“A State of Chaos”: The Joplin Tornado

» Hospitals

As the tornado sirens were sounding, the on-duty ER physician and emergency medicine resident stepped out of the Freeman West ER into the ambulance bay. All they saw was darkness. No defined tornado was visible, even as it demolished St. John’s a quarter mile to the north, but the sound was deafening as they slipped back into the department. Shortly afterward, the patients started coming.

The tra­di­tional man­ner of reg­is­ter­ing them was quickly aban­doned. People just took care of peo­ple.

The staff wasted no time in implementing the hospital disaster plan. Doctors and nurses quickly responded to the call for help, and soon the ER was awash in medical professionals. The first patient arrived through the main ER entrance with an obvious evisceration. He went promptly to the operating room as a multitude of additional patients began arriving.

The traditional manner of registering them was quickly abandoned. People just took care of people. They did their best to get names from the conscious and assigned numbers to the nameless. Over the next several hours, they saw approximately 300–400 patients. The surgical suites hosted 22 lifesaving surgeries that night. Many patients required emergency transfers to outlying hospitals. An EMS supervisor was stationed at the ambulance entrance and, along with an ER charge nurse, arranged transportation to those facilities. We only specified which patients required transport and provided a rundown of their injuries. He had a list of accepting facilities and assigned an ambulance for each transfer. In addition, multitudes of “walking wounded” were taken to other facilities by school buses.

St. John’s Medical Center sustained a direct hit from the tornado. Their inpatient census was 183 (low because they were in the final phases of implementing electronic medical records). Inside the facility, nurses began moving patients to the hallways. At the time of impact, most everything in the hospital became projectiles, including IV poles. Nurses covered patients with their bodies to protect them. Emergency lights and exit signs were ripped from their mounts as the ceiling collapsed. Doors tore from hinges, windows blew out. The oxygen delivery system was rendered useless, and the smell of natural gas permeated the structure. After the tornado passed, ventilator patients were quickly transferred to Freeman West and the rest of the facility evacuated. Because the fire-suppression sprinklers had activated, staff had to trek through up to six inches of water. The hospital generators were destroyed, and the rooftop HVAC units landed in the parking lot. Outside, the damage included the hospital helicopter and a state-supplied emergency trailer that had been used after the Newton County tornado in 2008. The trailer was in pieces several blocks away. It took a few hours to fully empty the hospital, but up to four days to fully account for each patient and their ultimate destination. Mattresses were placed in pickup trucks, and nurses rode in the beds holding IV bags as patients were evacuated to Freeman West. Weeks later structural engineers determined the hospital had shifted several inches on its foundation.

» Challenges

This disaster had it all

With so much destruction, there was no shortage of obstacles to face. This disaster had it all: community-wide communication failures (TV stations and cell service were seriously compromised); multiple sites requiring rescue and medical care; loss of a complete hospital, effectively cutting city medical facilities by half; minimal daylight early in the disaster; continuing incoming storms; and a finite number of responders and ambulances overwhelmed with requests for service. Although the local EMS agencies had participated in numerous exercises and drills over the years, no one had practiced for all the challenges this disaster brought.

A big problem was gaining access to patients still in their homes. The Joplin Fire Department was instrumental in initial operations, and was supplemented over the next several days by other agencies adept in search and rescue. This included members of the Kansas City Fire Department and 85 people with Missouri Task Force 1, a federal USAR team from Columbia. After rescue, priority patients were transported to Freeman West, while most of those with mild to moderate injuries went to either Memorial Hall on the north side or the MO-1 DMAT tent, which had a fully functioning treatment facility on the south side.

Roads remained blocked, but clearing those became a priority for the city and the Missouri Department of Transportation. Heavy machinery came in to move the immense amount of debris, including downed telephone and electric poles, parts of houses, cars and everything else congesting the streets. The movement of emergency vehicles throughout the city gradually improved.

Along with outside ambulances came supplies. METS and NCAD quickly amassed a medical stockpile that would be required in the days ahead to treat patients with every conceivable injury. A supply officer was assigned to account for the inventory and its allocation to crews.

The EOC incident command functioned in the basement of the city’s municipal building. Present were representatives from the major players in the response, including law enforcement, fire and rescue, EMS and city services. From this location they managed the disaster in a true unified fashion. They held periodic meetings to update everyone; however, many times the EMS command staff was excluded. This was a detrimental oversight, as it made it difficult for EMS staff in the EOC to communicate important details to field providers.

They wor­ried that using heavy equip­ment to search might cause fur­ther injury or pos­si­bly death to liv­ing peo­ple.

The next day, an informal meeting was held with the fire chief and city manager. They had questions about how long someone might survive in the debris. They worried that using heavy equipment to search might cause further injury or possibly death to living people. There was no definitive answer to their questions; visions of the recent earthquake in Haiti, with viable patients rescued after prolonged periods in the rubble, were fresh on their minds. They decided to do a daily evaluation of the areas being searched and the numbers of patients rescued. Each property was carefully checked before and during any use of heavy equipment. This approach worked well, and no additional injuries or fatalities resulted.

Long-term challenges for both EMS agencies included significantly increased call volumes. Despite a decreased population due to the destruction, people who remained had significant traumatic, medical and psychiatric conditions that required ongoing care. This, along with the fact that a large number of local physician offices and clinics were destroyed, meant more calls for EMS.

A fully functioning 40-bed psychiatric facility located inside St. John’s was also destroyed. Situated behind the hospital was an alcohol and substance abuse treatment facility; this was now gone as well. While both ERs saw a “healthy” population of psychiatric patients for medical clearance, this was now reduced to one handling them all. Since psychiatric inpatient beds were reduced, this meant more transfers to other facilities around the state.

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