On August 29, 2005, one of the greatest natural disasters in the history of the United States occurred when Hurricane Katrina devastated the Gulf Coast, making landfall just east of the Mississippi-Louisiana state line. Catastrophic damage extended from southern Louisiana and New Orleans east to Mobile, Ala. Although reports immediately after the storm suggested that New Orleans had dodged a bullet, the eventual damage caused by breaches in the 17th Street, London, and Industrial Canal levees led to flooding of over 80% of the city. The aftermath forced indefinite closure of businesses, schools, and essentially all activities in the greater New Orleans area. Access to the city by nonessential personnel was not allowed for several weeks.
Although both heroic and tragic Katrina stories abound related to the people of the Gulf Coast, the struggle for survival includes institutions as well as people. Educational programs at every level were affected. The hurricane forced the closure of the New Orleans public and private school systems, as well as every college and university in the greater New Orleans area. Tulane University School of Medicine (SOM) was no exception. After Katrina and the ensuing floods, Tulane University fought desperately to ensure that the doors of this 173-year-old institution would not close permanently. Despite being surrounded by water and with well over $100 million in initial damages caused by the flooding, the SOM has survived Katrina. It was able to reopen to all its students just one month after halting operations by temporarily relocating to Houston, thereby ensuring the graduation of senior students and the uninterrupted education of the other classes. Many challenges remain and will continue for some time, but the lessons learned at the Tulane SOM may help medical schools elsewhere in America better prepare for the possibility that a disaster could interrupt operations for an indefinite period of time.1 The purpose of this article is to provide an understanding of what happened at Tulane and to help others plan for a catastrophic disaster at their own institutions.
Background: The Tulane University Health Sciences Center
Tulane University Health Sciences Center consists of the SOM, the school of public health and tropical medicine, and the National Primate Research Center. The SOM, located in downtown New Orleans, is approximately one block from the school of public health and tropical medicine and is adjacent to its three major teaching hospitals, Tulane University Hospital and Clinic (TUHC), the New Orleans Veterans Affairs Medical Center, and the Medical Center of Louisiana in New Orleans, which consists of Charity and University Hospitals. The main SOM building, where most educational and administrative activities occur, is located adjacent to the J.B. Johnston (JBJ) Research Building and is less than one block away from another more recently acquired building (located across the street from the Superdome on Poydras Street), which was in the process of becoming the main administrative and educational facility for the SOM. The National Primate Research Center, located on the north shore of Lake Ponchartrain in Covington, experienced wind damage and power outages, but not flooding. The medical school and all adjacent facilities suffered extensive flood damage in the basement and the first floor, compounded by several weeks of standing floodwater. All basement and first-floor generator and electrical systems were completely destroyed, as well as elevator and other vital systems. As a result of the extensive facilities damage and the forced evacuation of the city and the Tulane University Health Sciences Center, all educational, clinical, and research activities of the SOM were no longer feasible in New Orleans. All 620 Tulane medical students and 520 residents, as well as faculty, administrative, and support staff, were displaced. However, approximately one month later, the SOM was able to resume its administrative and educational activities in Houston, Texas, while reorganizing both clinical and research activities in many locations in Louisiana and elsewhere.
The Storm
The following description of the events leading up to and immediately after Hurricane Katrina provides the background for the storm's impact on Tulane.
Wednesday, August 24, 2005: Hurricane Katrina enters the Gulf of Mexico, raising greatest concern to those living in southern Florida.
Thursday and Friday, August 25 to 26: A second landfall is projected for the panhandle of Florida, but preliminary hurricane preparations begin across the entire Gulf Coast.
Friday, August 26: Most faculty and students leave the medical center late in the day, expecting the storm to pass well east of the city. Later that evening, the National Hurricane Center updates its projections, declaring Katrina a category four or five storm, aimed directly at New Orleans.
Saturday, August 27: The city and the entire health sciences center initiate full-scale disaster plans. All of Tulane University closes and all nonessential personnel are advised to evacuate the city. Students are offered transfer and lodging to dormitories at Jackson State University in Mississippi. All necessary clinical staff on emergency teams prepare for a three-day stay, as called for in the disaster plan. A mandatory evacuation of the city is eventually declared, as the mayor urges all citizens of New Orleans to leave, calling this hurricane threat the real deal.
Sunday, August 28: The SOM and TUHC (owned and operated as a partnership with the Hospital Corporation of America (HCA) finalize preparations for a potentially extremely dangerous and destructive hurricane. Remaining citizens continue to evacuate the city, though approximately 200 faculty and staff evacuate to the SOM site with children and pets, instead of leaving New Orleans altogether, despite contrary recommendations. The senior vice president for health sciences evacuates to Tulane's backup site in Jackson, Mississippi, the dean to Shreveport, Louisiana, the vice dean to Monroe, Louisiana, the associate dean for student affairs to Houston, Texas, and the associate dean for graduate medical education to Dallas, Texas. Designated disaster teams staff TUHC, and on-call faculty and residents remain at the other two teaching facilities to provide patient care. Backup emergency generators and supplies are prepared in all buildings.
Monday morning, August 29: Before dawn, Hurricane Katrina crosses the coast of Louisiana and then passes east of the city of New Orleans. Initial projections of minimal to moderate damage seem to be correct.
Monday afternoon, August 29: The face of New Orleans permanently changes as the 17th Street, London, and Industrial Canal levees break. Prior published projections of the city filling with water became reality, as 80% of the city is eventually flooded. The streets around the SOM facilities begin to fill with water, making passage impossible without either wading through waist-high water or using a boat.
Tuesday through Friday, August 30 to September 2: Personnel in the medical center are stranded. Backup generators located in basements or first floors are flooded, but maintenance personnel use a makeshift system to deliver emergency power to the hospital from the JBJ research generators, the only ones not in a basement or first floor location. Similar problems were encountered at the Medical University of South Carolina after Hurricane Hugo.2 Medical careand the evacuation of all patients and personnel are complicated by the failure of communication systems, with loss of e-mail systems and both cell and landline phones. Text messaging remains functional and becomes the main source of communication. State and federal rescue efforts are chaotic and poorly coordinated, preventing patients and personnel at the SOM and its hospitals from being evacuated in a timely fashion. During this time, HCA provides security personnel and helicopters to evacuate all patients from TUHC, as well as many patients from Charity Hospital and medical school personnel and families who had initially evacuated to the medical school building.
The Immediate Aftermath of Hurricane Katrina
After all patients, faculty, and staff had been evacuated and the vicinity of the SOM and the hospitals was cordoned off, it became readily apparent that the school would not be able to resume any activities at its downtown campus for the foreseeable future. Despite communication difficulties, the senior administrators remained in contact by telephone, primarily using landlines at their evacuation sites, and subscribing to new cell phone service outside the New Orleans metropolitan area. It also became clear to students, residents, and faculty that they would not be able to return to New Orleans for some time. Communication was complicated by the fact that the university's information technology headquarters was located downtown at the health sciences center, and the Tulane servers were not functioning. As a result, all personnel spontaneously switched to personal, non-Tulane e-mail addresses. Although most faculty and residents and many students were unable to communicate with their institutional leaders, several first- and second-year students took the initiative to create their own listservs for communication with their classmates. Many students who were not from the New Orleans area did not have the nonfunctioning, local New Orleans area code as their primary phone number and were easily able to contact each other. Very quickly, the students created their own chatrooms and forums, where they speculated about what was ahead for their education. Several students and student leaders were able to obtain cell phone numbers of the deans, establish communications with them, and notify them of the locations of online student discussions.
As it became clear that extensive flooding was going to force the closure of the SOM for an indefinite time, members of the dean's office were forced to consider other options. One option was to distribute as many students as possible to other schools. However, there was no guarantee that all students would find positions. Furthermore, once students were dispersed, there was concern that the student body might never be reconstituted. Colleagues in Houston at Baylor College of Medicine and University of Texas-Houston Health Sciences Center understood the magnitude of Tulane's problem, having worked together four years earlier when Tropical Storm Allison wreaked havoc on the Texas Medical Center, closing many of their educational facilities.3,4 It was through this experience and a sense of shared commitment to medical education that discussions among the senior educational administrators of these institutions led to the suggestion that Tulane move its entire medical education enterprise to Houston, with the first two years of the SOM program based at Baylor College of Medicine. Tulane's dean and other senior leaders supported this concept, and more detailed discussions ensued. The vice dean and the associate dean for student affairs posted information on the student forums regarding the dean's commitment to assuring students that their education would continue and alerting them to the possibility of a move to Houston. Preclinical students were encouraged to wait for further information regarding returning to the classroom, and many third- and fourth-year students began to look for clinical opportunities at other academic institutions throughout the country. Similarly, the associate dean for graduate medical education remained in contact with residency program directors, who were also reassuring their residents about the future of their training. Concurrently, the senior vice president for health sciences and the associate senior vice president for research assisted research faculty as they began to look for temporary sites to continue their research until they could return to New Orleans. Clinical chairs began to locate and communicate with their faculty, many of whom had temporarily relocated with families throughout the country, so they could arrange temporary sites to resume clinical practice.
Tulane's senior leadership moved to Houston to provide operational oversight of activities and to continue further discussion regarding the possibility of temporarily relocating the administrative and educational core of the SOM there. Initial discussions with senior leadership of Baylor and UT-Houston were encouraging, but a definitive plan was necessary.
The watershed event in resuming classes occurred on September 7, 2005, only nine days after Hurricane Katrina, when the president and CEO of Baylor College of Medicine, Peter G. Traber, invited Tulane's leadership, as well as Dean Stanley Schultz of UT-Houston, Dean Michael Collenda of Texas A&M, and Dean Valerie Paresi of University of Texas Medical Branch-Galveston and their respective senior leadership teams, to a meeting at Baylor. These four Texas institutions created the South Texas Alliance of Academic Health Centers to provide all necessary means to ensure the continuation of the Tulane University SOM until its functions could be resumed in New Orleans. It was agreed at that meeting that Tulane's students and dean's office would be housed at Baylor and that first- and second-year classes would be held in Baylor facilities. However, it was felt essential that Tulane maintain its own curriculum and that Tulane students be taught by their own faculty. All four institutions in the Alliance made a commitment to provide educational materials and support and to provide clinical rotations and faculty supervision for both required clerkships and electives.
A target of Monday, September 26, was established for the resumption of the SOM's undergraduate and graduate medical education. Students were notified through their listservs and student forums of the start-up date. Facilities were provided at Baylor for administrative and organizational offices, and all efforts were focused on the resumption of classes for the more than 1,100 Tulane medical students and residents scattered across the United States. Housing was a significant issue that had to be addressed for all four classes of medical students, residents, and fellows. After the organizational meeting creating the South Texas Alliance, the educational and student affairs deans of the four institutions met and began to make opportunities available for clinical rotations by Tulane students.
How Tulane Was Reopened in Three Weeks
In September, none of the necessary infrastructure that maintains the functions of any medical school was available to Tulane's SOM. Information technology support, network communication servers, the University's payroll system, and e-mail were down, and student, resident, and faculty registration systems were not operational. Student and resident rosters did not exist, nor were there any methods to confirm credentials or grades. Despite these remarkable challenges, the educational programs were able to resume through a series of decisions and collaborations. Understanding these events may help others to craft a plan for coping with such a natural disaster.
Communication
The Alliance institutions generously committed resources that were not available to Tulane after Katrina: educational facilities, IT support, clinical training opportunities, and office space and teaching materials for Tulane faculty and staff. One of the initial steps was for Baylor's Center for Collaborative and Interactive Technologies to create a unique Tulane Web site, which was hosted on Baylor's server. The importance of recreating a system for communication after a disaster cannot be overstated. This public site, promoted through e-mails and listservs, provided an opportunity for the dean and associate deans to communicate to the SOM community and for members to sign in, provide their current e-mail addresses, and send messages. Equally important, this site provided an opportunity for members of the Houston community to offer free housing to students, faculty, and staff, and for students to request available housing. Most important, this site communicated to students that their education would resume in a timely fashion and that they could graduate with a Tulane medical degree on their anticipated graduation date.
Basic science curriculum
Resuming basic science education created its own special problems. At the time of the Alliance leadership meeting on September 7, most of the Tulane course directors were unavailable, and none were located in Houston. Gradually, the fall semester course directors were located and asked to make preparations for the resumption of classes. Almost all course directors relocated to Houston, both to evaluate the resources available from the Texas schools and to work with other course directors to meet the targeted deadline. Educational facilities for large- and small-group teaching were made available at Baylor. Tulane and Baylor alternated large- and small-group educational space, with Tulane scheduling discussion groups in the morning and lectures in the afternoon, in reverse of Baylor's schedule. This process was made easier by an online classroom registration system and curriculum staff support from both Baylor and Tulane. Baylor and Tulane anatomy faculty and students shared facilities, cadavers, and time slots. In addition, Baylor provided histologic glass slides and written materials for first-year students.
Other resources were also made available to Tulane faculty and students. Although some teaching materials were eventually recovered from the medical school building in New Orleans, most were not. Both Baylor and UT-Houston faculty provided problem-based learning cases for small-group teaching. When Tulane faculty were not available to teach selected topics, faculty from both Baylor and UT-Houston presented lectures. Although it might not have been possible to resume classes without the support received from the Texas schools, the dedication of the Tulane course directors was a key factor. Although initial reactions ranged from it can't be done to it must be done, concerted efforts transformed a nonfunctioning school to one ready and able to meet the needs of all its students.
To ensure a cohesive and effective basic science curriculum, course directors and senior administrators met regularly to address logistical and educational issues. Those responsible for medical student education had to decide quickly how best to organize and deliver the curriculum as close to its pre-Katrina state as possible. Several deviations from Tulane's original curriculum were necessary. For example, the first-year cell and molecular biology course had begun in New Orleans, but because the course director was unable to move to Houston, the material was postponed and taught in the spring semester in another course. Some clinically oriented small groups were not given in the first-year anatomical sciences courses, to allow sufficient teaching time for core content. For the second-year course in clinical medicine, the use of community preceptors was delayed. In the second year, curricular improvements planned before Katrina, including greater integration of microbiology into the organ-system curriculum, were still implemented. The importance of self-directed and cooperative learning was emphasized, and a strong partnership was created between students and faculty. The final curriculum for both first- and second-year students was remarkably similar to that which the students would have experienced in New Orleans.
Clinical curriculum
For the clinical curriculum as well as for preclinical courses, the resumption of medical students' education required rebuilding the educational program, its infrastructure, and all student affairs support activities. Both the Association of American Medical Colleges (AAMC) and the Liaison Committee on Medical Education (LCME) provided exceptional assistance during this crisis. Tulane students who evacuated across the country after Katrina sought and arranged required and elective experiences at numerous U.S. medical schools. To prevent the chaos that might ensue with students acting as free agents, the LCME approved and monitored a revised academic credit policy. Clinical experiences at some Tulane-supervised rotations remained, including those in the family medicine clerkship at rural sites in Louisiana and nearby states. Clerkship opportunities also became available in all disciplines through the Alliance institutions, although some students registered for required clerkships at institutions around the country. The LCME policy permitted students to complete one core clerkship away from Tulane supervision and, therefore, outside of the Alliance institutions.
Simultaneously, the AAMC agreed to provide student affairs information both to other institutions and to Tulane while Tulane's systems were not available. Thus, the registration of Tulane students became a manageable, though cumbersome, task. With normal technology unavailable, clinical students had to e-mail their requests and specify what clinical rotations they had already completed. Baylor provided a temporary registrar for Tulane students, and the AAMC sent personnel to help train a new temporary registrar for Tulane. The AAMC also agreed to post information regarding the institutions affected by the hurricane on its Web site, including the newly created policy for clinical rotations approved by the LCME.
Grading and small-group attendance
Two other important decisions about assessment or teaching were also made by Tulane SOM leadership. Recognizing the tremendous stress that the hurricane and the subsequent relocation created for students, a pass/fail grading system was established. However, the identification of either exceptional or struggling students was maintained through a record-keeping system that included all students' exam scores. Pass/fail evaluation was widely supported by the student leadership. Second, required attendance at small-group activities was eliminated. Nevertheless, attendance at these discussion and problem-solving activities remained very high, and faculty commented that student preparation and participation were notably greater than in the past.
The Team Effort
How could a medical school go from being rendered completely nonfunctional by the loss of all operational systems and all its facilities, to reopening three weeks later in another state? There are important lessons to be learned from the Tulane experience and subsequent alliance that may help other institutions as they revisit their own disaster plans (summarized in List 1).
Leadership, decision making, and communication
Effective communication among institutional leaders and rapid decision making are both critical in establishing and implementing any plan. In Tulane's case, although the leaders were spread from Mississippi to Texas, they were able to speak by telephone. However, communication was difficult and sometimes impossible because of the failure of the New Orleans phone network. Had all institutional leaders been at the same designated remote site, this would have ensured their availability for decision making at critical times. In addition, if designated institutional leaders (chairs, directors) knew in advance of the designated site, an effective communication network could have been established in advance.
Similarly, the importance of backing up essential data on off-site servers cannot be overstated. The rapid reestablishment of Web sites to enable accurate, timely, and reassuring information from key leadership can prevent misinformation and loss of confidence. One of the keys to the Tulane success was the ability to recreate a school Web site rapidly. Technologically facile students were among the first to recreate complete student listservs of new e-mail addresses and several discussion forums. In Tulane's response to the Katrina disaster, the ability of the SOM's leadership to make decisions expeditiously and somewhat autonomously in the first few weeks, without bureaucracy, was necessary to reestablish and implement systems at every level. Similar to a military operation, the rules that govern decision making must allow leadership to take prompt action for institutional survival.
Partnership
Tulane was fortunate to have the southern Texas medical schools offer to provide support. If institutions established cooperative partnerships in advance of a disaster, they could develop contingency plans for the complete closure of a partner school for an extended period of time. Although the likelihood of such an event is small, the experience of both medical schools in New Orleans (Tulane and Louisiana State University) attests that such events do occur. To their credit, the four medical schools in the South Texas Alliance were able to mobilize resources almost immediately to provide support at many levels for Tulane's faculty, residents, students, and staff. Other key partnerships were with the national organizations responsible for oversight and accreditation: the AAMC, the LCME, and the Accreditation Council for Graduate Medical Education (ACGME). Institutional plans should include the early involvement of these organizations after disasters. Affected schools will benefit from the support of national agencies that provide critical information and support services.
Key personnel
Although no individual should be indispensable to an organization, key personnel can rapidly activate operations essential to the successful resumption of the educational enterprise. Tulane quickly located and involved both faculty and staff who were essential to undergraduate and graduate medical education. In circumstances where personnel could not be located or were not available, other on-site faculty and staff were promoted to positions and charged to make decisions involving registration and educational programs. Tulane staff in Houston referred to these sudden changes in status as battlefield promotions.
Teamwork
One of the most important lessons that residents and students learn from their training is the importance of teamwork. Nowhere is this more essential than during and after a disaster. The displaced Tulane SOM was able to create an atmosphere conducive to the formation of effective teams. Certain activities were best handled by students, others by staff, and others by faculty. By giving smaller groups the authority to investigate and make recommendations to the larger collective group, efficiency and esprit de corps were established. At the conclusion of each weekday before the resumption of Tulane's educational program in Houston, teams presented their reports at a meeting of all available Tulane faculty, staff, and students. These daily meetings addressed key issues vital to success: housing, curriculum, work and study space, student affairs (including financial aid, admissions, registration), parking, and the orientation in Houston for all Tulane students. Appropriate Baylor personnel also participated in these meetings to provide avenues for addressing unresolved issues and to give assurance that plans could be implemented within the Baylor system. Student teams were particularly important in addressing the living and housing needs of their classmates, using housing arrangements donated through the generosity of Baylor faculty and the Houston community.
Systems-based approach
One of the six major ACGME competencies is a systems-based approach, a commonly misunderstood and frequently maligned competency because of the challenges in demonstrating mastery. The most serious problem in recreating the medical school after Katrina was the complete loss of the systems that support curriculum and faculty/staff/student interactions: Internet, e-mail, registration, finances, credentials. Tulane University wisely tackled a most basic concern shortly after the diaspora of its personnel to other parts of Louisiana and across the country, namely, the restoration of the payroll system. With assurance that their salaries would not be interrupted, faculty and staff could concentrate on their work assignments during the period of greatest need. Creating a contingent backup plan for every essential system in the event of disaster should be a high priority.
Institutions should maintain a record of essential personnel and establish rules and procedures for enforcing who will remain on duty during disasters. A process should be established for contacting each individual in the organization (administrators, faculty, staff, residents, students, etc.) after a disaster. Decisions regarding the evacuation of patients, hospital personnel, families, and even pets should be made before a calamity.
Classes Resume
Initial planning targeted Saturday, September 26, as the date for the orientation in Houston, and both faculty and students were prepared to start on that day. However, Hurricane Rita, with its projected landfall near Houston, forced the postponement of both orientation and the resumption of the curriculum by one week. On Saturday, October 1, an orientation that included over 275 of the first- and second-year students and over 200 third- andfourth-year students beginning clinical experiences in Houston was held at Baylor College of Medicine. Third- and fourth-year students completing clerkships and electives in other parts of the country did not attend; residents who relocated received individualized orientations. Both the Tulane SOM and Baylor leadership welcomed the Tulane students. Tulane alumnus Dr. Michael E. DeBakey gave a special address creating an atmosphere of confidence that their education would continue, even in the most trying of times.
This experiment of nature has been a remarkable success. During academic year 2005-2006, students continued their basic and clinical science education, knowing that the high quality of their training was preserved and that they would graduate on time. Student performance on examinations was unchanged from previous years, and Tulane's future doctors have learned about their own ability to deal with adversity. They have also been forced to take more responsibility for their own education while working more closely with classmates and faculty. Importantly, a special relationship was formed between Tulane students and faculty as they worked together to solve unique problems. Faculty and students regularly thanked each other for their efforts in maintaining the educational program. Tulane's success would not have been possible without the incredible support of the South Texas Alliance schools and their communities. This life lesson did not go unnoticed by the Tulane students and faculty, who benefited from the generosity of all personnel at these institutions. Finally, this experience demonstrated how institutions can connect in ways that are mutually beneficial and supportive. Although many more challenges remain for Tulane's SOM, all undergraduate and graduate medical education programs returned to New Orleans by July 1, 2006.
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