Georgia hospital hit by F3 tornado — All patients evacuated through the ED

Emergency nurses take lead role in triaging inpatients

Most ED managers are prepared to respond to a disaster in their communities, but what do you do when your hospital is the disaster? An F3 tornado struck Americus, GA, after 9 p.m. on March 1, 2007, and Sumter Regional Hospital was directly in the path of harm.

The ED staff had been warned of the tornado, says Schelly Murray, RN, BSN, nurse manager and ED clinical coordinator. "They were getting ready to transfer a patient, and a pastor said, 'You might not want to do that. [A tornado] has touched down.' Four minutes later, it hit," she says.

Charlie Robertson, paramedic, was in the ED. "All the doors were flopping, and the windows broke out," he recalls. Eventually, the two main doors to the ED broke off. "Pine straw from the flower bed blew through the ED." It was 1½ minutes of chaos, he says. "People were screaming and hollering," Robertson recalls.

Murray was at home when the tornado struck. She immediately left to run three-fourths of a mile to get to the hospital. "I was climbing through power lines to get in to the hospital," she says.

The area surrounding the hospital had been devastated, and two people died in a residence directly behind one of the hospital buildings. Because of the warning, all patients, including those in the ED, had been moved to interior hallways and away from windows, Murray says. There were few serious injuries among patients, visitors, or staff.

There was debris in the ED, including branches, dirt, grass, and leaves, and patients were everywhere in the hall. Because of its location, which is mostly below ground level, the ED suffered only cosmetic damage. However, the building was not structurally sound. The hospital had one side that was collapsing; additionally, it had lost part of the roof, had many windows blown out, and was flooding. Seventy-five cars in the parking lot were toppled on top of each other.

The hospital declared a Level 3 disaster and was evacuated. It was decided that two ED nurses would triage patients from the entire hospital. Murray had the role of evacuator.

Triage was relocated a couple of times as the building became increasingly unstable. Ultimately triage ended up being conducted in the OR hallway with patients moving out through the ED. Despite the precarious state of the building, staff members were calm and comforted patients, says Susie Fussell, BSN, RNC, vice president of nursing at Sumter Regional Hospital in Americus, GA. "We were in ankle-deep water, with water pouring over our heads and down stairwells, Fussell says. In the middle of those dismal circumstances, staff members were carrying inpatients down stairwells on mattresses into the ED, she says. "Everybody was all business."

One immediate problem in the ED was that gases were leaking and needed to be cut off. A house supervisor already had assessed that no ventilators were available, and she had deployed portable oxygen tanks.

Members of the fire department and emergency medical services were able to assist, and they joined all available hospital staff in moving patients, with the critical care patients being brought down first. There were few serious injuries inside the facility from the tornado. However, five inpatients fresh out of surgery on the third floor were a particular concern. Those patients needed pain medications after they were moved to triage. Amazingly, the pharmacy operated during the evacuation. The staff used an old-fashioned "runner" system and had staff go to the pharmacy to obtain medications, Fussell says.

Murray had all patients lined up in single file in this order:

  • critical care unit patients;
  • post-op patients;
  • a patient in labor;
  • general med-surg patients;
  • psychiatric patients. All of the psychiatric patients were stable and ambulatory, Murray says.

In the midst of the evacuation, the ED staff stabilized five patients having symptoms of heart attacks and one gunshot wound. "Emergencies continue, regardless of your conditions," Murray says. Also, one employee went into false labor, she says. "You have to be able to triage your own employees," Murray says.

Getting patients out the door

Murray was familiar with area hospitals, so she served as the destination coordinator for individual patients, based on their diagnoses and acuity. The most critical patients were sent to the largest hospital in the area. A small nearby hospital with one floor unit received stable nursing home patients.

Because Sumter Regional had not fully implemented an electronic system, staff members were able to send each patient's full record with them when they evacuated.

Many staff and area physicians showed up, with their identification badges on, to assist. "We had to know who was in there," Fussell says. Each patient had a nurse at his or her side, and many had a physician there as well.

As each patient reached Murray, she yelled, "What's wrong?" "I didn't want to know their history," she says. "I wanted to know the immediate problem."

At least two staff members stood outside the door where patients were being evacuated at all times, and they verified armbands, patients' names, their chief diagnoses, and where they were going. "People were going to get away from you, so we always had two or three people keeping that list," she says. Because power was out, that information was recorded manually with pen and paper.

Two of the ambulances at the hospital were damaged by the tornado, although one of those was usable. Area ambulances responded, as well as a school bus for ambulatory patients, and 53 patients were evacuated to area hospitals. The evacuation took about three hours.

Here's what they learned

As in any disaster, there were lessons to share. One is to be prepared for the unthinkable — that your facility will be hit by a disaster — by developing an internal evacuation plan, Murray advises.

Another lesson involves the internal wireless phones and cell phones. They were working initially, but most eventually were unusable, Fussell says. "Two-way radios would have been most useful," she says. Also, have backup batteries on hand for the radios, sources suggest. Additionally, Murray had difficulty supervising the triage and patient flow because she was constantly bombarded with questions. "There was so much help on top of me, it was difficult to organize," she says.

Additionally, Murray struggled to make her voice heard and to get people's attention above the noise and chaos, she says. "That was one of the biggest obstacles. We needed a megaphone," Murray says.

The hospital could have used additional security, Fussell says. "Everyone wanted to help and was coming in to help," she says. Murray was faced with directing patients and volunteers. "Eventually, we put volunteers in a waiting room and told them to await instructions," she says.

When she requested help from the police, Murray learned they were shorthanded trying to keep roads clear and manage traffic. The police requested backup from the Department of Natural Resources (DNR), which sent a game warden. "He stood behind me to keep people away from me," Murray says. The game warden, who was more than 6 feet tall, repeated Murray's instructions over her head when she couldn't be heard.

After the evacuation was complete, approximately six men from the DNR performed a final check of every room on every floor to ensure no one was left behind.

Next on the agenda was the establishment of a treatment area in the town. Someone suggested First Baptist Church, which already was being set up as a Red Cross shelter. "I called the pastor, and he said, 'You can have my church,'" Murray says.

In hindsight, the hospital staff responded wonderfully to the disaster, Fussell says. Even though the hospital had never drilled for an internal disaster, all the members of the staff knew their role, sources say. Previous disaster drills were a significant help, they say. Murray says, "They gave us a game plan on how to evacuate internally, because they were about handling massive amounts of patients."

Fussell agrees. "They might have not done it just by the book, but they knew someone had to track every patient as they were transferred, and they knew all hands had to be on deck to evacuate," she says. "We practice and we practice all the time, I'm telling you. When you get so panicked and in the midst of chaos, it takes that practice, because it becomes what you do instinctively." (Editor's note: To see photos of the tornado damage, go to www.sumterregional.org and click on the hyperlink for the disaster photos.)