbearable for the howl of the wind and the deluge of water so the patients who did not need life support were moved to the halls. Fortunately, the patient room doors open in, toward the patients. So the wind blew them closed and sealed them, providing some shelter in the hallway.
Those who needed life support were left in their rooms. At the height of the storm, the window in one intensive care unit blew in. But the patient was connected to too many machines to allow easy movement. While he was disconnected, Degina stood in front of the open window, holding a mattress against the frame and shattered glass to slow the blow.
The point became moot when the power went out and the emergency generator stopped working. For twelve hours thereafter volunteers pumped the heart and lung machines that kept the machine dependent patients alive. They did it calmly and with sufficient care that no patient was lost. And they did it while the hospital was being ripped to pieces.
Sgt. Arthur Gonzalez, a 10 year Metro-Dade officer, led a contingent of 11 officers who stayed on the streets of South Dade until ordered to take shelter. His group joined the others holed up at Deering.
Gonzalez recalls, "Almost as soon as the storm started our communications failed, except for one frequency. When we heard over the car radios that the worst of the storm was about to hit we took cover as directed at Deering Hospital."
At the height of the storm, a resident from the neighborhood fought his way to the hospital emergency room only to find the door barricaded with sand bags. Unwilling to allow the man to go without help, the ER personnel at Deering opened the doors to let the man in. But as soon as the barricade was removed the doors were ripped open, exposing the ER to the full fury of the storm.
Dr. Bryan D. Frederick , one of the two emergency room physicians on duty that night recalled, "The emergency room staff worked together and was prepared to handle just about anything. No patients came between 3:30 a.m. and 6 a.m. However, about 4 a.m., a wild-eyed man appeared at the ER door looking like a drowned rat. We move the supports from the door and helped him inside. He lived about a half block away. A tree hand blown over on his house and he needed a safe place to stay. Every so often he walked by me, appearing dazed. We never did learn his name."
Frederick continued, "After we let the man inside, we couldn't reseal the door as tightly. The storm became worse and soon rainwater and debris were flying around in the ER."
Gonzalez recalls, "I heard a commotion that the new emergency room doors on the south side of the hospital were gone. One door was off the hinges. We tried to get it back on and secured it with sandbags. The winds got worse and the other door flopped off its hinges. While some hospital staff members moved supplies and furniture out of the ER, Craig Bauer, Ray Smith and I went out into the storm to try and pick up the doors and secure them with more sandbags. While we worked, the wind blew through the emergency room and parts of the ceiling were dropping off.
"It was pitch black outside. Debris and rain flew around us and it was hard to walk erect. I saw a lit flashlight and picked it up. I later learned that the flashlight belonged to Officer Bauer. He had been holding the flashlight when a gust of wind swept him off his feet and sent him tumbling, I later learned."
The officers found the heavy emergency room doors and carried them back through the hurricane winds. Struggling against the torrent and the wind, the officers wedged the doors in their jambs and packed sandbags against them, effectively sealing off the emergency room so that nothing could enter from the outside. This, of course, made it difficult to get inside the hospital. The officers were forced to stagger between two buildings through a hail of debris to find their way to an unlocked door. And once they got back inside they found that the hospital staff had abandoned the emergency room and set up a MASH unit far down the main corridor in the surgical waiting room.
Gonzalez continued, "At about the same time the hospital's front entrance started flooding and maintenance crews needed to resource the roof latches. Efforts also were made to stop the water running down the heavily traveled stairways," Gonzalez recalled.
"Patients were moved farther into the center of the patient-care areas as the shaking and rattling of the building's walls grew worse," he continued. "We could see glass shatter and fly across abandoned rooms into sheet rock which separated from the wall and also flew across the room. Secured doors slammed in their frames. Everyone's feet were wet."
Degina said the water rose to almost two feet deep in the hallways as the storm ripped off the roof at both ends of the building and the rain cascaded down the stairways from the holes in the roof. Occasionally the generator would come on and send pulses of power into the soaked and submerged equipment, shooting sparks and sending smoke into the air. The lights would strobe, then go out.
As the storm raged, a staff engineer volunteered to check the generator and found it was working perfectly. But the rain had invaded the area where the switch was located and shorted it out so that only a random connection was made. Efforts to repair the switch were of no avail.
Another engineer figured a way to stem the rising tide in the hallways, however. Using a sledgehammer, he shattered several of the toilets creating a series of open drains that worked to drain off the water. The hospital was in shambles by the time the storm broke. But the ER continued to treat patients until plans were completed to evacuate Deering's patients to University Hospital in Tamarac.
Columbia's regional executive, Jamie Hopping, the former CEO at Deering, made arrangements with ambulance companies in Broward County. The evacuation was completed with the last patient traveling in a car with Hopping and two Columbia executives. The patient, elderly and slightly disoriented, thought she was going on a boat ride and complimented Hopping's navigation skills.
Homestead Hospital, associated with South Miami Hospital and located in the worst area of destruction, also took a serious battering. Most of the patient windows were blown in, driving the 82 patients and caregivers into the dark, dank hallways. A portion of the roof was destroyed and all power was lost.
Despite the damage to the hospital, it reopened four days after the storm. But 125 of its 350 staff members were left homeless. More than 90 employees quit and left the South Florida area for more placid climes.
Six hospitals, three that had been evacuated and three that were open during the storm, were closed for a week after the storm because of extensive damage. The hospital at Homestead Air Force Base never reopened.
Another 130 health care facilities were damaged including 90 ACLFs, two end stage renal dialysis clinics, four mental health sites and five community health clinics. This does not include 11 pharmacies that were destroyed and never reopened and 1,000 specialty clinics, physicians' offices and dental clinics.
More importantly, when all was said and done, no patient at a hospital died or endured a significant injury during the storm. and only the two emergency rooms were closed in the impacted area as a result of the storm.
The damage to community health clinics was potentially troublesome because the areas of far South Dade that endured the worst damage were also the poorest and most reliant on public assistance and public health services. Ironically, the after-Andrew proliferation of volunteer "doc-in-a-box" physicians, field hospitals and storefront clinics dramatically increased the amount and range of health care services available to the poor of far South Dade.
As Dr. Pedro Greer explained it, "There was always a desperate need for an increase in health care services to the poor and migrant workers of South Dade. The storm briefly increased the need for emergency care because of injuries that occurred during the storm-related clean up. But the storm peeled back the veil and revealed the desperate needs that existed before the storm."
Dr. Greer added, " That area was so underserved we had no idea who was being served and who wasn't. After the storm we discovered an entire tribe of Guatemalan Indians who spoke neither English nor Spanish. They spoke their native Mayan tongue. No one had any idea these people existed."
Anyone who had not visited South Florida prior to the passage of Hurricane Andrew would have a difficult time appreciating the shock that came with the dawn. The landscape was totally altered. Things that could never be seen before through the dense, lush tropical foliage now loomed large enough to touch on the horizon, questioning distances. What trees were left standing were withered and leafless. No bushes of consequence survived. All signage was damaged. The streets, avenues, driveways and parking lots were strewn with downed trees, sheet rock, lumber and aluminum. Many former buildings were only empty shells.
South Dade is a relatively new area, much of it built in the past 30 years and built using technologically advanced materials. Everyone who builds in South Florida is expected to build to withstand a "typical storm" of 120 mile per hour winds and 15 inches of rain. Andrew was anything but typical. The debate about the wind puts the sustained velocity anywhere from 140 miles per hour to 180 miles per hour. The rain was substantial but insignificant when compared to the wind.
When the victims of Andrew and their would-be rescuers emerged from shelter sometime between 7 and 8 in the morning, they found unimaginable damage. It took four months for the toll to be tallied. But that hot and soggy Monday no one could have known that 92 percent of the power grid in South Florida needed reconstruction with 1.4 million or 84 percent of FP&L customers in Dade without power and not likely to get power for longer than a week. It would take 34 days before power was restored to 100 percent of the Dade County homes that could accept it.
The darkness was total and remained total, with 7,300 streetlights down and 21,000 wooden power poles snapped and needing replacement. About 24,000 homes were unable to accept power, even after it was restored a month after the storm, because the damage to these homes was so extensive.
On Monday morning, at the moment when a quick and accurate assessment of the damages and the needs of victims was paramount, 5,300 road signs were down or gone and only 200 of the region's 2,000 intersections were left open.
Emergency personnel who lived in South Dade and were familiar with the area were, in many cases, trapped in their homes or neighborhoods by fallen debris. Volunteer relief workers living in South Dade were likewise trapped or too overwrought by their own fates to leap into action for the general welfare.
Into the lurch came relief workers and emergency personnel from other parts of the county and the state. The emergency personnel who had experience in the area were disoriented because they could no longer rely on street signs and landmarks to find there way through South Dade. So it was no surprise that emergency personnel who arrived from Broward County or other areas to the north and west were confounded. Even those who knew their way were confronted with a maze of blocked streets and dead ends.
The destruction was severe below South West 88 Street and it was difficult to imagine that things could be worse. But imagination was all that was possible for almost two days, since it was impossible to travel into deepest South Dade overland, and the official emergency air force was out of commission.
Like the executives at Columbia Hospitals who evacuated three hospitals to South Dade, the Dade County emergency officials and Florida Power and Light had put all their eggs in one basket. And that basket, Tamiami Airport in South Dade near South West 154 Street, was ground zero for Andrew. The police helicopters and the airplanes and helicopters of the various agencies that were left at Tamiami for protection were mangled, flipped or blown away.
With all the airplanes and helicopters destroyed and the roads impassable, the disaster response agencies went into a scramble to beg or borrow aircraft and get it in the air to begin an assessment. A prompt assessment is important for the deployment of emergency resources and for critically needed information upon which to plan the next phase of the relief effort.
In South Florida, as in most communities, the local chapter of the American Red Cross is the designated relief agency in case of disasters. The Dade County chapter of the American Red Cross, like most other Red Cross chapters spends much of its time in blood drives and fundraising. It is perpetually short of blood, money and trained volunteers. The job of recovery falls to the Red Cross and the local governments unless there is a declaration that the local governments are overwhelmed.
Under the federal law known as The Stafford Act, the Federal Emergency Management Agency (FEMA) cannot come into play until after the governor of the stricken state requests the President to declare a major disaster. This is defined as a finding on the part of the governor that the scope of the problem is beyond the state's ability to respond.
This rule anticipates that the local agents of the state will promptly develop the ability to make an assessment of their needs. After Andrew that was beyond the immediate ability of the residents in South Florida, since there were no communications, no open roads, no power nor any ability to conduct an orderly aerial survey. In addition, the phones that worked were jammed. The main communications link, the Channel 6 tower, had been toppled and the EOC phones were overloaded and unable to handled either incoming or outgoing calls.
At 10:45 a.m., Monday, Aug. 24, 1993 Florida Governor Lawton Chiles declared a state emergency and called in the National Guard which arrived in some strategic locations by noon.
The National Guard units were called in, not so much to dig in the debris for survivors nor to clear the roads. They were necessary to counteract the lawlessness that began, even before the winds subsided; a lawlessness and violence that stifled any other efforts to save the wounded, locate the dead or help those in need of food and water.
Mother Nature had issued a credit card to every malefactor in an area filled with crime, poverty and despair. For most of Monday, the area south of Kendall was looted with reckless abandon. Lone police cruisers were pummeled and driven back. Emergency personnel driving vehicles which clearly proved their benevolent intentions were, nevertheless, shot at, to keep them from calling in police who might stop the looting. Likewise, public safety, public health and medical emergency vehicles were either attacked or stolen. Not the least of the casualties on Day One was a truckload of Red Cross supplies on the way to Homestead that simply disappeared, truck and all.
By the afternoon of the first day, television shots come back from the only helicopters available, television station copters. They, of course, were not doing a systematic survey of the disaster and routes of ingress and egress. They were looking for dramatic images, concentrating on the damage to the coastline and the looting of the posh malls. The images were spectacular. But they bypassed Homestead, Naranja and Florida City.
The rescue effort was further complicated by the staffing shortages at the Red Cross shelters. The EMTs and paramedics who might otherwise have been available to relieve those on duty during the storm were pinned down in the shelters as thousands of injured and soaked people fled their demolished homes for the only place they could find help. Since the public health nurses and private duty nurses hired by Dade County failed to show up, the EMT personnel were desperately needed at the shelters.
Michael Weston, the recent appointee as director of disaster planning and operation for the Florida Department of Elder Affairs, was pleased with the operation of the local elder affairs unit before the storm. His group was able to notify virtually all of their clients of the need for evacuation, thus catching many of the frail elderly who did not get a notice from EOC.
Weston was also a coordinator for Red Cross stationed at the Dade County EOC bunker during and immediately after the storm. Once the storm had passed, Weston contacted his team of relief workers and prepared to move his 12 trucks full of food and medical supplies into South Dade. His problem was common to almost all others who attempted to bring in help from close by. The storm had toppled the trees and cluttered the driveways where his trucks had been sheltered.
About mid-day on Monday, Weston met with Kate Hale, the person in charge of the emergency operation in Dade. She told Weston she had a chore for him. The president, George Bush, would be arriving in the afternoon and wanted to drive into the storm-damaged area, Hale told Weston. Weston's job was to supervise the clearing of the roads so the president could make his prime time appearance. Weston says he complained to Hale that the county clean up crews should be used to clear the way so his trucks could begin their errands of mercy. He said he was overruled in favor of the presidential junket.
At 6:00 p.m. candidate President George Bush arrived at Miami International Airport and led a cavalcade South from the airport along Interstate 95 to a partially cleared US 1, then to a partially cleared Old Cutler Road, a tree-line lane through one of Miami's most affluent areas. Bush went as far as the road had been cleared, to Cutler Ridge near property developed by one of his sons, where he posed by a damaged tree. The visit took no more than two hours, counting nationally televised speech. In three hours Bush was back in the air with South Florida designated a federal disaster area.
First assessment, no assessment
The disaster was self evident to its isolated victims. But the scope of the disaster was not known for a week. No one had ever seen such wide spread devastation from such a compact storm. Each place a survey team would arrive, would seem to be the worst possible devastation. Hours later, a few miles further south or west, a new ground zero would be declared. And this assessment shortfall has been identified as the greatest flaw in the short-term recovery effort.
If President Bush's party had tried to drive a few miles further south along U.S. 1, the entire nation would have known what remained a mystery for two more days, the total destruction of two small towns and a major Air Force base. But no one was available to do a quick and efficient needs assessment. And, the ways the federal relief efforts are currently organized, you can get all the help you want, only if your disaster is official and only if you are specific about your needs.
Dexter Peach, the Assistant Comptroller General, describes the problem.
"The Federal Response Plan developed by FEMA after Hurricane Hugo does not have a support function that addresses the performance of damage and needs assessments, even though the plan itself recognizes that the magnitude of damage to structures and lifelines will rapidly overwhelm the capacity of state and local government to assess the disaster and respond effectively to basic and emergency needs. Instead, FEMA relies on state and local governments to identify services needed from the federal government, once they have determined they cannot adequately meet their own needs. In practice, their request for federal assistance must specify the type, amount and location of the needed services. State and local governments were unable to do this because of the overwhelming nature of Hurricane Andrew, causing delays in services."
Peach says, "Local officials who in many cases were victims of the storm, knew they were unable to meet their citizens' needs for life sustaining services. However, they were having trouble communicating with one another and with the state, and were unable to request specific assistance.
Peach said, "FEMA's director told us that FEMA is limited by the Stafford Act to responding only to state requests for assistance." Therefore, he said, "FEMA could not help the state unless it asked for assistance and specified how much it needed."
This interpretation of Stafford is not held by all parties, however. Peach and his group interpret the law to mean that once the President declares a national disaster, FEMA, "has the authority to conduct it own damage and needs assessment and then recommend to the state specific amounts of assistance that should be requested."
But the debate over assessment criteria and timing is an important lesson for health care providers in disaster-prone areas. The recommendations for revision of the law include provisions for damage and needs assessment provided by federal agencies. But the assessment cannot begin until a day after the storm and cannot be completed until two days after the storm. That means, an organized federal response is not likely until three days after the storm has passed, leaving medical facilities only one option. Prepare to survive with no help for at least three days after the storm.
Ironically, US intelligence spy satellites could have provided real-time information about the damage caused by Andrew. Military reconnaissance aircraft could have provided invaluable detailed photographs of the entire region within a day. Spy planes could have provided detailed surveillance information that could have been processed within hours.
According to Florida EOC director Frank Koutnik, the State of Florida never conducted a needs assessment or a damage assessment. He said that after the presidential declaration of a disaster area was made, the state argued that there was no need for a formal assessment. He said the state left it up to Dade County to conduct a needs assessment so it could provide the specifics required under the Stafford Act. Dade said it could not do the assessment and insisted the state take action.
"I was in the discussion over damage assessment and needs assessment with Phil May, the regional director, and we twisted Phil's arm and said, 'Why do we need to waste time and go do a damage assessment. He wanted to go do a preliminary damage assessment. Our logic was that we already had the presidential declaration, so why did we need it. Who gives a hoot how many buildings have shingles missing when you are trying to help people. Our problem was that we only had plans to do a damage assessment and not a needs assessment. We looked to the county and the county looked back to us. It was a foreign concept to us," Koutnik said.
"You heard it was not until Aug. 29 that the state hit the street. But the truth of the matter is that the state never hit the street. We learned that lesson big time. We are going to have rapid response teams whose only job is to get into the county and then come back with the information. We are going to have star wars technology with fly-overs and satellite tie-ins looking at a damaged area, tied in with tax assessors’ records. This will be tied in to a computer that will spit out a report that will be our damage assessment. And that report will drive our needs assessment," he said.
Even with the innovations planned for Florida, the system will remain untested until the next major storm. Not all states will follow the lead of Florida expediting the damage assessment. Nor can we be sure that the computer will anticipate the complex needs of those effected facilities and individuals in the health care delivery system. So it only makes sense that health care facilities and agencies must establish a procedure to assure they can deliver adequate emergency health care and basic public health needs for at least 72 hours after a disaster without any assistance from any organized outside entity. This leaves the organization to sort out a three-day survival plan within its own resources or in pair with the political subdivision it serves and with no outside help, utilities or reinforcements.
This includes, medical supplies, gases, dressings, food, water for drinking, water for cleaning, water for flushing toilets, fuel and batteries, electrical lights powered by batteries and generators, communications equipment, back-up personnel, ventilation, transportation, security, non-automated record keeping, fundamental film processing and a clear policy on admissions and transfers.
Though much has been learned from Andrew. It must be pointed out that much was learned from Hugo, then forgotten. Since past is prelude, what actually happened within the health care system in the days after Andrew is worth reviewing
When you talk to anyone who was on the scene in far South Dade during the first week following Hurricane Andrew, you discover that most of them have the same difficulty remembering what happened, when. Those first few days are a blur, filled with desperate efforts to reinvent order, stay dry, fight mosquitoes, and find something to eat and drink and find time to sleep. The first day after the storm is characterized as one when efforts to reestablish communications and learn the dimensions of the disaster were paramount and generally unsuccessful. It was, for the most part, a day of digging out, clearing short paths and reconnecting. Monday is recalled as a resolution of Sunday. Tuesday is the fulfillment of Monday's frustrations. Wednesday is when things seemed to begin happening. Thursday is about the time everyone realized they were in it for the long haul. Otherwise it is difficult for the participants to isolate specific events to the day they actually occurred, especially since, for many of the would-be saviors, Day One of the recovery was actually the second day after the storm. The first day was spent saving themselves.
In Dade County there are 26 municipalities each of which were
theoretically entitled to send a delegate to the primary Dade EOC. But it had no room for representatives from all the cities during or after the storm, so the county allowed only six cities to be present, representing the rest.
Jim Hampton, the city manager in the City of South Miami was
not one of them. The communications dilemma in the other cities where destruction was great can be understood when compared to the experience of the City of South Miami. Hampton remembers that he could not get in touch with any officials in Dade County until Friday of the first week, nor was he contacted or informed officially of any recovery plan. The lack of communication was disturbing to him since his city suffered relatively little damage, many phones continued in operation and it straddles the main routes to far South Dade, making it strategically important.
For the first four days, he recalls, as he waited for instructions, convoys of trucks and cadres of medical volunteers would show up at the South Miami city hall, wondering where the fight for survival was being waged. Many confused the City of South Miami with the area generally described as South Dade. Hampton had no way of providing official directions, so he simply sent them south and busied himself with dealing with his city.
Most of the South Dade area is unincorporated and, therefore, an exclusive responsibility of Metropolitan Dade County government. Homestead and Florida City were the only municipalities in the area of severe destruction. Under the current system, with its hierarchies of relief that coincide with political subdivisions, cities must beg counties for help while counties beg the state which then must beg the federal government. If you don't ask, no help can be expected. And asking was a real problem.
Since the Dade County EOC was built to resist nuclear devastation, its walls are shielded, making it impossible to use a cellular phone or radio within its walls. With its phone system crippled by poor planning and the massive demand, with the Dade County police command in South Dade deaf and limited to only one line, with all power out in the area, with official aircraft destroyed at Tamiami Airport, there was no way to initiate communications with Homestead or Florida City those first few days, except to travel through the heart of the destruction or to hope for a lucky phone connection.
Homestead City Manager Alex Muxo, his honeymoon home destroyed, his city in shambles, finally made contact with the EOC at 2:05 p.m. on Monday; Day One.
His message, "Ninety percent wiped out. Twenty to thirty thousand homeless. Won't have water until next week. Biggest need is port-o-lets."
Muxo's community was not the only place suffering a potty crisis. Back at the Dade EOC, one of the emergency generators failed soon after the storm, plunging the bunker into temporary chaos and reducing the water pressure for the bunker's limited lavatory facilities. The 150 crisis planners, already in the 24th uninterrupted hour of work, found themselves working in a room fouled by clogged toilets that would not flush until someone decided to issue a garbage can of water with every bowel movement to prime the toilet.
At the Dade EOC, Day One was spent patching together failed systems, scrambling for information, arguing with visiting state officials and preparing for a presidential visit.
At the Florida State EOC in Tallahassee, the staff was alternately attempting to learn what had happened, 400 miles away, and what was happening in Governor Lawton Chiles' conference room where the politicians had assembled and usurped the role of the professional planners. Much of the day was spent trying, unsuccessfully, to get through on the telephone to the Dade EOC.
According to Mike Williams, state EMS coordinator, the state set up a separate, state EOC solely for health services. He calls it, "probably the smartest thing we ever did."
He said, "After the storm passed, our number one problem was communications . There was none between Tallahassee and Dade County, absolutely none. There was one line going into the Dade EOC. Needless to say that puppy was jammed beyond control. So we did not know what the situation was down there."
Gov. Lawton Chiles had flown to Miami early in the day, Day One. When it was clear there were no airplanes available to do an assessment, he asked the state EOC to contact other agencies. The first call went out to the Civil Air Patrol, which is tasked in the state emergency plan with conducting an aerial assessment. The patrol refused, citing bad weather.
"They laughed uncontrollably and said there is no way," Williams recalls.
Next, the state asked the Air Force for satellite or military fly-overs. But the military said the cloud cover was too dense. Finally, Chiles sent his brand new aircraft back to carry emergency personnel and to be used in an aerial survey.
"The first two agencies they wanted down there were the Department of Environmental Regulations which controls the removal of debris and they also had a key roll in water and porta-potties. That is the number one thing in a situation like this. Get the water, get the porta-potties and you can get through everything else," Williams said.
At the Red Cross shelters in South Dade, the normal pattern following a natural disaster was reversed. Instead of reduced occupancy, the numbers increased dramatically. Those families who saw their houses destroyed around them fled to the already crowded hurricane shelters. There was nowhere else to go. But the shelters were not designed to house refugees after a storm and were already running out of water and food.
Those families that had weathered the storm in the shelters, hearing about the devastation, were anxious to get home to learn the fate of their homes, pets and valuables. Rather than requiring them to stay in the shelters for a few days, thereby reducing the logistics of public health and safety, the shelter managers were glad to lose some of their burden. And, since supplies were short, no effort was made to send the families home with the supplies of food, water and protective gear that most of them would immediately need. The flow of families returning to their destroyed homes in South Dade immediately became a law enforcement problem.
Even before the winds had subsided, thousands of people swarmed over the area of devastation, looting stores and homes. While it would have been wiser, in retrospect, to restrict access to the damaged area, it was impossible to separate the looters from the homeowners attempting to salvage some personal treasure. And it was impossible to separate the gawkers from those who needed to get home or wanted to aid their stricken families.
"After Hugo we felt that we were fully prepared for everything, " Ed Neafsey assistant fire chief for operations said. "Nothing but nothing could have prepared us for the crises caused by Andrew."
"As the winds subsided we were faced with over 250 priority calls. We had screened out over 1,500 non-priority calls. We had 600 square miles of devastated area, damaged fire stations and apparatus, little to no communication from command to field units. We found ourselves both the rescuer and the victim. We know now that every hurricane plan must address the psychological stress the loss of homes puts on your fire fighters and command staff.
"As we moved into the response mode, things kept getting worse. Our department logged 1,250 calls. Our normal average for the day was 350. And for every call that we logged, our staff told us that they handled at least three calls from people who would simply wave them down. Our best guess is that we handled 3,000. In most areas it took us an hour to go a mile with the debris in the way and the tremendous problem we had with flat tires. What we had was a 625 square mile square triage area and the nearest operating medical facility over 25 miles away. We were faced with hundreds of people who needed emergency care with no place to take them. In addition there were thousands who needed the basic necessities of life, simply food, water and shelter. And I am here to tell you that for the first 24 to 48 hours, the EMT and fire services are going to be the ones to provide those things. The resources they put in place prior to the storm are going to be all you have to work with. No matter how effective the system is, it is not going to get you support for at least that length of time. Simply because the fire and rescue units are in the neighborhoods, people are going to look to them," Neafsey said.
He said the region was divided into grids and 900 fire fighters and rescue specialists were each given a map of their assigned area, a radio and a promise of a hot meal at the end of the day. The teams went door to door asking if anyone was missing. They searched crumpled buildings using dogs, looking for the dead. The death toll attributed directly to the storm was 15.
The official fire department incident log shows the progression of injury types encountered in the first few days. On Day One, the first two cases were cardiac, the next a childbirth. Many of the earliest calls were for individuals having trouble breathing. All day long the maternity calls continued. By mid-day, individuals who had lost their medication began to experience seizures, the number of slip and fall injuries increased as people attempted to climb through debris. As night approached, the number of mugging victims increased as did the number of auto accidents. And, in one bazaar hour, apparently after the shock of the storm had worn off and desperation set in, there were three suicide attempts.
Since the two, $5 million helicopters belonging to air rescue were destroyed, there was no capacity for air rescue, however serious the injury, for 32 hours after the storm, Neafsey said.
The fire department's Hurricane Andrew after action report describes the situation on Day One.
"The number of serious injuries directly related to Andrew was low. However, as people began to clean up debris the number of injuries rose quickly. This, along with the backlog of calls, placed a great strain on the department, especially since there were no medical facilities available. Fire/rescue units soon found that all the primary and secondary medical care facilities in south Dade County were severely damaged and unable to accept any patients. This added to the strain on the pre-hospital emergency care system, since all patients in need of definitive care had to be transported to other hospitals. Baptist Hospital of Miami, on S.W. 88 Street, over an hour away under the circumstances, was the closest. In addition, patients already in the affected hospitals had to be moved to other facilities," it says.
"As a result, MDFD requested from Randle and Medi-Car ambulance companies that they make available their units for the transport of fire/rescue patients. Their participation allowed most fire/rescue unites to stay in the affected zones to provide the much needed care.
"With no medical facilities south of Kendall Drive, MDFD took the initiative to begin organizing and staffing field hospitals. The first one was located in the new government center building.
"Captain Ellery Gray, with the National Disaster Medical System (NDMS), a branch of the U.S. Public Health Service, had been pre-staged in the Dade County EOC. Capt. Gray facilitated the quick deployment and establishment of two field hospitals requested by MDFD. These freestanding facilities are each staffed by a Disaster Medical Assistance Team. They consist of 36 medical personnel and are capable of providing sophisticated emergency medical care in an austere setting. Their first field hospital relieved the first aid facility started by MDFD in the new South Dade government center.
"By design, the field hospitals are almost totally self-sufficient. However, in order for them to function efficiently, close coordination with the local EMS system is necessary. MDFD personnel were assigned to act as liaison officers in coordinating transportation of patients to and from the field hospitals," the report said.
It also pointed out a problem shared by other, less organized individuals.
"Damage to fire stations overhead doors, coupled with the number of people left homeless and without food and water created a security problem as they loitered around the local fire stations. The department could not access the proper mechanism to authorize personnel, such as National Guard, Metro-Dade Police Department or Florida Highway Patrol, to provide permanent security for the fire stations and its (their) resources and supplies. As a result, a considerable amount of equipment was reported missing," the report says.
When Gov. Chiles called in the National Guard on Monday morning, the troops were responding to a marshal law situation and had no time for other, more humanitarian goals. Looters were so prevalent and brazen that they attacked and fired upon any official-looking vehicle that entered the area for fear the occupants would call in the beleaguered police to end the plunder. A Red Cross van filled with critically needed medical supplies was one of the first official vehicles to enter South Dade. It disappeared and was never seen again. Chaos reigned.
The situation was worse in Homestead, which was left to fend for itself because of its municipal status. The situation was even more desperate in Florida City, the fifth poorest city in America which was both destroyed and bankrupted by the storm.
The health care system was equally devastated. Homestead Air Force base hospital was destroyed. Homestead Hospital, recently merged with South Miami Hospital, was virtually destroyed. It continued a crisis operation without power or a roof until it was compelled to relocate its patients and close. Deering Hospital was severely damaged and forced to close after a valiant day's work manually keeping respirator patients alive while treating the walking wounded. It had no power and no water. The roof had been peeled back, all the windows blown in. The emergency room had been gutted.
Baptist Hospital's emergency room, which saw less than 100 patients on a busy, full moon Friday night, was inundated with more than 600 walk ins. Though damaged by the storm and without water, Baptist stayed in operation. Likewise, South Miami Hospital saw its emergency patient caseload quadruple the first day and for weeks thereafter.
For many of the special needs patients who once lived in South Dade there was no place left to which they could return. More than 1,000 skilled nursing home beds were destroyed and 533 adult congregate living facility beds ceased to exist.
Only one medical facility in far South Dade survived the hurricane relatively unscathed. The Suburban Medical Center, just off U.S. 1, five miles south of Cutler Ridge on SW 97 Ave, in Perrine, in the epicenter of destruction, is a two-story structure designed to support several more floors.
The facility included three operating rooms and an endoscopy room, a five-bed recovery room, 18 patient rooms with 26 beds. It could have been expanded to 36 beds after a clean up of the second floor.
Jules Gary Minkus D.O. told the magazine "The DO" that the storm did more than $500,000 damage to his two offices including water damage to linens and instruments in the surgical center. But the majority of the destruction was at his Perrine office and to the library, records room and office at the surgical center.
Minkus had built the facility to meet the requirements for the small neighborhood medical centers that were advocated during the 1970's. But permitting laws changed in Florida and Suburban was classified as a clinic that could not keep patients overnight.
For several years Minkus had attempted to secure accreditation as a hospital. But resistance from the competing hospitals in the area and the glut of hospital rooms worked against him.
On Day One after Andrew, it seemed that fate had placed Suburban Medical Center in exactly the right place at the right time. But the facility and its substantial resources were totally ignored.
As the night approached, that first day, the homeless awaited official word that help was on the way. They packed their valuables, built shelters and tried to rig a way to store and chill their remaining food supplies. With no power for 30 miles and brazen looters on the prowl, it was the darkest and most dangerous night in the history of South Florida. Yet there was a sense of elation among the survivors, a giddiness that resulted from two days with little sleep, residual adrenaline and the pure power of having survived a life-threatening situation.
In Homestead and Florida City, according to one published study, one third of the families who remained at home during the storm spent the peak hours of the blow with nothing more than a mattress between them and the killer winds. Many of them would spend the next week with less in the way of assistance or protection. And there is no telling how long it would have taken official help to reach the remains of Florida City had it not been for fate and two neighbors.
Day Two: Ad Hoc, ad Infinitum
The Dade County EOC had been quick to ask for help. In fact, the EOC contacted the White House and asked for a presidential declaration of emergency on Sunday night, several hours before the storm arrived. And the EOC called for special emergency medical help from Federal Disaster Medical Assistance, DMAT, teams, long before the winds had subsided, according to Hurricane Coordinator Michele Baker.
The federal DMAT team from the Southeast region assembled at Eglin Air Force Base in the Florida Panhandled the morning of the second day. This was a force of 50 civilian and military men and women who had been trained specifically to fly into disaster areas and provide short-term emergency medical care. They had been to summer camp to train for the mission. But Andrew was their first real test.
The DMAT team was required to sign release forms to exonerate the federal government from liability before they could fly on the giant C-130 aircraft that had been provided for the trip from the Panhandle to South Florida. As they waited, several vans full of donated medicine and supplies arrived on the tarmac. Eager to get on with the mission and unfamiliar with the huge aircraft, the DMAT team began packing the gray and green bay with the donated stores, pleased that they would be so well supplied. As the last of it was crammed inside and the engines started, the DMAT team was shocked to see that most of their personal belongings and some of the medical gear were lying on the runway about to be left behind.
"The C-130's look bigger than they are," Dr. Charles Neal, a Gulf Breeze trauma center specialist and DMAT team member recalled. Rather than take off for Miami, the plane was shut down, unpacked and repacked with greater attention to priorities.
As the big plane winged toward Opa Locka airport, a crew of volunteers who had driven across the state from Lee County on the Florida west coast arrived at Florida City. They had followed the back roads through the Everglades to reach the east coast and serendipity placed them at Florida City.
The Lee Countians found little more than chaos among the survivors in Florida City. The city had no emergency management plan. Its 17 police officers were immobilized because their building was destroyed and the city's five patrol cars had been destroyed. The entire infrastructure had dissolved in the storm and the rains that followed. There was no power and no phones or radio communications.
The only building left standing was the water tower. The city of 15,000 mostly indigent, mostly unemployed or seasonal workers endured 80 percent destruction of its tax base. The primary mode of housing was either mobile homes or public apartments. They were, for the most part, gone. The city had an annual budget of only $4 million, no savings, no credit, no idea what to do, even when, on the second day, volunteers showed up to drop off supplies. There was no place-- official or unofficial-- where any supplies of food, medicine or clothing could be stored out of the weather. And as supplies arrived they were stacked in open lots only be soaked and rendered useless by the rainstorms that pelted the survivors every afternoon. Recognizing the desperation of the situation, the Lee Countians decided to make their stand among the survivors of Florida City. There, they set up a tent hospital, complete with a communications bus and two ambulances.
From Kendall and Homestead hundreds of residents rushed north in an attempt to get ice at Royal Palm Ice factories in Dade and Broward. In the afternoon before the rains, the temperature rose to 93 degrees. As the gravity of the events sunk in, the residents attempted to preserve the food in their refrigerators that they hoped would keep them alive until power was returned, the stores reopened or help arrived with new food.
Meanwhile, the Metro Dade Water and Sewer Department surveyed its devastated system and declared a water emergency. Back up pumps and generators did not work as promised and the public health crisis of more than a million citizens without potable water reared its rancid head.
Florida Power and Light reckoned 779,500 customers were without power in Dade and 132,000 in Broward. FP&L promised to restore power to all of Palm Beach, Broward and Collier counties by Aug. 27. But the delivery system that served South Dade would have to be rebuilt and the FP&L planners quietly confided that it could be months before the last home was connected.
Across the region, the looting that had begun as pure plunder became more an act of desperation. A woman and her three children were caught looting a drug store in front of security guards and reporters.
"God forgive me, but my children don't have anything. My house is destroyed. I don't have money. I'm living in my car," she said.
In Florida City several on-duty police officers hijacked a water truck headed to Homestead and diverted it to parched constituents.
At 3:00 p.m., 29 hours after they arrived to protect the Cutler Ridge Mall, the National Guard arrived in Florida City. At 4:30 p.m. Charles F. Pierce, president of the Florida Hospital Association sent a fax transmission to the member hospital chief operating officers:
"South Florida hospitals need supplies & personnel."
It said, "Early information from South Florida indicates many hospitals are struggling to maintain services in the face of power outages and lack of personnel and supplies such as food and water. Many roads are impassible, making transfer of patients difficult. The homes of many hospital employees have been damaged and they and their families are staying at their hospitals. At least two hospitals in the path of Hurricane Andrew - SMH Homestead and Deering Hospital are reported closed due to severe damage. When the storm hit Monday morning, the hospitals were caring for many patients evacuated from other hospitals on Sunday. Hospitals able to provide assistance should all a special HRS toll-free hot line Aug. 24-25 at 904/ 488-0390. Further information will be available in the news media."
Pierce advised the members, " The FHA is in touch with HCFA and the Medicare fiscal intermediary concerning transferring patients between hospitals."
The South Florida Hospital Association began its damage assessment on Monday and reported on Tuesday the status of 13 hospitals effected by the storm.
Baptist Hospital, "served as receiving hospital for evacuated patients from Miami Beach\ Coral Gables, having difficulty getting physicians.
Deering, "served as receiving hospital for evacuated patients from Miami Beach area, windows imploded, water everywhere, patients being evacuated, hospital totally closed, suppliers having difficulty getting to hospitals, linens in short supply, patients going to Kendall, Miami Beach and Victoria -- transportation a problem."
Kendall, "served as a receiving hospital for evacuated patients from Miami Beach, no major damage, taking patients from Deering, not accepting other patients unless it's an emergency.
Cedars of Lebanon, "served as a receiving hospital for evacuated hospitals, some windows out, trees down, ER patients still being admitted but not electives, minor problems experienced."
North Shore, "served as receiving hospital for evacuated patients from Miami Beach\ Coral Gables."
Jackson Memorial, "served as receiving hospital for evacuated patients from Miami Beach\ Coral Gables, initiated call for pregnant women in last three weeks of pregnancy to stay at JMH, suffered some damage, water/ windows out."
Miami Beach, "evacuated on Sunday, now taking patients from Deering, holding its own, no real damage."
Victoria, "closed Sunday, reopened Monday, taking patients from Deering, CEO's house pretty well gone, needs nursing and allied health personnel, hospital structural integrity appears OK."
Memorial, "structural integrity great, only two windows out, beds available at both locations for patients in following areas: med/surg, ICU, ped ICU and antepartum. Hospitals are fully staffed, expect to be back to normal operations by this afternoon."
Golden Glades, "very minor damage, staying tight with 78 patients, concerned that BFI not responding to waste disposal calls."
South Miami, "structural damage pretty bad, power gone, water damage, needs nursing staff support, SMH Homestead a disaster-- hit very badly -- will need to be totally rebuilt, looking to evacuate Homestead, patients that are at South Miami need nursing in following areas, OB, LD, med/surg, ER, have been told major arteries (streets) are open/passable- asking for any nursing support at all, at full occupancy."
Coral Gables, "possibly lost their parking garage."
Westchester, "some serious roof damage, fair amount of water damage, power and water problems under control, needs to find fuel, any thoughts? needs nursing staff- working off skeleton crew-- taking emergency patients only."
Bon Secours, "did not evacuate, limited structural damage, roof windows out, on emergency power, no water- needs City of North Miami to give special consideration to get water back on, staffing OK but everyone is tired."
Joe Anne Cox an executive with Florida Health Care Associates was the person who took charge of the recovery operations for the region's nursing homes. She said that the evacuation of the special needs individuals went reasonably well despite some unexpected incidents.
Saint Anne's nursing home was one of nine nursing home facilities destroyed by the storm. But it was not evacuated because it was not considered at risk. Instead St. Anne's was used as a shelter for its own residents and dozens of other special needs individuals including some from the Hospice organization. Those who sought refuge at St. Anne's survived the traumatic night. But things did not get better after the storm.
The region's nursing homes had no plan for recovery, Cox said. On Tuesday, Day Two, she began receiving calls with offers of donations from all over the nation. One hospital in Jacksonville was sending down a truck full of supplies. But Cox, like Hampton in the City of South Miami, had no idea where to tell them to go. Like Hampton she attempted to call the Dade EOC but could not get through.
She and Larry Mankoff, another nursing home administrator, established their own ad hoc emergency management program for the special needs people who had been evacuated from South Dade to other facilities.
"There was no plan. It just materialized," she recalled. Mankoff established a staging point and distribution center at Miami Gardens Care Center in North Dade and in the next few days accepted and redistributed more than a half million pounds of supplies including gasoline.
DMAT to the rescue
Back at Cutler Ridge, after one false start, the Disaster Medical Assistant Team, DMAT- had arrived from Eglin Air Force Base. It set up a temporary field hospital in the median of the road adjacent to the blown-out Cutler Ridge government center, opposite the Cutler Ridge Mall.
This unit had been established three years earlier and was comprised of 45 specially trained physicians, nurses, paramedics, emergency medical technicians, radio operators and fire fighters.
"We all had trained for the contingency of Andrew. Andrew was our first deployment into the field, so a lot of training was put to the test," Neal, the Gulf Breeze trauma specialist recalls.
"We were given vans from area hospitals in Pensacola full of all kinds of stuff. When it all arrived at the airfield we had to decide what we had room for. And we eventually had to requisition a second C-130. It was surprising how little you could get in one of those things.
"We were sworn in as federal employees to relieve some of the liability should the plane go down with us on board, so that our families would get that $10,000 check from the government and our personal insurance policy would be null and void," he joked.
The DMAT team wore uniforms comprised of different color T-shirts indicating whether the team member's function was administration, clerical or medical.
"We flew to Opa Locka then hopped to Cutler Ridge where we set up or first tent that night opposite the government center. We called it the DMAT Hilton.
"There was no potable water, although water was available from a nearby fire hydrant where two showers were erected using wooden boxes, served by fire hoses," Neal recalled.
The DMAT team carried its own food and water for seven days so it could be totally self-supporting. It did not carry food and water to share, however. The team is supposed to come in for five to seven days and then rotate back to its regular jobs. A second DMAT team arrived later in the day and was sent to Homestead where it set up a field hospital at a senior citizens center.
Neal said, "Nothing prepared me for what I was getting into. The denuded trees, the destruction, the smell of death and kerosene gave a war zone feeling. The people were all very well shell-shocked. Our food supply was questionable. There were always some nice little old ladies who were making sandwiches out of some meat they did not want to throw away when their refrigerator went bad and they were constantly bring food into us. But because there were only two physicians in the team, if one of us came down with dysentery our team efficiency would go down, so I restricted my diet to meals ready to eat (MREs)."
When the Army finally arrived, at the end of the first week, the DMAT crew found themselves billeted for sleeping within 30 yards of the landing and refueling area of the helicopters being used to fly in supplies. "You can't talk. You can't even open your eyes when one of them is taking off or landing," Neal recalled.
After the first week, the DMAT field hospital was moved to a former bank and divided into three, color coded zones. The green area was for the walking wounded where tetanus shots were administered and simple puncture wounds were treated. The yellow area was for the more serious trauma patients and the red section was the cardiac section. Bank teller windows where converted to three suturing bays that were in operation non-stop for the first few days.
"We were seeing 500 patients a day. Also we had to improvise to build everything we needed from scratch. We saw a lot of traumatic injuries that resulted from debris removal and were usually cuts and scrapes and puncture wounds," Neal recalled.
By the end of the second day, free-lance volunteer medical teams began arriving in vans and mobile homes. They became known as the "doc-in-a box" medical corps.
Neal recalls, "One problem we had was validating medical licenses. We had a lot of people who showed up at our doors with a stethoscope around their necks and they said, `Hey, I am a doctor or nurse and I want to help,'
"And it turned out that many of them were not. It was kind of a sick thing, but it repeated itself time and time again. So we established a policy that DMAT team members had ultimate control of our facility, and that everything that we said went. It was law, no questions asked, either our way or the highway. Then and only then would we accept volunteers."
Neal said they also patrolled the area they were serving to locate rival bands of doctors and make sure they were appropriately credentialed. Along the way they found a group of medical residents working out of a van Neal said was stolen. "We closed them down," he said.
With its paramilitary training, the DMAT team tolerated little in terms of interference with its mission. But it wasn't without heart.
Neal recalled, "We took care of everybody who had a problem. This little kid drove up with his dad. He was in the back of a pickup truck with his dog. The dog had been hit with debris and his ear had almost been cut off. I am not a vet nor am I licensed to do veterinary work. But what was I going to tell this kid who was crying there, holding his dog? So we sewed up the dog's ear and put him on some antibiotics."
Elaine Gorman works for the Health Care Trauma District of the Upper Keys transporting seriously injured patients to Jackson Memorial Hospital in Dade County. When it was predicted that the Upper Keys would be hit by Andrew and should be evacuated, she and other members of her unit of Monroe County employees evacuated their ambulances up Route 27 to Okeechobee, Florida.
Meanwhile, Monroe County sent its special needs patients to the designated Monroe County hurricane shelter at the Florida International University Campus in Southwest Dade along with a contingent of EMT personnel and paramedics to assist in their care.
After the storm had passed, the Trauma District's two ambulances and trauma vehicle made their way back to Monroe County through the rubble, arriving around noon on Monday. On the way back, the unit was contacted by a Monroe County sheriff's deputy and dispatched to FIU to pick up Monroe patients from the shelter and transport them back home. In the mean time the Key Largo volunteer fire department had begun setting up an ad hoc command post in a McDonalds restaurant in Florida City.
By the morning of the second day, there was a multiplicity of Emergency Operations Centers (EOCs)each trying to hold it own ground and connect with the others.
In Tallahassee there were two or three EOC's depending on the point of view. The official state EOC remained in operation but out of the decision-making loop, because Gov. Chiles had taken the lead. He assigned Carol Browner, head of the Department of Environmental Regulation , Tom Herndon, his chief of staff and state EMS coordinator Williams to South Dade to make a needs assessment and organize the effort.
Williams, meanwhile, had set up his own EOC for health related issues at his Tallahassee office to coordinate all the medical, paramedical, nursing, public health and EMS personnel and relief efforts.
Dade County's EOC continued in operation in West Dade. But a second EOC was already springing up at the South Dade government center in Cutler Ridge as the National Guard, local police and the DMAT team huddled together, beyond the reach of normal communications.
Another ad hoc EOC was established among Homestead city officials, the second DMAT team field hospital personnel and the National Guard, in Homestead.
Yet another ad hoc EOC was established by the volunteers from Lee County in Florida City.
The nursing home community established an EOC in north Dade to help feed and house their displaced constituents.
And, according to the MDFD after action report, there was a "doc in the box" on almost every corner in the area north of Florida City.
"Because South Miami/Homestead Hospital and Deering Hospital, the two major facilities serving south Dade County and two large (public) health clinics were closed due to storm damage, and almost all physicians offices and primary care clinics in the devastated area were completely destroyed, basic first aid and primary health care services were also provided by a large contingent of volunteer health care personnel. Many private organizations or groups set up temporary "first aid stations" or "clinics" . They operated out of recreational vehicles, vans, and tents in the devastated areas. At times there was almost one clinic per each square mile of populated land. Some of these clinics provided community outreach. Health professionals either drove or walked door-to-door to provide the medical assessments and care to the homebound, infirm or those who feared leaving their homes," the report says.
"While poorly organized from a systems perspective, these clinics fulfilled an immediate need and reduced the number of minor injuries treated by fire/rescue, hospital emergency rooms and field hospitals. Unfortunately, the numerous clinics weren't integrated into the EMS system because they could not or would not access MDFD Medical Communications or the 911 system, therefore the presence of most of their clinics was unknown to MDFD. As phone service was restored (two weeks into the process) and access became more immediate through the 911 system, MDFD was, for the most part, able to integrate this resource into the system."
Days 3 and 4
Joining Hands, helping hands
On Wednesday it was clear to all the participants in the rescue and recovery effort that the rescue was virtually over but the recovery was taking too long to get underway. The storm had caused far fewer deaths and serious injuries than anyone would have expected by viewing the damage. Thousands of fire fighters and rescue workers had marched into Dade County prepared to pay back the famous South Florida firemen who had, in previous years, flown all over the world sharing their specialty of urban search and rescue. Unfortunately, after the second day, they were neither needed nor had anyone made arrangements to accommodate them.
One entire unit from Jacksonville drove overnight to Miami. By the time they arrived there was little to do. Fortunately, they had brought their own food and sleeping gear so they were not, like hundreds of others, an expensive burden on the local firefighters. They drove around for a couple of days shooting videos of each other amidst the devastation and went home.
The crush of firefighter volunteers was similar to the crush of volunteers from the medical profession. Many more showed up than were actually needed to treat hurricane related injuries. The firemen quickly set up a system to deflect the tide of unneeded help with some element of tact. The medical profession did not.
By the fourth day, the fireman had secured the assistance of the fire department in St. Petersburg, Florida to act as the official agency in charge of logistics, re-supply and personnel under the long-standing tradition of fire fighter's mutual aid agreements.
Like the power companies, the fire fighters have formal and informal mutual aid agreements whereby departments from as far as 1,000 miles away assemble trained volunteers to travel to crisis areas to assist if needed or to back up the local forces and fill in when they need a break. These people have standardized training and universally recognized certification. They are willing to submit to a unified command and are guaranteed compensation from their local jurisdictions.
The federally sponsored DMAT teams are similar in many ways to their firefighter counterparts. They are streamlined, self-contained, paramilitary in organization and ready to travel to areas where there is great devastation, trauma and loss of life. Fortunately, after Day One, what South Florida needed was an army of Marcus Welbys; primary care physicians, general practitioners, public health nurses and pediatricians armed with a barrel of tetanus and accompanied by a phalanx of psychologists. That is not what they got, however. What they got were hundreds of skilled and inept medical personnel with a Ben Casey mentality who were convinced there was a trauma crisis, hordes in need of saving and enough glory to go around.
The glut of volunteer firemen was solved by the St. Pete clearing house in a method that the health care community should emulate in the future. All fire personnel who wanted to volunteer were told to report by phone first to the St. Pete dispatcher. There, if they were needed, they were given a tasking number that corresponded with a specific assignment in South Dade. If a volunteer showed up without the tasking number, he or she was courteously referred back to St. Pete. In this way an objective and uninvolved third party took the pressure off the busy local officials and secured only the help that was needed when and where it was needed.
Like the Metro Dade fire department, there was a brief moment when the medical professional in South Dade really needed some organized help. That period lasted longer in Florida City than in the richer areas. But it was over by the time the word of the emergency need for physicians and nurses was broadcast on CNN.
Nevertheless, it is hard to deter a determine physician on a mission.
On Wednesday Gov. Chiles decided to move the state EOC from Tallahassee to South Florida at the former Eastern Airlines office building at Miami International Airport. The first and most important goal to make the facility operational as an emergency operations center was communications. Unfortunately, the State of Florida had decided that it did not need to pay the additional annual cost of reserving priority telephone line re-installation from Southern Bell in case of emergency. So, when the state EOC officials asked for thousands of phone lines by the next day, Southern Bell told them they did not qualify as a top priority.
FEMA then set up a satellite phone system that connected the Miami office of the state EOC with the phone service in Baltimore, Maryland in the 201 area code.
Williams, the state's health care coordinator recalls what happened next.
"Somehow the number got out, I think CNN released it, saying that if any physician wanted to volunteer this was the number to call. This was our most abysmal failure, trying to deal with the health volunteers that came in. Metro Fire and Rescue took care of the fire volunteers. I was responsible for all medical volunteers which includes physicians, nurses, all EMTs, public health nurses, dentists, veterinarians and anybody else that is construed to have something to do with medical.
"The first phone call I got was seconds after the line opened. It was from this man who said, 'Young man I am on my way and I am coming to help. I am the president of the Korean War Doctors Association of America.'
"I said fine, what are you going to do.
"He said, 'Well we are going to come down there and save lives.'
"I said, Sir, to the best of my knowledge we don't have a lot of trauma victims down here. We mostly have a public health crisis."
"He said, ' Dammit we're coming.'
"I said, what do you mean, we?
"He said, 'I got all 14 members of the Association in my Winnebago.'
"I said, Sir, let me take your number. Please sit tight. We will call you back when we find an appropriate place to use you.
"And he said, 'You don't seem to understand. I just crossed the Florida state line and I'll be there in four hours and you better have some place to put me or I am going to set up shop.'
"This was reflective of the volunteers that were coming in. Frankly the medical volunteers were coming for guts, gore and trauma, and every nasty thing that you can imagine, and we had none of that to give them. It just didn't exist. What we needed were some primary care docs, " Williams explained.
Down in Florida City
Down in Florida City, however, the story was different.
By Wednesday, the Lee County contingent had established its ad hoc EOC in the remains of the Hampton Inn. The EOC was linked with the Lee County field hospital which had been set up near city hall. This was the only communications link that existed in the area.
When Elaine Gorman, the Key Largo EMT and trauma specialist, returned to Florida City on Thursday, she and her group of EMT volunteers from Key Largo located the ad hoc EOC at the Hampton Inn and paid a visit to offer their assistance. Gorman asked who was in charge of the medical component of the Hampton Inn EOC and, after some hemming and hawing, was informed that she was.
Gorman recalls the Florida City situation, beginning the day after the storm.
"Initially what we did was come back into Florida City on our way back to Monroe. Fire (and rescue) had set up a command post at McDonalds. We went back to Monroe County to make sure our district was covered. On Tuesday morning we headed back up with one ambulance. At that time we made contact with some of the (Lee County) field hospital personnel that were just coming in, setting up a tent near where Florida City's city hall had been.
"I went out with a group of physicians late on Tuesday to the migrant camp. But it took us a long time and there very few people there that we could see. We couldn't explore the camp because everything was torn down and across the road. The trailers were completely flattened. It was the worst devastation that I had seen. We did what we could to provide first aid.
"Florida City was extremely isolated, so in actuality we just went back to the Lee County headquarters and worked out of there.
"It was about day four that I started to realize that there were multiple physicians and nurses setting themselves up on street corners everywhere. Nobody was reporting to anybody. Nobody had any line access to tetanus and some of the things they needed. So I walked into the EOC the Lee County crew had set up and I said I would like to offer my services to whomever is in charge, the chief medical officers. And they said, ' well, um.' And I said, I beg your pardon, there is no medical organization out there. And they said, "Well then it's you."
"That's how I ended up becoming medical commander. So we started to try to link up. The National Guard had set up a tent down toward the prison. They were doing out-reach, sending out ambulances on a daily patrol through the area. We set up some public health nurses at Everglades neighborhood camp. We had volunteer ambulances from Tampa and Sarasota. I had them go to the tent hospitals and sit, so that when someone came into the tent hospitals and needed transport we were there. The first few days we sent them to James Archer Smith (SMH Homestead) until it closed. Then we sent most of them to Baptist. We did mostly primary care, however, treating people whose medicine had run out, the diabetics who had not been able to take their insulin, some primary wound care. There was a lot of tetanus given out, a lot of diarrhea. There was a lot of shooting going on, but we did not do that much in terms of serious injuries, mostly primary care," she said.
"Florida City was extremely isolated. It took seven days before we had assistance with water for drinking or cleaning. We were not able to get medicine through any chain. We basically had hospitals from all over the country send stuff directly to us, bypassing the organization north of us. We could not hook into the (official) system. They were not aware that Florida City had a medical command or that they had an EOC going. And I am not sure how that came about. I don't know now who thought who was taking care of Florida City.
"We used my car and runners to the Centro Campesino migrant camp, the Lee County tent hospital and a tent hospital the National Guard had set up and to a tent set up by Jackson Memorial Hospital staff near the water tower. We had five tents, but everyone was working independently. So what we did was go out and try to find what supplies everyone was short of, then try to get them. Literally, because the communications system had broken down so badly, we had to send out runners," she said.
Gorman said her people in Key Largo and in other areas made contact on the telephone to hospitals around the country including hospitals in Seattle and Bowling Green who wanted to help someone. They told them the needs of the volunteers in Florida City. The helpers, thousands of miles away, were able to send in supplies long before Florida City's rag-tag rescuers could get supplies from the official rescue and recovery operation just 10 miles north.
Gorman said, " There wasn't much order. We even ended up with multiple units of military. We had Seabees, we had paratroop type units, we had regular army, we had National Guard. Not one of those could communicate with each other, radio to radio. They all had different radio systems. It was very, very frustrating..
"Things came about because people made them come about. But there was no concept of incident command, at all. Because, in order to command you have to be able to communicate," Gorman said.
When Gorman learned that the federal government had set up a pharmacy at the South Dade government center to provide needed medication to field hospitals, she drove up and put in her request.
First she was greeted with surprise. "We didn't know you were there. We didn't know anybody was working there," they said.
"We ran into some real strange situations. We had medications coming through, but they were not coming through legitimately. We became uncomfortable with the process that things were floating through our hands that should not have been. So, when I went up to the government center and met with them, we told them that we had these meds, but they were not very secure at the Hampton Inn. They told us about the federal pharmacy at Opa Locka, and we agreed to bring up the excess meds that we had and take them to Opa Locka if the federal pharmacy would go ahead and provide for our tent hospitals. They said fine, we will do a site interview and do the rounds to make sure everything is OK, then we will provide for them and you won't have to. We agreed. But after two days, I found that none of our hospitals in Florida City was getting the medicine they requested from the federal pharmacy.
"So I went back up to the government center EOC to find out what was wrong. And I found out we had ended up in a classic Catch 22.
"They said, 'You can't have the medicine.'"
"And I said, why?"
"They said, "Well, they're tents."
"And I said, yes?"
"They said they could not deliver medicine to those pharmacies down there because they were tents, that medications had to be in a room that could be closed up and locked.
"I said, 'You don't understand.' There are no rooms in Florida City, no buildings. The Hampton Inn was the only two story building left standing and it was not secure.
"The irony is they said they were here to help us, they would provide us with everything we needed and we would no longer have to scramble, scratch and search, but you can't take medicine to the tents. It was like, the only thing we have are tents.
"These people were very frustrated too, because they were not allowed to do what they wanted to do. Everyone was locked into a command structure that would not allow anyone to make an ultimate decision," Gorman said. And the problem went beyond medication.
"We needed porta-potties at the migrant center. Everyone knew where there were 100 potties sitting in one place not being used," she said.
"Everyone agreed that we should have them. But no one had the authority to allow us to get them. And then it took seven days to get these porta-potties to where they needed to be. And then, five days later, when it came time to clean them there was no one in charge of the upkeep of them," Gorman recalled.
"So instead of becoming part of the solutions, the potties became part of the problem because they had overflowed and there were right near the food area and we had created a hazard, but not for not wanting to try. Everybody promised that they would do everything they could, and they did. But there were so many channels to go through, we were in quicksand all the time," Gorman said.
The Lee County ad hoc EOC was having similar difficulties in the early going when its commander ran into Gov. Chiles on Thursday in the middle of a field with a contingent of press in tow.
"We told him we were doing all we could for the people of Florida City and he said that was great and told us to keep up the good work and that he was supporting us. We took that to mean we had his authorization to do what we needed," he said.
"So, when we needed telephones at the EOC at the Hampton Inn we got Southern Bell to go out and find us a pair that worked. They found a pair with a dial tone down the road a few miles along U.S. 1. We told them we needed a hundred pair the next day and that the governor had authorized them to make it happen.
"They dug a mile and a half trench all night long and delivered the lines at the Hampton Inn. Then we told the manager of the Hampton Inn we would have to put yet another hole in the one room that wasn't damaged to bring in the wires and set up the phones. He was already upset because we had commandeered his business and evicted all his guests, under the governor's authority, of course. So we told him that, just like with the rooms we commandeered, the governor would pay him for the damage."
The Hampton Inn provided some amount of shelter. It had running water that was not potable, but could be used for cleaning. It reeked of mosquito spray, one of the necessities of life at the edge of the drenched Everglades. The mosquito spray, like much of the medicine in the early days, came from as far away as Seattle. The squadrons of mosquito control aircraft that covered much of South Dade with Batex and Malathion to fight the plague of mosquitoes, did not spray Florida City, as far as Gorman can remember.
"There was never any spraying," Gorman said. But then much of what went on in Florida City was, to the officials ten miles north, a fantasy.
"The authorities from Florida City asked if we could take over and a lot of money from Lee County and Monroe County was laid out. But essentially afterwards, it was like we were not in the chain. The big EOC did not invite us to come. We were not official. But then no one would have been there," Gorman said.
Fortunately, the migrants were the ones who were getting the short end of the public health wagon, rather than the more prosperous hurricane victims up north.
"I think the reason we did not see more people with diarrhea and other problems related to sanitation was that the people in our area were largely migrants who were used to living under less than sanitary conditions and had built up a resistance to bacteria and the germs associated with a loss of water pressure," Gorman said.
In truth, as Dr. Greer has said, the Florida City hurricane victims probably saw an improvement in the health care after the storm from what they were getting before the storm.
Gorman remains effected by, what she calls the madness that seemed to be everywhere. She recalls, "Somehow it had gotten out to law enforcement that there were baboons around that had escaped from the AIDS research center. On one trip we stopped and a baboon came up and was kind of hugging my leg. It was clear that he wasn't dangerous or going to hurt anybody. It was clear he was familiar with humans and probably trying to say he was hungry. They took him off to the side of the road and blew his head off. It was very bazaar.
"He was clearly not a research animal but somebody's pet who thought we were bringing him dinner. To me it underlined the madness that was existing at the time. I mean, nobody was doing it to be mean. There behavior was not abnormal. It just underlined how bazaar life had become," she said.
Meanwhile further north
Up the road in Homestead and South Dade where buildings and parts of buildings still remained, where people who had never lived without air conditioning were facing their fourth day without even electricity to power a fan, things were also getting strange.
By Aug. 26, tons of supplies, hundreds of would-be-helpers and a host of agencies were prepared to rush into South Dade, if only they had somewhere to go and a guard to protect them as they went there. Security beyond the military encampments was a real problem, since few buildings that could be locked were left standing and even fewer were solid enough to prevent looting at night and drenching during the day.
Affluent, hard working people who kept tidy yards and were concerned about their neighborhood's appearance, people who, only days earlier, would not have dreamed of covering their homes with graffiti, began spray painting messages, bon mots and curses on the remains of homes, openly carrying weapons. So many crimes were being committed that the police standing order was to respond only to assaults, murders and armed robberies that were in progress.
The air reeked with dead animals, human waste and soaked fabric. The rains became a curse far worse than the storm. A message was sent Wednesday, Day Three, to President Bush that the National Guard could not control the mob, feed the hungry, rebuild the infrastructure and police the streets. Within 24 hours the first contingent of federal troops arrived. The total number was two thousand.
Meanwhile, at the state EOC which had relocated to Miami Airport, the FEMA bosses knew that they and their resources were desperately needed, documents show. But they continued to wait for state officials to make a formal request in writing A commander of a helicopter group explains his difficulty that first week. "Initially our mission was not real clear. Get to Florida and help out. We like to have a little more information than that."
Pantries empty, spoiled food and body waste melding into a sickening fog, water impossible to find, mosquitoes biting, no help in sight, rain ruining remaining property, looters slinking in the dim, repair materials maliciously overpriced; the victims and their supposed saviors began to get a bit testy.
A new estimate put the storm's toll at 22 dead, 63,000 destroyed homes, 175,000 homeless, 1 million without power. Kate Hale, drowning in failure, noticed that the one way to get a problem solved in the midst of the chaos was to bring in a live action news team. Within hours, whatever problem the news media highlighted was on its way to being solved.
Bedraggled, exhausted, and frustrated with the mélange of agencies trying, but not succeeding to execute the relief and recovery, Hale called a press conference and insisted that it be carried live.
At 10:30 a.m. Thursday, Day Four, Hale stood on a chair and issued her famous prayer: " Enough is enough. Quit playing like a bunch of kids," she said. "Where the hell is the cavalry? For God's sakes, where are they? We're going to have more casualties because we're going to have people dehydrated. People without water. People without food. Babies without formula. We need food, we need water, we need people down here. We're all about ready to drop and the reinforcements are not going in fast enough."
Transportation Secretary Andrew Card Jr. materialized at the Dade EOC within an hour. "Help is on the way," he promised.
Four hours later, smug in his feeling that the administration was doing everything it could, Card convened a meeting of the federal relief officials assembled in South Florida. FEMA's senior official promised a significant federal presence within a day. Card asked what that meant and the FEMA official told him there would be not one, but two FEMA disaster assistance centers open the next day.
Card asked how many personnel that would mean.
"Six," the FEMA executive responded.
"Six in each?" Card asked.
"Three in each," was the response Card was given to present to the president and current candidate for re-election.
The 18th Airborne Division with 20,000 troops, on standby since Monday was finally released that evening. At 9:15 the next morning an Army C-5A was on the ground amid the remains of Homestead Air Force Base disgorging rangers in Humvees to restore order and set up kitchens.
Within 24 hours, a million rolls of toilet paper and 4,000 portable toilets were being unloaded on the dock at Dodge Island.
It was the end of the beginning and the beginning of the end.
The realization that Hurricane Andrew had turned from a trauma oriented, search and rescue mission to a major public health problem came with the discovery that Metro Dade Water and Sewer had overestimated its ability to survive a storm using back up pumps and emergency repairs. The discovery came on Tuesday, Day Two. On Wednesday, Day Three, the Metro government announced that no one south of Coral Reef Drive had running water or would have it for some time. The system had failed to survive the storm and its backups had failed to meet the demand. Water pressure is the critical component of public health in contemporary society. Without pressure, with pipes ripped apart by fallen trees, the entire system was susceptible to intrusion from biological contamination. For some, the water was sufficient to shower or boil. For most, there simply was no water: nothing to drink, boil, wash or flush.
Wednesday, the real health care emergency began. And almost immediately the participants who gathered at the South Dade government center in Cutler Ridge for the morning Health Task Force meeting set to arguing about the potential problems and their possible solutions.
What to do with the rotting bodies of domestic animals? Where and how to get water supplies? How to distribute the water? What about airborne insects? How to combat typhus and cholera?
Williams, the state EMS coordinator who established the health EOC in Tallahassee and then in Cutler Ridge, remembered that the meetings took an average of six hours, those first few days and accomplished nothing since no one was actually in charge of anything except their own little zone of responsibility.
The men from FEST
The first systematic attempt to quantify the public health problem was undertaken by two University of Miami physicians, Claudio Cabrejos, MD., MPH and Jorge Hermida, MD, members of the university's Field Epidemiology Survey Team (FEST).
Their unedited notes demonstrate the problems that were common in all the ad hoc medical facilities and emergency food kitchens. The huge dimensions of the problem of providing nourishment and shelter overcame any sense of public health consciousness, despite an awareness on the part of the participants. Their report is remarkable in that it shows how two and only two men insisting on the basics of public health can make a difference in the face of enormous resistance.
According to their field report, they were tasked, "To establish an autonomous but interrelated epidemiology and public health unit in a reference disaster relief center."
The objectives included, "To inspect. evaluate and assist the basic epidemiology and public health needs of the reference center and inform the other logistical units of it and establish first action priorities."
They were to, "Inform and ask for specific aid from the media."
They were assigned to evaluate and manage the disposal of biohazards waste and sold waste, evaluate the management of solid waste and basic sanitation facilities and to make recommendations about food preparation and distribution facilities.
The two of them were also tasked to establish a system for infectious disease control, a system of record keeping and a health education system. And they were supposed to conduct an, "Inspection and evaluation of the community needs and environmental conditions of the devastated area."
Like many of the other official relief efforts, they counted Day One as Tuesday. On that day the Metro Dade Fire and Rescue dispatched them to the Cutler Ridge command center. It took them five hours to reach the location, "Because of the lack of central coordination and organization."
When they reached their destination, according to their field report, they found, "A basic emergency room rudimentarily built, a truck with medical supplies, a truck with food and water, 25 medical personnel and ambulance transport."
They said, "The first cases were lacerations, dog bites and traumas."
This was, apparently, the EMT unit that had been set up prior to the arrival of the DMAT unit. The FEST team was sent south the next day by the director of the field hospital to an ad hoc facility that had been established at Homestead Middle School in conjunction with a Red Cross shelter by volunteers and physicians from the U.S. Public Health Service.
"The disorganization was quite evident," the FEST team wrote. "It was a clinic of 35-40 medical personnel, a supplies distribution center for food, clothing, water and medical aid with logistical management and services. There was no organization for distribution. the clothing was being wet in the auditorium. The American Red Cross shelter was divided for elderly, families and a nursing facility.
"After making contact with the medical director, Dr. Young, the epidemiology and public health component of the center was established with the help of a nurse and supplies coordinator," the report says.
"Biohazardous waste was not being handled properly. No proper containers or bags. No location for that waste. They started using an external debris area to dispose of it. We found children playing in that area and asked for the National Guard to control the area," the report said.
It continued, "In the food preparations area they informed us that they were preparing 7,000 meals a day. We observed that some employees were not wearing gloves. We stressed to them to do it and provided them with gloves. The lines of people waiting for food were too close to solid waste and with external sun exposure. (After our intervention) These lines were changed and the solid waste was handled appropriately in plastic bags."
In another area, "The solid waste was improperly disposed of in boxes and in many sites of the center. We observed flies on food waste. We created a central collection point for garbage disposal and stressed the use of plastic bags.
"A record keeping system was initiated. Approximately 300-350 patients were being seen every day. The first cases were fractures, wounds, traumas, post disaster syndrome, chronic patients: diabetics, asthmatics, hypertensive asking for medications; dermatitis and rashes in children.
"Having made contact with the media, we asked for latrines," the report continues, "and a system to maintain them, plastic bags, shoes for children due to the increased number of wounded feet. We started seeing it on Channel 51 and 4."
The report for Thursday shows an improvement. "Sanitary conditions improved. We received 30 portable toilets and gloves. Plastic bags for solid waste were received and distributed. Shoes and general supplies were received, as well as medical supplies. We brought from the University, biohazardous waste containers, bags and labels. We distributed them in the clinic and set up a room with the proper signs outside. We also brought bleach in plastic containers. First cases of gastrointestinal complaints and otitis media were seen."
On Friday the FEST team reported, "Record keeping to identify infectious disease trends. Cases of gastrointestinal and diarrhea diseases on increase. Otitis median in children, contact dermatitis, respiratory problems as well as psychological disorders."
Even before Hurricane Andrew, Dade County was a public health disaster area. Rates for tuberculosis and AIDS were the second highest in the nation. Health costs were in the upper one third of the nation while one in four: 500,000 residents, had no insurance or too little to make a difference. Almost 40 percent of the newborns in the county suffered some sort of complication at birth. There were at least 25,000 residents with serious mental illness and 25 percent of Dade residents were not getting the basic health care they needed. In many areas of the county, especially in the poor neighborhoods, citizens waited an average 11 months before seeing a physician, according to a study of public health issues completed in 1990.
In a letter, dated Sept. 11, 1992, Dr. Young detailed the problems facing the public health services and requested about $7 million from FEMA to assist in the transition from a military and public health service (PHS) responsibility to local and state agencies.
His attached documentation demonstrates the enormous need that existed prior to Andrew.
"Parinatal health status indicators were examined in 1998, 1990 and 1991 to develop a primary care picture for the target area before Hurricane Andrew struck. The farther south one goes in the target area the poorer the perinatal health outcomes. Such outcomes are associated with the greater amount of poverty that exists in south Dade, in particular target communities. In 1989, less than 30 percent of the 2,200 births to women in Homestead and Florida City area had their deliveries funded by private insurance. One-quarter of the 2,200 deliveries were reimbursed by Medicaid. In Dade County as a whole these figures were 45 percent and 18 percent respectively. The economic plight of low income persons in this area will only worsen because of the total collapse of the $ 1 billion nursery industry, the loss of over $400 million related to Homestead Air Base expenditures, the complete termination of tourist activity during the rebuilding phase.
"Moreover, within the target area there are significant number of census tract and/or zip code areas which paint a very stark picture of the health status of families within the target area, even prior to the hurricane. For example, the most densely populated zip code in the target area (33157) had an infant mortality rate of 16.2/1000 live births in 1989. In 1990, its infant mortality rate, although reduced, was 14.3/ 1000. In each of these two years there were more than 1100 live births to women residing in this zip codes. The rate of low weight births for this zip code in these two years was 9.7 percent and 12.8 percent, respectively. Of the 18 zip codes that comprise the target area, 33 percent had infant mortality rates in excess of 11.7/ 1000 live births in 1990.
Young also reviewed immunization status. There too, the data was both old and depressing. A 1991 study of first grade children in all of Miami, conducted by the Center for Disease Control had found 29 percent to be fully vaccinated by their second birthday. Another CDC study had found that 73 percent of those individuals in the Hurricane affected area who needed medicine had no transportation.
"It was dismal two years ago and it hasn't gotten any better," Miami Beach Mayor Sy Gelber told the media just a few months before Hurricane Andrew.
That moment of reevaluation was in response to a plan by the Dade County Public Health Trust to address the problems of primary care for the poor by building yet another hospital in South Dade as part of the Jackson Memorial Hospital system. Other alternatives that were suggested at the time included a decentralization of health care delivery system through neighborhood clinics that focused on primary care. That recommendation was modified and re-submitted by the Health Planning Council of South Florida with a request for funding from federal disaster sources. More than a year after the storm, the plan had not been funded or implemented.
In the wake of Andrew, the residents of far South Dade got a huge dose of free primary care. Some might argue, the previously underserved population of South Dade got an overdose that led to a temporary addiction. The health care community responded with a rush immediately after the storm, as we have seen, that turned into a stampede.
Unfortunately for the citizens of South Dade, the surge of assistance retreated almost as quickly at it was amassed, leaving them with unfulfilled medical needs, inadequate follow -up care and raised expectations. The problem of how to wean the medically deprived from their post-storm infusion is a major one that must be addressed for South Florida and other battered regions.
In the short term, however, the unofficial medical relief efforts were about the only hope the indigent had until Kate Hale summoned the military for a dose of benevolent dictatorship. Even then, some opportunities were missed.
Not calling Dr. Minkes
The Health Council of South Florida was back in operation within three days after the storm, surveying health service providers in concert with the South Florida Hospital Association and the HRS Office of Licensure and Certification. Its staff attended the daily meetings of the Health Care Task Force held at the South Dade Government Center.
By Day Three, Linda Quick, the executive director of the Health Council had identified a facility, the Suburban Medical Center, as a potential site for emergency care that was far cleaner and better suited than the tent facilities that were being erected around the south end of the county.
In a letter to Jules Minkes, DO, Quick outlined her efforts to direct officials to the undamaged hospital within their midst.
"Within the first three days after the storm, my staff and myself had contacted all of the organized health facilities and programs in South Dade to ascertain their state of functioning. At the same time, my senior staff and I were attending meetings with Doug Cook from the Agency for Health Care Administration, Dr. Jim Howell (then with HRS Health Program Office), Sandra Owen of the Office of Licensure and Certification, Mike Williams of the HRS's Emergency Medical Services , Ellery Gray of the United States Public Health Service and other state, local and federal officials working on the recovery response," she wrote.
"Several times in the first few weeks, we mentioned to them that your facility had not been substantially damaged, that you had beds available for use by people in need, and that although licensed as an Ambulatory Surgical Facility, the emergent nature of the situation might make it a more attractive short-term hospital than transporting people out of the area. With each conversation, I was assured that someone would get right on it, until I was finally told that there appeared to no longer be any need for such short-term hospitalization. Specifically, at the point when recognition of the capability of Suburban Medical Center was made, new people necessitating its use were no longer being identified."
Restated briefly, Quick's ramble meant that the need for emergency hospitals had long passed by the time anyone paid attention to the ambitions and preparations of one osteopath. The moment had come and gone within a week. And it was time to get on with the recovery.
Williams identifies the turning point in health care delivery as the moment President Bush designate Ellery Gray as the federal public health official in charge. That action was followed promptly by Gov. Chiles who designated Gray as the state public health executive. And, in an abundance of logic, Dade County followed, designating Gray as their man in charge. The unified command worked wonders, however slowly.
Williams also recalls the difference in the length and success of the daily Health Care Task Force meeting once Gray, a retired military man, volunteered to take charge, on Day Five.
"We spent six hours and got nothing done. He came in and volunteered to take over the meetings with his flip charts and schedules and we were out of there in an hour knowing what we were supposed to do," Williams recalled.
Livingstone in deepest darkest Dade
Walter Livingstone is a veteran in the public health wars. During Andrew he served a number of functions including Director of Environmental Health in the effected district for the Florida Department of Health and Rehabilitative Services. As such, he has been ruthlessly candid in his appraisal of the public health functions immediately after the storm.
"We were unprepared in three particular ways and failed to respond in three ways," he said. "We were not prepared to dispose of human waste with the water problems to preclude the flies and the diseases flies can carry.
He continued, "We could not provide temporary shelter. The Pan American Health Organization recommends that people be allowed the opportunity to remain on their own property. We could not do this, but we are looking for something that can be dropped on the door step to provide temporary shelter and easily installed."
"The other problem was hand washing facilities. We had very few except at the tent cities (which were not open until late in the second week.) This is the most important way to prevent the spread of gastrointestinal illness. And we did not deploy adequate washing stations."
He said the advent of the large tent cities meant that the problems of delivering water and food were reduced as was the problem of locations for hand washing facilities. But the tent cities were cities with the same trash and sanitation problems as any other concentration of humans can create.
"When the military came into play here and set up our famous tent cities, the need was also immediately present for some means of deposing and removing waste. Porta potties were an essential part of our emergency response," Livingstone recalled. "Trash and garbage were a continual problem of this thing."
The garbage glut resulted in a need for fly control, he said. "The enormous quantities of organic debris spread around by the storm, with every home with every refrigerator, every little grocery store, every food warehouse, every supermarket destroyed, created a problem. Then, with the animal carcasses and the human waste, we had a wonderful fly breeding machine with the warm weather and the rain."
"We tried control with baits around the feeding station, but that was totally inadequate. Electric light traps were a drop in the bucket," he said. "What we are proposing for the future does the same that was done in Desert Storm. That is to utilize flytraps in great numbers. They are very cheap to build and easy to stockpile. This proved to be very effective in Desert Storm."
With the arrival of the military, the pest management system got the combat treatment. "We brought in the specialized military units from the Armed Forces Pest Management Corps, the preventive medicine team from the disease control center in Jacksonville Naval Air Station and they worked with the Metro Dade Mosquito Control. The helped establish the need for the US. Air Force Reserve Aerial Spray Corps. They reduced the population of biting mosquitoes by about 95 percent. But we did that for humanitarian reasons, not disease control," Livingstone said.
He said he found, since the storm, a portable personal commode he expects would help greatly with the sanitation problems of the future. The product is a cardboard base with a plastic liner that is biodegradable. In areas of the nation with a low water table, the bags can be sealed and buried. In places with a high water table, like South Florida where the drinking water supply lies less than a yard below the surface in many places, the bags can be collected for disposal in another location.
How do you spell Relief?
By August 27, Day Four, the Federal Emergency Management Administration was in place issuing emergency checks for food, shelter and medical needs including prescriptions. The rush to find emergency housing for volunteers had already created a shortage of hotel and motel rooms in Dade County. With the receipt of FEMA funds, the shortage of housing extended to apartments and rental homes as far north as Palm Beach County.
The out-pouring of relief aid was nothing short of spectacular. By Aug. 27, Anheuser-Bush had donated $1 million as had Humana Hospital Corporation. Second Harvest Food Bank in Orlando had sent 56,000 meals in hopes they would get to the Red Cross shelters. Publix Food Stores had donated 22,000 one-gallon bottles of water. AT&T had donated $100,000. Zephyrhills Co. had sent 200,000 cases of bottled water. Xerox Corp. had sent copy machines, workstations and Fax machines to emergency centers that were still without power. Motorola had sent 1,500 walkie-talkies capable of connecting 750 people to each other as long as they never got further than three miles apart.
McDonalds and Pizza Hut had opened field units in South Dade that became more popular than the MaRE (meals almost ready to eat kitchens), 100 yards away. The Florida Dairymen's Association had sent 50,000 gallons of water. Texaco had sent two tankers of gasoline, a truck filled with water and one truck filled with food.
The Naples Fire Department had sent 10,000 gallons of water. The government of Taiwan had sent $100,000 and the U.S. Department of Agriculture had sent nine trucks full of food and water. The disorganized rush of relief workers and supplies into South Dade created massive traffic problems as their vehicles mingled with former South Dade resident attempting to go back and forth from their temporary homes in North Dade and Broward County.
To bring some order to the relief effort, community leaders in Dade County established We Will Rebuild as the consensus agency where cash donations would be channeled then spent. Gov. Chiles established the Florida Relief Center in West Palm Beach at the fair grounds where relief supplies could be accepted, sorted and routed to the appropriate destinations. Among those supplies were a substantial number of winter sweaters and a few sets of ice skates. In many cases, the clothing that was donated was so fouled with mold, dirt and parasites, the volunteers who worked sorting out the clothing broke out in contact dermatitis and insect bites. In the end, much of it was burned for fear of infestation.
Water, water everywhere but not a drop to drink
For the stricken hospitals the need for water was desperate. August and September in Florida is extremely hot and humid. Few buildings built since 1950 when air conditioning came into popular use, have adequate ventilation to keep them cool by opening windows and doors. Mold and algae spread with amazing speed in the moist and hot environment.
Immediately after the storm, Mt. Sinai hospital needed 100,000 gallons of water just to restart its air conditioning system. Baptist Hospital needed a similar amount to refill its water tower so the toilets at the hospital could be flushed. While the Baptist staff and their families waited for the precious water, they used a bucket brigade, transporting water from a nearby swimming pool to flush the hospital's toilets. The Baptist toilets were installed with water saving Flush-O-Meters to match demand with supply, when supply was abundant. On Tuesday, August 25, when the Baptist engineering department secured a truckload of water to fill the tower, a wave of relief spread through the hospital. But the relief quickly subsided. The Flush-O-Meters on the toilets were all in their open positions as the water entered the tower. Pressure was never sufficiently established and the water simply flowed through the system, non-stop and out into the sewer system.
The irony of the water crisis is that South Dade has thousands of shallow and deep water wells. It was once an agricultural area growing hundreds of acres of mangoes, avocados, decorative plants and vegetables. It was not part of the county sewer system until the last decade, so it relied on wells for potable water and agricultural water and it relied on wells and septic tanks for waste disposal. Yet no effort was made to put emergency generators on pumps that were already in place to water lawns and fill swimming pools and thereby draw water directly from the ground. Well water, however poor its quality, could have been used for hand washing, cooling, and toilet flushing. A generator, a pump and some hoses could have saved tens of thousands from discomfort and the risk of illness. But no one seized this initiative, assuming, instead, that the water that was not contaminated by a century of septic tanks would be contaminated by a few days worth of rotting animal and vegetable life.
In addition to the problems caused by the lack of water, all the hospitals in the affected area suffered from the continued loss of power that created a cascade effect. All had emergency generators, but not sufficient generators to power lights, medical equipment, critical refrigeration, the kitchens and the air conditioners. Computer controlled equipment, especially in the laboratories, was no longer dependable for critical tests. The generators required huge amounts of fuel and none of the hospitals had planned to be on generator power a week after the storm. Each of Baptists' four generators burns 2,000 gallons of diesel fuel in 24 hours, for example.
At Baptist, for example, the ER patient load tripled. The hospital housed 900 patients, staff and family members. The Baptist kitchen that fed 300 on an average day when it had complete power for refrigeration, water and ovens, was feeding an average of 800 people at each sitting after the storm. At Jackson Memorial Hospital , the crush of patients and families, when added to the large staff in attendance after the storm, over burdened the limited resources in the cafeteria.
Jackson required its employees to pay for their food as if it was a day in spring and they had a hundred choices where to eat. That led food fights among the medical staff and other employees some of whom insisted on being fed before the indigent patients, who were after all, not paying their own way. It took an executive order to resolve the dispute in favor of the patients and assure that patients would be fed before anyone on staff.
The shortage of water and power meant a desperate need for clean linens, sheets, towels and gowns at all the hospitals, since the laundries could not function at anywhere near capacity when they could function at all.
Water, fuel, food, laundry, medicine, gases, dressings: the moral of the story is that medical facilities cannot function after a destructive event such as a hurricane without strong relationships with their vendors and suppliers. Many times, as in the case of Hurricane Andrew, even strong relations will not be enough.
Less than a month after Andrew, the South Florida Hospital Association reviewed the most common problems experienced by its member hospitals. Water was one of the most pressing problems and the association recommended the drilling of six to eight inch wells.
The Association also noted that hospitals that had negotiated contracts with water suppliers had underestimated their needs by up to 200 percent. It recommended that hospitals review their planned requirements and triple the estimate when negotiating with suppliers. They also suggested arrangements with a backup supplier for water-- a good idea for all critical material -- at some distance from the facility, since many of the suppliers in South Florida were destroyed .
Compensation was also a concern. Those hospitals that used payroll services that operated off campus had little difficulty with payroll. Those who produced the payroll in house had substantial problems, both with accuracy and timeliness of making the payroll cycles.
The question of compensation from Medicare for patients who had been evacuated from one hospital to another was quickly solved by Richard L. Warren, the regional administrator for Medicare.
On August 26, 1992, he issued this ruling.
"The following special billing guidelines will apply to services provided Medicare beneficiaries who were evacuated due to Hurricane Andrew."
"In situations where Medicare beneficiaries were evacuated from one hospital to another hospital, the originating hospital should bill from admission to final discharge as though the patient was never moved. It will be the responsibility of the two providers involved in the evacuation to resolve the financial issue of payment for services rendered by the receiving hospital during the evacuation period, as the originating hospital will receive the full Medicare reimbursement for covered services.
"There should be no discharges or transfers from the originating hospital to the receiving hospital unless the patient was ultimately discharged from the receiving hospital during the evacuation period. If a patient was discharged from the receiving hospital prior to a transfer/move back to the originating hospital, the normal prospective payment procedures apply to those hospitals reimbursed under the prospective payment system. The originating hospital should transfer the beneficiary to the second hospital. The receiving hospital should follow normal admission procedures and file the discharge claim.
"Charges for ambulance transportation will be paid according to the usual reimbursement guidelines. Ambulance transportation charges for patients who were evacuated from and returned to originating hospitals should be included on the inpatient claims submitted by the originating hospitals. Payment will be included in the DRG reimbursement amounts made to hospitals paid under the prospective payment system. Outpatient claims may be submitted for ambulance charges incurred by those patients who were transported from the originating hospitals and subsequently discharged by receiving hospitals."
Evacuation from nursing facility to nursing facility or to hospital:
"In situations where a beneficiary receiving a skilled level of care is evacuated from one nursing facility to another nursing facility or from a nursing facility to a hospital, there should be no discharge. The originating nursing facility should bill the claim for a covered skilled level of care as normal. The nursing facility or hospital receiving the evacuated patient should bill the originating provider for services rendered.
"In a case where a patient was an inpatient in a nursing facility and not receiving a skilled level of care and the patient was evacuated and admitted to a hospital, the situation should be treated as an admission and must be reviewed by the PRO individually to determine the medical necessity of the admission. Waiver of liability would be applied as usual, based on the medical necessity criteria for any denied admission."
Admission from home setting to hospital or nursing home:
"In some situations, patients either under a physician's general care or who were receiving covered home health services, may have been admitted to a hospital or nursing facility due to the evacuations or conditions resulting from the hurricane, for example, a patient who otherwise would not have been admitted required admission because he or she was dependent on special equipment that did not function due to the loss of electricity. The medical review entity must determine case-by-case the medical necessity of each admission. The usual billing procedures will apply relative to billing ambulance services."
As we will see later, the most urgent need in South Dade after the hurricane was a consolidated delivery system that included mental health, health and mental health prevention, primary care, social services and civics. There were many facilities in place to dispense medication and social services. It was difficult for even the affluent to travel around because their transportation was limited by the destruction of one or more vehicles. For the less affluent who lost their one and only vehicle or saw the public transportation system fail, the need to get around was desperate.
The poor needed food and water and medicine and a way to get to the various agencies that offered relief.
Charles Johnson, a publicist for several cab companies who normally remains dispassionate about his clients, speaks with pride about the volunteer army of mini-van drivers and their accomplishments setting up the remarkable system that grew to respond to the transportation needs of South Dade.
"As South Dade reeled from the blows inflicted by Hurricane Andrew, a group of county administrators and private transportation executives met and in hours put together a disaster relief transportation service that became one of the great but little known success stories of the recovery from the killer storm," he said.
"Within 66 hours, the first van of what was to become a fleet of 260 privately owned and operated vehicles was out on debris-clogged streets, pioneering a program that is now being viewed as a model for other communities facing a similar disaster.
"In Andrew's wake relief officials set to work. The military moved in. Storefront clinics opened. Tent cities and tent hospitals sprang up. Distribution centers for food, water and clothing and other emergency supplies went into operation. But hundreds of thousands of people had no way to reach these centers," he recalled.
"By Friday after the Monday hurricane, FEMA had obligated $45.8 million dollars to the Metro Dade Transit Authority to provide emergency transportation. That same day, the mini-vans of Miami started running on 12 routes. By the next Tuesday, the number of vans had grown to 140. Within a week, 180 vans and buses were running 16 hours a day on two shifts with 300 drivers participating," Johnson recalled.
The system was organized by Metro and private companies including Mayflower Transportation Services, Red Top, Airocar and Handi-van. Most of the drivers were involved in airport service while some had been driving disabled individuals. Few of them knew South Dade with enough intimacy to follow directions, especially with all the street signs and traffic lights destroyed. So the volunteer supervisors and dispatchers set up a cellular phone dispatch system and marked the routes with stripes of yellow paint. There were not enough cellular phones to go around, however, so the drivers had to try to find working phones along their routes from which they called the dispatchers.
The fleet of vans and jitneys operated 16 hours a day, free of charge to users and became the lifeline of the South Dade underclass. Drivers were willing to pick up stranded homeowners and carry them to important meetings with attorneys or insurance agents, as well as get the workers to work and the family to the food kitchens and health care facilities. The service averaged 20,000 boardings a day. Without it, any effort to provide public health or mental health relief would have been impossible.
Beyond the service for the general public, 6,000 disabled and elderly hurricane victims were transported each day by the 66 vehicles and drivers that had been assigned to the 40 non-profit and social service organizations who participated in HANDS, Hurricane Network Dispatch System.
The HANDS system got dialysis patients to treatment. They carried an average of 300 frail elderly a day to meals and medical care. Another 300 daily riders were carried to job training programs to help them learn to help rebuild South Dade.
Most of the vehicles were owner operated and many had been operating at the edge of legality. But the coalition required all of them to pass safety inspections. The drivers were required to have valid licenses and the entire fleet was covered by a blanket liability policy. Since the vans were running without charge to passengers, a salary rate of $16.50 an-hour was established for the drivers. Spanish speaking drivers made up 65 percent of the work force. Afro-American drivers represented 35 percent. But many of those counted as Afro-American were actually Haitian immigrants, in effect, Afro-Franco-Haitian-Americans. But that category is yet to be created amid the search for politically correct monikers.
MDTA printed 300,000 fliers about the disaster transportation system in three languages and distributed them through the FEMA funded facilities, the tent cities and the health care system. There was no power, no television and little radio in much of South Dade for a month after the storm. The jitney drivers, whose makeup approximated the cultural mix and language abilities of the riders, therefore became both the transportation backbone of the relief effort and its messengers and interpreters.
This system grew spontaneously and in response to a very political dilemma. The jitneys had been operating without licenses and regulation in pockets of poverty in competition with the government backed system. It worked so well because the jitneys were, in almost all ways, a reflection of the community.
Other communities ought to consider adopting in their plan, many of the things that happened by accident in the HANDS program and the emergency routes. Keep the routes fluid. Respond to calls. Task a set of vans to social service agencies for exclusive use. Match the drivers to the demographics of their routes. Teach the drivers the basics of public health and the system. Use them to spot people at risk passing through their area. Put public health nurses or aides on the buses at certain increments to monitor what is happening beyond the treatment centers. Integrate the emergency transportation system into the public health and mental health relief roles by using the buses and vans as rumor control and places to dispense and collect important health care information.
A Unique opportunity
When Hurricane Andrew wiped out the physical landscape it also leveled the health care landscape of South Florida as well, providing an opportunity and a challenge to start over again, especially in the delivery of primary care.
Andrew destroyed or severely damaged the few public health care centers serving the area including Perrine Health Center, the Doris Ison and the Martin Luther King Health Centers. In their place, ad hoc health care facilities blossomed in storefronts and from trailers they called "doc in a box." But they wilted as the damaged traditional systems emerged from the shambles and returned to action. With their expectations raised by the sudden outpouring of medical assistance, the poor among the hurricane victims flocked to hospitals and clinics for follow-up care and the treatment of the wide range of trauma that is inevitable during extended hurricane clean-up.
As the frustrations that followed the storm ramified, anger built within the victims without an appropriate vent. Guilt, fear, loss and anguish dominated the emotions of the victims, creating a festering psychological sore that no one had prepared to treat, let alone prevent. The need for psychological outreach grew exponentially among the residents.
Into the mix of victims and rescuers came high paid but uninsured construction workers and their families who put enormous demands on the already stressed health and mental health delivery system. The re-construction workers' mission was essential to the rebuilding. Their needs were real and their right to access the local health care system undeniable. Yet their unpaid medical bills were not regarded as a consequence of the hurricane and therefore not eligible for federal underwriting. Because of this, Homestead/SMH Hospital, which treated many of them as walk-ins at its emergency room, was forced to go to the state to offset $18 million in unanticipated costs associated with post-storm clients.
South Dade County was lavished with free health care immediately after the storm. Plans were announced to continue rehabilitation of the area and its people far into the future. They were not unlike competing plans that had been promulgated before the storm. Everyone had a plan to help the underserved population of rural South Dade.
If all the good intentions for the delivery of health care to South Dade were turned into plates and stacked on top of each other, they would fall over. Prior to the storm, South Dade had been a political arena where the Dade Public Health Trust and the officials of Jackson Memorial Hospital practiced variations on the theme of primary care and public assistance. It was a pocket of poverty that was projected as a target of future, more affluent population growth. As such, it was an area coveted by the commercial hospitals already operating in the area. They were opposed to the construction or expansion of competing hospital facilities, especially the planned opening of a branch of Jackson Memorial. Jackson and its parent political organization, the Dade County Public Health Trust, on the other hand, felt Jackson ought to enter the South Dade market.
The Health Planning Council of South Florida, a state funded advisory panel, had proposed a community based primary care system for South Dade that would expand existing services without any additional demand for bricks and mortar. This plan excluded Jackson and other potential new facilities. The SFHPC concept focused on prevention and intervention especially among women and children. It rejected the need for a new hospital building and all that that means.
After the storm the SFHPC submitted its plan to rebuild the South Dade health care delivery system along the same lines it had recommended to the Public Health Trust prior to the storm. At press time, more than a two years after the storm, the proposal remains unanswered.
Hark, the Herald angle
Perhaps the most successful interim program spawned by Andrew was the mental health and social service delivery program established by Sara Herald. Herald, an attorney and pro-bono advocate for children and families, assumed the unfilled position of Disaster Relief Coordinator for the Alcohol, Drug Abuse and Mental Health section at the Florida Department of Health and Rehabilitative Services (HRS) District XI.
Since the agency had no plans for post hurricane service, she assembled a team of social workers, public health nurses, psychologists and volunteers and launched a door-to-door program that became the definition of successful out- reach.
Her teams stayed in the same neighborhoods, tracking the progress of the same families, providing preventive help from public assistance to drug counseling to family planning.
According to Kate Hale, the out-reach function was critical in the first seven days. But, in Herald's estimation, the only outreach function performed during the first two weeks after the storm was ad hoc, disorganized and uncompensated.
Dr. Evelena Bestman, a psychologist on the teaching faculty at the University of Miami, recalled that a group of psychologists who had been organized by the National Association for Psychology arrived in South Florida within the first week after Andrew, the first time any such effort on the part of mental health professionals had been attempted.
"Pre-Andrew, mental health had a slow evolution into the disaster arena," Bestman recalled. "This is the first time, maybe in history, that mental health was put into the disaster relief program. We were given a real presence. But the key question is, 'What is mental health in disasters.' People are still wondering what mental health in disaster really means because most people associate mental health with psychology and psychiatry," she said. And she praised the efforts of Herald and her group.
"I am one of the strongest admirers of the team that Dade County put into effect because it shows that the anguish, the anger and the pain cannot be put into a little square of piece of paper called mental health. It is the combination of so many factors of what people are going through," Dr. Bestman said.
"This has been the problem of most states, pre-Andrew. So in most states planning doesn't exist.. You look at the mock drills. They have people covered with catsup who lie there and they practice with them. But nobody has a protocol for questions about what have they gone through. Then you follow through, after a few months, to find out what happens to the citizens, and there is no data, there is no research. It is an area that very, very slowly is emerging."
"We do know an awful lot about what happens to people in general terms," Dr. Bestman said. "We do know how to help. But we are not putting it into action. But one agency that is doing it is the Red Cross . The Red Cross finally has a mental health component within its system. They have a very good profile for mental health assistance," Dr. Bestman said. But she said that these worthwhile first steps are not sufficient nor do they compare to the system developed by Herald and her team.
"Post Andrew there is a great need to anticipate mental health issues at the state, county, local levels, and that does not exist. We did not anticipate and prepare way back before Andrew, not even a week before Andrew. And what is the anticipation based on? Knowledge.
"There is a relationship between the impact area and the amount of consequence you are going to have for mental health. There is a difference between working in the first month and the sixth months. People will be doing trial and error," Dr. Bestman recalls.
"There was a tendency to call it post disaster dysfunction. The percentage of emotional problems in families are very deceptive. They don't stop at the moment people answer the questioneers. It is a process or planning and leaning and of training. The whole field of mental health is an evolutionary field. We are a bit primitive, but in Dade County it is moving because of what Sara Herald is doing and that her model comes closer to what we need to be thinking of, " Dr. Bestman said.
Herald recalls her introduction to mental health and social services, government style.
"I was working on getting aid for foster kids and getting foster kids relocated and the stuff that I normally do. And I got a call, two weeks post storm. I got a desperate phone call to come in and be the disaster relief coordinator. Does that kind of tell you the kind of planning that we had going on for alcohol, drugs or mental health? There was no plan. And the federal government couldn't find anybody at the state level or at the county level that was in charge in alcohol or mental health. So what you had was a whole bunch of very well meaning individuals and group social services and community based organization and university personnel and doctors and psychologists and counselors that were coming into town, and absolutely no coordination.
"And the irony of this is that the only stream of funding, at the federal level, that is an absolutely guaranteed in the case of a natural disaster is money for mental health. Can you believe it is the only one that anybody could have told you, six months before the hurricane, that you were going to get (a grant) after a hurricane? It is a recognized part of the Stafford Act, therefore, everyone could have been guaranteed mental health services, if we had had a plan," Herald said.
"Number one, you need a plan and you don't do the plan after. But we did. And the only thing I can tell you that qualified me for the job is that I am very good on my feet and I have a background in community based planning and I believe in listening to what people need and not dictating what they need or what they want," she said.
"So, one of things that we did not do in the planning process is that we did not jump in and say , 'I' m here. I am the disaster lead coordinator.'
"We decided not to spend the money until we polled the community individuals who knew something about what should be done, before we spent millions of dollars," Herald recalled.
Absent an established plan, Herald decided to create a plan that would have the support of the agency personnel required to make it a success. This took time and, in a sense, postponed the receipt of the coveted grant funds.
Herald recalls, "I can't tell you the number of people who said, ' lets spend it, it 's just sitting there. If we don't use it we don't get anymore.' Unfortunately, I am not a bureaucrat and I did not have any plan on keeping my job, so I did what I thought was right and I said no.
"I brought in people like Evelena Bestman, over 150 people who provide substance abuse and mental health services, both in the public and private sectors, and we developed a plan for the community health team," she explained.
"We took a holistic approach. Most of the people we were dealing with were well. They were not mentally ill. They were well. But they were having to deal with extraordinary stress. And if you help them create linkages and let them vent to you and get crisis counseling done at their door, then you reduce the risk that they will become mentally ill," Herald explained.
"The nursing factor is there because primary health problems become mental problems if they cannot get primary health services. Environmental health is there because we all need to work together to make sure we are not decompensated," she explained.
As a veteran of state and federal entitlement programs, Herald looks at the fruits of public assistance programs as entitlements. Those who are entitled to the "compensation" that helps alleviate their problems are considered "decompensated" when they do not get it. And they can be "decompensated" by the mere fact they are not aware of their entitlement.
Herald reviewed the condition of the mental health system when she came on the scene after Andrew.
"There was a plan for the mentally ill but the population with mental illness was very poorly sheltered. They were not cared for in shelters. There were no nurses, counselors, psychiatric nurses or mental health workers. This is ok if you are only going to be there for a day. But they weren't, they were there longer. And even when tons of pharmaceuticals were brought in, there were not any mental health medication in the pharmacy at the time. We are still having trouble six months later because the mental health centers that serve the indigent populations had already exhausted all of their money for medication," she recalled.
"You had people who got prescriptions for $60 medication, then they could not get the medication and they were decompensated. Then how did we treat them? We put them in a crisis stabilization unit at significantly higher cost than the sixty bucks the medication would have cost. We are paying to have the hospital or Medicare, or whatever they qualified for, because we did not get them the $60 they needed to function.. They need to be sheltered and medicated so that they can remain stable at a time when there is a greater likelihood that they will be decompensated anyway," Herald recommended.
And Herald warned that the system of applying for government assistance could be daunting.
"I was dealing with six agencies that have some role in disbursement of money that Congress allocated. All had a different set of rules. They had different review criteria. We had people sitting in Vermont reviewing our grant applications asking questions like, what plans do you have for housing the homeless."
And Herald warned that the consequence could be dire to grant recipients if they do not keep good books.
"You need a single audit trail and a different set of accounting procedures depending on which agency you are dealing with. And if you do not do it right, they can ask you for a refund as long as four years later, depending on the audit procedures," she said.
She also pointed out that it could be difficult to get aid from the state when the state is relying on funding from the federal government.
"Florida has a zero based budget which means you cannot spend money you do not yet have. I had 600 people in the field working for 45 days without contracts because nobody at the state level would let me hire anybody. The staff did it because they had faith that I would sue on their behalf and that I would sue the federal government. But you cannot count on leaps of faith in managing people for 60 days at a whack while you wait for the state to contract," she said.
Herald also suggest that the state not only waive the normal requirements for purchasing and bidding but also let the agency that pays the bills know that the change has been made. She said she waited six months to get the state's permission for desperately needed computers.
Her final recommendation was for coordinated emergency planning that is holistic and includes social service delivery. "I recommend a master plan that is integrated to include social services delivery and neighborhood based organizations. Beyond that, make sure you can take care of yourself and your family. Do not wait for the government to respond," Herald said.