Fertilizer plant explosion: Pre-planning makes the difference in facilitating care for hundreds of injured victims

Two days after bombs went off near the finish line at the Boston Marathon, another horrific disaster rocked the tiny community of West, TX. In that incident, a reported fire at a fertilizer plant was followed by a huge explosion that leveled four blocks of the city. The blast killed 14 people, most of whom were emergency responders, and injured more than 200 others.

Unlike Boston, which is home to multiple academic medical centers, West is a small town of about 3,000, so most of the injured had to be transported to hospitals in Waco, 20 miles to the south. Hillcrest Baptist Medical Center received about half of the injured patients, including more than two dozen with serious injuries.

Providence Health Center, which is also in Waco, received 64 patients that night, and 23 additional patients the next day, explains Eileen Bohannon, BSN, CEN, the director of Emergency Services. “The initial phone call [notifying us that there was a fire] prompted phone calls to go out to key people, including myself and the medical director,” she explains, adding that within 20 minutes, the hospital was notified that there had been a big explosion with an unknown number of injures. “That’s when we initiated our code Green, which triggers our disaster plan.”

Providence Health Center is not trauma-designated, but it has a busy 51-bed ED that sees roughly 84,000 patients a year, says Bohannon. And the staff had their hands full that night. “The crisis started at about 8 p.m., which is typically a very busy time for us,” she says. “The charge nurse on duty at the time had already taken action by the time I arrived, which was within 15 minutes. She had moved all the patients who were already in the ED to one section, freeing up all of our resuscitation rooms and all of our bigger rooms for patients we could expect from the explosion.”

The ED is divided into three zones, so it has the ability to increase or decrease in size when needed, says Bohannon. This gave staff the flexibility they needed to gear up for the patient surge. “The intensive care unit [was] emptied out, freeing up at least 12 extra beds,” adds Bohannon. “We weren’t doing any surgeries at the time, so we also took account of our surgical suites that we would have available.”

As was the case in Boston, the ED had no trouble finding adequate staff. “Almost every employee in the department came in, and our physician response was phenomenal. We had surgeons, orthopedists, and intensivists, in addition to all of our emergency resident physicians,” explains Bohannon. “Nursing staff and ancillary staff responded as well.”

Fortunately, with many staff onsite, patient needs could be addressed and extra staff were still available. However, Bohannon stresses there is room for improvement in how these extra personnel are managed. “Even in our drills, it always seems to be a problem, so we will definitely be working on our process for crowd control,” notes Bohannon. “In our response plan, we have a room set up for media as well as for family members to go to, so these groups did not contribute much to the crowding. Most of the problem was just due to employees showing up and wanting to help.”

Communications between staff also proved problematic. The hospital has always tested and drilled with walkie-talkies, but some of the batteries went dead in the midst of the disaster, complicating the flow of information. Consequently, this will be another focus for improvement going forward, says Bohannon.

The ED did get a heads-up on some of the patients who would be arriving from one of the department’s emergency physicians who actually lives in West. “She responded immediately to the scene and called us to tell us what she was sending in,” says Bohannon. Some patients also arrived at the hospital with instructions from the assistant manager of the ED, another West resident who responded to the scene of the explosion.

Be prepared for patient surge

It was a big challenge for the ED to just keep up with all the incoming patients, says Bohannon. However, staff managed to stay on top of the influx by relying on their preparations for this type of surge. “We had one nurse assigned to each of our 39 acute rooms, and we also had an assistant — either another nurse or a tech — assigned to stay with that nurse in that one room,” explains Bohannon. “That really helped us to have everybody taken care of rather quickly.”

One thing the ED did not anticipate, though, was two busloads full of nursing home patients who had been rescued from a nursing home that was destroyed in the blast. “All of their identifications and all of their medical histories did not come with them. They basically came with the clothes on their backs,” recalls Bohannon. “Some of them were confused, and they did not know their names.” Eventually, one of the employees of the nursing home arrived and was able to confirm the identities of most of the patients. “There were two patients who had their names mixed up, but that was fixed within several hours,” says Bohannon, noting that ED staff worked through the problem by checking to see if there were any identifying materials in the patients’ clothing, and searching through the hospital’s records to see if any of the patients had been admitted in the past. If so, there would be medical information on file. “Our admitting staff did an excellent job of working with the people who brought the patients to the hospital to get accurate identifications,” she says. “Ultimately, I think we only had one ‘Jane Doe.’”

While Providence Health Center did not receive the patients with the most serious and traumatic injuries, many of the patients had just seen their homes destroyed and were emotionally distraught. “Some of them were amazed that they were alive because everything around them fell,” says Bohannon.

The disaster also personally impacted a number of hospital staff members who either live in West or have family who live there. “We have several employees who lost their homes in the explosion, and we have many employees who now have family living with them because they lost their homes,” adds Bohannon. “That has been the most emotional aspect of this — the impact this has had on the community and our employees.”

Consider plans for security

Having successfully negotiated through the biggest challenge the ED has ever faced, Bohannon’s advice to colleagues is to remember that there is no such thing as too much practice. “We drill within our facility and we drill with our region also. We were able to set up our ED very, very quickly because of those drills,” she says. “We identified rooms that would take the most acute patients, so we had all of that planned out. You can just never do enough pre-planning.”

Secondly, Bohannon advises that hospital leaders need to prioritize how they will handle security during such emergencies well in advance. “Security is not something that a lot of facilities have in abundance, so it is important to figure out who will handle this aspect and what their role will be,” she says. “Our employees thought they should have the right to come back on site, but that did aggravate the situation to some degree.”

Another lesson Bohannon has taken from this event is the importance of having alternatives in place when emergency plans call for any type care to be completed outside. The night of the explosion, it was very windy, and that did cause some problems, she says. “If you are going to do any outside care at all, designate alternative sites in the event of inclement weather,” she says. “We have thought about this and talked about it, but it is not yet planned out enough, so we will be looking into this further.”

Although this was the first time most of the staff at Providence Health Center have ever been involved with a disaster of this magnitude, they handled the situation very well, stresses Bohannon. “We did an immediate debrief the next morning. They did well emotionally, and they were very proud of themselves and how they responded,” she says. “But I think they are now motivated to learn more and be more involved [in disaster planning and preparations]. They are looking forward to doing more training.”