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When disaster strikes: Treating patients when your department shuts down
Response to Hurricane Charley holds lessons for all ED managers
(Editor’s note: In this special package on responding to unexpected events, we take a look at how ED managers should plan for disasters — natural or otherwise — that can stretch your resources and your nerves beyond their normal limits. We consider the challenge of treating patients when there is no longer an ED, as was the case at one hospital after Hurricane Charley. We discuss communicating with hospital administrators and community officials before and after disasters. We also tell you about a tool to help quickly locate alternate health care sites if you are overwhelmed by patients. We hope you find this information invaluable.)
You really couldn’t blame the folks in Punta Gorda, FL; after all, they expected Hurricane Charley to hit Tampa. Nevertheless, when a surprise right turn put Charlotte Regional Medical Center directly in the storm’s path, the ED was as well prepared as it could have been under the circumstances. "We actually had a hurricane drill just a month before the storm hit, which was one of the reasons we were so successful," says Mata Guttman, RN, lead supervisor.
During that drill, significant flaws in the plan were noted and corrected, including finding a new location for psychiatric patients who had to be evacuated and backing up all records for a newly purchased X-ray computer.
Nevertheless, administrators and staff had short notice and a unique situation after learning Charley had changed direction, says Derrell Billington, DO, FACEP, medical director of the ED.
"We probably had three hours before it actually hit, maybe only one hour before tropical storm-force winds hit, and we still had about 75 patients in the hospital — 10 in critical care," he says.
The hospital hurricane plan called for moving the ED to the second floor in case of flooding. "The plan was that we would actually close [the ED] during the storm, but open space on the second floor for people to come to after that," Guttman adds.
They took whatever supplies they could carry or cart up and moved all the patients to that floor, Billington recalls. "The third floor was for family that employees had brought to the hospital," he adds.
All of this movement was done very methodically. The least unstable patients were moved first (the ED has 12 beds), which left the critical ventilated patients for last. "The last thing was to move the ER staff upstairs," Guttman says. "We figured we needed them to the very last minute."
For the patients who were placed upstairs, there was a full complement of staff; and as patients moved, the nurses assigned to them went with them, she explains.
Even the best-laid plans, however, must sometimes adjust to the fury of Mother Nature. "We knew as soon as the brunt of the storm passed over us that we had to evacuate the hospital," Billington explains. "Most of the windows, even on the second floor, were blowing out on us. We had patients in the rooms, so we had to evacuate them into the halls while windows were exploding and glass was flying."
After the patients were moved to the hallways, three male staff members put mattresses against the windows to protect against flying glass, but "you could see parts of the roof fly off," he recalls.
Once the winds began to damage the hospital, the order to evacuate the facility was given, and family members on the third floor were advised to leave, Billington adds. The staff members were reunited with their family once all patients were transferred to other facilities.
Although it was clear the hospital needed to be evacuated, it was easier said than done. Five area EMS facilities were damaged or destroyed, and its headquarters was no longer functional.
"EMS stops running and bridges close down if winds are more than 45 miles per hour anyway, so we had no ambulance services," Billington notes. "It took the hospital 24 hours to completely evacuate."
And even though "we knew we could actually die in the storm," in his words, patients already in the ED, as well as new walk-ins, had to be cared for. "We had a lot of people walking or driving up," he says. "They started to show up rather quickly right after the storm came through."
At first, they were sent up to the second floor, but the hallways soon became too crowded.
"We had to make a decision about where to hold these people coming off the street," Billington recalls. "We didn’t know the structural integrity of the building, but finally we decided because of the great number of people looking for treatment, we’d move down to the first floor," which had not flooded.
The ED filled quickly. Some small children had to lie on counters due to the lack of beds and space, and ultimately the cafeteria, which is next to the ED, was transformed into a triage area, where the walking wounded could be treated and laceration centers set up. Food services kept working and provided a limited menu of sandwiches and water because power was limited.
"We discharged some patients if they had a way to go home once we knew we were under an evacuation order, or quickly made them admissions and moved them into an admitted bed," Billington explains. "The admitted patients had to ride out the storm with us, after which they were transferred."
During this period, conditions remained far from ideal. "When we moved back downstairs, a lot of ceilings had caved in, there was water on the floor, and half the ED did not have emergency power," he says. "In some cases, we had to put people in dark rooms."
Staff had to determine which parts of the hospital had emergency power to run extension cords to hook up fans, lights, and other equipment, Billington adds. Housekeeping proved invaluable in clearing debris, moving cafeteria tables out to make room for hospital beds, and mopping the floors to prevent additional injury from slips and falls.
How did staff handle triage and treatment of the 40 or so patients who came in? "You focus on life and limb," he points out. "We had no EMS, no communications, no X-ray."
Most of the injuries were soft tissue and orthopedic, although there were amputated fingers and one patient whose leg had nearly been amputated through an injury.
"You use your trauma basics: We stopped hemorrhaging, used splints, tried to maintain neurovascular status, and gave a lot of antibiotics and used a lot of narcotics," Billington adds.
What can ED managers facing disasters learn from the experiences of Charlotte Regional?
"You have to be able to make decisions very rapidly, and they had to change rapidly," he says.
In retrospect, Billington adds, your leadership team in the ED should try to meet with the entire staff every hour or two for updates and change direction as your resources change or improve, he says. Communication is difficult in such situations, he concedes, but when decisions are made — such as opening the cafeteria to patients — the word must get out.
"You could even set a time, like meeting every hour on the hour," Billington suggests. "It also would have been nice to have some radio contact, even hand-helds." Disaster response can be very dependent on inexpensive devices: two-way radios for hospital staff, flashlights, batteries, battery-powered radios, and TVs, say sources interviewed by ED Management.
Anticipating post-disaster injuries is critical, adds Billington. "We knew we had to have lot of antibiotics, narcotics, and splinting material to handle the influx," he says.
Billington concedes, however, that some things are very hard to plan for. "We had an internal disaster as well as an external one," he notes, referring to the damage to the hospital building. "All the disaster plans I’ve seen have been one or the other, but not both."
In disaster planning, it’s important to anticipate many different scenarios, particularly disasters that might hit your specific area, he notes. "Also, we all underestimate the lack of services we will have in times like these," Billington says. "We think we will always have electricity, water, be able to flush toilets, and to clean up after a disaster." Because these facilities did not always work, housekeeping was a crucial part of a successful response, he says.
Finally, Guttman recommends you do a drill every year and plan what you will do with the staff, in terms of protecting and helping them.
"After worrying about how to service the community, you have to worry about how to keep the staff mentally and physically healthy," Guttman says. In the case of Charlotte Regional, that help was provided after the hurricane hit on a Friday in the form of in-house psychiatric staff and counselors.
"Beginning Monday morning, our behavioral center staff positioned themselves, along with our pastoral care persons, in our chapel and ED to provide help to staff and their families," she recounts. "In addition, FEMA [the Federal Emergency Management Agency] had behavioral personnel assisting throughout the county."
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