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Emergency department medical director D. Sean Smith, DO, says the new Mercy hospital location in Joplin, Mo., set to replace St. John's Regional Medical Center damaged by a tornado in 2011, will contain a number of structural and design features to protect patients in case of a repeat tornado including a windowless area on each floor, high-impact resistant windows and underground electrical wiring to prevent power failures. Photo by Shane Bevels / AP Images for American Medical News

Physicians find solutions in the face of disaster

Although such events are tragic, they move medicine forward by providing physicians critical lessons in emergency preparedness and response, medical experts say.

By — Posted July 15, 2013

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Doctors at Boston Children's Hospital had only a few minutes to prepare for the youngest victims of the Boston Marathon bombings before paramedics rushed the first patient into the emergency department.

One child was burned and covered in soot with a tourniquet compressing a mangled leg, said David P. Mooney, MD, MPH, a surgeon and director of the hospital's trauma center who was on duty that day.

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Dr. Mooney

Eight children arrived that afternoon. Many patients had leg injuries from shrapnel and from pellets and nails packed into the two bombs. The April 15 explosions injured more than 200 people and killed three.

“It was difficult at first, because we didn't know who anyone was. Kids don't have IDs,” Dr. Mooney said.

Although hospital doctors and staff spent years preparing for this type of disaster, parts of the emergency response plan didn't work quite as they had hoped, Dr. Mooney said. The same was true at other hospitals throughout the city.

Issues included insufficient communication with those on the scene about the number of wounded and the severity of their injuries. Staff, eager to help, ended up crowding EDs. Some hospitals struggled to register large numbers of unidentified patients.

But from those problems came solutions.

Among them: pre-assigning staff to specific rooms before patients arrive; monitoring social media to watch for any trouble during a large event in the city; evaluating hospital systems to improve naming and registering unidentified patients during a mass casualty.

Man-made and natural disasters, while tragic, also can lead to change by providing the medical community with crucial lessons in emergency preparedness and response, doctors say. And what is learned at one scene is shared with health professionals elsewhere.

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Dr. Zane

“It's not as though someone develops a new technique and it benefits them to keep it secret,” said Richard D. Zane, MD, an emergency medicine physician at University of Colorado Hospital, which treated some victims of the Aurora movie theater shootings on July 20, 2012. “Your obligation when you go through some kind of event and response is to share your lessons.”

A shock to the system

Former colleagues of Dr. Zane from when he worked at Brigham and Women's Hospital in Boston called him for advice the night of the marathon bombings. He told them to “debrief as much as possible, and make sure we have enough [mental health] resources for our staff,” said Eric Goralnick, MD, medical director of emergency preparedness at Brigham and Women's Hospital.

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Dr. Sasson

Nearly everyone who experiences such a traumatic event will be affected psychologically in some way, mental health experts say. Symptoms vary from difficulty sleeping to posttraumatic stress disorder. Like their victims, physicians are susceptible to a lingering effect.

For about two weeks after treating victims of the Aurora shootings, emergency physician Comilla Sasson, MD, struggled to fall asleep at night. She thought she heard gunshots. She kept picturing the critically wounded and couldn't stop thinking about what else she could have done.

The night of the rampage, she was working at University of Colorado Hospital when a police dispatcher called at about 12:55 a.m. to alert physicians that they would be receiving gunshot victims.

“We didn't understand the magnitude” of the situation, Dr. Sasson said.

In the first hour, the hospital received 15 patients, most of whom were in critical condition and arrived in the back of police cars. Some had been shot in the chest and head. In all, 23 victims were admitted.

“I can see six to eight gunshot wounds in a night and that's nothing unusual,” Dr. Sasson said. “But when you get 15 patients who are critically ill, then you get a total of 23 — that's when all of a sudden things change and overwhelm your resources.”

Physicians had to put two patients in each of the two trauma bays and created a critical care area in the hallway. The electronic health record system stopped working due to the crushing number of scans physicians were ordering — 150 tests in the first hour.

“Initially, there's an adrenaline rush,” Dr. Sasson said. “Then everyone leaves, and all the patients are upstairs. And you get a sense of overwhelming relief, then shock and disbelief. No matter how much training you do, it's hard to get your mind around what you just saw and did.”

The hospital learned from the emotional and psychological impact the shootings had on staff. Its response included letting the emergency staff visit patients after their conditions improved. The hospital held sessions where colleagues could talk to one another about the event, and staff could speak with a pastor.

“Every person has a different level of response. So every person needs different levels of support,” Dr. Zane said.

Additional support has been offered to hospital staff after traumatic events in other communities, such as the Sandy Hook Elementary School shootings in Newtown, Conn., on Dec. 14, 2012. These later tragedies sometimes cause memories of the Aurora shootings to resurface, Dr. Zane said.

The challenges physicians faced caring for the Aurora victims prompted changes to the hospital's EHR system, Dr. Sasson said. Now screening tests can be ordered quickly during a disaster situation.

Disasters “expose weaknesses that we hadn't thought of before,” Dr. Zane said.

Identifying weaknesses

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Dr. Maese

At Coney Island Hospital in Brooklyn, N.Y., physicians realized one such weakness as they evacuated 28 patients from the flooded ED with flashlights in the darkened building while Hurricane Sandy pummeled the city on Oct. 29, 2012. Patients were moved to the hospital's adjoining tower building, which didn't take on water.

Although staff had practiced evacuating patients — a common drill after Hurricane Katrina — they had never done so in the dark.

“Things that look familiar to you in [the hospital] during the day” are difficult to recognize without light, said internist John Maese, MD, chief medical officer of the hospital. “People need to practice evacuations in the dark.”

DID YOU KNOW:
15 patients arrived at the hospital the first hour after the Aurora shooting, most by police car and in critical condition.

In the New York metropolitan area, 97 people died during Hurricane Sandy and thousands were displaced from their homes. Similar to other health centers in New York, Coney Island Hospital didn't expect flooding from the Atlantic Ocean, which is nearly a mile away. But at 9 p.m., water began pouring in through the ED doors.

Damage caused by the water still is being repaired. Several changes to the hospital will include raising its generators higher off the floor and finding a way to elevate the emergency department to prevent future flooding, Dr. Maese said.

Because residents sought shelter there after the hurricane, the hospital realizes it can be a refuge for the community and will develop plans to address that need.

“The hospital is a stabilizing bar for the community,” Dr. Maese said. “You have to be prepared for the community to come in. Even if they don't see a light on, they will come.”

Getting ready for the worst

In Joplin, Mo., not even the sight of a windowless hospital twisted on its foundation could keep away people injured by the May 22, 2011, tornado that leveled much of the town and killed more than 130 people.

Immediately after the twister, St. John's Regional Medical Center in Joplin set up triage centers outside the building, as was practiced in disaster drills. The critically injured were taken to another hospital that wasn't damaged in the storm. Most other patients were moved to a nearby gymnasium where physicians treated hundreds of people.

“I don't know that the staff's response [to the tornado] could have been any better,” said emergency medicine physician Sean Smith, DO, medical director of the center's ED. “They had a six-minute warning, and they did a phenomenal job of protecting everyone in the building.”

Of the more than 300 people who were in the hospital when the tornado struck, only five patients and one visitor were killed.

In the aftermath of the storm, extra safety features will be added to a new hospital, which is expected to be completed in March 2015. For example, the facility is being constructed into the side of a hill for additional protection during a tornado. Sections of the hospital will be built to withstand sustained winds in excess of 200 mph. Others areas will have high-wind resistant glass. Backup generators will be partially sunken in a hardened structure about 400 yards from the hospital.

“We always took disaster drills seriously,” Dr. Smith said.

But the staff takes them even more seriously now. “You have to practice for the worst-case scenario,” he said.

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ADDITIONAL INFORMATION

Lessons from crisis situations

Man-made and natural disasters have brought about changes in emergency preparedness and response. A sampling of disasters shows what recommendations have been spawned from such tragedies.

Hurricane Katrina, Aug. 29, 2005

  • Develop hospital evacuation plans and practice them regularly.
  • Elevate or relocate electrical equipment, including generators and fuel pumps, to prevent damage during a flood.

Joplin, Mo., tornado, May 22, 2011

  • Stock each floor with emergency kits, which should include flashlights and gloves.
  • Install materials that can withstand high winds.

Aurora, Colo., shootings, July 20, 2012

  • Provide emotional and psychological support for staff who care for patients.
  • Evaluate how well electronic health record systems will work during disasters.
  • Develop a system to track large numbers of unidentified patients.

Hurricane Sandy, Oct. 29, 2012

  • Practice evacuations in the dark to simulate disasters during which there is no electricity.
  • Implement plans to care for community residents who seek shelter.
  • Prepare a mobile medical unit that can be taken into neighborhoods to treat injured residents who don't want to leave their homes.

Boston Marathon bombings, April 15

  • Make sure emergency plans detail what to do with existing ED patients when there's a disaster.
  • Designate a space where staff members can wait until they're needed, to prevent crowding.
  • Use tourniquets at the disaster scene and in the hospital to prevent amputations.
  • Monitor social media during big events to be aware of trouble early.

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External links

“Deaths Associated with Hurricane Sandy — October-November 2012,” Morbidity and Mortality Weekly Report, May 24, Centers for Disease Control and Prevention (link)

“Emergency Preparedness and Public Health: The Lessons of Hurricane Sandy,” The Journal of the American Medical Association, Dec. 26, 2012 (link)

Emergency Preparedness and Response website, CDC (link)

Injuries and Mass Casualty Events, CDC (link)

Coping with a Traumatic Event, CDC (link)

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