Dr. David Persse is the EMS Medical Director for the Houston Fire Department and the Public Health Authority in Houston. In these capacities he helped to coordinate the response to Hurricane Harvey. At the start of the conversation, Persse details his job responsibilities and how he coordinates with other local, state, and federal authorities during a disaster. He explains that it is sometimes frustrating that the local elected officials, who are the emergency managers in the community, have no medical experience and how it can lead to misunderstandings. Persse says that planning for disasters is the most important part of an emergency response, because best practices can be established from past experiences. The plan to respond to major flood events, as of 2017, did not involve the use of George R. Brown Convention Center (GRB) as a shelter because it had not worked well in the past. However, smaller shelters filled quickly, and organizers were forced to use GRB as a shelter even though there were no supplies pre-positioned at the convention center. Persse says that the federal government worked quickly to provide supplies for the shelter at GRB, but that they got stuck in Conroe due to flooded roads, and that the delay caused the shelter to operate on its own for a couple extra days. The shelter at GRB had more than 10,000 people staying there, which can easily lead to outbreaks of highly contagious diseases like norovirus. Persse points out that one of the major challenges of operating a shelter is closing the shelter, as some people cannot or do not want to leave. The housing department works with residents to find them a place to live in these cases. Persse stresses the importance of staying out of flood waters whenever possible because of the high levels of contamination from raw sewage and chemical waste. Injuries and infections are also common after a disaster ends, as people work to clean up and rebuild. Persse touches on the importance of communicating correct information with the public during a disaster, and details how misinformation can spread quickly. He says that he did not make any recommendations for future disasters because the city has a good idea of how to respond and no matter how much planning, there will still be changes for each new event. Persse talks about the pushback they received from volunteers who wanted to keep helping, even after official resources arrived. After years of consecutive flooding events, Houston EMS has developed a robust swift-water rescue team and purchases several high-water vehicles. Persse adds that the lesson learned from Harvey is that the local officials are going to have to work on their own in the first days of the disaster because federal response teams will take time to arrive. To end the conversation, Persse explains that it is important to understand the limits of the disaster response team.
Interviewee: David Persse
Interview Date: September 13, 2019
Interview Location: Houston Fire Department
Interviewer: Christina Shibu
INTERVIEWER: I am Christina Shibu. I’ll be interviewing Dr. David Persse. Today is September 13, 2019. And we are at the Houston Fire Department.
CS: Our first question, how long have you been Physician Director of Houston EMS and the Houston Public Health Authority? And could you describe your responsibilities in those two roles?
DP: I’ve been the EMS Medical Director since 1996 — since the fall of 1996, so that makes that just short of 23 years I’ve been in that role. In the role as EMS Medical Director, I’m responsible for all medical care provided by the firefighters, EMTs, and paramedics when they’re out on the ambulances and on the firetrucks. I’m mostly responsible — we train police officers as well. Now, that’s not part of the traditional EMS Medical Director role, but because we work with the police department, we also train their officers in some very basic first aid techniques. And so we — that’s part of that role as well here in Houston.
My other role as the Public Health Authority began in 2004 [0:01:00]. And in that role, I’m responsible really for disease control and containment across the city. And it’s the Department of Health, but it’s Health and Human Services. That’s an important distinction, because I don’t have responsibility over the human services part — really only disease control. But that includes things like restaurant inspection, reports of communicable illnesses and trying to control those, HIV, hepatitis, syphilis, gonorrhea, those — tuberculosis. Trying to control those diseases within the community falls under the role of the Public Health Authority.
CS: How do you coordinate with your counterparts at Harris County Public Health, other EMS providers, National Guard, FEMA, and others in preparing for and responding to situations like Hurricane Harvey?
DP: The response to major disasters is extremely complicated. And all disasters begin, certainly, locally. So we work closely with our counterparts in Harris County. And so from the health department [0:02:00] standpoint, it’s with the Harris County Health Department and Dr. Umair Shah is the Public Health Authority — he’s also the director over there. So here within the City of Houston, we have two people. Stephen Williams is the Health Director, and I’m the Health Authority. I’m the physician. He’s like the business mind. For Harris County, those two roles are combined into one individual. And so it actually makes it a little bit more difficult for Dr. Shah from Harris County, because he deals with two people over here, whereas we both know we just need to deal with Dr. Shah over at the Health Department.
But our roles here are a little bit different in that Director Williams is responsible for the budget, police implementation, so on and so forth, whereas I’m more responsible for some — anything medical or disease control policy development is mine. And then if we have to do anything during disasters, sometimes we have to actually execute some public health laws, which requires dealing with the attorneys. And then we have to go before the judge and so on and so forth. That falls under my umbrella. Whenever there’s a disaster, it rarely is the [0:03:00] disaster — sometimes but rarely is the disaster confined to the City of Houston. Certainly a weather-related disaster like a tropical storm or hurricane is across the entire region, so the issue crosses many, many jurisdictional borders. So it’s not just even the City of Houston and Harris Health, but it’s City of Houston and multiple public health entities across the region as well as the state.
So here, the state — it’s Region 6/5 South, Texas Department of Health or the Texas Department of State Health Services out of Austin, so we work very hand-in-hand with them. There is a chain of command however. And when it comes to disasters, your question really touches on an interesting point that most people don’t recognize. So when we think about a disaster coming into a community, the local, elected leadership is ultimately responsible. So for the City of Houston, it’s the mayor. And for Harris County, it’s the county judge [0:04:00]. And they are the emergency managers. By law, they are known as the emergency managers for their community, so they’re responsible for managing the disaster and the emergency response. So that’s everything from bulldozers to fresh water to bringing — you know, making sure the people have food and clothing and power and sanitation and all of those sorts of things. And there — for decades, there has been a chain of command to help facilitate that.
Curiously and interestingly, I guess, but more frustratingly is within healthcare we have the same needs. The problem is that the people that populate the chain of command for getting streets opened and so on and so forth have little or no understanding of medical needs. And so years ago, when we had Tropical Storm Allison in 2001, the [0:05:00] hospitals were running short on ventilators, the machines that we use to breathe for people. And so we put in a request through the traditional pathway to get ventilators. We had an emergent need for ventilators. And it went up that pathway, and we got a truckload full of fans. Because someone in the line thought they’re looking for something to ventilate rooms. And they sent us an 18-wheeler full of 36-inch fans, which was not what we needed.
And so it became evident then that we needed to develop basically a parallel emergency management communication pathway with people specifically trained in healthcare and medical needs. And so that now exists. And there’s some cross-bridging of the two to make sure there’s coordination, but that actually began here in Houston. And we’ve used it in, you know, succeeding disasters. So as we’re moving up with our requests for — whether it be vaccines, medication, beds, you [0:06:00] name it, we are constantly communicating back over to the traditional chain of command so that they know what’s going on. But they don’t supersede our requests anymore like they did in the past, because they have come to understand that they don’t necessarily understand our language. So your question was how do we coordinate with the National Guard and FEMA and so on and so forth. We have actually had to build a parallel communication pathway in order for us to get our needs met.
CS: I understand from an earlier interview that you believe that the act of planning is more important that the plan itself since plans frequently require changes during an emergency. So were there trainings or protocols updated after responses to previous natural disasters for Public Health, EMS? And could you give other examples?
DP: Absolutely, there’ve been plans — every time we have a disaster, we learn from that disaster. And part of my thought that it’s all about the plan, that really comes from something that General Eisenhower said in World War II — was that [0:07:00], you know, “The plan is nothing but planning is everything.” And I’m really stealing that from the general. In the planning phase is when you learn what is going to work and how it works and how strong it is or how weak it is. And you use that for any sort of tool or technique or process that you plan on using during the disaster. Then during the disaster — because the disaster doesn’t read your plan ahead of time. You find that your plan never matches exactly to what your needs are. But if you understand your assets, whether it be a piece of equipment or a concept in a plan — if you understand it well enough, you will be able to then apply it, perhaps in a twisted, changed fashion to meet the need that you have during the actual disaster.
And you’re only going to come to learn the limits on that piece of equipment or that policy or that technique by having not only planned for it but drilled and exercised [0:08:00] with it so that then on game day, you know whether or not this is going to be a good idea. Because you’re going to be using something for something it was never intended to — happens every single time. And you’re going to use something for — you know, like I said, for something it was never intended to, but you’ve got an idea whether it’s going to work or not. That’s what we call MacGyvering something.
And then every time we wind up doing that, we then afterwards go back to the drawing table and say, “Okay, we need to have a better solution.” We had to use a — we had to use a hammer last time to drive that screw. And hammers, of course, are supposed to drive nails, not screws. But we had to use a hammer, so let’s find out about getting screwdrivers this time. So how are we going to do it? And you know, I greatly simplify it by using that example, but even as you come up with that new solution to the problem you had never faced before, once again, you need to put it into your plan. And then you need to drill with it, because sure as I’m sitting here, the next disaster — while we now have this new asset, guess what? It’s not going to fit exactly the way we intended it to, and we’re going to have to MacGyver it and use that for something new.
And that’s — and people shouldn’t get frustrated by that [0:09:00]. And they often are. People get frustrated when we have a plan and the plan doesn’t go as we expect it to. During the event, people become frustrated with that. And I will tell you — I find those to be the most difficult people to work with, because you have to understand. It’s a disaster because nothing’s going according to plan. If it was all going according to plan, it would be an incident. It’s a disaster because things are going — so you’ve got to be flexible enough. And you’ve got to be accepting enough of imperfection to be able to not let that get under your skin and look forward and figure out how we’re going to — how are we going to solve this problem with what we’ve got?
CS: How did Hurricane Harvey compare to your expectations of the storm forecast? And what sorts of preparations were made for Public Health Safety and for EMS based on those expectations?
DP: We were fortunate in that we had really good warning that Hurricane Harvey was going to be bad, which is a little bit different from Tropical Storm Allison, where we expected — first of all, it was never — Tropical Storm Allison [0:10:00] was never a hurricane. Secondarily, it was basically formed almost right over land. And the thought was that it was going to — once it became a tropical storm, it was going to blow through, and it didn’t. It sort of like went around the neighborhood a couple of times before it finally felt. And we wound up getting way more rain than anyone had predicted.
Harvey was a hurricane by the time it made landfall and really inundated Houston. It was actually down to a tropical storm force, but like Allison, the problem was it didn’t leave as quickly as we had hoped it would. And it just continued to rain, so we didn’t have the high winds. But we had the continual rain and the flooding that occurred. So I felt that we had — the forecasting was far better with Harvey than it was for Allison. So that did give us time to pre-position a lot of assets and a lot of emergency response equipment. The problem was that even with that forecasting there were — again, it never goes — if it goes according to plan, it’s an incident. It became a disaster [0:11:00] when the flooding accumulated before we were able to get some assets in place.
The example that I give is we wound up — the plan was that we will never, ever use the George R. Brown as a shelter again. The City decided we’re never, ever going to do that after having done it multiple times. We’ve got to have a better plan. So the plan was — we had worked with the American Red Cross and a number of other community partners to have large shelters set up around the city. And so when Harvey hit, those shelters all stood up exactly according to plan — went great. Except they got filled up like almost immediately. They were — they were filled to capacity way earlier than we had expected that they would have. So we wound up having to use the George R. Brown in spite of that fact that the plan was we would never use it again. We had to do that. And as we did that, the George R. Brown, because we hadn’t planned on using it, had no cots, had like no supplies for disaster preparedness.
Now, quite honestly, the George R. Brown does not usually or routinely have cots there [0:12:00]. But with notice, had the storm been coming and we had planned on using the George R. Brown, we probably would have pre-positioned cots and water and food and some other supplies. But because the plan was, “We’re never going to do that,” there was nothing pre-positioned. So that’s how during Harvey we kind of got caught by surprise. And the surprise wasn’t so much the storm. The surprise was the number of people who needed shelter. And of course, with Hurricane Harvey, that was then compounded by the problem with the Addicks and Barker dams reaching capacity and them having to release water and basically flooding a whole other part of the city. And that was a couple days later, but again, all of the sudden, we had this big population or people who needed shelter.
And certainly, that was never part of anybody’s plan to release water from those two dams and flood all those neighborhoods. So to your question, the water rose. We hadn’t pre-positioned stuff, because we hadn’t anticipated the volume of people needing it. And so when we made the requests for those supplies, the federal government actually did a very good job of getting [0:13:00] us support. But that support got to about Conroe and then couldn’t get in, because it was — the streets were all flooded. And I’m not making that up.
There’s — from — we had a thing called — I’m blanking on the name of it now. It will come to me. But it’s basically a 250-bed — it’s like a 250-bed nursing home. It’s an intermediate care level facility that — it’s not a hospital, but it’s intermediate-level care. They came, and they got to Conroe as well as the Disaster Medical Assistance Teams, the DMATs. Now, those are like mini-emergency departments. And they were in the area, but they couldn’t get to us at the George R. Brown, because we were basically completely flooded. All the streets were flooded all the way around. And so we operated on our own for an extra day to two, because those assets, while nearby, just couldn’t actually get to us, where, you know, in a more perfect world, they would have been pre-positioned in the George R. Brown or wherever else we were going to use. And so when the people started showing up, we would have been — we would have been ready to handle them [0:14:00]. So I think that answers your question.
CS: What is the Houston Health Department’s role during a hurricane or flooding event?
DP: Yeah, the Houston Health Department’s role during a flooding is — well, the Health Department does many, many things. One of the things that we step up and do during the disaster at the — is to provide support at the large shelter operations in making sure that people have access to whatever needs they may have. So we may not be providing the need, but we make sure that we coordinate with those care providers or those social services that are in the community and make sure that the people in the shelters have access to them. So there’s some things that we provide direct care for, but for the most part, it’s going to be coordinating and facilitating people to get to those that have really got robust services for folks.
At the same time, we have to continue doing our regular job, which means, you know, making sure that the restaurants are still serving food that’s safely prepared [0:15:00], looking for disease outbreaks. And shelters, unfortunately, are great places for disease outbreaks. You take a large number of people. You cram them into small places in maybe not the best sanitary conditions — for example, in the George R. Brown during Hurricane Harvey, we had 10,000 people — actually in excess of 10,000 people living in the George R. Brown. Now, the George R. Brown’s got bathrooms. And there are bathrooms with multiple sinks and multiple stalls. And you know, they’re used to having large-crowd events there, but they’re used to having large-crowd events there for two or three hours — not for a week or two.
So while we got really good — you know, we’ve got lots of sinks and lots of toilets and so on and so forth, we have no showers. Because we don’t routinely expect people to be showering at the George R. Brown. So there’s no showers. So after a couple of days, while your hands may be clean, the rest of your body may be not so clean, right? And so when that starts happening, people [0:16:00] can spread diseases. And then other thing is when people get close in together, once one person becomes sick, the ability to spread that illness to the next person becomes very, very easy, because you’re all living so closely together.
The other thing that happens in those things is that people look out for each other, right? And so if somebody’s got a bottle of water and somebody else is thirsty, they’ll often hand them that bottle of water as opposed to, you know, pour the — at home, you’d pour the water into cup, and I’d be drinking out of it. You want some, and I pour the water into your cup. That way, we’re not using the same cup. In a disaster situation, people are passing that bottle around. Guess what? They’re also passing around whatever viruses they may have. And so there are certain viruses — the norovirus being the one that we worry about the most. This is the one that makes the national news, because you hear about it on cruise ships. So norovirus is highly contagious. It’s extremely easy to be passed from one person to the next. It causes vomiting, diarrhea. And it could cause — you know, if you’re otherwise ill and have chronic medical problems, it can actually be life-threatening [0:17:00] vomiting and diarrhea. It can be really, really serious. And it’s spread very, very fast. And so that’s why you see it on the cruise ships.
Well, a shelter is similar to a cruise ship, except people don’t have their own cabins. You know, I mean, you’re even better off on a cruise ship than you are in a disaster shelter, because that virus will spread like wildfire. And so the Health Department, getting back to your question, is — our job is to work to prevent those illnesses. So one of the things our folks do is they are constantly going through these shelters looking for people who may look like they’re ill. And they don’t want to ask for help. They’re too proud. They don’t want to be a problem — so on and so forth. They’re afraid to ask for help. Whatever it may be, we need to seek those people out. Take care of them early before we run into a problem.
CS: So is the Health Department responsible for setting up the shelters?
DP: Say again.
CS: Is the Health Department responsible for setting up the shelters?
DP: The Health Department is not responsible for setting up the shelters. The City will set up the — well, whoever owns the property is responsible for setting up the shelter. So we have some of the [0:18:00] mega churches. And we have some community centers, and some large businesses will host a shelter. And so when that occurs, they’re responsible for setting them up. Some of them have got contracts or agreements with the American Red Cross, who is well-known for managing the shelters. So they’ll bring in management teams to help manage the shelters. So in our case at the George R. Brown, the city is responsible, so it’s multi-departments, right? There’s obviously a convention and entertainment bureau, which owns the building, right? And then all the different departments will come together to provide, so the police department provides the law enforcement and security and safety, right? The health department is going to do all the things that I just talked about a couple minutes ago. [Unclear, 0:18:42] City’s Housing Department is going to come in. The mayor will appoint somebody to be the boss of the shelter — and somebody or somebodies to be the boss of the shelter, because things — again, it’s like things occur minute to minute that you just can’t predict.
I mean, there’s some things you can predict, right? So you need sanitation. We talked [0:19:00] about that, but you also need to have food, right? People need clothing. The other thing is that volunteers are going to show up wanting to help. Somebody has to manage that and make sure that the people coming in are really — you know, that we don’t have any bad guys coming in who’ve got ulterior motives. People come in with all kinds of donations to help. That has to be managed. There’s just — all kinds of things occur. And that’s why the Red Cross is good, because they develop expertise in this, right? And they’re very helpful in that manner.
CS: How long were the shelters open?
DP: Couple weeks. I don’t remember exactly how long they were open, but that does bring up an interesting point. One of the most difficult things about a shelter operation is closing the shelter. Because while there’s a significant number of folks who are going to want to get back home as quick as they can, there are a lot of folks who don’t have a home to go back to anymore. And of course, they can’t stay at the George R. Brown — they can’t stay at the shelter forever. So you know, we need to help them [0:20:00] get to family or somebody. And sometimes that’s out of state. Sometimes it’s nearby. And then there are other folks who didn’t have a home to go to before. And so now, they’ve got this nice little home where they’ve got three hot meals a day and a cot. And they don’t want to go back to their homeless situation they had before. And we’ve got to move — we’ve got to figure out some way to get them moved out as well. So one of the most difficult things about a shelter operation actually is shutting it down.
CS: Did the City assist with connecting people to temporary housing?
DP: The city does work heavily — in fact, the housing department, whenever we have this, is very much a part of the solution. As I just said, a lot of folks don’t have a home to go back to, because it’s been damaged by the storm. And so the housing department works very heavily in finding folks places to stay. And the funding for that often comes from the federal government. And we will get folks into — right off in the beginning, they’re going to be put into hotels, where we can get them out of the shelter and get them into the hotel, where now they’ve got a place where their family unit can be together under one roof and, [0:21:00] you know, at least start some semblance of a normal life again. And then we like to get them into apartments.
Again, the funding becomes an issue. There’s help from the federal government for much of that but certainly not all of it. And certainly, some people have enough money that they can pay for their own apartments. But they don’t know where to find the apartments. And so our housing department works heavily with that. And then eventually, you know, people need to get their homes repaired and so on and so forth. And that really, for a large part, is just back onto the homeowner. But there are some folks who are going to meet the federal qualifications where the federal government is going to help them get their house repaired or if — or sold, whatever the case may be. But it’s not just getting them out of the shelter. It’s getting them into some sort of temporary housing — then getting them into semi-permanent housing before we get them back into whatever permanent housing they’re going to live in hopefully and never have another storm.
CS: The people who provided care during Harvey, did they provide care [0:22:00] outside of shelters? If so, what did that include?
DP: So when you say care, do you mean medical care? Or do you mean –?
CS: Yes, medical assistance.
DP: Medical care — okay, so medical — so what was the question again?
CS: Did they provide care outside shelters? And if so, what did that include?
DP: The folks that provided medical care inside the shelters was a hodge-podge as it always is in the beginning. It was predominantly firefighters, EMTs, and paramedics. That’s what we start off with. The health department then comes in with some physicians and nurses. We got a lot of help, and we have in the past, and I anticipate we will in the future, from the medical schools and from the hospitals. And we’re going to get — folks are going to come in, and we try to coordinate that. And then the federal government will come in with the Disaster Medical Assistance Teams and the forward medical shelters, which is the term I was looking for earlier, the FMS — the Federal Medical Shelters, I should say. And they will then set up care. It is predominately [0:23:00] in the shelters however. It’s not outside the shelters. And also, those tend to go to the largest shelters, because these are big operations. When a DMAT comes in, it’s a fairly large operation. When an FMS comes in, it’s a fairly large operation. So they go to the big shelters.
But at the same time across the community, there are these pop-up shelters that occur, which are totally fine. But they’re often neighborhood-based, and they tend to be very small with 10, 20, 30 maybe people staying there. And we do what we can to support them, but that is a — very often a — I want to say it’s an uncoordinated network, because they pop up prior to having any plans for it — totally encourage them. They’re great — no problem with them. It’s just communicating with them when we don’t have communication plans ahead of time — we don’t have supply lines set up ahead of time. It becomes a little bit of a challenge. There’s no problem with it. It’s just one of those things that we have to deal with every time to try to help the folks that are staying there.
CS: What challenges did the public healthcare providers face during and [0:24:00] after Harvey?
DP: There are a number of challenges we face during. And one of them, of course, is the complete unpredictability of what’s going to happen next. The other is sort of the competition in recognizing that our day-to-day responsibilities don’t — you know, they don’t turn off. So we have to continue doing that as well as all of the disaster-related responsibilities that we acquire moving forward. Now, some of those day-to-day things — some of them, you know, tone down — the volume tones down, because for example, with the restaurant inspections. If the restaurants are all closed, we can’t go inspect them. So then that means that those inspectors are now available to go do something else.
But at some point, those restaurants owners, they want to get back open again. And so when that happens, we need to be able to match that, while we still have a major shelter to operate. So it’s balancing keeping our day-to-day responsibilities met. And of course, nobody feels that they have too many people to do a job, right? All of us feel like we’re short-staffed even without the disaster [0:25:00]. And so then when you lay the disaster on top of it, it adds another stress. And that’s where people like Director Williams and I have to sort of triage and make value decisions about which responsibility at this moment is more important than the other to direct those employees as to what they need to do. And that’s our job. And we try to do a well job, and afterwards, we always find places where, you know, next time, I’m going to have to remember this, that, and the other and maybe do a little bit better job. There’s nothing perfect happens in a disaster. Again, it’s a — they call it a disaster for a reason. Otherwise, it’d just be an incident.
CS: What sorts of preventive measures, if any, were implemented to ensure this safety of healthcare providers, first responders, and community members?
DP: The biggest preventive measure we’ve done is the training that occurs during what I call the off-season. Most of that — the federal government has been very generous in providing training dollars and equipping dollars to predominately hospitals and nursing homes and some to public health entities [0:26:00] for when a disaster occurs. And so we have an entity locally known as the Regional Hospital Preparedness Council. It is part of our SETRAC, Southeast Texas Regional Advisory Council, which is a — it’s a group that is — it’s an arm of the state actually. It’s an arm of the Department of State Health Services. It is not authoritarian, but it does a lot of coordination. And we funnel federal dollars for preparedness. So when it comes to preparing the healthcare workers, a lot of it is that training that goes in. And we do these mock drills. And a lot of our mock drills — you know, there’s all kinds of things there.
We talk about notice and no-notice disasters. So a disaster with notice would be a hurricane. It forms in the Gulf. People tell us it’s coming — so on and so forth. A no-notice event would be an earthquake. So it’s still a natural phenomenon, but there’s an earthquake. You can have manmade disasters as well — again, notice and no-notice. So if we have — so for example, just last evening, we had the debate [0:27:00] for the Democratic candidates for president here in Houston. Well, you know, that’s a target for people who are politically active and want to make an issue. And there are some people that are more aggressive than others. And so that was a — clearly, a notice event, and we had lots of security in place — and you know, related to the debate itself, we had no issues, right?
But then if you have somebody that walks into a Walmart with an automatic rifle and starts firing at people, that’s a no-notice event, right? So in both of those scenarios, healthcare workers are going to be responding to those. And they need to be prepared at how to respond and how to do so as safely as possible. Again, these are disasters, so even in the active shooter incident, when we have healthcare folks respond, we don’t want them responding into the hot zone. Quite honestly, we want them responding to where they usually work, because the public safety — we’re going to get the patients there. We’re going to bring them to where you usually work, whether it be the emergency room or the operating room or the intensive care unit. We’re going to being them there. We really don’t want people running into the hot zone [0:28:00], because you really do need to know what you’re doing to operate in there. And you need to be very specifically trained and equipped to do any good there.
The big example I always give of that is, you know, the Oklahoma City bombing. People whose hearts were absolutely in the right place left a nearby hospital and went to the site. So a lot of the people who were injured were able to walk and leave. So where do you think they went? They went to the nearest hospital. And they walked into the emergency department, where half the nurses and the staff had left to go to the site. So now, we have this big mass of patients walking into an emergency department about to overwhelm it with patients. And half of their staff have gone someplace else. So the hospital responded by taking people from the intensive care unit and other places in the hospital and putting them down in the ER, which was great — smart move, except they don’t know where to find things. And they don’t know how the computers work. And they didn’t know — so the best thing would have been for the emergency department folks to stay there, because the patients are going to come.
And the other tragic thing about that story is that one of those hospital workers was killed at the site when a piece of rock fell or a piece of the concrete fell from up above and [0:29:00] struck her in the head. And she was killed. She wasn’t equipped. She wasn’t trained, you know. So today, we want to make sure that people know not to do those things. Her heart absolutely was in the right place. I don’t want to say anything to make anybody think I’m saying anything negative about her. She put herself in harm’s way to try to do the right thing. My heart goes out to her, but as a society, we have now learned from that. And in her honor, we need to not make that mistake again, right? So we spend a lot of money, and the federal government has provided a lot of money to train healthcare workers on how to respond in both notice and no-notice events.
CS: Were waterborne infections or bacteria an issue?
DP: Absolutely, the waterborne bacteria were an infection. We had a woman die up in Kingwood from an infection that she got from the water. And the one thing I like to stress, folks, is that — I don’t care how calm the water may look. Floodwater is dirty water. You need to think of it as raw sewage, because that’s what a lot [0:30:00] of it is. It’s raw sewage. It’s either chemical pollution from whatever chemicals are on the roadway or are in the dump. And it doesn’t even have to be down the street. The dump could be miles from where you live. And it gets in that water, that water is slowing moving. It’s going someplace, right? And so there could be the contaminants from the dump. It can be contaminants from the chemical plant. It could be contaminants from what you have in your garage. You have all kinds of bacteria that are coming out of the sewage. The sewage systems are always overwhelmed. The sanitary sewer systems are always overwhelmed with this. And that is in the water. So that water is very, very dirty.
And we see all kinds of people with rashes and infected — you know, little — if you’re walking around in this water, you’re going to ding something. You’re going to hit your shin against something. It’s going to happen. You’re going to have a cut, a bruise, an abrasion. And that dirty water is loaded with bacteria. It’s going to get it in there, and you’re going to get some sort of an infection. Now, fortunately, most people, they get some redness. They get a little bit of pain. They may get [0:31:00] a small infection. They may develop a rash. Most people get well with it but not everybody. And we have had people die from the infections they’ve caught from that dirty water. And so, you know, we need to warn people. And the big thing — one of the big things that drives me crazy is when I see children playing in that water. You know, Mom and Dad, no, you can’t — I know that you got 8,000 things going on. And I know the kids are driving you crazy, but find something for them to do that does not include playing in that dirty water.
CS: What, if any, health issues arose as a result of debris and debris clean-up? And was the Health Department responsible for answering that?
DP: We see a lot of injuries with people cleaning out their homes — tearing out the sheetrock, pulling up the floors. That material is all contaminated. We stress hard for people to wear long sleeves, long pants, heavy work gloves, but you know what? Here in Houston, when it’s August or September and it’s 90, 100 degrees [0:32:00] outside with 85 to 100 percent humidity, that is really asking a lot of folks. So we do see a lot of injuries that occur, you know, in the weeks afterwards from people injuring themselves. Again, for the most part, these are minor injuries. People get over them. They’re minor infections that go with these, and most people get over them — but again, not everybody.
So the people most at risk are the people with chronic medical problems and people who are immunosuppressed for whatever reason — immunosuppressed people being those — for instance, diabetics, obviously patients on cancer therapy. Just being elderly is a risk factor. Our immune system doesn’t work quite as well, but that doesn’t mean those are the only people that have the worst outcomes. We have seen cases of people who are young and otherwise healthy and have no chronic medical problems and no medications who will get a devastating infection and either lose large areas of soft tissue from the infection — they may lose a limb. And some people have died. And these are — these are all preventable. And again, I don’t [0:33:00] want to be throwing anybody under the bus, but these are all preventable with the right precautions are taken in place. It’s awful to see a young person who lost their leg or their hand from an infection following a hurricane or a tornado or whatever the natural disaster was from an infection. But you’ve got to be very, very, very careful.
CS: How are health instructions communicated to the public?
DP: Our single, most powerful tool in public health, above all else, is public messaging. So we have got to work with the local media. And that can be a challenge at some point to get the message out. And it’s a challenge because we want to get the right message out. And we live in a world today where the media are often looking for the juicy story. And they will focus on the juicy part of the story and not the meat of the story that we need to get out to people. And we see this during disasters, and we see it during other sorts of things, for example [0:34:00], when we had the H1N1 flu bug. And as it turned out in the end looking back, while that was a novel virus and, therefore, we had a lot of people get ill with it, the death rate associated with that virus is no different than the seasonal flu, which is still too big. But it was no more deadly of a flu virus than the one that we usually see.
The difference was that, as a community, we had basically no immunity towards it, so many more people became ill. But there was worry about children being, you know, especially susceptible and dying. And there was one physician who got on the local news and said that he knew of — and I can’t remember exactly how many — like, you know, six or seven children who had died as a result of the flu. And of course, I’m the city’s Public Health Director, and we know of — we knew of one at that point. And that was actually a child who was infected in Mexico and came to the United States for help [0:35:00]. He came to [unclear, 0:35:01], got transferred to Texas Children’s, because the child was so critically ill and unfortunately died. Then shortly after that, we have a local pediatrician who is saying that he knows of six kids who have died. And we have no reports of this.
And so I — it took a little hunting down to get ahold of this doctor. And I spoke to him on the phone. I said, “What are — you know, what six kids are you talking about? Because I don’t — I don’t know. If you know, I need to know names. I need to know dates. I need to know how to get in touch with their parents. We need to know what’s going on.” He said, “Well, I don’t really know. It’s just the moms told me.” I said, “What do you mean the moms told you?” He said, “Yeah, you know, the moms come in. They were telling me that they knew about these kids.” I said, “So you have no direct knowledge?” He says, “No.” “Why don’t you give me the names of those moms?” He goes, “Well, “I’m not going to give you the names of those moms.” I said, “Well, you need to, because they’re reporting deaths of children. I need to know about it.” He goes, “Well, I can’t, because I don’t remember their names.” “So were these patients of yours?” He goes, “No, no, no, this was at a dinner party.”
So we had a very frightened community, and then this doctor, in my opinion, quite irresponsibly, repeated something that he heard at a dinner party [0:36:00] that then made the headlines. And so now, parents across the region are panicked that their kids — that there’s this virus out there that’s killing children, which was not at all the case. And in the end, we only wound up with that one death of the child. And that wasn’t even a child from Houston. The child didn’t even get infected in Houston. Tragic death, but public messaging is critically important. And we worked so closely with the media, but it can be a challenge.
Getting back to my original point, it can be a challenge when we work with the media that’s looking for the juicy story. And so it’s a relationship that we have to constantly build and constantly be massaging and constantly making sure the media understands how important they are to protecting the public.
CS: Are any vaccines recommended? And if so, what were they?
DP: The vaccines that were recommended for everybody was tetanus — for everybody to make sure they were up-to-date on their tetanus vaccines, especially during the period when people are going to be out, you know, cleaning and pulling up [0:37:00] sheetrock and so on and so forth. The other thing though is that, you know, the vaccine doesn’t work immediately after you get the vaccine. It takes a while for your immune system to respond and develop your own immunity. That doesn’t happen. That takes several, you know, days to weeks for that to occur. So we want people to get vaccinated before the storm, right?
The other was that for a lot of the public safety workers that were going to be doing work in waters that we knew were particularly at high risk for certain hepatitis strains — that we tried to get them some hepatitis vaccines ahead of time to protect them. Now, that wasn’t needed by everybody in the community. However, there’s no reason that people can’t get — we just try to focus on those folks we knew were at very highest risk. Part of the reason is that there’s not an unlimited amount of those vaccines. And so we try to, you know, get them where we can, but anybody wants to take advantage of those vaccines, certainly, there’s no reason that they shouldn’t.
CS: Were any mass vaccinations ordered?
DP: No, we had no mass [0:38:00] vaccinations ordered during Hurricane Harvey.
CS: Were there any assessments done for mental health, inside and outside the shelters? And if so, how was that handled?
DP: One of our best partners through all of this, especially at the George R. Brown, was Baylor College of Medicine. And within the Baylor College of Medicine team that came was their Department of Psychiatry. And we continue today — here, all these years later, we continue to be working with the Department of Psychiatry on a number of research projects where we’re looking back on what was the behavioral health and the psychiatric impact of Hurricane Harvey on the community. We were fortunate that we had — almost from Day One, we had members of the Department of Psychiatry at the George R. Brown with us every day – in fact, until about midnight every day – working with patients. And at that point, a lot of it was trying to control their behavioral health illnesses so that they were able to stay at the shelter quite honestly [0:39:00].
Remember, a lot of these folks when they left home, they left their medicines behind. Or they brought their medicines with them, but they got saturated when they were walking through the water. And the pills are all disintegrated. And they didn’t have medications. So a lot of it was trying to manage those patients’ illnesses with a sister drug or whatever it was that we had access to until a pharmacy came in. And a lot of it just had to do with counseling — just being there and talking to the folks and having them manage the emotions that they were feeling. The last thing we wanted was for somebody to decompensate there that didn’t need to — again, going back to the health department, going out and looking through the community trying to find people who are struggling.
But even today, we are continuing to look at the behavioral health issues. And what we found so far has been there was really not a big spike. At first, actually, there was a dip — during the event, there was a dip in the number of folks that are asking for behavioral help. That’s probably only because they couldn’t get to the places to ask for help. It’s not that people actually felt better. It’s — in fact, they probably were feeling much worse [0:40:00]. But they couldn’t get to the places to ask, so it’s a little bit of a statistical variance. And then things quickly sort of came back up to normal. And then about six, eight months later, we start seeing an increase.
So what’s happened six, eight months later is where people are realizing they’re not going to get back into their homes soon. They’re realizing that they’re running out of money. They’re realizing that the federal aid is about to end. They’re realizing that they’ve got more problems, right? And they’re emotionally fatigued. They’re exhausted. And so that’s when we start seeing it — is actually months later. And that needs to be addressed, because these are people who need help in order to get themselves — you know, really get them and their families back where they need to be.
CS: And for those people specifically, do you know how they are treated over the long-term?
DP: How they’re treated long-term? A lot of it is getting them — so for a lot of folks, they had long-term care before. For the people who had diagnosed behavioral health issues before, just getting them in the acute phase — in the first couple weeks — getting them back into that [0:41:00] care pattern. Again, six, eight months, they often need more. They need to see their therapists more frequently. Maybe they need adjustment in medications.
The other group, though, are the people who before the storm didn’t have any behavioral health problems, who — then the storm pushed them over the edge. So they may have been somebody who was either managing their own issues on their own and gets pushed over the edge or people who, you know, didn’t even think that they had any issues. And all of the sudden, they get pushed over the edge. So there was a slight increase in the number of — total number of folks who were seeking help — maybe not at a highly acute level but at a low level — but nevertheless in need of help. And so the whole thing is to try to get them plugged into the long-term care. And in this community, Houston, just like every other major metropolitan community across the nation — and even not major — the suburban communities, we have a completely inadequate amount of behavioral and psychiatric help available to people. This country is — we’re very, very short on that [0:42:00]. I know you love the background noise. That’s my own Muzak.
CS: Post-Harvey, did you suggest any long-term improvements for the future to patient care, record-keeping, or hygiene promotion, for example? And if so, what measures are recommended?
DP: So the answer is no, but it’s going to sound like, “Why not?” Well, it’s — by Hurricane Harvey with a lot of this record-keeping, except for the advances in technology, we’ve sort of got it figured out, right? Now, the problem is that during the event, we wind up having to go back to paper and pencil. And so that’s the one area that we need improvement in, but we don’t have really have a great plan for that just yet. Because when there’s no power — you know, you can have all the tablets and internet connectivity in the world, but when there’s no power, none of that stuff’s going to work. So we wind up going back to paper and pencil. And then somebody’s got to input that later [0:43:00].
So we have a very robust — it’s called Health Information Exchange here in Houston, where if people opt into this program, then their records are in a place that’s centralized so that if you come to me and you’ve never seen me before — and you come to me for care and you give me your permission, I can then get into the Health Information Exchange. And I can look up — I can pull up all your old records. It will tell me everything that’s been going on with you. And it gets me up to speed to be able to help you much more quickly. So we’re fortunate here in Houston. We have one of the most robust health information exchange programs in the country. And we have tapped into that. And we work with them. But still, in that very acute phase when there’s no power, we’re back to paper and pencil and, you know, keeping them in a cardboard box and having to input those later. I don’t have a good solution to that.
CS: Many people in the private sector assisted with rescues during Harvey as you mentioned. And how did that impact the continuity of care provided by EMS during [0:44:00] the storm and as waters receded?
DP: Yeah, the folks that came to help their neighbors or they came to the shelters were nothing but a great help. And we so much appreciate them coming. We did run into a point, however, where we had a little bit of friction, because when we started getting resources coming in through the more formal way, a lot of the volunteers wanted to continue performing. And we had to inform them that, you know, you may have been protected under the Good Samaritan Act up until now, but now that we’ve got paid professionals here to help, you know, the courts aren’t going to give you that Good Samaritan protection anymore, so you need to decide.
And it was really — it was heartbreaking, because I was the one who had to tell some of the doctors and nurses what was going on. And the city wasn’t going to be able to offer them any protection, because we now have the federal government coming in to help. And some of them were really angry about that. So it was an interesting phenomenon, because their passion was so strong and their desire to help was so strong. Then we told them, “Thanks, but you can stop now.” Some of them became angry [0:45:00]. And I can understand that. And you know, this is the whole reason you go into healthcare — is because you have that passion to help other folks.
And during a disaster, what a great time — especially if in your career — you know, all of us, as our careers — there are periods in our careers where it becomes kind of mundane, right? We got our processes down, and we’re just going to work every day and helping out people. And maybe the newness and the excitement is washed off. And then when you have a disaster and you get to really tap into that emotion that you had that drove you into it in the first place, it’s really exhilarating. And it makes you feel really good about yourself as it should. And then to have somebody come and tell you, “You know what? You need to stop now,” for a medical-legal-bureaucratic reason is really frustrating for folks. And you know, I was the — I was the poor guy who got to tell them that. And I took the brunt of a lot of displeasure. But at the end of the day, I had to tell them, because had something gone wrong, from a medical-legal standpoint, they were [0:46:00] then completely unprotected. So I’m not sure if that even answers your question.
CS: That’s alright, yes. Were any hospitals down during Harvey? And if so, how did EMS assist them?
DP: So during Hurricane Harvey, East Houston Regional Medical Center flooded. And that’s a hospital that had flooded several times before. And in fact, it never opened again after Hurricane Harvey. That was the last time. The hospital closed after that. So that was the only hospital that comes immediately to mind that closed during Hurricane Harvey. But back during Tropical Storm Allison, we had five hospitals, including East Houston Regional — we had five hospitals all close within about three hours of each other. And the others were big hospitals. And they didn’t come back online for months, so that was a much bigger adjustment back during Tropical Storm Allison.
And the reason, I think, for the big difference is all of the work that had been done, particularly in the area of the medical center, with changing Brays Bayou and the drainage patterns [0:47:00], and putting up other protective measures throughout the medical center to protect the hospitals from flooding that didn’t exist during Tropical Storm Allison. There was many, many millions, if not billions, of dollars spent on that. And I’ll tell you what. When Harvey happened, I’m so glad every penny of it was spent, because for us, a community this size, to lose all those big hospitals again would have been just as devastating as it was the first time. And it was devastating the first time, because if you recall, we lost Memorial Hermann, Methodist, Saint Luke’s, Saint Joe’s, and East Houston Regional. So those are big hospitals to all go offline and stay offline for months. So they didn’t even start coming back open again — I think Memorial Hermann opened their ER like four months later. And that’s a huge hit to this community.
CS: Houston EMS has responded to many weather events over the last 20 years. And building on what the department has learned from each event, are there any other improvements that were made [0:48:00] in the approach of EMS between Ike in 2008, floods in 2015 and 2016 and in 2017, Harvey?
DP: The department has done a number of things. We now have a much more robust, swift-water rescue team — so to be able to go out and get people — so swift-water means moving water. That’s — this is where the cars drive into deep water, and the water is — the flooding is still occurring and you’ve got somebody sitting on top of a car. And there’s current going by, because if people get off, they’re going to float away, right? So they’ve got a much more robust swift-water rescue. We also have — now, we’ve got the high-water vehicles. These are the big, big trucks where the air intake for the truck is basically on top of it, so the engine will continue to run even though it’s under water. And those are the trucks we can use to go driving down through neighborhoods. And we’ve got the boats to go pick up somebody off the roof and bring them back to the truck and get them out of the neighborhood. So a lot of that has been done. In fact, also, the police department also has these types of vehicles. Public works has some of these vehicles. So we actually have multiple departments with these new [0:49:00], very large, very high-water vehicles to help rescue people.
CS: What lessons were learned during Harvey that will be carried forward to the next storm?
DP: I think — from my standpoint — from a healthcare standpoint, we’ve relearned that in the first 24 to 48 hours, we have got to be prepared to take care of ourselves. The help — the calvary isn’t going to be here that quick. We had learned that before, but as the nation responded more and more robustly with disaster infrastructure and disaster response capability, there was sort of a believing — a belief that was developing that, “This is — the calvary will get here much more quickly next time. And they’re going to be much more robust.” And I think that the calvary is much more robust and far-better tailored to our needs. But they’re not actually going to get here any sooner than they did before, because the disaster is still occurring. And I think that we’ve got to recognize [0:50:00] that that’s probably not going to change. And so we need to expect that we’re going to be on our own for 24 to 48 hours and plan for that.
Again, we need a plan. We need to drill. We need to exercise. And then on game day, we need to be able to not be so adherent to our plan that we can’t solve the problem using a tool in a different way than it was originally expected to. So I think those are the things — and we now have had enough disasters here that those of us who have been through several of them – and we know each other for the most part – have gotten pretty good at being able to adjust the plans and so on and so forth. And we’ve gotten comfortable with the fact that we’re going to be on our own for 48 hours. Some of the newer people to the game — pretty good people that come from other communities who’ve never experienced this, they continue to have a lot of consternation about that. And we will hold their hand to get them through it.
CS: So that actually concludes the questions that I had, but is there anything we haven’t [0:51:00] discussed that you would like to add?
DP: No, the thing that I always talk about – and you hit on it with the questions – is the concept — there’s two concepts interrelated. But one is that planning is nothing — I’m sorry. The plan is nothing, but planning is everything. And then the other concept is — we already sort of touched on — is that your assets to respond to a disaster are like tools in a toolbox. And I can — I can drive a Phillips-head screw with a flat-head screwdriver. I can do it. It’s not great. I can drive it with a hammer. It’s not great, but I can do it. But it’s because I know what those tools are capable of, because I’ve used them before.
And in disasters, it’s the same thing. And I already talked about this. But it’s knowing the limits of your team. It’s knowing the limits of your assets. It’s knowing the limits of your systems that allows you to be able to use those in ways which they were never intended in order to succeed at a problem you never anticipated [0:52:00]. But you have to — that is the key to surviving a disaster — is being able to get creative. And sometimes you have to inspire your team members to do something which they’ve never been asked to do before. And you have to do it in a way that you impart the confidence to them that, “Yes, you are going to make this work. You can do this. You can succeed here. Here’s how we’re going to do it. Here’s the plan. It’s a new plan, never though up before. You know, it’s on the back of his napkin, but here it is. And you know what? We can do this.”
And every time you do that and you succeed, your team becomes a little bit more courageous, a little bit more resilient. Because they are dealing — remember, the other thing is your team members have got homes in the neighborhood. And they’ve got families in the neighborhood, too, right? So it’s not like they’re coming to work with no burden of their own. And so if we can do those things, no matter what comes our way, we’re going to figure out a way to minimize the damage and maximize the positive results [0:53:00].
CS: That’s good. Thank you.
DP: Sure thing. [0:53:05]