45 Seconds of Danger, a Lifetime of Lessons

The EF5 tornado that struck Joplin, Missouri, during the evening of 22 May 2011 was among the deadliest in U.S. history. More than 140 persons died, over 1,000 were injured, and thousands of others were left homeless. In addition, it has been estimated that the cost to “rebuild” Joplin could be as much as $3 billion.

Over the past two weeks, hundreds of emails, blog reports, and both print and broadcast media stories reported on the heroic actions, selfless dedication, and creative determination displayed by the staff of many Joplin healthcare facilities, conspicuously including the doctors, nurses, and other staff of the St. John’s Regional Medical Center, which was totally devastated.

The 228-bed facility was one of Joplin’s two main hospitals, and is now one of the few hospitals in the nation ever to be all but completely destroyed by a tornado – the last one was hit in Americus, Georgia, in 2007. If nothing else, though, the initial reports from Joplin serve as a reminder to other hospitals and long-term healthcare facilities, not only in the United States but everywhere in the modern world, about some very important lessons to remember.

Planning Ahead – Starting Yesterday

Tornadoes are well known in Missouri and the states surrounding it, and no doubt appear high on every healthcare facility’s hazard-vulnerability analysis. Based on what St. John’s encountered, a truly comprehensive plan must address an exceptionally broad spectrum of extremely complex issues and potential problems – including, but not limited to, the following:

• The operational and economic ramifications of running a hospital that has been heavily damaged or destroyed;
• The operational demands on the staff that would be needed to rescue and care for the injured – probably including other staff members;
• The necessity of providing ongoing in-patient care while simultaneously overcoming complete utility, phone line, and radio failures;
• The parallel need of providing emergency care for newly arriving patients who were injured elsewhere in the same general area (but outside the hospital itself);
• The urgent requirement, if and when it becomes mandatory, to transfer all in-house patients to other healthcare facilities, including hospitals that are perhaps hundreds of miles away;
• The use of both medical and non-medical volunteers, many from the local community and others from healthcare facilities both in and out of state;
• The need to establish, and follow, a complete and reliable medical-record recovery procedure that takes into account not only print materials but also x-rays (some of St. John’s records were found two counties away);
• The management of in-patient deaths caused by and/or otherwise related to the storm;
• The difficulties encountered in carrying out a reliable damage assessment – while at the same time trying to establish a new, albeit temporary, facility a few miles away;
• The importance of immediately securing, insofar as possible, critical “economic/fiscal” departments or areas of the facility such as the pharmacy, the gift shop, debit machines, and hazardous-material storage sites; and, last but not least,
• The problems involved in: (a) quickly relocating the additional medical resources needed; (b) transferring those resources to newly established triage and treatment sites; and (c) eventually moving all usable equipment to temporary alternative-care sites.

Responding, Recovering, and Remembering

Although the tornado’s physical impact on the St. John’s Center lasted only about 45 seconds or so, there had been, fortunately, a general 20-minute alert to the entire Joplin area. That providential warning gave the St. John’s staff enough time to move many patients into the hospital’s hallways and stairwells. However, when the explosive pressure and storm winds knocked out most windows, the flying glass and other debris injured a number of the still exposed patients and their protective staff. The burst pipes pouring huge quantities of water onto the floors and down the stairs, coupled with the rapidly approaching general darkness, further complicated the situation.

Carrying out their duties in accordance with the hospital’s response plan – and/or possibly by mere human instinct – staff members quickly organized themselves, implemented the facility’s incident-command guidelines, and started moving patients to safer areas both inside and outside the hospital. All available resources – tables, chairs, and doors, for example – were among the “equipment” creatively used to carry out the massive transfer. These initial efforts were supplemented by those of other rapidly arriving hospital staff – as well as by local police, firemen, EMS, and community volunteers who came to help in any way needed – moving patients, caring for the injuring, and/or even transporting patients in their own trucks and SUVs to other hospitals. For patients awaiting transfer, medical care was provided using the limited quantities of available medical supplies; medications, especially pain medicines, were in high demand.

Within the next several days, a mobile hospital – consisting primarily of an 18-bed Emergency Department and 60-bed in-patient capability – was being staffed by St. John’s personnel and by state and federal healthcare providers (Missouri’s Disaster Medical Assistance Team 1, for example). An engineering evaluation of the damaged facility is still being carried out to determine the viability of rebuilding options. In the meantime, all movable items – including the pharmacy inventory, hospital beds, x-ray equipment, ventilators, and IV pumps – have been relocated for use elsewhere.

The other major hospital in Joplin, the multi-facility Freeman Health System, was spared major damage and has remained fully operational. The Freeman staff are now working with St. John’s administrators – and with local, state, and federal health and emergency management officials – to determine how the community’s healthcare needs will be met in the months and, quite possibly, years to come. The Missouri Hospital Association has also played a major leadership role both by assisting local communities with their initial responses and by helping orchestrate the overall planning for the future.

In time, the real-life storytellers who lived and worked through the horrors and challenges of the Joplin tornado will share their firsthand accounts. Until then, the early reports that are read or heard in emails, blogs, print and broadcast media, and various social networks have provided a wealth of preliminary lessons that healthcare facilities should start studying immediately – before, and just in case, one of them becomes “the next Joplin.”