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Virginia Tech disaster response shows value of regular drills and planning
Despite smooth response, however, leaders plan improvements for the future
When Mike Hill, RN, the ED director at Montgomery Regional Hospital in Blacksburg, VA, reported to work at about 7:30 a.m. on April 16, 2007, he noticed a large number of people in the trauma room. Although he didn't know it yet, "They were working the second victim of the first shooting" at Virginia Tech University.
"We got her stabilized and transferred her to the Level I trauma center at Roanoke [VA] Memorial to treat her neurological problems," he says. "Among ourselves, we thought it was a murder-suicide — domestic incident."
By the time the second wave of 17 patients arrived, David Linkous, RN, MEd, the hospital's emergency planner, also knew this would be no ordinary day. "I had called in to take a vacation day, because a large tree had fallen down in my yard," recalls Linkous, himself a former ED manager. Police were looking for a suspect for the first shooting. "Then roughly at 10 o'clock, I heard on the [police] radio that shots had been fired, and a response was requested at North Hall," he says. "About that time, I was notified I no longer had the day off."
If there was any "silver lining" to the horrific tragedy that befell Virginia Tech on that Monday morning, it is that the medical community responded magnificently. At Montgomery Regional, which received most of the patients, the lives of all 17 patients who arrived there were saved. What's more, say those in charge of disaster response, the staff responded so enthusiastically that in at least one department the manager had more help than he needed.
Linkous and Hill attribute the response to regular disaster planning and drills. "We generally have three or four drills of some type each year. Some are full-scale drills, while others may be table-top exercises," says Linkous, noting that The Joint Commission requires at least one large-scale disaster drill and one table-top drill per year.
"We also participate in statewide and regional drills," he adds. "For example, last April, we utilized an old abandoned motel and staged the explosion of a chemical truck."
The hospital disaster plan delineates staff responsibilities, policies, and appropriate responses for different types of disaster. "It's basically the same 'tree,' modified by condition," notes Hill.
The planning process is handled by the Emergency Management Committee, which includes department directors: ED director, director of pharmacy, infection control, the lab, X-ray, safety and security, engineering, chief nursing officer, the associate administrator, an emergency physician, and a public relations representative.
From drill to reality
Much of what was practiced during the drills was put into use in the aftermath of the Virginia Tech shootings. For example, as part of the hospital's HICS (Hospital Incident Command System) plan, all victims receive a red, yellow, green, or black tag after being triaged in the field.
Of the 17 patients, all but four were gunshot wounds. Four were critical (red); eight immediate (yellow), deemed able to wait an hour or so for treatment; and five green, which meant care could be delayed. The green patients were sent to outpatient surgery for holding, and they were cared for by nurses. (Patients with black tags, for "non-viable," were not even brought to the facility).
The majority of the "immediates" were broken bones or "through and throughs" (gunshot wounds), recalls Hill. "You have to remember, any yellow can change to red, but they get reassessed if they turn pale, if their BP drops, and so forth." Still, he says, the tagging in the field done by EMS was "pretty much on the money."
In the event a patient arrives with a green tag but appears to be sicker, a nurse at the door can re-tag them.
Calls hardly needed
While the disaster plan clearly outlines a method for calling in extra staff, this part of the plan was hardly needed on the day of the shootings. "If there is a large influx of patients we go to Condition Green. We go on alert and call all the staff, including ancillary staff, which is what we did that day," says Hill.
Once employees arrived at the hospital, they reported to the cafeteria to sign in, indicate their skill level, and then they were assigned to a unit based on what was needed. "We did all that, but we had a huge turnout," says Hill. "Most people in the ED did not even have to get a call. They saw a report on the TV or heard about it on the radio."
The ED had no problem getting staff to report. "I have 40 staff members, and 33 of them were here," says Hill. In fact, he adds, a list had to be made of staff who should be asked to leave the ED. "You don't want too many staff, because then you can't maneuver around," he explains.
Communications an issue
One of the issues that became more serious as the day went on was communications — which involved the use of cell phones. "When you've got a school of 27,000 students and the shootings made the national news, the Moms and Dads all called, and all cell phones shut down," explains Hill.
The hospital was receiving conflicting reports, adds Linkous. "From one source, we were told we had gotten all the patients we would get," he says. "Another said more were coming. That's where another part of our plan came into play."
That part of the plan involved putting a liaison at the scene, so when communication became a problem Linkous headed down to the command center to fill that role. "He was able to contact me directly, so we had a better understanding of what was going on," says Hill.
Still, in the hospital debriefing that followed the incident, it was agreed that the committee would look into some portable two-way radios to be used as another source of communication.
For the most part, Linkous is pleased with the hospital's response. "I think it went just like the plan predicted — a lot better than anticipated," he says.
People from the lab, from X-ray, and nurses from other departments were in the ED, Linkous says. "When you implement Code Green, you are supposed to send nurses there from each department," he says. "Other department directors also came down."
In addition, he notes, elective surgeries were cancelled to relieve pressure on the ED. "People who were there being prepped for outpatient surgery were sent home, and we called those who were scheduled for surgery [to cancel]," he says. "This opened up 24 beds for ED overflow."
Another aspect of pre-planning that proved very helpful involved disaster carts, which contained intravenous solution, bandages, and other general trauma supplies. "We had designed these carts several years ago, and they were rolled down to an area between the ED and outpatient surgery, in case they ran out of supplies," says Linkous. "We emptied a couple," Hill reports.
You can't plan for everything, Linkous concedes, but in some cases staff members anticipated things the formal plan did not. "A pharmacist came down and brought extra meds — mostly antibiotics and rapid-sequence intubation drugs — and stood at the nurses' station and dispensed them as needed," he says. "This will be in the plan from here on out."
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