Carol North, M.D.: The scale and nature of a disaster influence a first
Medical technicians from the East Baton Rouge Parish Emergency Medical
System interview elderly evacuees in a shelter in Baton Rouge after Hurricane
Katrina swept through the region. Photo courtesy of Mark Olson
Ten years ago, Tommy Loyacono wrote up a plan for disaster staffing of the
East Baton Rouge Parish Emergency Medical System. The plan called for his
100-person staff to work 12-hour on/off shifts for up to a week, by which time
most emergencies would be over. But Hurricane Katrina upset his best-laid
plans, said Loyacono, the system's chief of operations and a spokesperson for
the National Association of Emergency Medical Technicians.
The 100 crew members stayed on that schedule for three weeks after
Katrina— and then Rita—swept through Louisiana. Evacuees had
doubled Baton Rouge's population. Ambulances ran with lights and sirens and
still had hourlong transport times through the clogged streets. The 911 system
was so swamped with calls that Loyacono had emergency medical technicians
(EMTs) set up triage posts in the shelters. He worried about how long his
crews could keep up the pace. Three weeks after Katrina, one EMT had simply
walked off the job after a trying day, and another was in a psychiatric
"I'd say we have some highly notable stress," said Loyacono in
an interview in late September. "Our people are working long, hard
hours. Vacations have been canceled. There's barely time to do laundry and
sleep. One woman was supposed to get married. I told her, `Sure, you can get
married on Saturday; I'll just move you to the night shift.'"
Hurricane Katrina doubly shocked police, firefighters, EMTs, and other
first responders along the Gulf Coast. Many saw their own homes damaged,
families displaced, or lives disrupted just like the people they were trying
around the clock to help. More than 200 New Orleans police officers left their
posts, and two committed suicide after the hurricane.
Stress on the job is nothing new to those who are first on the scene of
emergencies. Their work may be physically draining, demand long hours without
sufficient sleep, or expose them to long-term health risks. They may witness
mass destruction and mutilated bodies.
Emotional responses to such events are inevitable. Such reactions can range
from irritability to depression to posttraumatic stress disorder (PTSD).
The scale and nature of the disaster influence a first responder's
reaction, said Carol North, M.D., who studied the mental health aftereffects
of the Oklahoma City federal building bombing and the attacks of September 11,
2001. "Bigger is worse than smaller. Human-caused tragedies are worse
than natural ones, and terrorism is worse than engineering
"Professionals have more training and experience and are thought to
be a lot less overwhelmed by the event, but there's not a lot of data,"
said North, a professor of psychiatry at the University of Texas Southwestern
Medical Center in Dallas.
In Oklahoma City, symptoms of PTSD were few immediately following the
disaster and decreased a year later. "Only preexisting alcohol abuse or
dependence and psychological problems predicted postdisaster mental health
symptoms," she said.
Rescue work is usually accomplished quickly. However, the severity and
geographic extent of Katrina's devastation forced public safety workers to be
on duty for weeks instead of days. Organizational failures have only added to
"A lot of people are getting tired of 24/7 operations," said
Anthony Ng, M.D., chair of APA's Committee on Psychiatric Dimensions of
Disasters, who spent two weeks volunteering in Mississippi after Katrina."
Chaos from lack of coordination affects the morale of emergency
workers. They're action people. They want to go to work, and they get switched
off when they sit around and wait. Many medical teams have spent more time
waiting around than working."
"These are not milquetoasts," agreed North. "They
developed a macho culture in which people don't talk about their
In the right setting, perhaps, that attitude can change. When New Orleans
police officers and firefighters were finally released on leave, they passed
though a clinic at the Belmont Hotel in Baton Rouge. After a brief physical
examination and vaccinations, they all stopped by the mental health section
for evaluation and psychological first aid by a team that included two
psychiatrists, Elmore Rigamer, M.D., of New Orleans and Cheryl Person, M.D.,
Team members asked them for basic information, said Person, a postdoctoral
fellow in disaster psychiatry at the Bloomberg School of Public Health at
Johns Hopkins: How old were they? Were they married? Did they have children?
Were their families safe? They told stories about their dual status as victims
and responders. Families were in different states, homes destroyed. Their
efforts to respond were hampered by communications breakdowns in command. Some
had heard the shot when a fellow police officer committed suicide in the next
room of a shelter. One firefighter's grandfather had died in an abandoned
nursing home. Another's 95-year-old grandmother had spent the night on a
In general, most of the people the psychiatrists saw were having normal
reactions to abnormal developments, said Person in an interview. She could not
diagnose PTSD because contact with the officers came so soon after their
exposure. Most of their problems related to sleep, for which the psychiatrists
prescribed a short course of sedatives. "We tried to depathologize their
reactions and give them information on what to expect as time passed,"
said Person. "It was a very destigmatizing experience. We left follow-up
to them but advised them that if they had any concerns that they should see a
Loyacono had some volunteer help for his crew from two clinical
psychologists who were among the 100,000 evacuees in the Baton Rouge area.
Little relief appeared on the horizon a month after Katrina, though. One crew
of out-of-state volunteers arrived, worked one shift, and then didn't show up
the next day, which Loyacono attributes to poor coordination by emergency
What can be done to help first responders during and after such a
"People everywhere cope by turning to trusted loved ones and
friends," said North. "We need to look at the whole gamut of
psychosocial issues, not just PTSD."
Even before disasters occur, workplaces should offer confidential access to
mental health care. Public safety workers often worry that if their concerns
reach their bosses, their jobs might be threatened, she said. Alcohol and drug
problems must be addressed too, given the heightened risk they create.
Postdisaster treatment can take several approaches. Early symptoms may call
for counseling or short-term sedatives to help people sleep and get through
the acute stress. North prefers to use nonbenzodiazepines in a population
containing possible drug or alcohol abusers, she said. Later, a diagnostic
approach can identify major depression or PTSD, which can be treated according
Use of "critical incident stress debriefing" is now in
disfavor. After a disaster, candidates for PTSD have prominent avoidance and
numbing responses and are not ready to face an intervention involving the
processing of memories and experience, she said, but it may still have its
place among therapeutic options.
"Some people find it helpful," said North. "It's not
intended to treat or prevent PTSD, but it can help them process and share the
Administrative reforms can also make a difference in public-safety workers'
stress load. Good communications from leaders and clearly assigned tasks can
The anxiety New Orleans police felt about their families might have been
reduced if they had known what happened to their families. The department had
no spouses' organization and no off-site personnel database that listed next
A few days after the storm passed, New Orleans psychiatrist Harold
Ginzburg, M.D., J.D., M.P.H., helped set up a confidential e-mail matching
system to help families and police locate each other. But by then much of the
emotional damage had been done. ▪