Brain Injury Professional, vol. 6, issue 4

B R AIN INJURY professional vol. 6 issue 4

The official publication of the North American Brain Injury Society

Preparedness and Recovery for Vulnerable Populations Hurricane Pr e p a r e d n e s s , a n O x y m o r o n : Are You Ever R e a l l y P r e p a r e d ?

A Compariso n O f M e n t a l H e a l t h F i n d i n g s A m o n g Oklahoma Ci t y B o m b i n g S u r v i v o r s A n d H u r r i c a n e K a t r i n a E v a c u e e s Disaster Cas e M a n a g e m e n t : C a s e M a n a g e m e n t an d Individu a l s w i t h D i s a b i l i t i e s F o l l o w i n g H u r r i c a n e K a t r i n a Homeless in t h e F a c e o f a n I m p e n d i n g N a t u r a l D i s a s t e r : Strategies fo r S u p p o r t i n g P e o p l e w i t h T r a u m a t i c B r a i n I n j u r y Injury and Il l n e s s D u r i n g a n d A f t e r H u r r i c a n e I k e Factors Driv i n g E m e r g e n c y P r e p a r e d n e s s f o r P e r s o n s with Brain In j u r i e s a n d O t h e r Di s a b i l i t i e s : Late Lessons f r o m K a t r i n a Su rviving the S t o r m : I n n e r S t r en g t h a n d R e s i l i e n c y Following Hu r r i c a n e I k e BRAIN INJURY PROFESSIONAL

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Long Term Acute Care Hospital - Medically Complex & Coma Recovery

Neurobehavioral & Rehabilitation Programs - Children, Adolescents & Adults

Special Education Accredited Schools - Grades 1 - 12; Early Intervention Programs

Residential Treatment Programs - Brain Injury, Autism & Neurodevelopmental Disorders

Community Integrated Programs - Homes, Assisted Living & Supported Apartments

www.lakeviewsystem.com

Lakeview NeuroRehabilitation Center Effingham, New Hampshire 800.473.4221

Lakeview Specialty Hospital & Rehab Waterford, Wisconsin 800.611.2063

contents departments 4 Editor in Chief’s Message 6 Guest Editor’s Message 32 Non-profit News 34 Legislative Round-up

BRAIN INJURY professional vol. 6 issue 4

The official publication of the North American Brain Injury Society

north american brain injury society

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family Liaison Skye MacQueen executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

brain injury professional

publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD Editor, Legislative Issues Susan L. Vaughn founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker

EDITORIAL ADVISORY BOARD

features 8 Hurricane Preparedness, an Oxymoron:

Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

Are You Ever Really Prepared?

By Gary S. Seale, MS and Brent E. Masel, MD 16 A Comparison of Mental Health Findings Among Oklahoma City

Bombing Survivors and Hurricane Katrina Evacuees

by Carol S. North, MD, MPE 18 Disaster Case Management: Case Management and Individuals with

Disabilities Following Hurricane Katrina

by Laura M. Stough, PhD, Amy N. Sharp, PhD, Curt Decker, JD and Nachama Wilker 22 Homeless in the Face of an Impending Natural Disaster: Strategies for

Supporting People with Traumatic Brain Injury

by Gretchen Stone, PhD, OTR/L, FAOTA 26 Injury and Illness During and After Hurricane Ike

by Kathleen Sherrieb, PhD, Fran H. Norris, PhD, and Sandro Galea, MD, DrPH 28 Factors Driving Emergency Preparedness for Persons with Brain

Injuries and Other Disabilities: Late Lessons from Katrina

by Michael H. Fox, ScD, Glen W. White, PhD 30 Surviving the Storm: Inner Strength and Resiliency

Following Hurricane Ike

By Gabrielle Morales, MOTR, CBIS, AMPS Certified

editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2009 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

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editor in chief’s message

Ronald Savage, EdD

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BRAIN INJURY PROFESSIONAL

With the horrific images in the aftermath of the earthquake in Haiti fresh in our minds, this special issue of Brain Injury Professional could not be more timely.

The articles contained in this issue should serve as a call-to-action for all of us to be mindful that disaster preparedness is a responsibility we share with our families and the persons we serve. We would like to acknowledge Brent Masel, MD, and the participants of the 2009 Galveston Brain Injury Conference for their work on this extraordinary edition of BIP. To members of NABIS, thank you for your support of our Society over the last year. Your participation has allowed NABIS to be heard in the industry and make a difference for the people served in our professional capacities.

During the last year the circulation to this publication has grown, NABIS conducted it 7th annual clinical programming event, held another successful legal programming track, and grew membership more than 20% over the previous year.

NABIS also presented its three annual awards this year to recognize individuals who have made significant contributions to the field of brain injury. The awards were presented at the annual symposium and exhibition in October. The Randy Evans Clinical Treatment Award was given to Janet Williams, PhD, the NABIS Clinical Research Award was given to James F. Malec, PhD, the NABIS Legends Award was presented to Neil

Brooks, PhD and the NABIS Award for Public Policy was given to the Christine M. MacDonell of CARF. NABIS is eagerly anticipating its first regional conference in Anchorage, Alaska in July. This conference will bring experts, both local and from the lower 48, together to discuss how to better serve the native and local populations in Alaska.

In another effort to bring professionals together, NABIS is pleased to announce that the annual meeting will be held with the National Association of State Head Injury Administrators. This effort allows for solid cross interaction of professionals in brain injury. Visit the NABIS website for more details. Program planning is underway.

In order to continue to provide products and services to professionals in the field of brain injury we need your commitment again. We are asking you to renew your membership, or if you are not a member, join today! Don’t miss a single issue of Brain Injury Professional.

In the coming months, watch our website — www.nabis.org — and your mail for programming and registration information for the 8th Annual NABIS Clinical Conference and 23st Annual Medical and Legal Issues in Brain Injury conference slated for the fall of 2010 in Minneapolis, MN. Ronald Savage, EdD

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guest editor’s message

Brent Masel, MD

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BRAIN INJURY PROFESSIONAL

Since the day Noah became interested in ship-building and celestial navigation, man has realized the necessity of preparing for disasters — natural, and alas, manmade as well.

On September 13, 2008, Hurricane Ike roared across the Texas Gulf Coast.

Only a Category II in wind speed (up to 110 mph), it was a Category IV in terms of flood surge (13-18 feet) potential. An immense hurricane the size of Texas, Ike was the third costliest Atlantic storm in history, causing $32 billion in damages. Eighty per cent of the buildings on Galveston Island sustained water damage. On Bolivar Peninsula, just to the east of Galveston, 90% of the homes were destroyed. The exact death toll will never be known, but it is believed that about 90 individuals died as an indirect effect of the storm (most of those individuals were unable to access medical care immediately after the storm), and 25 individuals are still missing. (Interestingly, there also appeared to be a large spike in deaths in the first few months after the storm as well suggesting a relationship of stress to medical disease.)

Along with the citizens of the upper Texas cost, the 60,000 residents of Galveston Island were placed under a mandatory evacuation order by the Governor. Think of it. If you had 12 hours to board up your home and business, and then pack up what was most valuable and get out, how would you do it, what would you take, and where would you go? Moreover, what would be your plan for return if your home and business were significantly damaged? Where would you live? Where would you work? What would you do with your employees while you were rebuilding? And how would you do it all if a significant percentage of the individuals for whom you were responsible had physical and cognitive disabilities?

The Transitional Learning Center and its long term living program, Tideway, were faced with that exact issue. On September 11, the staff was advised to get their homes and families prepared for evacuation, and then report to work to prepare TLC and Tideway.

On the morning of Sept 12, with rising water beginning to lap at our tires, a caravan of cars, SUVs and busses took 27 staff

and 26 patients out of harms way and into a learning experience we hope none of you will ever have to endure.

After hearing of our experience, Wayne Gordon, Ph.D., recommended that the topic of the 2009 Galveston Brain Injury Conference should be Emergency Preparedness. My first thought was that no one would be interested in this issue, but the more we spoke with individuals, we realized that everyone is susceptible to disasters — perhaps not hurricanes, but floods, fires, ice storms, terrorist actions, etc. It’s not if; it’s when. After all, Galveston had not sustained a hurricane of this magnitude in 110 years.

What I hadn’t anticipated was my complete lack of interest in taking on one more project.

I never really understood how very depressed individuals have no interest in doing anything---and I mean anything, until I experienced the post-Ike depression (“Ike brain”) that was endemic in our community. Quite frankly, we were all still reeling from the incredible mind-numbing impact of the personal and business issues relative to our recovery. Have you ever had a contractor or insurance adjuster with whom you were 100% happy? Did you know that FEMA stands for: “F___ Everyone; Move Away?” Our homes had anywhere from 2-8 feet of water. TLC had 3-4 feet of water and mud. Wayne obviously could read our minds, and also graciously volunteered to do all the heavy lifting, contact the speakers and arrange the schedule. The conference went off flawlessly, and was one of the most interesting GBIC conferences I can remember.

The focus of this issue of Brain Injury Professional is on Emergency Preparedness and Recovery for Vulnerable Populations.

The articles are abstracts of the works presented at the May 2009 Galveston Brain Injury Conference by some of the most knowledgeable individuals in the field of emergencies and disabilities — some at a professional level, and some from a personal perspective as well.

The article by Gary Seale focuses on TLC’s experience with two storms — one that never made it to Galveston, and one that did. It discusses planning and replanning.

Everyone who runs a residential program for individuals with disabilities should meet with their staff and come up with a true disaster game plan, and should revisit it every single year. Robert Burns was right on the money when he wrote about the best laid plans of mice and men.

Not only are a Plan A and a Plan B needed, but a Plan C is necessary as well. (We had never considered the possibility that we would not be able to immediately return to our homes and physical plant once the storm had passed.) Planning must involve all levels of staff. I never really understood the challenges faced by our line staff until I functioned as one during our evacuations.

I certainly was humbled by their knowledge, patience and caring.

Carol North presents a fascinating look at the survivors of a man made disaster: the Oklahoma City bombing of 1995, as well as the survivors of a natural disaster: Hurricane Katrina. The populations were significantly different in many aspects, and subsequently, the problems and recommended approaches to helping those individuals were significantly different as well. Disaster planning clearly requires an individualized approach.

The article by Laura Stough and her co-authors hits home personally for me. As President of the United Way of Galveston, I have seen first hand what a critical role case management plays in disaster recovery. This article points out that the basic needs for an individual with a disability are the same as for one without a disability, except that the issues are magnified multifold. They also point out that many of the resources available to case management quickly move on to the next disaster, leaving case managers and their clients with many unmet needs. Hopefully, we

can find a way to keep this from happening in Galveston.

Gretchen Stone’s article is specific to the homeless population with TBIs. Galveston seems to attract a large number of homeless individuals. It is an island with a large state funded hospital, 32 miles of beach and a temperate climate. As we are all aware, many of those homeless in-

tude of the storm. I suspect this was due to an excellent evacuation plan by the city, and the resilience of the individuals who choose to make their home on Galveston Island.

Glen White and Michael Fox tell of some very personal experiences of individuals with disabilities who survived Hurricane Katrina, and the broad major themes that were interwoven within those shared experiences. Although three years separated Katrina and Ike, I can say that our government really didn’t take full adequate advantage of what was learned in Katrina, as the exact same article could have been written about the victims of Hurricane Ike. The article by Gabrielle Morales hits me right in the gut as she tells her personal experience with Ike. Gabby is one of the young TLC staff who evacuated with our patients, and got a decade worth of education in three weeks. I watched Gabby grow as a professional and as a person. She represents the very best of what we brain injury professionals should strive for, and the very best of what we all can be.

dividuals are living with the physical and cognitive consequences that follow a brain injury. Her article focuses on how to help these individuals deal with the total chaos that comes with an impending disaster.

The article by Sherrieb, Norris and Galea focuses on the relationship of injury and illness during Ike to disaster experiences. They found that disaster-related injuries and illnesses were associated with increased stress, distress and disability. Interestingly, although the number of families interviewed was impressive, the rates of injury and illness are far less than I would have anticipated considering the magni-

We wish to thank our dear friend, Wayne Gordon, the 2009 Moody Prize award winner, for his support and his work in this endeavor. We also wish to thank TLC’s co-sponsors of the GBIC, Kenneth Ottenbacher, Ph.D, Professor and Director of the Divison of Rehabilitation Sciences, and Elizabeth Protas, Ph.D., Dean of the School of Health Professions at the University of Texas Medical Branch. Most of all, our thanks to the staff of TLC and Tideway, the glue that held us all together during the terrible dark months following the storm.

Brent Masel, MD BRAIN INJURY PROFESSIONAL

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Hurricane Preparedness, an Oxymoron: Are You Ever Really Prepared?

By Gary S. Seale, MS and Brent E. Masel, MD INTRODUCTION Facilities providing residential services to persons with traumatic brain injury (TBI) in coastal areas are potentially vulnerable to the devastating effects of hurricanes. While it is impossible to develop contingencies for all possible scenarios arising from a hurricane, investing the time and effort into a planning, preparation and practice process is a prudent endeavor. Persons with TBI represent an extremely vulnerable population, particularly in an emergency situation, due to the cognitive, physical, emotional and behavioral impairments stemming from injury. The consequences of moderate to severe TBI can impair the ability to recognize and respond to a weather emergency, and may complicate facility evacuation. Programs serving persons with TBI must plan for weather emergencies, conduct evacuation activities, and provide care during and after the event. Hurricane preparedness is now considered part of the standard of care and an element of best practice for residential TBI programs in coastal regions.

In this paper we reflect on two complete facility evacuations conducted in advance of major hurricanes (Rita, 2005 and Ike, 2008). The lessons learned, how the evacuations influenced changes in emergency preparedness plans, and the creative problem-solving process employed to address unanticipated needs will be reviewed. From our evacuation experiences, three themes emerged and will be illustrated through this narrative reflection. First, while preparing for a hurricane may appear to be a relatively straightforward administrative task, it is actually quite complex, requiring significant planning and forethought.

Planning and preparation beyond what is recommended by li8

BRAIN INJURY PROFESSIONAL

censing/accrediting agencies is necessary. Secondly, while patient care and clinical service delivery are the primary tasks of rehabilitation and must continue following an evacuation, an equal measure of attention must be provided to staff. During and after an evacuation, staff may sacrifice attending to personal needs in order to respond to the emergency and/or to the needs of their patients, potentially placing them at risk for stress-related conditions. Finally, after emerging from the crisis, information and experiences (i.e., “lessons learned�) must be reviewed and incorporated into the hurricane preparedness plan. Lessons learned should be shared to benefit other facilities, and made available to researchers and policy makers interested in using the information to develop evidenced-based guidelines for hurricane preparedness.

DEVELOPING A BASIC PLAN Developing a basic emergency preparedness plan involves critical components: a thorough review of licensing and accreditation standards addressing emergency preparedness, assessing the facility’s vulnerability to a hurricane, and assessing the patient population and resources available to manage them in an emergency.

Review of Licensing and Accreditation Standards All states have an agency responsible for licensing residential facilities providing nursing, rehabilitation, long-term care, and assisted/supported living services. Licensing agencies require written evacuation plans to be filed annually, and notification provided to the agency in the event an evacuation is ordered.

A Team Approach to Evacuation TLC developed a team approach to hurricane preparedness, evacuation, and recovery involving all facility personnel. Three evacuation/response teams were proposed, each with distinct responsibilities. Table 1 describes the primary responsibilities of each team. Team A was responsible for packing and transporting patients to the designated evacuation site, developing a care and activity schedule, and engaging the patients for 24-48 hours following the evacuation. When the emergency resolved, patients were transported back to TLC. If it was necessary to remain away from the facility for an extended period of time, Team B relieved Team A. Team B was responsible for continuing to engage the patients in the care and activity schedule for the next 24-48 hours. Once the “all clear” was given, Team B was responsible for packing the patients and returning to TLC facilities. Team C was engaged when the “all clear” was given. Team C prepared TLC facilities for resumption of normal operations.

Team C was responsible for cleaning and organizing the facility, ensuring basic services were restored and operational (i.e., power, water, computer systems, alarm systems, etc.), and receiving the patients when Team B returned.

Team membership was required of every staff member. Staff was encouraged to select a team assignment consistent with their family situation, skills and experience. Requiring all staff to participate in hurricane preparedness, evacuation and recovery activities, and allowing staff to select the team assignment created Table 1

Evacuation Team Responsibilities

Team A

Assess the Patient Population and Available Resources The last step in developing a basic hurricane preparedness plan is estimating the number of patients requiring evacuation and care, assessing the functional level and special needs of the patient population, and the resources available to manage that population.

Moderate to severe TBI often produces significant impairment in physical, cognitive, emotional, and behavioral functioning (NIH Concensus Statement, 1999). These consequences impair the ability to independently recognize and respond to an emergency situation and can complicate evacuation. Patients with physical impairments who require assistance evacuating (i.e., exiting a building, transferring into a vehicle, etc.), those patients requiring assistance with basic activities of daily living (ADL’s) such as feeding and self-administration of medications, and those with medical co-morbidities (i.e., high blood pressure, diabetes, a seizure disorder, allergy, swallowing problem, etc.) should be identified.

The resources required to conduct an evacuation and meet patient needs following the evacuation should be identified. Determine the number and type of vehicles (e.g., vehicles equipped with a wheel chair lift) required to transport patients away from the facility. Estimate the number of staff necessary to conduct

TLC’s EMERGENCY PREPAREDNESS PLAN PRIOR TO RITA, 2005 The Transitional Learning Center (TLC) developed a basic hurricane preparedness plan as outlined in the previous section. The plan was reviewed and updated at regular intervals. However, over time a significant change occurred in referral and admission patterns and the functional level of the patient population, necessitating a revision in the emergency preparedness plan. The updated plan had to account for the multiple and complex needs of this patient population. The plan required the presence of nursing and clinical staff in the event of a facility evacuation.

Following evacuation order, pack patients and transport to evacuation site Unpack patients; organize belongings and equipment in rooms Implement schedule of activities for patients; implement supervision schedule Continue to care for patients and engage in activities for 24-48 hours

Team B

Assess Vulnerability to a Hurricane and Community Response TLC is located on Galveston Island in the southwestern Gulf of Mexico. The TLC facilities are approximately 9 feet above sea level and are situated behind the city’s protective seawall. However, assessing vulnerability to a hurricane requires more than determining the facility’s distance from the coast, its elevation, and hardiness of construction. It also requires knowledge of the community’s history with and response to hurricanes. For example, the type and accuracy of information available to the public during an emergency (i.e., local radio and television news, the Weather Channel, etc.) should be determined. Designated evacuation routes should be identified and the traffic patterns on those routes during evacuations investigated. The time required to restore basic services (power, clean water, hospital facilities, police and fire service, etc.) after an emergency event should be reviewed.

an evacuation, and the types of staff required to care for the patient population after the crisis has passed (i.e., direct-care staff, nurses, therapists, etc.). Identify the adaptive equipment, medicines, special food, and other supplies (i.e., incontinence supplies, diabetic supplies, etc.) required to deliver care, and how those materials will be transported with the patient population.

A primary evacuation route and an evacuation destination capable of housing the patient population, staff, and equipment/ supplies must also be identified.

Travel to evacuation site and relieve Team A (if necessary) Continue to care for patients and engage in activity schedule for 24-48 hours Pack patients and transport back to TLC facilities when “all clear” is announced

Team C

When evacuating, agencies require facilities to report the number of patients and staff evacuating, and their destination. The agency follows up with the facility after the emergency. (Licensing Standards for Assisted Living Facilities Handbook, 2009).

Many facilities providing medical, rehabilitation, vocational, and/or long-term care services to persons with brain injury also seek accreditation from an outside agency. The Commission on Accreditation of Rehabilitation Facilities (CARF), an accrediting agency for brain injury services, is responsible for developing standards for emergency preparedness. CARF standards require: 1) a written plan for weather and/or other event(s) specific to the geographic location of the facility; 2) contingencies for a complete facility evacuation, including the disposition of both staff and patients; 3) a test of the plan at least annually and an evaluation of the plan’s effectiveness and efficiency; and 4) staff to receive training regarding the preparedness and evacuation plan, including their specific roles and responsibilities (CARF Medical Rehabilitation Standards Manual, 2001).

Travel to TLC facilities and prepare for resumption of normal operations Clean facility and grounds; ensure basic services are operational (power, water, etc.)

Receive patients when Team B arrives at the facility Unpack patients and organize belongings and equipment in rooms

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facilities conducted after hurricanes Katrina and Rita indicated mortality was higher for frail elderly in facilities that evacuated in advance of a hurricane as compared to facilities that sheltered in place (Dosa, Grossman, Wede & Mor, 2007). TLC administration opted to follow recommendations from local authorities.

Unless a mandatory evacuation was ordered, patients and staff would shelter in place. Only the TLC Administrator and Medical Director had authority to order a facility evacuation.

a sense of equity, ensured “buy in” by all staff, and encouraged a sense of responsibility to the patients and TLC organization.

When the preparedness plan was reviewed annually (prior to the beginning of hurricane season), staff was allowed to change team assignment if their status had changed since the previous year.

Additional Components of the TLC Emergency Preparedness Plan Identification of a primary evacuation site.

A hotel north of Houston, Texas (about 60 miles inland) capable of accommodating a large group of patients and staff was selected as the primary evacuation site. The hotel was contacted at the beginning of each hurricane season (June 1st) and a bank of rooms for a group of 50 was “reserved” in the event an evacuation was necessary.

Pre-evacuation protocols were developed for specific departments in the event of a hurricane.

When a hurricane entered or formed in the Gulf of Mexico and Galveston was within the high probability strike cone, physical plant staff and designated facility support staff was assigned to monitor weather information and announcements from local authorities (i.e., local weather station, city and county offices of emergency management, etc). Physical plant staff was responsible for fueling all facility vehicles and for securing items that might move about in high winds (i.e., furniture, planter boxes, trash cans, etc.) and cause damage to the facility or injure patients and staff. Nursing and Residential staff was responsible for organizing patient belongings (clothing, adaptive equipment, etc.), preparing food for patients on special diets, and packaging medications. Case Management staff was responsible for contacting families and funding sources and informing them of a possible facility evacuation, reminding them of our evacuation destination, and allowing families an option to take their loved one home until the storm passed. Information Technology staff was responsible for securing computers, servers and other information technology.

Criteria for evacuating the facility and administrative authority.

Not all emergencies require facility evacuation. Risks are involved in evacuating persons with physical and cognitive impairments, and medical problems. Studies of nursing and assisted living 10 BRAIN INJURY PROFESSIONAL

Rehearsal of a complete facility evacuation.

Research demonstrates practice is essential to hurricane planning and preparedness (Gebbie, Horn, McCullom & O’Hara, 2009; Slattery, Syvertson & Krill, 2009). In order for staff to participate in an evacuation rehearsal, and to ensure continuity of facility operations (i.e., therapy, billing, etc.), the evacuation drill must be incorporated into usual facility practices. TLC’s programs participate twice yearly in a three-day special activities camps. Camp attendance was used to rehearse a full facility evacuation. The location of the camp (“Camp-for-All”) is approximately 90 miles inland in Burton, Texas, about a 2-hour drive from Galveston. The majority of rehabilitation and long-term care patients participate in this activity. The camp is fully accessible and offers a range of adapted recreational activities. Participation in the camp requires packing three days of clothing, food for special diets, medicines, and necessary adaptive and durable medical equipment to provide care. It requires loading and transporting patients and their belongings to camp, unpacking, and engaging patients in an activity schedule. At the end of camp, patients must be packed and transported back to TLC. These same activities are required in a facility evacuation.

The elements in the emergency preparedness plan outlined above met or exceeded all state health licensing and CARF requirements. However, planning for and actually responding to a hurricane, as illustrated in the descriptions that follow, can be very different endeavors altogether.

HURRICANES KATRINA AND RITA, 2005 – LESSONS LEARNED Hurricane Katrina Hurricane Katrina, a powerful category 3 hurricane at landfall (winds 111-130 miles per hour), struck the Louisiana coast approximately 30 miles northeast of New Orleans on August 29, 2005. Katrina caused catastrophic property damage and killed 1,833 persons across 5 southeastern states (Carpender, Campbell, Quiram, Frances & Artzberger, 2006). Over 1,500 were killed in Louisiana. Most deaths resulted from storm surge, the extensive flooding caused by the wall of water preceding the eye of the hurricane. People over the age of 60 constituted the majority of storm-related deaths. A considerable number who perished were in residential care facilities.

Hurricane Rita – Inadequacy of Our Plan Less than one month after Katrina made landfall near New Orleans, hurricane Rita formed in the Gulf of Mexico. As Rita tracked westward across the Gulf of Mexico, Galveston was placed within the high probability strike cone. The local and national media began re-broadcasting images of the destruction caused by hurricane Katrina. A few days prior to landfall, Rita grew into a powerful category 5 hurricane with winds in excess of 175 miles per hour and a predicted storm surge of approximately

18 feet. Meteorologists forecasted the storm surge would likely engulf the island of Galveston and inundate the area surrounding Galveston Bay. Houston, Texas would likely sustain severe damage from rising water, high winds, and heavy rain.

Based on this information, it was apparent our hurricane preparedness plan was inadequate. Though the plan met or exceeded standards established by the state health agency and CARF, certain aspects of the plan were inadequate for a category 5 hurricane. The plan did not move patients and staff far enough inland to avoid the storm surge and strong winds associated with a category 5 storm. The facility (hotel) identified as the primary evacuation site did not meet the patient needs. There were not enough beds to accommodate the patients requiring evacuation and the number of staff needed to provide care. Toilet and shower facilities were not accessible in all rooms. There were a limited number of washers/dryers to launder clothing and bed linens for incontinent patients. There were no cooking facilities to prepare special diets for patients with dysphagia, diabetes, and/or heart conditions. The hotel had little or no storage space for durable medical equipment, and no space for conducting group activities.

On Tuesday, September 20, 2005, just 4 days before landfall, TLC’s management team assembled and discussed options.

The primary task before the management team was locating an accessible facility large enough to accommodate patients, staff, and equipment necessary to provide care. Facilities in Texas providing post-acute and long-term care services to adults with TBI were contacted. All facilities contacted offered assistance. The CORE facility (formerly Brown-Karhan), located a few miles west of Austin, Texas, was selected as it was the closest facility.

The management team reviewed the remainder of the plan and agreed to follow established duties and role responsibilities outlined in team assignments, and to follow the other facility preparedness protocols. TLC’s Administrator and Medical Director issued the order to evacuate at 8 a.m. on Wednesday, September 21, 2005.

Unfortunately, media reports panicked the public. Approximately 2.5 million residents in the Houston/Harris County area began a mass exodus (Stein, Duenas-Osorio Subramanian, Post, Zuiener, Hoffman, & Feldman, 2009). Vehicles overwhelmed the roadways and within a few hours, all routes leading away from Houston were inundated with traffic. A trip across the Houston metropolitan area that generally took one hour required as many as 24 hours to complete. Service stations and convenience stores ran out of gasoline and basic staples such as snack food and bottled drinks. Lack of restroom facilities along evacuation routes resulted in unsanitary disposal of human waste, creating a potential public health hazard.

Hurricane Rita turned northeastward and missed the Galveston-Houston area, making landfall near the Texas-Louisiana border on September 24, 2005. Rita contributed to the deaths of 119 people, 113 of those in Texas. Sadly, only 6 of the deaths were attributed to the storm. The other 107 deaths were caused by activities related to the evacuation (Carpender, et al, 2006).

As was the case with hurricane Katrina, the most vulnerable in the population, the elderly, the sick, and the disabled were the largest casualties of the evacuation.

Lessons Learned from Rita The evacuation experience in advance of hurricane Rita evacuation provided TLC with a wealth of information, all consistent

with the post Katrina-Rita evacuation literature (Department of Health and Human Services, 2006). The difficulties encountered included: Transportation While the number of TLC vehicles was adequate to transport patients and staff, there was little space for equipment, food, medicines, medical records, clothing and other supplies. The trip to CORE, normally a 4-5 hour drive, required 12-14 hours.

Staff and patients remained in cramped seating arrangements for the duration of the evacuation. Traffic density precluded exiting the roadway for a meal, stretch or bathroom break. Vehicles were separated in traffic resulting in a disorganized arrival at the CORE facility.

Communication Communication with staff and families was difficult. Families and staff had been provided the number to the hotel in Houston, the original evacuation site, not the number to the CORE facility. Staff had provided supervisors with the phone number corresponding to a location in or near Houston. Most staff, however, opted to travel further inland and was not at the number provided. Cell coverage was “spotty” at best, making it difficult to contact families and staff in order to provide current contact information.

Care for Patients and Staff Patients and staff were spread over three of the CORE campuses, restricting the implementation of planned care and activity schedules. Team B staff were unable to relieve Team A due to congested roadways and fuel shortages. Staff quickly began showing signs of stress. Many were unable to sleep, most were working long hours providing direct care, and all were concerned about family and property.

The management team was assembled and established a very basic daily activity schedule around meals, medicine administration times, and ADL activities. Collaboration between the host facility and TLC allowed for CORE staff to rotate into the activity schedule and care for TLC patients. This collaboration allowed TLC staff brief periods away from patient care duties to rest, sleep, exercise, read, or leave campus. A reliable land line was accessed and family members of patients were contacted. A communication schedule was established allowing families daily phone contact with their loved one. The management team continued to meet daily to ensure staff needs were met.

Team A staff and patients returned to TLC facilities on Monday, September 26, 2005. Per the emergency preparedness plan, Team C staff cleaned and organized the facilities, and received patients. Within a week of returning, staff was debriefed and changes to the emergency preparedness plan were proposed.

What Worked Not all aspects of the plan were revised. The staff orientation and review of the emergency preparedness plan at the beginning of each hurricane season (i.e., June 1st), phone trees and the team approach to evacuation, and the protocols developed to prepare the patients and facility for evacuation remained in the plan. The responsibility of case management to contact families and funding sources prior to evacuation, the criteria for evacuating, and administrative authority for ordering an evacuation remained in the plan.

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What Changed Evacuation Facility Camp-for-All, the facility hosting biannual weekend activities camps for our patients, was identified as the primary evacuation site; CORE remained the back up evacuation site.

Transportation A large, covered utility trailer was purchased to transport food, clothing, medical records, and equipment. Primary and secondary evacuation routes were identified. Maps displaying evacuation routes, and locations of fuel, food, and medical care on the routes were laminated and placed in vehicles. A “preparation team” and a “communications officer” were proposed and added to the plan. These team members were to leave immediately when the evacuation order was given and ensure the primary evacuation route was clear, to prepare the primary evacuation site for arrival of the patients and staff (i.e., room/bed assignments, placing linens on beds, unloading equipment, etc.), and to communicate with families and staff.

Communications Phone and web-based messaging was developed, allowing families and staff to log-on to the TLC web-site, or call a phone number to access updated information about the status of staff and patients, and to receive instructions.

Caring for Patients and Staff A simple schedule of activities around meals, medications and ADL’s that could be quickly implemented upon arriving at the evacuation site was developed. Vehicle and room assignments would be decided prior to evacuating. A staff rotation schedule would be developed upon arriving at the evacuation site to prevent staff burn out.

The updated hurricane preparedness plan addressed all the shortcomings (i.e., “lessons learned”) identified from the hurricane Rita evacuation. The revised plan was rehearsed annually, and the plan was reviewed with all staff at the beginning of each hurricane season. Staff was allowed to change team assignment at the beginning of the hurricane season. Revisions to plan were not put to the test until 2008.

HURRICANE IKE, 2008 – LESSONS LEARNED In early September, 2008, hurricane Ike entered the Gulf of Mexico. Though criteria for evacuating had not changed, the decision to evacuate was difficult. The extreme conditions experienced by patients and staff in 2005 while evacuating in advance of hurricane Rita, and a rapidly changing path as Ike tracked across the Gulf of Mexico were important considerations. Sheltering in place was preferred, if possible.

Mid morning on Thursday, September 11, 2008, a mandatory evacuation order was issued by Galveston’s mayor. TLC’s management team met to review the evacuation plan. No changes were recommended. TLC’s Administrator and Medical Director issued the evacuation order at 7 a.m. on Friday, September 12, 2008. The “prep team” departed in advance of patients and Team A staff, and prepared the evacuation facility for arrival. The main evacuation group arrived approximately two hours after leaving Galveston. By early afternoon, a schedule of activities had been developed, a staff rotation schedule was in place, and the communications officer had contacted families announcing our safe arrival at the evacuation site. The changes 12 BRAIN INJURY PROFESSIONAL

to our evacuation plan following hurricane Rita resulted in a flawless evacuation.

Hurricane Ike - Inadequacy of our Plan Unfortunately, unlike Rita, hurricane Ike did not make a turn to the northeast prior to landfall. In the early hours of Saturday, September 13th, the eye of hurricane Ike struck the east end of Galveston Island. Winds in excess of 100 miles per hour and a storm surge of over 13 feet devastated the island. TLC facilities sustained severe damage from rising water. A return to Galveston was not possible.

While lessons learned from hurricane Rita resulted in significant changes in the hurricane preparedness plan, it did not account for a disaster of this magnitude. TLC’s management team was assembled and options discussed. The management team opted to temporarily relocate patients and staff to a “sister” facility recently opened in Lubbock, Texas until other arrangements could be made. As Lubbock was a 12-hour drive from our evacuation site, a comprehensive travel plan was developed.

Families and TLC staff were notified of the plan. Team B staff were contacted and a partial staff rotation occurred prior to departing for Lubbock.

After arriving in Lubbock, routines for patient care and a staff rotation schedule were established. Patients participating in rehabilitation were admitted to the Lubbock post-acute program. Long-term care patients were housed on a separate wing of the Lubbock facility.

Over the next 3 weeks, B and C Team staff rotated in and out of Lubbock, providing care to patients and allowing A Team members to return home. Administrative staff searched for a temporary facility near Galveston. In early October, space was located in a nursing facility in northern Galveston County capable of accommodating both rehabilitation and long-term care patients. One wing of the facility was leased for rehabilitation, a second wing for long-term care. Staff and patients returned to Galveston County in mid October, 2008, and rehabilitation and long-term care programming resumed in the leased space.

Lessons Learned from Ike - Unanticipated Staff Needs Staff presented a number of unanticipated needs following hurricane Ike. Contingencies to meet these needs were not part of the hurricane preparedness plan prior to Ike. Financial support Staff residing in Galveston was unable to return to their homes.

Many staff could not afford the additional expense associated with leasing an apartment or renting a hotel room for an extended period. TLC provided a one-time cash advance for living expenses to staff impacted by hurricane Ike. Transportation Staff on the A Team left personal vehicles at TLC prior to evacuating. These vehicles were damaged or destroyed in the storm.

TLC allowed staff to use facility vehicles for transportation to and from work. TLC’s Administrator and Medical Director negotiated with a local automobile dealership to offer special pricing and financing to staff that lost vehicles in the storm. Staff offering personal vehicles for car pools received an allowance for fuel.

Reassurance Staff required considerable reassurance regarding employment.

TLC’s Board of Directors opted to repair the facilities on Galveston Island and resume rehabilitation and long-term care programming as quickly as possible. All staff employed at the time of the storm was retained. Though this information was enthusiastically communicated to staff, some opted to resign and seek other employment. This eventually created a temporary staffing shortage.

Something to do Many staff, particularly some members of Teams B and C and those not providing patient care, were idle for several weeks following the storm, causing anxiety and provoking concerns about maintaining employment. Once Galveston was deemed safe for citizens to return, TLC staff was contacted and work crews were assembled. TLC staff cleaned facilities, discarded damaged furniture and equipment, and placed usable items into protective “pods”. Staff also helped inventory losses and damages for insurance claims. Staff assisted with preparing the temporary program location for rehabilitation and long-term care activities (i.e., purchasing supplies, setting up office and treatment space, etc.). Providing staff with opportunities to be productive was a crucial element in the recovery effort following the storm, and proved to be beneficial for staff retention.

What Worked Following the storm, staff was debriefed in an effort to determine what aspects of the emergency preparedness plan worked and those that did not. It was determined that all of the changes made to the plan following hurricane Rita resulted in an orderly and efficient evacuation. The changes in the communication systems allowed B and C Teams to be fully engaged in evacuation and recovery activities.

What Changed Lessons learned from Ike resulted in another significant revision of the hurricane preparedness plan.

Lease space for interim use A contingency was developed for leasing space in the event TLC facilities were unable to be occupied following a future storm.

This contingency involved making tentative arrangements with “sister facilities” (i.e., rehabilitation facility in Lubbock, nursing facilities in the Houston area), a strategy recommended by nursing facilities in Louisiana damaged from hurricanes Katrina and Rita (Dosa, et al, 2007).

Placement of patients after the storm TLC Case Managers placed patients in other rehabilitation facilities following Ike to ensure continuity of care and rehabilitation. This case management duty was incorporated into the revised plan.

Meeting staff needs following the storm Contingencies were developed to provide financial assistance to staff on an as-needed basis (i.e., for housing, etc.), providing TLC vehicles to transport staff to and from work, and providing a fuel reimbursement for staff offering personal vehicles for car pooling.

Staff well-being Contingencies were added to the plan to provide staff with information, reassurance, debriefing, productive activities, and stress management/resilience exercises immediately after the storm.

DISCUSSION Facilities providing residential services to persons with TBI in coastal areas are potentially vulnerable to hurricanes. Thoughtful planning is required as persons with moderate to severe TBI represent a vulnerable population and are dependent upon staff to conduct evacuations and provide care during and after a storm.

Hurricane preparedness is required by state licensing and accreditation agencies, and is considered an element of best practice. Standards require written preparedness plans specific to the type(s) of emergencies that might occur given the geographic location of the facility. Standards also require the plan to account for staff and patients in the event an evacuation is necessary, and to provide education and training to facility staff.

However, despite mandates from licensing and accrediting agencies, not all facilities have a plan. Following hurricanes Katrina and Rita in 2005, it was determined that several nursing facilities and assisted living facilities were without an evacuation plan (Carpender, et al., 2006). Even when plans are in place, not all staff knows about them. A survey conducted in 2005 found that many health care professionals had limited awareness of their facility’s emergency plan (Gebbie, Silber, McCullum, and Lazar, 2007).

Standards also require facilities to rehearse and evaluate evacuation activities. Research indicates that practice is essential in emergency planning and preparedness (Gebbie, et al., 2009; Slattery, et al., 2009). When possible, in order to ensure staff participation and continuity of facility operations, the evacuation drill should be incorporated into usual facility practices.

It is also important to review and revise the plan periodically, considering the current functional level of the patient population and resources required for an evacuation. Following hurricanes Katrina and Rita, it was discovered that some facilities contracted with the same bus or ambulance service for evacuation, causing an extreme shortage in vehicles to transport patients out of harm’s way (Carpender, et al., 2006).

The community surrounding the facility is another important consideration when developing or revising an emergency preparedness plan. Recent reports indicate that enhanced weather predictions, as well as improved construction standards and the placement of man-made barriers (e.g., seawalls) create a false sense of security among residents of coastal communities vulnerable to hurricanes (Carpender, et al., 2006). As was seen in the chaotic evacuation in advance of hurricane Rita in 2005, overdevelopment in coastal regions and sources of information received by residents regarding an approaching storm can affect traffic patterns and efficiency of evacuations (Stein, et al., 2009).

Noticing and responding to staff needs is yet another consideration for hurricane planning. During an emergency situation, staff is likely to focus on the crisis or needs of their patients, rather than attending to personal needs. Exposure to stress brought on by physical exhaustion, lack of sleep, and concerns about family and property can create burnout and may increase risk for developing post-traumatic stress disorders (Brandt, Fullerton, Saltzgaber, Ursano & Holloway, 1995). Our experiences during and after evacuations demonstrated the benefits of providing staff with information, reassurance, and productive activities (“something to do”). Conducting debriefing sessions and BRAIN INJURY PROFESSIONAL

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stress management/resilience exercises immediately after the crisis proved beneficial to our staff. These interventions have also been suggested for rescue and health care workers who respond to disasters (Brandt, et al., 1995).

In conclusion, our experiences suggest that preparation beyond what is required by the standards is necessary. While the planning process appears to be relatively straightforward, actually responding to an emergency is another matter altogether.

Though the emergency preparedness plans prior to Rita and Ike met or surpassed state health and CARF standards, both were inadequate to meet the challenges of the crisis at hand. In both instances the plans failed. Relying on the wisdom and experience of the TLC leadership, and the creativity and flexibility of the staff was required to overcome shortfalls of the plans. We recommend contemplating a worst case scenario and developing contingencies accordingly.

References

Brandt, G.T., Fullerton, C.S., Saltzgager, L., Ursano, R.J. & Holloway, H. (1995). Disasters: Psychologic responses in health care providers and rescue workers. Nord J Psychiatry, 49, 89-94.

Carpender, S.K., Campbell, P.H., Quiram, B.J., Frances, J & Artzberger, J.J. (2006). Urban evacuations and rural america: Lessons learned from hurricane rita. Public Health Reports, 121, 775-779.

Commission on Accreditation of Rehabilitation Facilities (2001). Medical Rehabilitation Standards Manual, Tuscon, Arizona.

Department of Health and Human Services, Office of the Inspector General (2006). Nursing home emergency preparedness and response during recent hurricanes. Washington, DC: Office of the Inspector General, US Department of Health and Human Services, Thousand Oaks, California.

Dosa, D.M., Grossman, N., Wede, T. & Mor, V. (2007). To evacuate or not to evacuate: Lessons learned from louisiana nursing home administrators following hurricanes katrina and rita. J Am Med Dir Assoc, 8, 142-149.

Gebbie, K.M., Horn, L., McCollum, M., & O’Hara, K. (2009). Building a system for preparedness: The NYCEPCE NEST experience. Journal of Public Health Management and Practice, 15 Supplement, 53-57.

Gebbie, K., Silber, S. McCollum, M. & Lazar, E. (2007). Activating physicians within a hospital emergency plan: a concept whose time has come? Am J Disaster Med, 2, 74-80.

NIH concensus development panel on rehabilitation of persons with traumatic brain injury (1999). JAMA, 282, 974-983.

Slattery, C., Syvertson, R. & Krill, S. (2009). The eight step training model: Improving disaster management leadership. Journal of Homeland Security and Emergency Management, 6, 1-13.

Stein, R., Duenas-Osorio, L, Subramanian, D., Post, S., Zuiener, L., Hoffman, D. & Feldman, I. (2009) A comparison of the experiences of harris county residents during hurricanes rita and ike. http://www.media.rice.edu/images/media/0312_CCE_HurricaneIke_report.pdf. Accessed September 29, 2009.

Texas Department of Aging and Disability Services (2009). Licensing Standards for Assisted Living Facilities Handbook. http://www.dads.state.tx.us/handbooks/ls-alf. Accessed September 29, 2009.

About the Authors

Gary Seale is the Director of Clinical Programs at the Transitional Learning Center at Galveston. He has worked exclusively in post acute brain injury rehabilitation since 1990. Mr. Seale received his Master’s degree in Psychology from Jacksonville State University in Jacksonville, Alabama, in 1982. He is licensed in Texas as a Psychological Associate and Chemical Dependency Counselor. He is also a pre-doctoral student in the Rehabilitation Sciences division of Preventative Medicine and Community Health at the University of Texas Medical Branch in Galveston. Mr. Seale was instrumental in developing and implementing TLC’s hurricane evacuation plan and is responsible for training TLC and TideWay staff regarding hurricane preparedness. Mr. Seale was a member of the evacuation and recovery team during hurricanes Rita and Ike. Brent E. Masel M.D. is the President and Medical Director of the Transitional Learning Center at Galveston. Dr. Masel received his Medical Degree from the Loyola University Stritch School of Medicine, and completed his postgraduate training from the University of Texas Medical Branch. He is a Board Certified Neurologist. After 16 years of private practice, he accepted his position with TLC. He holds clinical appointments at UTMB in the Departments of Neurology, Internal Medicine, Family Medicine, Physical Therapy and Occupational Therapy. He has conducted research and published in the areas of brain injury rehabilitation and virtual reality, as well as sleep abnormalities, metabolic abnormalities, and hormonal dysfunction after brain injuries. Dr. Masel is the President of the United Way of Galveston, and on the Board of Directors of the TIRR Foundation, the North American Brain Injury Society, and the Brain Injury Association of America. He is the recipient of the Lifetime Achievement Award from the Brain Injury Association of Texas and the Innovations in Clinical Treatment Award from the North American Brain Injury Society.

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S Y S T E M S

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A COMPARISON OF MENTAL HEALTH FINDINGS AMONG OKLAHOMA CITY BOMBING SURVIVORS AND HURRICANE KATRINA EVACUEES

by Carol S. North, MD, MPE

Introduction Comparison of divergent findings from disaster studies may clarify needs for varied approaches to mental health responses specifically targeted for particular disaster scenarios. Two published disaster mental health studies, one of survivors of the Oklahoma City bombing and another of sheltered Hurricane Katrina evacuees, both independently conducted by the author’s research team, have yielded remarkably different findings. This article will compare findings from these two studies to inform disaster interventions and future research.

Psychosocial effects on survivors of the Oklahoma City Bombing The bombing of the Murrah Federal Building in Oklahoma City on April 19, 1995 was, at the time, the most severe terrorist act perpetrated on American soil. In a landmark study conducted approximately 6 months after the bombing, 182 directly exposed adults were randomly selected from a state registry of survivors, with a 71% participation rate.1 The Diagnostic Interview Schedule (DIS) for DSM-III-R2 and the DIS Disaster Supplement3 were used to assess full diagnostic criteria for both postdisaster and predisaster psychiatric disorders as well as other variables relevant to disaster exposure.

The sample of Oklahoma City bombing survivors was approximately one-half male, middle-aged, predominantly Caucasian, educated through two years of college, employed, and more often than not currently married. This sample was highly exposed to the bomb blast: approximately one-third were in the Murrah Building at the time of detonation, and the rest were either unprotected in outside locations or in nearby buildings that were badly damaged where people were injured or killed. Most (87%) of the study participants sustained injuries in the bombing and 20% of the participants were hospitalized for injuries.

Despite their high level of exposure to this disaster, the majority of the survivors did not develop a psychiatric disorder afterward. Among those who did not develop a psychiatric disorder, however, nearly all (96%) had one or more symptoms of posttraumatic stress disorder (PTSD). Such prevalent posttraumatic symptoms in the absence of psychiatric illness can be interpreted as representing normative distress. PTSD related to the bombing was the most prevalent postdisaster diagnosis, identified in 34%; women (45%) had approximately twice the rate of men (23%).

The second most common postdisaster disorder was major depression, diagnosed in 23%.

Nearly two-thirds (63%) of those with bombing-related PTSD had a comorbid postdisaster psychiatric disorder. Additionally, more than one-half (57%) of those with PTSD had a predisaster disorder. Predisaster psychiatric illness more than doubled the 16 BRAIN INJURY PROFESSIONAL

likelihood of having a postdisaster psychiatric disorder. No new alcohol or drug use disorders were identified after the disaster. Somatization disorder, antisocial personality disorder, schizophrenia, and bipolar disorder were not among the disorders found.

The onset of PTSD was rapid, with 76% of cases beginning the day of the bombing, 94% within one week, and 98% within one month. There were no delayed-onset PTSD cases (defined

by DSM criteria as beginning at least 6 months after the event).

All PTSD cases were chronic (defined by DSM criteria as lasting at least 3 months).

The three defining groups of PTSD symptoms were not all equivalent in their prevalence and in their associations with indicators of psychopathology. Criteria for groups B (intrusive reexperience) and D (hyperarousal) were each met by about 80% of the sample, but group C (avoidance/numbing) criteria were met by only about one-third of the sample. Compared to group C symptoms, symptoms of groups B and D were much more prevalent. The B and D symptom groups alone, in the absence of group C, did not reflect psychopathology. Group C criteria were pivotal to the development of PTSD: 94% of those meeting group C went on to meet full criteria for PTSD, and, by definition, none of those not fulfilling group C developed PTSD. Symptom group C further predicted other indicators of psychopathology: predisaster psychiatric illness, postdisaster psychiatric comorbidity, receiving mental health treatment, taking psychotropic medication, coping by drinking alcohol, and interference with functioning. In contrast, symptom groups B and D in the absence of group C did not predict PTSD or these other indicators of psychopathology.

The Oklahoma City bombing study and other major studies of disasters have yielded consistent findings from which several general principles of disaster mental health have been established.

These findings are described in substantial detail in published reviews of many disasters involving tens of thousands of survivors.4-8

Mental health problems of sheltered Hurricane Katrina evacuees Hurricane Katrina was the costliest disaster in American history, and one of the deadliest.9,10 A study by this author’s research team examined the psychiatric records maintained on evacuees who sought mental health services in the medical clinic of a temporary Dallas shelter.10 A total of 503 unique mental health contacts were recorded among 421 patients treated between September 1 and 15, 2005. This group of evacuees was 55% female, 76% AfricanAmerican with few other minorities, and 40 years of age on average (with 8% of the patients comprising children under age 18). Of the patients for whom insurance information was available, 32% were uninsured, 48% had public insurance, 9% had VA benefits, and only 11% had private insurance. This sociodemographic pro-

file reflects problems of an economically disadvantaged population.

About 10% of these individuals were directly exposed to hurricane wind or subsequent flooding, and 5% were physically injured in the disaster.

The most frequent presenting complaint among these patients was need for psychotropic medication refill (28%). Antipsychotic medication (20%) represented the psychotropic agent refill most requested, followed by antidepressants (17%) and benzodiazepines (11%). The most common symptom complaint was insomnia (21%) followed by sadness (17%) and anxiety (16%). Only 5% presented for management of posttraumatic symptoms. Among the children served in the mental health clinic, nearly three-fourths presented for management of attention deficit/hyperactivity disorder, all of which represented pre-existing problems.

Unlike the findings of most other disaster studies, PTSD was not the most common psychiatric problem identified from the clinic’s mental health records in this study. A diagnosis of PTSD was recorded in 3% of the records and acute stress disorder in 9%.

The most prevalent psychiatric diagnosis recorded in the medical record was major depression (25%), most of these cases having predated the hurricane. The next most prevalent psychiatric diagnostic category was schizophrenia/schizoaffective disorder, diagnosed in 21%, all of which predated the hurricane.

More than one-fourth of the patients (28%) had a pre-existing serious and persistent mental illness (defined as schizophrenia/ schizoaffective disorder or bipolar disorder). Alcohol use disorders were identified in 20% and cocaine use disorders in 17%. Additionally, mental retardation, autism, attention deficit disorder, delirium, and dementia were represented in this population. Overall, 40% of patients presented with a predisaster history of any of the above disorders, a far higher percentage than the 24% who presented with a new-onset postdisaster disorder.

Implications for postdisaster mental health interventions and disaster research Disaster mental health research has traditionally focused on PTSD or PTSD symptoms. The picture emerging from the study of sheltered Hurricane Katrina evacuees reviewed here, however, differs from more traditionally reported mental health outcomes reported in studies of other disaster-affected populations such as the Oklahoma City bombing survivors. This paper’s comparative review of two distinct disaster-affected populations and settings in studies of the Oklahoma City bombing and Hurricane Katrina found two collective sets of problems with very different needs for interventions, yielding significant implications for service delivery and research studies.

The prominent finding among sheltered Hurricane Katrina evacuees was an abundance of unmet treatment needs for serious and persistent psychiatric illness. These problems were endemic in the population long before the disaster, however. An unusual characteristic of the population of sheltered Hurricane Katrina evacuees was the marked socioeconomic selection bias inherent in the evacuation after the hurricane and the associated pre-existing chronic and severe mental illness, including substance abuse, endemic in this population. A large proportion of the Dallas shelter population consisted of evacuees who were transported by bus after the disaster because they lacked resources to evacuate by their own means before the hurricane. This group represented a disproportionately underprivileged segment of the population of the New Orleans area that could be expected to have (long before Hurricane Katrina) an endemic overrepresentation of chronic medical and mental health

problems including substance abuse.10,11 Careful interpretation of research findings resulting from interviews of Oklahoma City bombing survivors and study of psychiatric records of sheltered Hurricane Katrina evacuees yields concrete directions for interventions requiring very different strategies for these two different populations. Oklahoma City bombing survivors with PTSD will be best served by the availability of appropriate treatment for PTSD; more generic interventions for distress, such as psychological first aid, may be helpful for most survivors because of the nearly universal psychological distress following exposure to the bomb blast. For the sheltered Hurricane Katrina evacuees with ongoing serious and persistent mental illness including longstanding substance abuse problems, the intervention needs are more complex. Although psychological first aid was appropriate for the majority of distressed Hurricane Katrina survivors in the shelter, the main tasks in the psychiatry clinic were rapid diagnostic assessment, resumption of psychotropic medications, and linkage to ongoing psychiatric care for these disorders. Distinctly divergent research findings from these two very different disaster scenarios may help guide future disaster intervention plans to target mental health needs most effectively according to anticipated needs in these different populations and settings.

References

1. North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, Smith EM. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282(8):755-762.

2. Robins LN, Helzer JE, Cottler L, Goldring E. NIMH Diagnostic Interview Schedule, Version III-Revised, 1989.

3. North CS, Pfefferbaum B, Robins LN, Smith EM. The Diagnostic Interview Schedule/Disaster Supplement (DIS-IV/DS), 2001.

4. North CS, Hong BA, Pfefferbaum B. P-FLASH: development of an empirically-based post9/11 disaster mental health training program. Mo Med. 2008;105(1):62-66.

5. North CS. Epidemiology of disaster mental health response. In: Ursano RJ, Fullerton CS, Weisæth L, et al., ed. Textbook of Disaster Psychiatry. New York: Cambridge University Press, 2007: 29-47.

6. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry. 2002;65(3):240-260.

7. Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry.

2002;65(3):207-239.

8. North CS. Psychiatric effects of disasters and terrorism: empirical basis from study of the Oklahoma City bombing. In: Gorman JM, ed. Fear and Anxiety: The Benefits of Translational Research. Washington, DC: American Psychiatric Publishing, 2004: 105-117.

9. Norris FH, Rosen CS. Innovations in disaster mental health services and evaluation: national, state, and local responses to Hurricane Katrina (introduction to the special issue). Adm Policy Ment Health. 2009;36(3):159-164.

10. North CS, King RV, Fowler RL, Polatin P, Smith RP, LaGrone A, Tyler D, Larkin DL, Pepe PE. Psychiatric disorders among transported hurricane evacuees: acute-phase findings in a large receiving shelter site. Psychiat Ann. 2008;38(2):104-113.

11. Greenough PG, Lappi MD, Hsu EB, Fink S, Hsieh YH, Vu A, Heaton C, Kirsch TD. Burden of disease and health status among Hurricane Katrina-displaced persons in shelters: a population-based cluster sample. Ann Emerg Med. 2008;51(4):426-432.

About the Author

Carol S. North, MD, MPE, is the Nancy and Ray L. Hunt Professor of Crisis Psychiatry and Director of the Program in Trauma and Disaster at the VA North Texas Health Care System and also a Professor in the departments of Psychiatry and Surgery/Emergency Medicine in the Division of Homeland Security at UT Southwestern Medical Center in Dallas, Texas. For more than two decades, Dr. North has continuously conducted federally funded research investigation into mental health effects of disasters, psychiatric aspects of medical illness, psychiatric issues in homeless populations, and has developed specialized education programs for professionals, patients, and families. She and her research team have studied nearly 3,000 survivors of major disasters, including the bombings in Oklahoma City and the US Embassy in Nairobi, Capitol Hill anthrax attacks, the September 11th terrorist attacks, and Hurricane Katrina. Dr. North has trained thousands of mental health and other health professionals on disaster preparedness and has provided expertise and leadership for major disaster response operations.

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DISASTER CASE MANAGEMENT Case Management and Individuals with Disabilities Following Hurricane Katrina

by Laura M. Stough, PhD, Amy N. Sharp, PhD, Curt Decker, JD and Nachama Wilker This article, submitted for inclusion in an upcoming issue of Rehabilitation Psychology, investigates the long-term recovery of individuals with disabilities following Hurricane Katrina through data collected from disaster case managers. Case management is frequently used by disaster relief organizations to coordinate resources and to provide a single-point of service delivery to those affected by disaster. Disaster case management usually involves the development of a disaster recovery plan and has as its objective to restore a disaster victim to or near their pre-disaster living status. Faith-based organizations frequently use a case management model as a vehicle to distribute resources donated by their member organizations to their disaster-affected clients. The Red Cross, United Methodist Committee on Relief, Lutheran Social Services, and Catholic Charities, are the largest disaster organizations that use case management as a tool.

In this study, case managers, along with their supervisors who were part of the Katrina Aid Today (KAT) National Case Management Consortium were interviewed to better understand the needs of individuals with disabilities post-disaster. Katrina Aid Today was the largest single coordinated case management program used in the U.S. in response to disaster and had as its goal to provide case management to 100,000 families affected by Hurricane Katrina. Nine member organizations were part of the original consortium, and were later joined by 16 grassroots organizations that also used case management. The National Disability Rights Network (NDRN) joined the consortium with the primary objective of providing case management specifically to individuals with disabilities. NDRN is the umbrella non-profit organization for the federally-funded Protection and Advocacy agencies (P&As) that are the largest network of legally-based advocacy services to individuals with disabilities in the U.S.

Method

This study collected data from two groups; 47 case managers, who provided direct case management services to disaster survivors, and 12 case management supervisors, who oversaw the administrative and managerial components of the program. All participants were employed by an NDRN-affiliate in either Louisiana, Mississippi, Alabama, Texas, or Georgia, which were also the states to which the largest number of Katrina survivors relocated postdisaster. The case managers collectively provided case management 18 BRAIN INJURY PROFESSIONAL

to a group of 2,207 individuals with disabilities and their families, with an average case load of 48 families. The 12 case management supervisors in this study all had been with the KAT program from its inception 18 months prior to the interviews.

The telephone surveys conducted with each of the case managers and included 9 open-ended questions and 12 demographic questions. As part of the open-ended questions, case managers were asked to describe the biggest challenges that their clients with disability faced, as well as the factors that they believed best supported their successful recovery from the disaster. Case managers were also asked to reflect on the role that disability played in delivering service to their clients, and the importance of disabilityrelated expertise in effectively responding to the needs of clients with disabilities.

The interviews with the case management supervisors were conducted face-to-face and consisted of five interview questions, along with follow-up probes. The questions similarly asked about the role of disability when providing case management to individuals with disability, and the extent to which disability-related expertise was instrumental in the case management process. All interviews were audiotaped and then transcribed for further analysis.

Analysis

The qualitative data from both the telephone surveys and the interviews were first analyzed using line-by-line open coding, and then collapsed into larger categories (see Glaser & Strauss, 1967; Strauss & Corbin, 1990) within each interview type. These categories were then grouped across the two data sources to form overarching categories systematically using the constant comparative method (Glaser & Strauss, 1967; Goetz & LeCompte, 1981). The analysis thus produced categorized results, a description of each of the categories, quotes that exemplified each of the categories, and a summary of how these categories interrelated. In the article, the results are reported under the categories of 1) supports to recovery, 2) barriers to recover, 3) the role of disability in disaster case management, 4) disability-related expertise of case managers, and 5) the influence of disability specialists on disaster case management practice.

Discussion of Results

The results section of this article suggest that considerable barriers

continued to exist for the over 2,000 individuals with disabilities in their combined caseload over two years following Hurricane Katrina. The reported needs of these individuals, such as housing and transportation, parallel those reported by other survivors of the storm; however, the presence of disability impacts the intensity and duration of case management required post-disaster.

Reports from the case managers in this study suggested that the needs of individuals with disabilities mirror those with survivors without disabilities who were impacted by Hurricane Katrina.

Specifically, other studies on the long-term recovery of Katrina survivors (see, Lein 2009; UMCOR, 2008) have found that over two years following the disaster they continue to have basic needs in areas such as housing, employment, and medical attention.

However, resources from volunteer organizations and other agencies have dissipated since the storm, leaving case managers with few resources to which they can refer their clients. The disabilityrelated needs of these clients, layered on top of the disaster-related needs of these clients, complicates the recovery process and was reported to necessitate a higher level of skill in case management.

The National Response Framework now includes case management as a mandated part of all federally-funded disaster response. As a result, case management will be used more frequently and with a greater number of disaster survivors. While guidelines for the case management of individuals with disabilities have been incorporated into a working draft released by the Administration for Children and Families (2008), these guidelines have been primarily policy-driven rather than research-driven. The results reported in this article suggest that additional study of individuals with disabilities post-disaster is needed in order to more effectively address their case management needs.

References

Administration for Children and Families (2008, December). Disaster case management implementation guide: Working draft. Washington, DC: U.S. Department of Health and Human Services. Retrieved on September 15, 2009 from http://www.acf.hhs.gov/ohsepr/dcm/docs/Draft%20 DCM%20Implementation%20Guide.pdf National Organization on Disability (2009. August). Effective emergency management: Making improvement for communities and people with disabilities. Washington, CD: Author.

Rose, S. M., & Moore, V. L. (1995). Case management. In R. L. Edwards, J. G. Hopps (Eds.) Encyclopedia of Social Work, 19th Ed. (pp. 335-340). Washington, D.C.: NASW Press.

Stough, L., & Sharp, A. (2008). An evaluation of the National Disability Rights Network participation in the Katrina Today project. Washington, DC: The National Disability Rights Network.

United Methodist Committee on Relief. (2008). Katrina Aid Today: A National Case Management Consortium. Final Evaluation Summary. New York: Author.

U.S. Government Accountability Office (2009, July). Disaster assistance: Greater coordination and an evaluation of programs’ outcomes could improve disaster case management (GAO-09-561).

Washington, DC: Author.

About the Author

Laura M. Stough, PhD, is Associate Professor of Educational Psychology and Interdisciplinary Training Director at the Center for Disability and Development at Texas A&M University. Her research focused on the affects of disasters on vulnerable populations, particularly individuals with disabilities and their families.

Amy Sharp, PhD, serves as the Associate Director at the Center on Disability and Development, Texas A&M University. Community Education, parental/self advocacy concerning disability issues, family-school collaboration, and public policy are her areas of focus.

Curt Decker, JD, has been affiliated with the National Disability Rights Network (NDRN) since its inception in 1982. As Executive Director of the nation’s largest non-governmental enforcer of disability rights, Curt oversees all activities related to training and technical assistance, membership services, and legislative advocacy.

Nachama Wilker is responsible for overseeing the training and technical assistance activities of NDRN, supervising the in-house advocacy and publications staff, as well as providing technical assistance on management, governance, and fiscal issues.

BRAIN INJURY PROFESSIONAL

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Homeless in the Face of an Impending Natural Disaster: Strategies for Supporting People with Traumatic Brain Injury

by Gretchen Stone, PhD, OTR/L, FAOTA

Making decisions about what to do and where to go in the face of an impending natural disaster is challenging for anyone but even more so for people who are homeless and living with traumatic brain injury. Complex systems designed to provide health care and other services for people with TBI become nearly impossible to access in an emergency situation. Timely intervention that is individualized and directive is needed when inaction is not an option. Since the prevalence of TBI is disproportionately high among the homeless, community-based shelters serving people without a legal or permanent residence may be in the best position, and may offer the only resource, for providing emergency preparedness.

On September 13, 2008 the east end of Galveston, Texas sustained a storm surge estimated at 17 to 20 feet with estimated winds of 110 mph and gusts of 125 mph. The area is known to have the largest concentration of people who are homeless living on this island in the Gulf Coast. Urban Search and Rescue task forces rescued more than 3,540 Texans and helped an additional 5,798 people evacuate from extremely dangerous situations (http:// www.galveston.com/hurricaneike.) People with frontal lobe injury who were served by Our Daily Bread, a homeless shelter on the island, were among those who evacuated voluntarily and did not require assistance. They were prepared using a customized approach based on assumptions formulated within The Executive Plus Model (Gordon, Cantor, Ashman & Brown, 2006).

The Executive Plus Model attributes dysfunction to problemsolving mechanisms which can be thwarted by poor emotional regulation and decreased attention (Gordon, Cantor, Ashman & brown, 2006). To focus their attention, clients were presented with compelling information about the magnitude of the problem they were about to face. As it was anticipated that focusing attention on an impending disaster was likely to elicit intense emotional responses, the intervention strategy was initially designed to objectify the event (Hewitt, Evans, Dritschel, 2006). The provider, an occupational therapist, presented a series of scenarios describing what two other people, with the fictitious names of Mike and Chris, would do if the mayor issued a mandatory evacuation order. Clients were asked to reflect about whether they were more like Mike or more like Chris. Engaging in this line of questioning enabled the clients to examine their own attitudes and beliefs about what people should do and how people should act toward one another during a disaster. Clients were also confronted with knowledge about the extent to which they had access to at least one other dependable person if they chose to remain on the island 22 BRAIN INJURY PROFESSIONAL

after the center closed rather than to evacuate. This was accomplished by covering a table with paper and asking nine people, including several people with TBI sitting around the table, to draw a line between themselves and any other person they knew how to find if they needed help. Then they were asked to place a hatch mark across the line if the person they identified knew how to find them. This activity created a visual representation to enable clients to see the extent to which they would be isolated and without help if they remained on the island.

The provider reviewed self-report activities and exercises she had on file which revealed clients’ responses to questions about their perceived positive characteristics, ways they coped with stress, and self assessments about how they related to other people. Based on this information she gathered inexpensive personal supplies that were likely to be accepted and used by the clients. These included items such as a comb and mirror for a man who liked to keep clean, a to-do list to use at the evacuation shelter for a woman who liked to keep busy and avoid unexpected events, and a cap for a man who was sensitive about his thinning hair. As a next step the provider and people known to have TBI walked from the shelter to the location where buses would be parked in the event of an evacuation order.

The provider and the clients met for the last time two days before Hurricane Ike reached landfall. She gave a 4” X 6” index card to each client with the following directives: “Go to the bus.”

“I will be waiting for you.” “I want to see you get on the bus.”

“I will say a prayer for you when you leave.” The intent of this last step in the intervention was for clients to visualize a specific sequence of actions they would take and to visualize themselves being greeted by someone who was known to them and who was interested in their safety and well being. The visualization included clients thinking about themselves as leaving safely and knowing that they were part of a social support system and not alone.

Emergency preparedness among community-dwelling homeless people with TBI in Galveston, Texas illustrates the importance of establishing a relationship with people who often think of themselves as invisible and who may have diminished sense of identity (Yllvisaker, McPherson, Kayes & Pellett, 2008). Community living offers open, less structured environments with less predictable consequences but more demands for planning and decision-making (DePompei, R., Frye, D., DuFore, M., & Hunt, P., 2001) People with TBI living in the community may display disorganized behavior and difficulty making decisions

when faced with ongoing uncertainty (Duncan, 1986; Cicerone & Giacino, 1992). They require carefully designed interventions to minimize the effects of executive dysfunction and impaired problem solving (McDonald, Flashman & Saykin, 2002; Shallice & Burgess, 1991). Recommendations for emergency management personnel who are responsible for developing evacuation procedures for people with TBI who are homeless include: • Identify local agencies (typically non-governmental agencies) whose mission it is to reach out to homeless people in their community.

• Compile information comparing resources before and during a mandatory evacuation so it is clear to people who are homeless that resources will not be available if they fail to evacuate.

• Engage in conversations with people who have TBI to increase awareness about the extent to which they can depend on other people when a disaster strikes.

• Identify health-care providers who are trained to elicit self-reflective statements from persons with TBI with the intent of collecting information that can be used to help predict how people will respond when notified of an emergency evacuation.

• Establish a network so that people with TBI can be assured that if they take appropriate action they will be safe and there will be a place to go.

• Train personnel to customize intervention strategies that meet individual needs.

REFERENCES

1. Cicerone, K.D. & Giacino, J.T. (1992). Remediation of executive function deficits after traumatic brain injury, NeuroRehabilitation 2, 12-22.

2. DePompei, R., Frye, D., DuFore, M., & Hunt, P. (2001). Traumatic brain injury collaborative planning group: A protocol for community intervention. Journal of Head Trauma Rehabilitation, 16, 217-237.

3. Duncan, J. (1986). Disorganisation of behavior after frontal lobe damage. Cogntiive Neurophschology, 3 (3), 271-290.

4. Gordon, W. A., Cantor, J., Ashman, T., & Brown, M. (2006). Treatment of post-TBI 5. Executive dysfunction application of theory to clinical practice. Journal of Head Trauma Rehabilitation, 21, 156-167.

6. Hewitt, J., Evans, J. J., & Dritschel, B. (2006). Theory driven rehabilitation of executive Functioning: Improving planning skills in people with traumatic brain injury 7. Through the use of an autobiographical episodic memory cueing procedure. Neuropsychology, 44, 1468-1474.

8. McDonald, B. C., Flashman, L. A., & Saykin, A. J. (2002). Executive dysfunction 9. Following traumatic brain injury: Neural substrates and treatment strategies.

10. NeuroRehabilitation, 17, 333-344.

11. Shallice, T. & Burgess, P.W. (1919). Deficits in strategy application following frontal lobe damage in man. Brain, 114, 727-741.

12. Ylvisaker, M, McPherson, K., Kayes, N. & Pellett, E. (2008). Metaphoric identify mapping: Facilitating goal setting and engagement in rehabilitation after traumatic brain injury. Neuropsychological Rehabilitation. 18 (5/6), 713-741.

About the Author

Gretchen Stone, PhD, OTR/L, FAOTA is a fully qualified occupational therapist certified by the U.S. National Board for Certification of Occupational Therapists. She received the designation of Fellow by the American Occupational Therapy Association. Dr. Stone serves as chair of the occupational therapy department at the University of Texas Medical Branch in Galveston, Texas. In addition to 17 years as an academic in occupational therapy programs, she has 39 years of practice experience in residential, outpatient and community-based settings. She has served adults with mental illness and mental retardation, children with dual sensory impairments and other severe and profound impairments, and both adults and children with physical rehabilitation needs. Although the majority of her practice experience is in the United States, through sponsorship by Project HOPE she has served individuals with crush injuries and traumatic brain injury following natural disasters in international settings. Currently she is practicing in a community-based setting serving individuals with traumatic brain injury who are homeless.

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Injury and Illness During and After Hurricane Ike

by Kathleen Sherrieb, PhD, Fran H. Norris, PhD, and Sandro Galea, MD, DrPH Disability research and disaster research can show the extent to which disasters are a source of injury and disability in community populations. We address this here, with a particular focus on the psychological consequences of illness and injury. Although past research suggests a link between physical injury during a disaster and postdisaster distress (e.g., Maes, Mylle, Delmeire, & Altamura, 2000; North et al., 1999; Thompson, Norris, & Hanacek, 1993), injury has to be understood as one type of stressor that occurs along with many others in the context of disaster. Thus to determine the psychological and disabling impact of injuries, researchers need to control for a variety of other aspects of exposure.

Norris and Wind (2009) organized the array of potential disaster experiences into four categories of (1) traumatic stressors, (2) loss, (3) ongoing adversities, and (4) community effects, which are not discrete categories but reflect the multitude of factors affecting psychosocial outcomes in the aftermath of disaster. In addition to injury, traumatic stressors (the first category) include bereavement, threat to life, and witnessing grotesque and aversive sights, which have been shown to be associated with posttraumatic stress and depression (Norris, Perilla, Riad, Kaniasty, Lavizzo, 1999; Galea et al., 2002). The second category, resource loss, has correlated highly with symptom severity in several disaster studies (e.g., Arata, Picou, Johnson, & McNally, 2000; Freedy, Shaw, Jarrell, & Masters, 1992; Hobfoll, Tracy, & Galea, 2006). The losses studied include property loss or damage, financial loss, personal loss, and loss of a job.

In the aftermath of many natural disasters, the acutely stressful experiences of trauma and loss are soon followed by a host of other challenges associated with poor housing conditions, rebuilding, and other stressors in the postdisaster environment (e.g., Burnett et al., 1997). Such ongoing adversities (the third category of stressors) typically show strong relationships to distress (e.g., Galea, Tracy, Norris, & Coffey, 2008; Norris et al., 1999), and displacement may be especially problematic (e.g., 24 BRAIN INJURY PROFESSIONAL

Najarian, Goenjian, Pelcovitz, Mandel, & Najarian, 2001).

Finally, disasters create the potential for community-wide economic, environmental, governmental, social, and cultural disruptions (the fourth category). These disruptions have been shown to influence mental health and social functioning over and above the effects of trauma and personal loss (Phifer & Norris, 1989; Kaniasty & Norris, 1993).

The present study explores the prevalence and short-term consequences of disaster-related illness and injury for distress, disability, and perceived needs for care relative to other elements of exposure – specifically (1) severity of fear (representing the traumatic stress category), (2) number of types of property damage and disaster-related unemployment (loss), (3) length of displacement (ongoing adversity), and (4) severity of area damage/disruption (community effects). The disaster was Hurricane Ike, a strong Category 2 storm, which struck Galveston, Texas in 2008. The Galveston Bay area had more than 200,000 people heavily affected by the hurricane. In November 2008, we launched the Galveston Bay Recovery Study (GBRS), a longitudinal epidemiologic survey of households (defined according to predisaster residence), the long-term purpose of which is to study the components, trajectories, and determinants of postdisaster wellness. The target population was persons 18 years and older living in Galveston and Chambers counties.

Method Participants A disproportionate stratified cluster sampling was employed in order to acquire samples in areas that experienced more damage from the hurricane and to sample groups that were more likely to be more heavily exposed to hurricane-related traumas (sampling details described in Norris, Sherrieb, & Galea, 2009). Of 861 eligible households, 658 or 74% agreed to participate.

In weighted data, 52.5% of the participants were women; 61.1% were non-Hispanic White, 14.8% were African Ameri-

can, 18.9 % were Latino, and 9.4% were foreign-born. About one fourth (26.3%) of the sample had less than a high school education, 50.4% completed high school or some college, and 23.3% were college graduates. Most participants (57.0%) were married or living as though, and 39.6% were parents. The mean age of the sample was 48.3 (SD = 19.5).

Measures Exposure. Participants were asked a series of questions about their experiences during and after Hurricane Ike. In relation to Hurricane Ike, illnesses were assessed for all household members and injuries were assessed for the adult respondent. The first element of exposure, fear severity was measured as the occurrence of shortness of breath; trembling, shaking, or buckling knees; heart pounding or racing, and sweaty palms or other sweating (Bracha et al., 2004). Losses were measured as property loss or job loss.

Displacement, representing ongoing adversities, was measured as number of days outside of the home because of evacuation. Finally, community damages were assessed as the level of damages and disruption to (1) area schools, churches, or hospitals, (2) streets and highways, and (3) places for recreation.

Outcome measures. Global stress was assessed on a 10-point scale with10 indicating extreme stress. Three scales were used to capture the symptoms of posttraumatic stress disorder (PTSD; PTSD Checklist; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996), major depressive disorder (MDD; Patient Health Questionnaire; Kroenke et al., 2002), and generalized anxiety disorder (GAD; GAD-7; Spitzer et al., 2006). Two measures were included to provide more general measures of dysfunction and disability. The Perceived Need for Care Questionnaire (PNCQ; Meadows et al., 2000) assessed different categories of need, including information, medication, psychological intervention, and social intervention.

Results Sample Experiences and Outcomes Results from the study and supporting statistical tests are described in more detail by Norris et al. (2009). Approximately one fifth of the sample (20.8%) experienced either personal injury (4.7%) or household illness (16.1%) because of the hurricane.

Approximately 10% of all households required medical care, but only 1.7% required hospitalization. Relevant to the interpretation of injury prevention data, personal injury was greater in areas with above-average damage and among persons who did not evacuate from their homes. Injuries were virtually non-existent given the combination of evacuation and below-average area damage. Household illness showed a similar pattern.

At least one indicator of acute fear was experienced by more than 11% of the respondents. On average, participants experienced two types of property loss, and 13% had experienced disaster-related unemployment for one month or longer. Most of the sample was briefly displaced from their homes, but a minority (14%) was displaced four weeks or longer. Sizable percentages reported that the hurricane had damaged the schools, churches, hospitals, streets, and recreational settings in their areas “a lot.”

Participants perceived a considerable amount of stress in their lives, with 13.4% claiming “extreme stress.” The prevalence of probable current Ike-specific PTSD (9.3%) was greater than the prevalence of either current MDD (5.3%) or GAD (3.1%).

Moderate levels of dysfunction were reported for daily role activities (11.2%), handling other life stressors (14.2%), health

caretaking (16.0%), and social activities (18.3%). On average, participants reported 4 days of disability in the past month.

Injury Effects Using continuous outcome measures and dummy variables to depict personal injury, household illness or neither, we found significant associations with global stress, posttraumatic stress, and disability, but not with depression, anxiety, or dysfunction when controlling for other stressors. In the regression analysis, the stressor that most consistently showed strong associations with outcomes was the severity of the person’s immediate emotional response.

Loss (either property or job loss) had significant but modest independent effects on posttraumatic stress, depression, and dysfunction and a somewhat stronger effect on global stress. Displacement was, surprisingly, not independently related to global stress, anxiety, dysfunction, or disability, although it did show modest effects on posttraumatic stress and depression. Community-level damages showed effects on global stress, posttraumatic stress, anxiety, and dysfunction, but not on depression or disability.

No effect of injury/illness was detected with an analysis of a dichotomous outcome for Ike-specific PTSD. In contrast, acute fear showed a strong influence on PTSD in the multivariate analysis. Job loss and community damage also showed effects.

Needs for care ranged from 8.2% for help discussing the causes of distress to 25.9% for help sorting out tangible problems. However, in the logistic regression analyses, which controlled for demographics and other exposure measures, personal injury was not associated with any of the assessed needs, and household illness was associated only with the need for help with tangible problems.

Discussion The prevalences of personal injury (5%) and household illness (16%) translate into sizeable numbers of affected people in Galveston and Chambers Counties – that is, approximately 9,500 injured adults and 32,500 ill adults. Nevertheless, the rates of illness and injury were less than they might have been without the concerted effort of public safety officials to evacuate Galveston Island and the Bolivar Peninsula. Our findings further support the significance and potential effectiveness of evacuation incentives with regard to the prevention of disaster-related injury and disability.

Perhaps because injuries were relatively infrequent and less serious than they might have been, their consequences for distress, disability, and perceived needs were also relatively modest when losses, adversities, community effects and, especially, trauma in the form of acute fear were considered. These findings support the basic tenet of this paper that it is necessary to evaluate the impact of one type of disaster stressor in the context of the others with which it co-occurs.

More than any of the other measures, including injury, the measure of fear showed particularly strong associations with PTSD, depression and anxiety symptoms, disaster-related dysfunction, and perceived needs for care. These findings suggest that in the absence of fear or panic, minor to moderate injuries may not be particularly traumatic or likely to lead to mental disorders, such as PTSD. However, even with other aspects of exposure controlled, personal injury and household illness were each independently associated with increased stress, distress, and days of disability in the population, and thus further bolster the importance of preventing injuries to the extent possible.

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Acknowledgement

This research was supported by the National Center for Disaster Mental Health Research (NIMH Grant 5 P60 MH082598), Fran H. Norris, Center Director, Sandro Galea, Research Director. Address correspondence to Kathleen Sherrieb, NCPTSD, VA Medical Center, 215 North Main Street, White River Junction, VT 05009 or kathleen.sherrieb@dartmouth.edu.

References

Arata, C., Picou, J., Johnson, G., & McNally, T. (2000). Coping with technological disaster: An application of the conservation of resources model to Exxon Valdez oil spill. Journal of Traumatic Stress, 11, 23–39.

Blanchard EB, Jones-Alexander J, Buckley TC, & Forneris CA. (1996). Psychometric properties of the PTSD Checklist (PCL).

Behavioral Research and Therapy, 34, 669-673.

Bracha, H., Williams, A., Haynes, S., Kubany, E., Ralston, T., & Yamashita, J. (2004). The STRS (shortness of breath, tremulousness, racing heart, and sweating): A brief checklist for acute distress with panic-like autonomic indicators; development and factor structure. Annals of General Hospital Psychiatry, 3, 8.

Burnett, K., Ironson, G., Benight, C. G., Wynings, C. G., Greenwood, D., Carver, C. S., et al. (1997). Measurement of perceived disruption during rebuilding following Hurricane Andrew. Journal of Traumatic Stress, 10, 673–681.

Freedy, J., Shaw, D., Jarrell, M., & Masters, C. (1992). Towards an understanding of the psychological impact of natural disasters: An application of the conservation resources stress model.

Journal of Traumatic Stress, 5, 441–454.

Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., et al. (2002). Psychological sequelae of the September 11 terrorist attacks in New York City. The New England Journal of Medicine, 346, 982–987.

Galea, S., Tracy, M., Norris, F., & Coffey, S. (2008). Financial and social circumstances, the incidence and course of PTSD in Mississippi during the first two years after Hurricane Katrina.

Journal of Traumatic Stress, 21, 357-368.

Hobfoll, S. E., Tracy, M., & Galea, S. (2006). The impact of resource loss and traumatic growth on probable PTSD and depression following terrorist attacks. Journal of Traumatic Stress, 19, 867–878.

Kaniasty, K., & Norris, F. (1993). A test of the support deterioration model in the context of natural disaster. Journal of Personality and Social Psychology, 64, 395–408.

Kroenke, K., & Spitzer, R. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32, 1-9.

Maes, M., Mylle, J., Delmeire, L., & Altamura, C. (2000). Psychiatric morbidity and comorbidity following accidental manmade traumatic events: Incidence and risk factors. European Archives of Psychiatry and Clinical Neuroscience, 250, 156–162.

Meadows, G., Burgess, P., Fossey, E., & Harvey, C. (2000). Perceived need for mental health care, findings from the Australian National Survey of Mental Health and Well-Being. Psychological Medicine, 30, 645-656.

Najarian, B., Goenjian, A. K., Pelcovitz, D., Mandel, F. S., & Najarian, B. (2001). The effect of relocation after a natural disaster. Journal of Traumatic Stress, 14, 511–526.

Norris, F., Perilla, J., Riad, J., Kaniasty, K., & Lavizzo, E. (1999).

Stability and change in stress, resources, and psychological distress following natural disaster: Findings from Hurricane Andrew. Anxiety, Stress, and Coping, 12, 363–396.

Norris, F., Sherrieb, K., & Galea, S. (2009). Prevalence and consequences of disaster-related illness and injury from Hurricane Ike. Unpublished manuscript (under review).

Norris, F., & Wind, L. (2009). The Experience of disaster: Trauma, loss, adversities, and community effects. In Y. Neria, S. Galea, & F. Norris (Eds.) Mental health consequences of disasters (pp. 29-44). NY: Cambridge University Press.

North, C., Nixon, S., Shariat, S., Mallonee, S., McMillen, J., Spitznagel, E., et al. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282, 755–762.

Phifer, J., & Norris, F. (1989). Psychological symptoms in older adults following natural disaster: Nature, timing, duration, and course. Journal of Gerontology, 44, 207–217.

Spitzer, R., Kroenke, K., Williams, J., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166, 1092.

Thompson, M., Norris, F., & Hanacek, B. (1993). Age differ-

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ences in the psychological consequences of Hurricane Hugo.

Psychology and Aging, 8, 606–616.

About the Author

Dr Galea is a physician and an epidemiologist. He is the Anna Cheskis Gelman and Murray Charles Gelman Professor and Chair of the Department of Epidemiology at the Columbia University Mailman School of Public Health. Dr Galea’s primary research has been on the causes of mental disorders, particularly common moodanxiety disorders and substance abuse, and on the role of traumatic events in shaping population health. His research program seeks to uncover how determinants at multiple levels of influence — including policies, features of the social environment, molecular, and genetic factors — jointly produce the health of urban populations. Dr Galea has conducted large population-based studies in several countries worldwide including the US, Spain, Israel, Ethiopia, Tanzania, and Liberia, primarily funded by the National Institutes of Health. Dr Galea’s interest in the complex etiology of health and disease has led him to work that explores innovative methodological approaches to population health questions primarily funded by a Robert Wood Johnson Health Policy Investigator Award. Dr Galea has published more than 250 scientific journal articles, 50 chapters and commentaries, and 5 books. Dr Galea did his graduate training at the University of Toronto Medical School, at the Harvard University School of Public Health, and at the Columbia University Mailman School of Public Health. Prior to his arrival at Columbia Dr Galea was on faculty at the University of Michigan. Several media outlets

including The New York Times, NPR, and NBC have featured Dr Galea’s work. He was named one of TIME magazine’s epidemiology innovators in 2006.

Kathleen Sherrieb, DrPH, MS is a Research Associate in the Department of Psychiatry at Dartmouth Medical School and the Associate Director of the National Center for Disaster Mental Health Research, a multi-institution center established to facilitate the rigorous study and effective promotion of resilience and wellness in the context of disaster. Dr. Sherrieb is a social epidemiologist with a concentration in maternal-child health and is currently funded by the National Consortium for the Study of Terrorism and Response to Terrorism to study community resilience, terrorism impacts, and population health outcomes.

Fran H. Norris, PhD, is a Research Professor in the Department of Psychiatry at Dartmouth Medical School and Director of the NIMH-funded National Center for Disaster Mental Health. She is also a member of the Executive Division of the Department of Veterans Affairs National Center for PTSD and a member of the National Consortium for the Study of Terrorism and Responses to Terrorism (START). Her research interests include the epidemiology of posttraumatic stress, cross-cultural studies, mobilization of social support after disasters, and community resilience. Her professional involvements include chairing a task force on disaster recovery for the Society for Community Research and Action, serving as the Deputy/Statistical Editor of the Journal of Traumatic Stress, and editing the PTSD Research Quarterly. She received the 2005 Robert S. Laufer Award for Outstanding Scientific Achievement from the International Society of Traumatic Stress Studies.

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21-25 – 6th World Congress for Neurorehabilitation, Vienna, Austria. For more information, contact Tracey Mole, traceymole@wfnr.co.uk or on the web, www.wcnr2010.org.

MAY 7-9 – 15th Scientific Congress Of The Euroacademia Multidisciplinaria Neurotraumatologica, Antalya, Turkey. For more information, visit: www. emn2010.com.

(800) 774-5516 425 Kings Highway, P.O. Box 20 Haddonfield, NJ 08033-0018 www.bancroft.org

Holding Standards High.

23-27 – 17th European Congress on Physical Medicine & Rehabilitation, Venice, Italy. Contact: www.esprm.org.

JUNE 14-17 – 28th Annual National Neurotrauma Symposium, in collaboration with the AANS/CNS Section on Neurotrauma & Critical Care, Las Vegas, NV, USA. For more information, visit: www. neurotrauma.org/2010.

SEPTEMBER 12-16 – 14th International Conference On Intracranial Pressure And Brain Monitoring, Tubingen, Germany. For more information, visit: www. icp2010.eu.

OCTOBER 13-16 – Annual Meeting of the National Academy of Neuropsychology, The Westin Bayshore, Vancouver, BC. For more information, visit: www. nanonline.org.

For over three decades Beechwood’s interdisciplinary brain injury program has been competitively priced and is nationally recognized for its comprehensive community-integrated approach. As a not-for-profit rehabilitation program, Beechwood has demonstrated that it is possible to provide state-of-the-art treatment at a reasonable cost to the consumer.

Services include: • Physical, occupational, speech, language and cognitive therapies and psychological counseling • Case management • Medical services including on-site nursing, neurological, physiatricand psychiatric treatment • Vocational services from sheltered employment through to community placement • Residential services on a main campus, in community group homes and supported community apartments • Outpatient services

A COMMUNITY-INTEGRATED BRAIN INJURY PROGRAM

NOVEMBER 4-7 – 71st Annual Assembly of the AAPM&R, Seattle, Washington. For more information, visit: www.aapmr.org.

An affiliated service of Woods Services, Inc • Program Locations in PA 1-800-782-3299 • 215-750-4299 • www.BeechwoodRehab.org Beechwood does not discriminate in services or employment on the basis of race, color, religion, sex, national origin, age, marital status, or presence of a non-job related medical condition or handicap.

BRAIN INJURY PROFESSIONAL

27

Factors Driving Emergency Preparedness for Persons with Brain Injuries and Other Disabilities: Late Lessons from Katrina

by Michael H. Fox, ScD, Glen W. White, PhD

The impact of disasters on vulnerable populations is profound, at times in ways not always obvious to public health professionals.

Approximately five months following the worst natural disaster to ever hit the American Gulf Coast, we visited persons with disabilities surviving Hurricane Katrina in Mississippi and Louisiana to discuss how they coped with this catastrophe. Our research, described elsewhere (1-4) and in pending publication, provides evidence of systemic failure in government response, communication and individual preparedness towards vulnerable populations.

Disasters such as Katrina and Rita eventually fade in the collective memory of our society, but evidence of timely improvements in these systemic failures lag. Thus, we felt it worthwhile to review our transcribed conversations of three years ago. In reviewing our notes, we were struck not just by the pathos of the commentary we received, but also by the vividness with which our observations illustrated the connection between people with severe disabilities and their communities. These connections range from the simple to the complex, visceral to cognitive, mundane to extraordinary.

By sharing these with colleagues who work with brain injury survivors, we hope that they can serve not just as a kind of catharsis, but also as a reminder of our larger mission, at times forgotten amidst the many worthwhile activities we engage in during our daily routines: to advance knowledge, we must also try to understand life in ways that sometimes make us uncomfortable. We both returned from our visits to the areas ravaged by Katrina as changed individuals, but in ways we couldn’t easily define. This commentary is an observation on observational research, impossible to ever duplicate, but important, perhaps, as a motivational compass for helping us find our way amidst problems that at times appear insurmountable.

On Saturday, February 25th, 2006, we got up early hoping to go on a tour of different parts of New Orleans with the Executive Director of the New Orleans Resources for Independent Living, Inc. As it turns out, she couldn’t join us, so after making a couple phone calls, we rented the one car left in the Budget Rental agency across from our Canal Street hotel with the idea of using it for the day and returning it to the airport before our flight left that evening. We headed east. Things looked somewhat normal until we drove through the Bywater neighborhood, where we started seeing damaged houses, abandoned cars, trees that were down, and other signs of major carnage. We continued east to the Lower Ninth Ward. The devastation left by Katrina was mind-numbing both in intensity and magnitude. Signs of any sort of life were largely absent that day.

In driving through the area, we noticed that one of the corner houses had a ramp. Heading through the gate and up the ramp to 28 BRAIN INJURY PROFESSIONAL

the porch, the first thing we saw in the living room was an abandoned power wheelchair facing the front door. Right next to the front door was a black cane. The TV was turned over and there was one garbage bag that had moldy papers in it. Outside of the garbage bag, there wasn’t much else in the living room. There was a little clock in the shape of an owl next to the door. There was a memorandum book in which there were some names and phone numbers. We immediately recognized we were on sacred ground, in that this was a home for an individual, yet they were torn from it due to catastrophic events. In a sense, the house felt like a shrine.

We wanted to try to find what happened to the person who had lived there. We found a name on an old luggage tag and told ourselves that we would try to find her, to hear her story.

One of the people whom we spoke with in Baton Rouge the day earlier was a resident of the Lower Ninth Ward. He was despondent about sharing his experiences with us. It wasn’t so much losing his house or material things. It was, he shared with us, more about displacing their whole beings, losing focus on where and how they lived in the community of which they were once a part.

All of their community was gone. Other things, material things, were still there, but rendered useless for people to do anything with. The clothes were still there; things such as TVs, homes and cars also remained. The doors are open but the people are gone.

He told us – and we saw – its basic qualities: unique, eerie, disheartening, disconcerting. There was really no way to describe it through pictures.

We visited one more home on our way out of town, through another neighborhood called Arabi in St. Bernard parish before heading back to the airport. A FEMA (Federal Emergency Management Agency) trailer with a ramp was parked in front of a house that had been destroyed. After leaving our cards, we received a phone call in the days following from a gentleman whose residence where the FEMA trailer was located. We found out that the ramp was built for his wife, and that he and his wife safely evacuated a couple days before the hurricane hit. They had been living about 15 miles from New Orleans, deciding whether to resettle back in their community. He estimated that at that time, there was only about one household living on each block in his neighborhood. Their big concern, he stated, was that five months post-Katrina, there still were few city services. At the time, the community, Arabi, was borrowing money to pay for their police and fire service. Schools, social services, the post office had recently opened on a limited basis. Mail delivery wasn’t reliable and they were concerned about moving back, even with the FEMA trailer.

They didn’t know whether services were going to be restored. They were holding their bets.

We went on to summarize similar conversations with over fifty additional persons affected by the storm, including the person whose power wheelchair we encountered when entering her abandoned house. We were able to locate her after her evacuation to Arkansas. Findings from our qualitative study are pending publication (12/2009), but the broad themes we identified are those which we have discussed in earlier forums and are likely to persist with minor modifications in subsequent studies in this area.

We identified six major themes that affected how people with disabilities prepared for, adjusted to, or recovered from events of this magnitude: faith, incredulousness, blame, family, resiliency, and professional responsibility.

Faith: “I did as much as I could and then left it in the hands of the Lord.”

Incredulousness: “I just don’t understand how could the water get so bad. How could the water get so bad than it ever did before? How did it come so bad? I didn’t know that there were so many people stubborn like me who didn’t want to leave out their house.

Blame: “The people don’t know how to treat people in the shelters.

When I was trying to get FEMA to get me a handicapped trailer, they didn’t want me to have people coming in there with cameras and things, especially the Red Cross. There’s a lot they’re probably still trying to hide. So I told FEMA that I wanted a handicapped trailer. They put a trailer over here, but it wasn’t a handicapped trailer. It was just a regular trailer. I couldn’t even get in the door. They kept messing, lying back and forth. Then they said they made a mistake. They sent all the handicapped trailers to Mississippi and Louisiana. So, I had to call Channel 10 to come down. That’s how I got this trailer here.”

Family: “The sad part about that is there are a lot of people who, for lack of better terms, disabled citizens, don’t really have a lot of family around. Their friends pretty much are other disabled people.

We need to get city and government officials to help. We have learned a lesson from Katrina and we need some backup plan.”

Resiliency: “I needed a place to stay and I knew because I was on everybody’s list that there was no room at the Inns for the little fat lady in the wheelchair. I’ve been praying to God to help me figure out a way around it and my daughter calls me and tells me, “This man’s got a handicapped bus for sale.” The first thing that popped into my head was, “Wow, I could make a camper out of that really easy.” They’re wide enough I could drill my bed across in the back, either along the side or along the back wall and it wouldn’t take me much to make a nice little camper where I could live in until I could figure out what I need to do. So I took the money from FEMA to sign an apartment, the $3,000 they sent us, and I went and bought the bus.”

Professional Responsibility: “We, as people with disabilities, were unable to just load up a pick-up truck and go down to the coast and do what we wanted to do and that was a very frustrating thing for us.

Those who were on home and community based waiver programs that would have been really the most vulnerable; I gave all those names and phone numbers and addresses to the Department of Rehab. And they used the Department of Labor people, who had come into the state and they found them and checked on them.”

These themes describe the different dimensions of a broader and pragmatic approach to preparing for and coping with hardships associated with disaster for persons with disabilities. We are struck with the ongoing need to build upon them in order to retain social systems that can maximize opportunities to maintain full participation in society for persons with disabilities. As these themes are understood better among professionals working with

and serving disability communities, effective measures can be undertaken to assure that persons with brain injuries and other disabilities are not left behind when disasters strike.

References

1. White, G. W., M.H. Fox, C. Rooney and A. Cahill. 2007. Assessing the Impact of Hurricane Katrina on Persons with Disabilities. Lawrence, KS: The University of Kansas, The Research and Training Center on Independent Living. http://www.rtcil.org/products/NIDRR_FinalKatrinaReport.pdf.

2. Glen W. White. Katrina and Other Disasters: Lessons Learned and Lessons to Teach: Introduction to the Special Series Journal of Disability Policy Studies 2007 17: 194-195 3. Fox, M.H., White G.W., Rooney C., Cahill A. Responding to Disaster: The Psycho-Social Impact of Hurricane Katrina on Persons with Disabilities. Submitted 1/16/2009.

4. Michael H. Fox, ScD, Glen W. White, PhD, Anthony Cahill, PhD, Roberta Carlin, JD, and Catherine Rooney, MA. Experiences of Persons with Disabilities Before, During and After Hurricane Katrina. American Public Health Association, 134th Annual Meeting and Exposition. November 6, 2006. Boston, Mass. http://apha.confex.com/apha/134am/techprogram/ paper_131985.htm

About the Authors

Glen W. White, Ph.D., has been involved in the rehabilitation and independent living field for over 30 years. He is currently Director of the Research and Training Center on Independent Living at the University of Kansas.

He serves as Principal Investigator of the NIDRR-funded Research and Training Center on Measurement and Interdependence on Community Living. Dr. White has had numerous opportunities to work with consumers with disabilities in identifying, developing and shaping on-going disability research. For the past several years he has been developing a systematic line of research in the area of prevention of secondary conditions and health promotion. More recently, Dr. White has been conducting research in the area of disaster planning and emergency response for people with disabilities, and has also been conducting research and training on community leadership and development and supportive entrepreneurships for people with disabilities in Perú. He is past president of the National Association of Rehabilitation Research and Training Centers, past Chair of the American Public Health Association’s Section on Disability, and currently serves as Chair of the International Committee for the National Council on Independent Living and Board Member of the United States International Council on disability. Dr. White is currently Professor in the Department of Applied Behavioral Science and directs the Research Group on Rehabilitation and Independent Living at the University of Kansas, where he teaches in the areas of applied behavioral science, community psychology, and disability studies.

Michael Fox is a professor in the Department of Health Policy and Management with a joint appointment in the Department of Preventive Medicine and Public Health at the University of Kansas, and at the time of this writing was Associate Director for Policy in the Research and Training Center on Independent Living at the University of Kansas. A native of Wisconsin, he received his BS in Zoology from the University of Wisconsin in 1971 and an MS in Studies in Behavioral Disabilities from the University of Wisconsin in 1975. He taught special education for four years before completing another MS in Biostatistics and Clinical Epidemiology from the Medical College of Wisconsin in 1983. After working as the MIS Director of an HMO in Milwaukee, he went on to complete his doctorate in Health Policy and Management from The Johns Hopkins University School of Hygiene and Public Health in 1992. He was a senior administrator with the Maryland Department of Health and Mental Hygiene from 1989 – 1995, teaching evenings at Towson University his last two years. He moved to Kansas in 1995 to accept a faculty position with the University of Kansas, where he has taught both masters and doctoral level courses in public health administration, Medicare & Medicaid, outcomes evaluation, reimbursement, health policy, and clinical and administrative data analysis. His funded research has focused on health system changes, program evaluation of state programs for the under-served, and disability. He is a past recipient of a Robert Wood Johnson HCFO grant to evaluate Medicaid payment, a Christopher Reeve Paralysis Foundation grant to investigate ways in which paralysis is identified, a CDC grant to investigate county disaster planning for disabled persons and has explored the issue of emerging disabilities and financing health care for persons with disabilities in depth through other funded research. He is cofounder and a past-president of the Kansas Health Consumer Coalition, a consumer organization whose purpose is to advocate for expanding affordable, accessible and quality health care for every person in Kansas.

BRAIN INJURY PROFESSIONAL 29

Surviving the Storm: Inner Strength and Resiliency Following Hurricane Ike

By Gabrielle Morales, MOTR, CBIS, AMPS Certified As national news programs presented to the world, Hurricane Ike struck a devastating blow to the Texas Gulf coast when it made landfall on Galveston Island on September 13th, 2008. At that time, I was working on the island at the Transitional Learning Center (TLC). TLC was my first position as an occupational therapist after earning my master’s degree in June, 2008. Naturally, I was eager to work hard.

The following narrative describes my experiences during the transfer of 26 clients to safer inland facilities and the extended care we provided during and immediately after hurricane Ike. My duties were originally expected to last 24–36 hours. Instead, due to the severity of the storm, the care of my clients lasted 21 days.

As I reflect on my experience in graduate school, there was never a time that I doubted my decision to earn a Masters of Occupational Therapy (OT) degree. The practice of OT appealed to me because of its involvement with clients and its handson approach to care. My final internship before graduation was at the Transitional Learning Center, a post acute rehabilitation facility for adults with acquired brain injury. It was not long into my internship before I realized I had found the specialty I was meant to work in, and TLC’s philosophy of care matched my personal and professional values. Upon completion of my internship, I was offered a full-time posi30 BRAIN INJURY PROFESSIONAL

tion at TLC, which I happily accepted.

As an enthusiastic new graduate and staff member at TLC, I volunteered to be a member of the A Team, one of three evacuation and recovery teams that were a part of the facility’s hurricane preparedness plan. Team A’s role involved preparing the clients for evacuation, escorting them to the designated evacuation facility, and engaging them in a care and activity schedule. After approximately a day and a half, my team would be relieved by Team B and I would be allowed to return home.

Being a native Galvestonian, I felt I knew what I was in for. I had experienced several close calls with hurricanes in the past, and my family and I had evacuated the island for a stretch of 3 or 4 days.

On the morning of September 12, 2008, the evacuation order was given and A Team assisted 26 clients into facility vehicles. We loaded the clients’ belongings and all the equipment and supplies necessary for a 2–3 day stay off the island.

Once all assignments were complete, our caravan departed the island via Interstate 45, and headed north toward Brenham, Texas. Our destination was Camp for All, a fully accessible facility designed to provide adapted leisure and recreational activities.

Each year, our clients participate in two extended weekend camps at this facility.

The trip was uneventful, traffic flowed smoothly unlike evacuations in earlier

years that I had personally experienced, and we arrived at Brenham within the expected 2 hours.

At Camp for All, we assisted in unpacking the clients’ personal belongings and prepared to settle in for the next few days. I have to say, it was organized chaos.

We felt fortunate to have arrived safely, but there were still so many tasks ahead of us. Rooms needed to be assigned and adaptive equipment distributed. Those tasks were no sooner completed than it was time for dinner. Each staff member was well aware of the need to maintain a sense of normalcy for the sake of the clients, but very little could be considered normal under these circumstances—for clients or for staff. We realized that after ensuring the safety of our clients, we needed to reintroduce them to familiar routines to offer some semblance of stability and structure. After the trauma of brain injury, our clients needed this manner of care on a regular basis, but under these desperate circumstances, the need to maintain normalcy appeared greater than ever, while the means to attain this goal seemed virtually beyond our grasp.

Nevertheless, we organized activities such as karaoke, board games or painting the women’s nails, where our goal was to present the familiar whenever and at whatever level possible. We tried to meet every challenge by asking: What will best serve the

needs of the clients under these extraordinary circumstances? What could we do to make things easier for them and help them not be overwhelmed by the obvious changes in their environment that we could not control?

During my stay at Camp for All, the role of caregiver became an intense experience as a majority of the clientele required maximum assistance with basic self care. Some of the activities included assisting clients with bathing and dressing and helping them transfer from the cabins to the main dining hall. We also helped to distribute meals and assisted with feedings. I discussed with my clients how they felt during this evacuation and the change from surroundings they were familiar with. The intensity was nonstop from the moment I woke up until the second my head hit the pillow at night. After only a couple of days, I was physically, mentally, and emotionally exhausted. But as it turned out, the challenges were far from over.

After hurricane Ike passed, my administrators realized that we were not able to return to Galveston. Not only had our island facility been severely damaged, but Galveston Island was closed to the public due to safety concerns. Unfortunately, not all of Team B was able to relieve us due to the severity of their individual circumstances brought on by the storm. Our next plan, then, was to travel to our sister facility in Lubbock, Texas, normally a 10-hour trip from Brenham. Once again, we packed up our clients, their belongings, supplies and equipment, and headed north. Frequent restroom breaks were necessary, and the behaviors of some clients became exceedingly challenging. At one point, I spent 20 minutes convincing a client to re-board the van; our 10-hour trip took 14 hours.

When we arrived in Lubbock, we faced the same challenges that we experienced in Brenham. Due to the longer duration of this leg of the trip, we had to turn our attention to our clients’ bladder and bowel incontinence that occurred since the last rest stop. Immediately following a 14-hour drive, my intense caretaking tasks continued. Following unpacking, my duty was to assist clients with bathing and dressing for the night. I was on shower duty from 9:00 pm to 1:30am. At that point, my thoughts were blurred and I was hurting physically. I knew I had to report back at 7 am the next morning,

at which point it would all begin again. I managed to keep a smile on my face most of the time and to present the best possible attitude that I could to help my clients cope with their own challenges. During that first night at Lubbock, until unconsciousness overtook my body and mind, I struggled with doubts as to whether I could keep going. By then, the media was reporting severe damage to the island, and I was afraid my family and I might have nothing to return to. What about my car that I had to leave parked on the street — a street that was inundated by 6 feet of salt water from Galveston Bay? What about my household belongings? How did the houses fare that belonged to my family and friends? What was left of my island home? But by the next morning, I simply had no time to dwell on those concerns and fears. Whether a voluntary or involuntary reflex, work became my defense mechanism. I was so preoccupied with the challenges of this level of caregiving and in fighting my fatigue that I only allowed myself to cry right before I fell asleep on a couple of nights.

When I was given a day off, I again worried that on the following day, I would have nothing left to give. But my mantra became, “I am here for my clients, and they deserve the best care I can offer.” I returned to work the next day and managed to keep going. We remained in Lubbock for a total of 18 days.

Now that almost a year has passed since I returned home where my island community is rapidly rebuilding, I find that I am still coming to recognize lessons learned from this experience. One of those lessons is that it might have helped had I allowed myself to cry more often about the fears I was facing. But the interesting thing to me is that I don’t think I consciously tried to rein in such acts of emotional cleansing, it was just that I was too tired to indulge them for any length of time before exhaustion overtook me. The immediacy and intensity of the need to stick with the job of caregiving and to do the best I could for my clients under such extraordinary circumstances became in itself the steady force that saw me through the ordeal. I also realize I have never felt so much gratification for the services I provide as an occupational therapist. This realization has made me reflect on the joys and struggles of intense caretaking. It has become an inspiration for my career and

has reshaped my thinking and adaptation strategies to trauma. Finally, I learned that it sometimes takes a disaster to see that the extraordinary challenges that we faced as occupational therapists during this ordeal reflect the normal challenges that our clients face every day. Each day, our clients must persevere under circumstances of reduced ability where the difficulties may at times appear insurmountable. Hurricane Ike, despite the vicious damage it inflicted, helped me validate my choice of profession where it is the duty of OT’s to empower our clients’ continued struggle.

Their courage inspires me and encourages me to give my very best every day.

About The Author

Gabrielle (“Gabby”) Morales is a native Galvestonian and a staff Occupational Therapist at the Transitional Learning Center (TLC) at Galveston, Texas. She earned her bachelor’s degree in Exercise Sports Science in 2004 from Texas State University. She attended the University of Texas Medical Brach (UTMB) in Galveston, Texas where she earned a Master’s degree in Occupational Therapy in June, 2008. She is a Registered Occupational Therapist and is AMPS certified. She is also a Certified Brain Injury Specialist.

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Phone 763.479.3555 www.vinlandcenter.org BRAIN INJURY PROFESSIONAL

31

non-profit news NORTH AMERICAN BRAIN INJURY SOCIETY NABIS held a successful Seventh Annual Conference on Brain Injury along with the concurrent event, the 22nd Annual Conference on Legal Issues in Brain Injury in October, 2009, in the lively city of Austin, TX. We enjoyed a record number of scientific abstracts submitted to the meeting and added several new features to the educational program including Candlelight Sessions with the Experts, and a special full-day pre-conference Symposium on Children, Adolescents and Young Adults with ABI. NABIS also presented its three annual awards this year to recognize individuals who have made significant contributions to the field of brain injury. The awards were presented at the annual symposium and exhibition in October. The Randy Evans Clinical Treatment Award was given to Janet Williams, PhD, the NABIS Clinical Research Award was given to James F. Malec, PhD, the NABIS Legends Award was presented to Neil Brooks, PhD and the NABIS Award for Public Policy was given to the Christine M. MacDonell of CARF. Looking ahead, NABIS is working with the Alaska Brain Injury Network on a regional conference in Anchorage, Alaska in July. This conference will bring experts, both local and from the lower 48, together to discuss how to better serve the native and local populations in Alaska.

In another effort to bring professionals together, NABIS is pleased to announce that the annual meeting will be held jointly with the National Association of State Head Injury Administrators (NASHIA) on October 5-8, 2010, at the Minneapolis Hilton Hotel. This effort allows for solid cross interaction of professionals in brain injury. The Joint Meeting will be held concurrently with the 23rd Annual Conference on Legal Issues in Brain Injury, a three-day event specifically for attorneys involved in brain injury litigation.

Visit the NABIS website www.nabis.org for more details in the coming months as program planning is underway.

Brain Injury Association of America BIAA and its Business & Professional Council (www.braininjurycouncil.org), fought hard to include rehabilitation in health care reform legislation; preserving this victory will be a top policy priority in the New Year. In 2010, BIAA will also pursue TBI Act reauthorization, access to care at non-VA facilities, and sports concussion legislation at the federal and state levels. Our newest position paper, Early vs. Late Treatment, is posted to our main Web site (www.biausa.org) as is the latest edition of THE Challenge!, which features great articles on “Love After Brain Injury.” In our virtual Bookstore, you’ll find the business, caregiver, clinical and research webinars planned for the first quarter plus links to other educational programs, including BIAA’s Business College, Feb. 22-24, at The Menger

32 BRAIN INJURY PROFESSIONAL

Hotel in San Antonio, and our 2010 Litigation Strategies Conference, Apr. 29-30, at The Signature at MGM Grand Hotel in Las Vegas. Technology upgrades to fully automate the Academy of Certified Brain Injury Specialists’ application, testing and grading processes will soon be complete. March is Brain Injury Awareness Month; sports concussion materials will be available from our Web site soon. In the meantime, BIAA is pleased to recognize Suzanne Doswell as the recipient of the Founders’ Award, to welcome the BIAs of Ohio, Missouri and Virginia to the National Brain Injury Information Center, and to congratulate Nebraska as the newest chartered state affiliate. BIAA needs support from the professional community to spread help, hope and healing nationwide. Please consider making a taxdeductible donation, becoming a corporate sponsor or joining the Business & Professional Council.

International Brain Injury Association IBIA is putting the finishing touches on our 8th World Congress on Brain Injury to be held March 10–14, 2010 in Washington, D.C. The final program is available on the IBIA website, www.internationalbrain.org, and includes an exciting array of pre-Congress, Congress and post-Congress activities.

From a scientific standpoint, pre-Congress workshops include the Neuropsychiatry of TBI, Applications of transcranial magnetic stimulation and transcranial direct current stimulation, Advances in assistive technology for cognition, and Constraint induced therapy. Our post-Congress symposia include Effort testing, Family issues, Blast injuries, Pediatric brain injury, Neurobehavioral challenges following TBI, as well as, TBI vocational rehabilitation.

Our Congress sessions will bring together some of the top international scientists, clinicians and researchers working in the field of brain injury to provide attendees with cutting edge information, reviews of controversial topics in brain injury diagnosis and care. Attendees will learn clinically practical information that they can translate to real world applications to create better patient outcomes and improve their brain injury systems of care.

We have a number of other exciting conference sessions planned for attendees including “Meet the Expert” sessions where attendees will have the opportunity to meet in small groups with the ten top international experts in the field of brain injury care.

We are expecting a wonderful turnout by exhibitors which will provide attendees an opportunity to gather information on new products germane to brain injury assessment and treatment, international treatment programs for brain injury, as well as, review and examine some of the latest scientific publications in the field of brain injury care and research.

Our social and entertainment agenda is also full for the conference with a number of wonderful tours of the international, diverse and historical city of Washington DC, social activities including our Congress Gala Dinner at Mount Vernon, the home of George Washington. IBIA awards will be given out at the Gala Dinner and include the Henry Stonnington award for best review articles for 2009 (1st and 2nd place), Car of the year award and the Young Investigator award (this will be the first time this award is given out by IBIA). Our awardees in 2010 for the Jennett and Plum Clinical Achievement Award are Professor Graham Teasdale and Professor Henry Stonnington, MD, the latter posthumously. For more information, visit www.internationalbrain.org.

NATIONAL ASSOCIATION OF STATE HEAD INJURY ADMINISTRATORS The National Association of State Head Injury Administrators held a highly successful 20th Annual States of the States (SOS) Conference in Santa Fe, New Mexico in October 2009.

NASHIA secured a variety of impressive speakers and panelists from across the country to present, highlighting alternative therapeutic approaches, supported employment, substance abuse, waiver issues, public policy, state capacity building for student services, cognitive rehabilitation, and innovation in identification and assessment, with updates from national brain injury programs.

Restore-Ragland

NASHIA and NABIS are now making plans for the joint 2010 conference, October 5-8, being held at the Hilton in downtown Minneapolis, Minnesota. Bringing together clinical perspectives, public policy and state interests, both organizations are gearing up for a training collaborative you won’t want to miss! More details will be coming soon on the NASHIA website.

The NASHIA Public Policy Committee, with Susan Vaughn, Director of Public Policy, and Jean Berube, Governmental Relations, has supported a number of issues in 2009, and collaborates with numerous disability organizations for crucial program and funding initiatives related to civilians and returning service members.

NASHIA is the first and remains the only forum addressing State government’s significant role in brain injury. NASHIA encourages and facilitates communication among state programs in order to share successes, replicate beneficial programs and services and maximize options for individuals with brain injuries and their families. Seventeen states have recently been awarded four-year grant funding through the HRSA Federal TBI Program, allowing them to focus on creating and enhancing comprehensive, multidisciplinary, and accessible systems of care. Additional funds will allow four more states to be awarded in the near future.

Please consider supporting NASHIA by contacting Jeff Henderson at jphenderson@nashia.org or by visiting our website for additional information at www.nashia.org.

Restore-Roswell

Restore-Lilburn

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems.

Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

www.restorehealthgroup.com 800-437-7972 ext 8251 BRAIN INJURY PROFESSIONAL

33

legislative round-up Susan L. Vaughn, Editor, Legislative Issues “There are two things you don’t want to see being made — sausage and legislation.”

Otto von Bismark (1815-1898), Germany’s Chancellor The 111th Congress reconvened for its second session after the first of the year with several heavy lifting bills yet to be considered, including health care reform. Before Congress recessed for the holidays, each of the legislative bodies passed its version of health care reform as delineated in the H.R. 3962, the Affordable Health Care for America Act and H.R. 3590, the Patient Protection and Affordable Care Act. At the time this article was written the House and Senate had begun working out differences informally, in lieu of a Conference Committee, as a way to avoid any delaying tactics that may be initiated by those in opposition. In terms of disability-related issues, there are several differences between the bills relating to the new Insurance Exchange’s essential benefits package; Medicaid provisions; health disparities; the CLASS Act (Community Living Assistance Services and Supports), the Medicaid Community First Choice Option and several other improvements to Medicaid home and community based services.

Disability and health care advocates have worked to ensure that the essential benefits package include rehabilitative and habilitative services and devices; mental health and substance abuse services, including behavioral health treatment; oral health, vision and hearing services, equipment and supplies for children under 21 years of age; and preventive and wellness services and chronic disease management. These provisions are to ensure that the individual needs of persons with disabilities are met and to prevent further deterioration in order for individuals with disabilities to be healthy and to live as independently as possible in the community.

Meanwhile, on December 21st, President Obama signed the FY 2010 Defense Appropriations bill, which also provided twomonth extensions of various programs, including unemployment insurance, COBRA health benefits, a fix to Medicare payments to physicians, surface transportation funding, flood insurance and Small Business Administration loans. Included in the bill is $120 million for Traumatic Brain Injury and Psychological Health Research and $472.4 million for Family Advocacy programs and for Family Support and Yellow Ribbon to provide support to military 34 BRAIN INJURY PROFESSIONAL

families, including quality child care, job training for spouses and expanded counseling and outreach to families experiencing the separation and stress of war. The defense bill was the last of the 12 annual spending bills to be enacted.

Five days prior to that signing, President Obama signed the Consolidated Appropriations Act, which provided funding for FY 2010 for Transportation, Housing and Urban Development (HUD), Labor, Health and Human Services (HHS), Education and other federal agencies. The discretionary spending bill for HHS-Education-Labor is 9% more than FY 2009 levels and 0.3% above the President’s request. The HRSA Federal TBI Program received an increase in the amount of $62,000.

On December 9th, Reps. George Miller (D-CA) and Cathy McMorris-Rodgers (R-WA) introduced H.R. 4247, the Preventing Harmful Restraint and Seclusion in Schools Act, and Sen. Christopher Dodd (D-CT) introduced a similar bill, S. 2860, on the same day. The bill directs the Secretary of Education to establish federal minimum standards for the use of restraint and seclusion in schools. Also in December, Senator Robert Menendez (D-NJ) introduced S. 2840 to establish concussion management guidelines for school-aged children. This bill is similar to H.R. 1347, the ConTACT Act of 2009, introduced by Rep. Bill Pascrell, Jr. (D-NJ) in March.

Often, when speaking of the legislative process, people will compare it to sausage making -- you do not want to know how it is made or what goes into it. Certainly, the 111th Congress has provided opportunities for learning how the process may work, particularly with regard to health care reform. A part of the process that often gets lost is the importance of hearing from constituents.

One of the venues for providing information and education to members of Congress is during the annual Brain Injury Awareness Day organized by the Congressional Brain Injury Task Force. This year, the Awareness Day has been scheduled for March 17th. As in the past, organizations and agencies will exhibit information on brain injury in the Rayburn House Office Building Foyer, followed by a briefing and reception. For further information contact Mandy Spears, Health Policy Advisor for Rep. Bill Pascrell, Jr. at Mandy.Spears@mail.house.gov or Rebeccah Wolfkiel, Legislative Director for Rep. Todd Platts at Rebeccah.Wolfkiel@mail.house.gov. Representatives Pascrell, Jr. (D-NJ) and Platts (R-PA) are co-chairs of the Task Force. You may go to the Task Force website to see if your representative or senators is a member. If not, you may want to encourage him or her to join.

About the Editor:

Susan L. Vaughn of S.L. Vaughn & Associates, consults with states on service delivery and serves as the Director of Public Policy for the National Association of State Head Injury Administrators. Ms. Vaughn retired from the State of Missouri after nearly 30 years, where she served as the first director of the Missouri Head Injury Advisory Council. She founded NASHIA in 1990, and served as its first president.

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