https://orcid.org/0000-0002-5205-8015
“All happy families are alike; each unhappy family is unhappy in its own way.” Leo Tolstoy, Anna Karenina.
The same can be said about disasters- each unhappy disaster is an unhappy disaster in its own way. What are the roles of pediatric pathologists in a disaster? Overlapping roles involving the hospital, university, and community will be different in each disaster. This editorial will focus on a disaster occurring almost 20 years ago as one example of what roles the pediatric pathologist may assume.
Background: Extent of the disaster
August 29th, 2005, Hurricane Katrina made landfall as a strong category 3, just east of New Orleans. While in the city there was widespread wind damage, loss of electricity and communication interruption (cell towers were down), the significance of the levy breach and resultant flooding was not appreciated until 2 days later. Children’s Hospital began evacuation 2 days after the storm. By day 3, all had been evacuated, with the help of many other Children’s Hospitals aiding in ground transportation (as the airport was closed to civilian traffic). In all, 9 of the 11 Orleans Parish hospitals suffered extensive flooding, with Children’s being one of the 2 hospitals unaffected by the flood. Even the two non-flooded hospitals closed days after the storm as the extent of the disaster become evident.
Nine days after the evacuation, Children’s Hospital established administrative offices in Baton Rouge, 90 miles away, and initiated clinics for the displaced children in the area. Children’s Hospital guaranteed continued salaries to all the employees until they could be called back to work, only terminating the employment if they were unable to return. All physician contracts would be maintained and honored for any physician wanting to return.
In New Orleans, the levies were repaired, the flood waters were drained, allowing power to be first restored to a section of the city on September 29th. Children’s Hospital was included in this section in which power was first restored. Most families were displaced. Often only one family member returned to New Orleans to begin recovery efforts. Repopulating the city with families required reestablishment of services for children, specifically schools and medical care. Children’s Hospital called back the employees Oct 3rd. The first week was spent cleaning, assessing the services that could be provided, and re-supplying the hospital. October 10th, the hospital re-opened for service.
Pathologists’ activities
As there was no laboratory, the pathologists had no specific role in the temporary clinics. Two of the 4 pathologists volunteered at the coroner’s office that had been established in a warehouse in St Gabriel, LA., performing autopsies of storm victims and working with the Disaster Mortuary Operational Response Team (DMORT). The pathologists returned to the laboratory once Children’s called back the employees on Oct 3rd.
There were 4 pathologists at the time of the storm. One immediately resigned, as their home was near the levy breach and was extensively flooded. Several months later, a second pathologist took a position elsewhere.
The week before the hospital reopened was spent assessing the laboratory damage, resupplying reagents, and revalidating tests. A limited number of technologists were able to immediately return. Which tests were initially offered had to be determined, and there were on-going assessments of what and when to re-institute the remaining tests.
As the blood supplier for New Orleans was affected, effort was directed to assuring/establishing a steady blood supply from the neighboring parishes.
The same week Children’s Hospital re-opened, Joint Commission inspected the hospital to determine if the Hospital deserved to maintain accreditation. This inspection was required since the hospital had been closed for greater than 31 days. Joint Commission accreditation was maintained.
The College of American Pathologists (CAP) and the American Association of Blood Banks kept to the normal accreditation cycle and inspected the laboratory in the following spring.
For CAP surveys that could not be completed during the time that Children’s Hospital was closed, we responded with code 55 - exception granted due to a natural disaster. This was accepted by CAP without requirements for further alternative proficiency testing.
The coroner’s office was not established in New Orleans for several months. During this time, the pathologists at Children’s Hospital performed the pediatric autopsies normally performed by the coroner. Most of these were either sudden unexpected deaths or trauma.
The Children’s Hospital laboratory had a cytogenetic section, mainly involved with constitutional karyotypic analysis. Louisiana State University Health Science Center (LSU) Department of Pathology had a cytogenetic laboratory that provided constitutional and tumor karyotypic evaluations. The cytogenetic technologist at Children’s Hospital could not return. The cytogenetic technologists at LSU were available, but the facilities for the laboratory at LSU were not open. Arrangements, including a CAP grant, allowed the temporary transfer of the cytogenetic technologists at LSU to Children’s, where constitutional and tumor karyotypic analysis was resumed. As LSU re-opened (∼ 1 year later), cytogenetic laboratory operations were resumed at LSU, made possible by retaining the cytogenetic technologists’ expertise in New Orleans by employment at Children’s Hospital.
Three of 4 liquid nitrogen freezers storing human progenitor cell (HPC) products failed. 120 HPC products on 60 patients were lost. There was only one patient that needed to be re-collected- the rest of the products were from older cancer surviving patients or patients that had died. Twenty years of frozen tumor tissue (banked) were lost due to thawing.
Education
Resident programs
The 2 medical schools (LSU and Tulane University) and all of the training location hospitals for pathology in New Orleans were closed due to storm and flood damage, with the exception of Children’s Hospital. The Children’s Hospital Pathologists were faculty at LSU’s Department of Pathology. Of 16 LSU pathology residents before the storm, all 4 first year and 2 fourth year residents immediately joined other programs. The remaining 10 residents were distributed to either Children’s Hospital or other system hospitals throughout the state. Until teaching facilities were reestablished in New Orleans, the residents met one day a week 80 miles away in Baton Rouge, would assign themselves topics to present, and pathology staff, including the pediatric pathologists, would alternate attending morning sessions for teaching and other interactions.
Before the flood, Children’s Hospital had 1 resident position for 12 months/year for LSU pathology residents. Children’s Hospital immediately approved an additional 12-month position for the LSU pathology program, and a 12-month position for the Tulane pathology program. In addition to anatomic pathology, the residents rotated through the clinical laboratories- chemistry, hematology, microbiology, and blood bank, all under the direct supervision of the pediatric pathologists who subsequently devoted a larger portion of their time to resident teaching. As the program sites in the area returned, permanent changes to resident positions included 18 months/year for LSU pathology residents and 12 months/year for Tulane pathology residents.
The ACGME immediately inspected the LSU pathology program, reducing the approved positions from 16 to 8. There were no applications for the next year, and with the 2 graduating residents, there remained 8 LSU pathology residents. A similar reduction in resident positions occurred at Tulane. As recovery progressed, both programs expanded to 12 pathology positions. The pediatric pathologists became adjunct faculty at Tulane.
Fellowships programs
The Pediatric Pathology fellowship program had closed earlier in 2005. After the storm, the three LSU fellowship programs-forensic, blood bank, and cytology immediately closed. The Pediatric Pathology fellowship program was the first to re-open in 2010, training someone familiar with the local issues to subsequently join Children’s Hospital Pathology.
Students
The LSU Medical School’s first 2 years of classroom activities transferred to Baton Rouge. As all the pathology slides were scanned prior to the storm, this facilitated the laboratory experience. The pediatric pathologists participated in sophomore in lectures and laboratories.
Research
The Children’s Hospital IRB suspended function until the spring of the next year. While previously approved clinical research could continue, new protocols could not be processed.
Several researchers located at LSU were able to transfer their basic science research to research facilities at Children’s Hospital. The proximity allowed closer collaboration between researchers and the Children’s pathologists.
The LSU website and desktops, which included PubMed access, was restored immediately after the storm, before any hospitals reopened. This allowed continued work on different academic projects such as manuscripts during this service “down time “.
Miscellaneous
The US Mail was disrupted for several months. There was “mail call” at the local post office stations (it was exciting to get any mail- even a bill). This disrupted delivery of our journal subscriptions, resulting in gaps of several issues in the hospital and laboratory journal collections. With the on-line access to PubMed, we now have access to all issues of these journals. In our library, instead of bound volumes for 2005 and 2006, there are loose individual journals with missing issues.
In mid-November, 2 ½ months after the storm, several schools combined resources allowing them to open, permitting those families with children to return. These resourceful educators had to explore alternative educational activities for their students. My children’s school approached me to see what I could share with the science classes. I brought 4 brains to their 4th grade class, one from a premature infant, one from a term infant, one from a 2- year -old, and one form a 12- year -old. For years afterward, I brought human organs to share with the science classes. I always knew what their dinnertime conversations included that night.
In June of 2021, there was a 16-year-old that developed a fatal Hemophilus influenza meningitis who was 8 months of age at the time of the storm. The family was displaced by the storm, and we question whether the immunization schedule was not completed due to the disruption of medical services during and after the storm as we had not encountered a Hemophilus influenza meningitis since 1991.
Conclusion
Most pediatric pathology practices depend upon a hospital to be able to work, and their community is the immediate hospital. In times of disaster, this community may expand, and pediatric pathologists can have a role in the larger medical and lay community.
Editor, Fetal and Pediatric Pathology
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