The Joplin Tornado Medical Surge

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The Joplin Tornado Medical Surge
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Objectives
Understand its not just a clinical
issue Preparations Response Obstacles Work-aro
unds Lessons learned Take-aways
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Freeman Health System

• 446-bed, three hospital system providing
  comprehensive medical and behavioral health
  services
• Freeman West Level II Trauma Center
• Freeman East 1.2 miles
• Freeman Neosho Level III, 20 miles
• Ozark Center
• Area includes more than 450,000 residents in
  Missouri, Kansas, Oklahoma, and Arkansas
• Locally owned, not-for-profit

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Freeman Health System
St. Johns

• 350 beds
• 17,229 admits
• 4,976 inpt surgeries
• 8,842 outpt surgeries
• Approx. 50,000 ED visits

• 357 beds
• 15,651 admits
• 2,562 inpt surgeries
• 4,350 outpt surgeries
• 43,376 ED visits

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Timeline of Events
130 pm CDT NWS/SPC Tornado Watch issued for Southwest Missouri in effect until 900 PM CDT
509 pm CDT - WFO Springfield Tornado Warning Polygon 30 issued for Western Jasper County MO (including northeastern Joplin) in effect until 600 pm CDT
511 pm CDT Initial 3 minute siren alert sounded for Jasper County and Joplin
517 pm CDT WFO Springfield Tornado Warning Polygon 31 issued for southwest Jasper County MO (and Joplin), northwest Newton County MO and southeast Cherokee County (KS) in effect until 600 pm CDT
534 pm CDT Approximate initial Tornado touchdown ½ mile southwest of JJ Highway and Newton Road (southwest of Joplin City limits).
538 pm CDT Second 3 minute siren alert sounded for Jasper County and Joplin. EF-4 Damage begins as tornado approaches Schifferdecker Avenue in western Joplin
548 pm CDT WFO Springfield Tornado Warning Polygon 32 issued for southern Jasper County MO (including Joplin), northern Newton County MO and western Lawrence County MO in effect until 630 PM CDT
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Timeline of Events
130 PM watch in effect until 9 PM
Overhead announcement 511 PM 3-minute siren
Emergency notification system to staff
Suspected track north 517 PM 3-minute
siren Suspected track south Announced
again and every 15 minutes thereafter Start
generators
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Freeman Health System Prepares

• Tornado warning procedures activated 511 PM
• During shift change
• Hospital at capacity, on diversion 1-2 days
  prior
• Close blinds/window coverings
• Close doors
• Provide pillows/blankets
• Move patients to hallway
• Identify oxygen-dependent patients
• 534 PM the storm arrives
• Main power lost
• Brief interruption to Pyxis access
• Magnitude unknown

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The Path of the Storm
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Infrastructure Damage - Immediate

• Roof damage
• 17,000 sq ft
• Cardiology/ICU waiting
• Patient relocation

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Infrastructure Damage - Immediate

• Oxygen and propane
• Retaining wall collapsed
• 8-ft long
• Landed on supply line
• Tore loose bulk oxygen fill station
• Tore off wiring controls for propane evaporator
  system
• 1 differential no oxygen

12
Infrastructure Damage - Immediate

• Water and sewer
• 8,000 main breaks
• 40/12 lbs. pressure
• Boilers, SP, ORs, ICU, CVICU, NICU, Medical 1-3,
  OB, Cardiology, Nutrition
• No cooling water loop no freezers/coolers/steam
  
• No fire protection
• No boilers
• Dialysis - 5/20, no EDC

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Infrastructure Damage - Immediate

• Electrical
• Main feed destroyed
• Backup feed 1 destroyed
• Backup feed 2 - destroyed
• Substation 1 destroyed
• Substation 2 destroyed
• Generators
• Not everywhere
• No AC, food, or drink
• Darkness
• Beacon of Hope

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Infrastructure Damage - Immediate

• Network
• All connections severed
• Not all switches on emergency power
• 4 POTS lines 1 worked a little

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ED Realization of Disaster
Within minutes hundreds of injured arrived on
foot and in the back of trucks
20 200 90 gt700 180 gt1,000
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ED Realization of Disaster
Atypical walking wounded Move patients
quickly Stabilize and transfer
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Freeman Health System Response

• Incident command established at 610 PM
• Location issues split up
• Boots on the ground
• Numerous triage and alternate care sites
  established
• West Campus
• EMS entrance
• Main ED entrance
• Heart Institute
• Freeman East
• Freeman Neosho

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Patient Care Challenges
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Patient Care Challenges Immediate

• Severity of the injuries
• Life-threatening
• Injured beyond recognition
• Emotional state of staff and patients
• NOT the expected chaos hushed
• Patients offering others to be seen first
• Staff stayed
• No communication with outside
• Best indication where patients were coming
  from
• Number of staff available to provide care
• Five deep
• Shoulder to shoulder

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Patient Care Challenges 2 to 4 Hours

• Flooding in multiple patient rooms
• Patients in halls
• Oxygen tanks depleted
• Meals/refrigeration
• Inundated with family and visitors
• Many injured
• 3-4 family members average
• Nowhere to go
• Troubling news shared with patients

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Patient Care Challenges 2 to 4 Hours

• Auxiliary power
• One operating elevator
• Limited or no lighting in restrooms, dressing
  rooms, and temporary care areas
• Decreased water pressure
• Hemodialysis
• Flushing toilets
• Sterilizing equipment

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Patient Care Challenges 4 to 6 Hours

• Hand-venting
• Lack of patient information
• Volunteers arriving
• Alternate holding area resources
• Breeched water system boil order
• Portable radiology
• gt800 x-rays
• gt400 CT scans

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Patient Care Challenges 6 to 12 hours

• Critical patients triaged to ICU communication
  issues
• Lab tests
• Difficult to match to patients
• No network
• Analyzers ok, no QC ranges
• Handwritten results
• Nursing time hundreds of procedures

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Patient Care Challenges 6 to 12 hours

• Thousands of supplies diminished
• Ortho supplies, splints
• Chest and ET tubes
• Tetanus
• Morphine
• Emotional and physical trauma
• Personal losses
• Troubling news
• The unknown
• Patient cleansing

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Patient Care Challenges 6 to 12 hours
Discharged patients - homeless Arranging
follow-up care physician offices
gone Discharged prescription needs Ambulatory
aids and home oxygen
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12 Hours Post-Tornado
467 registered patients at Freeman Health System
West, hundreds unregistered Thirty-nine
treated at Freeman Neosho Performed 22
life-saving surgeries in 12 hours Transferred 64
patients to other hospitals 888 Freeman 100
non-Freeman clinical staff
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Four Days Later
All Freeman entities fully operational More
than 1200 patients within 48 hours 124
transferred to surrounding hospitals Employee
disaster relief store fully operational for
Freeman Health System employees and families
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Four Days Later Wounds and Injuries
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Post-Traumatic Mucormycosis

• 18 suspected and 13 confirmed cases according to
  CDC analysis
• Infection implicated as a contributing factor of
  fatality in five patients
• First outbreak following the tornado, although
  similar outbreak occurred following the March
  tsunami in Japan
• Further CDC research underway to elicit etiology

http//www.joplinglobe.com/tornadomay2011/x2057655
110/Fungus-cases-first-to-be-connected-to-a-tornad
o
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Post-Traumatic Mucormycosis

• Ubiquitous
• Diabetic sinus infection first discovery
• Needs little oxygen
• First time to see this strain in tornado
• Indonesia
• Tornadoes most common source
• Needs driving winds
• High-risk populations
• Severe diabetics
• Elderly needs iron to reproduce
• Immunosuppressed

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Post-Traumatic Mucormycosis
4 days post incident Penetrating
trauma Surgical debridement necessary Antifungal
s
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Post-Traumatic Mucormycosis
48 hours after initial debridement
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Post-Traumatic Mucormycosis
Immediately following second debridement
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Post-Traumatic Mucormycosis
24 hours after second debridement
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Post-Traumatic Mucormycosis
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Post-Traumatic Mucormycosis
Same day
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Post-Traumatic Mucormycosis
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Post-Traumatic Mucormycosis
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The Losses
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The Losses
Eleven patients expired at Freeman West Two
Freeman employees perished in the storm
Multiple Freeman employees lost friends/loved
ones 464 Freeman Health System employees and
volunteers were directly affected, 272 displaced
from their homes 10 Freeman Health System
facilities damaged/destroyed 8 of 14 Ozark
Center facilities destroyed or endured
significantly damaged
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The Losses

• Death toll 161
• 18,000 cars destroyed
• 5,000 jobs affected
• 1,308 pets displaced
• 6,954 residences destroyed
• 1,000 businesses and other offices destroyed
• 875 homes damaged
• 500 businesses destroyed
• 150 medical and dental offices destroyed
• 28 churches destroyed
• 4 pharmacies destroyed
• 3 nursing homes, 1 senior center destroyed
• 33 of day cares destroyed
• 45 of Joplin destroyed

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How We Overcame Challenges
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How We Overcame Challenges
Sheer dedication and ingenuity on behalf of our
employees Our hearts and hands Selfless and
heroic duties Blood, sweat, and tears
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How We Overcame Challenges
Planning, preparedness, and collaboration at all
levels System EPC cross-functional team
members Annual drills, competencies
Real-life situations Local LEPC and
subcommittees Regional Region D Healthcare
Coalition State MHA Coordinating
Council Mutual Aid Agreements with external
agencies
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How We Overcame Challenges
Discharged patient needs Follow-up care ED and
Urgent Care facilities Prescriptions
Outpatient pharmacy Hospitalist State
Executive Order Ambulatory aids and home health
supplies Patient Services Administration
Homebound checks Alternate sites for Midwest
Ortho, physician offices Relocated business
departments
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How We Overcame Challenges
Water and sewer Missouri Hospital
Association, help from other hospitals
Memoranda of Understanding Baxter Springs,
Kansas fire department Cooling
towers Non-potable water tankers 24/7 5 days
Bucket brigades, Rubbermaid trash cans
Exterior water storage tank to filtration system
for Dialysis Potable water transported from
neighboring community Tanker trucks 1
week, 7k gal/20 min
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How We Overcame Challenges
Oxygen and propane Facilities repaired supply
lines Nursing oxygen ports in
rooms Electrical Six sets of redundant
generators 300 gal belly tanks, 10,000 gal
underground MOU fuel supplier refrigerated
trailers Construction contractor arrived within
60 minutes Crew of 15 Semi load of
generators Telescopic lights Electric Company
arrived within 2 hours 14 trucks, new feed 5
miles Generator power 13 18 hours
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How We Overcame Challenges
Gas No gas for community Kept our
pressure up Network Telephony within each
facility but not outside Texting
Hand-held radios Fiber providers disaster
zone Backup circuit repair West to East 36
hours Communications Trailer via MHA
satellite internet
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How We Overcame Challenges
Supply shortage Par levels Missouri Hospital
Association/Mutual Aid Agreement Surge
cache Blood products CBCO, St.
Johns Pharmaceuticals Morphine St.
Johns Lactated ringers IV solution
Wholesale order via HAM radio Fully
stocked and operational by Monday at noon
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How We Overcame Challenges
Patient census Surge areas numerous,
constantly resupplied Multiple triage
locations 40 additional ED beds in conference
room Transferring less critical patients Door
to ICU ICU ED Dirty patients, unknown
injuries New lines on each patient Monday
morning
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How We Overcame Challenges
Patient tracking John Doe system did not
work Statewide system No internet Scanners
inefficient Wrote on patients Where they were
found Who brought them in
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How We Overcame Challenges
Staffing needs/volunteers Do not
underestimate 154 physicians, 883 employees in
2-3 hours Security guards 3 guard staff
17 Nurse Physician dedication Media requests
for employees Corporate disaster plan
Facebook TV stations Local radio
Local newspaper website
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How We Overcame Challenges

• Emotional needs
• Hospital staff
• Hospital volunteers
• Preschools centers lost
• Children more than 3,500 Joplin R-VIII
  children displaced
• Elderly nursing homes lost
• First responders
• Helping organizations

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How We Overcame Challenges

• Ozark Center grants awarded since May 22, 2011
• Missouri Foundation for Health Emergency Grant -
  115k
• SAMHSA Emergency Response Grant (SERG)-990,335
• Assertive Community Treatment Team - 1,000,000
• Governors award - 2,000,000
• FEMA ISP, CCP and RSP - 4,060,000

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How We Overcame Challenges

• Emotional needs of staff and volunteers
• 24-hr onsite counseling 48 hours
• Debriefings
• Hotline 9 months
• Support group sessions for staff 1 year

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How We Overcame Challenges

• Emotional needs of community
• Widespread, long-term
• Debriefings gt 27 businesses and 700 citizens
• Hotline 1,500/mo first 3 months
• Licensed staff to FEMA DRCs, shelters, et al
• Grief counseling groups/critical incident stress
  debriefings to first responders
• Public education

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How We Overcame Challenges

• Emotional needs of community
• Healing Joplin
• 100 additional employees embedded in community
• School support
• 5 licensed counselors, 5 community support
  workers
• Support for school systems efforts in School
  Wide Positive Behavior Supports program to reduce
  drop outs, behavior referrals and in/out of
  school suspensions
• Evidence Based Practices
• TF-CBT (trauma focused cognitive behavior
  therapy)
• AF-CBT (abuse focused cognitive behavior therapy)
• TF-PCIT (trauma focused parent child interactive
  therapy)
• TG-CBT (trauma grief cognitive behavior therapy)
• CPP (child and parent psychotherapy)

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Taking Care of Our Own
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Taking Care of Our Own

• 36 hrs all accounted
• Fully-functioning distribution center
• Personal necessities
• Cleaning supplies
• Tools
• OTC medications
• Diapers, formula
• Toys
• 40 beds
• 30,000 bottles of water
• 4,000 pounds of food
• 50 car seats
• Financial assistance to 500 employees

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Taking Care of Our Own
300 pair of shoes!
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Lessons Learned
Who is included in your disaster plan? Emergency
services Local EOC
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Lessons Learned Command Center Operation

• Longevity
• 113 hrs 10 min
• 12-hr shifts AFTER the first couple of days
• Redundancy on paper ? redundancy in real life
• HCC its an idea, not a location
• Critical decisions may not have time to go
  through the HCC
• Beware of imposters
• Open room to Command Center staff only
• Find alternate location HR/staffing
• Volunteers
• Woodwork
• Validating credentials impossible
• Train operators to efficiently triage calls

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Lessons Learned Preparations
Identify ambulatory patients Keep patients
informed Provide instructions Common
terminology e.g. tornado warning Take drills
seriously NLE 2011 radio and media
issues Leaders need to consider labor pools in
drills Everyone needs to know controls that are
in place
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Lesson Facilities
Waste management Disposable bags Body
bags Security Cameras backup power
Identify needs for security personnel
Locking entrances isnt always practical Resource
s Know your lighting and gas capabilities
Consider dedicated backup water feed lines for
boilers Treat monthly gen tests as drills
requiring staff response Install more
emergency outlets
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Lesson Equipment
Piping/hoses for dialysis Portable radiology
equipment Hands-free lighting Radios
hand-held and AM/FM
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Lesson Equipment

• System processes easily converted to manual
• Know how to manually override critical equipment
• Know if a key is needed and where it is keep
  two
• Updated downtime procedures for critical IT
  functions
• How easily can it convert to manual?
• What forms/policies/procedures do I need?
• Do I need additional staff?
• How long can I function this way?
• What resources do I need to transition back to
  normal operations?

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Lesson Patient Care
Isolation patients consider time, donning with
PPE Look for more central locations than the
hallway Patient identification - embossed manual
tags Lab and radiology reports develop a plan
to track Re-evaluate your par levels 96 hour
supplies Triage predetermined supplies,
constant restock Sustained increase in census
1 year and counting Longevity in MOUs with
outside agencies
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Lesson Staff Considerations
Staff assignments be careful Hospital ID and
wallet Hard copy staff phone numbers
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Lesson Staff Considerations

• Take care of your employees
• Shocked, overworked, tired
• Survivor guilt
• The effects are long-term - as of September,
  2012
• 20 suicides since May 22, 2011
• 20 in child sexual trauma
• Alcohol and drug use is up 80
• There is a 50 increase in domestic violence
• Gambling has increased 40

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Changes Policies and Procedures

• In progress still in surge
• Disaster Plan report to work
• Mass Fatality Plan workers, location
• Process on units for tornado watch

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Changes Network
All fiber underground Diverse path to
FNH Offsite options for backup data center
location
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Changes Infrastructure Supplies
Pumps for tanker truck connections are now on
generator power More headlamps Just in time
caches ready for triage
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Changes - Statewide
Communications trailer Interoperable Training
and exercise Streamlining coalition response
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Freeman Health System

• Recently ranked 4 hospital in the state of
  Missouri
• U.S. News World Report
• Recognized among best hospitals in SW Missouri
• Named as a Best Regional Hospital for 2011-2012
• Special designation in 5 high-performing
  specialties 140 of 4,825 hospitals ranked in
  one
• Gastroenterology
• Nephrology
• Neurology and Neurosurgery
• Orthopedics
• Pulmonology