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Rebuilding from ruin

Training, teamwork and system support help restore Joplin, Mo. hospital after tornado

From the September ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Janet Colwell

Sidebars: Fast facts Lessons learned

Moments after a fierce tornado ripped through the 370-bed St. John's Regional Medical Center in Joplin, Mo. on May 22, Syed Anwer, MD, looked out a fifth-floor window and realized help wouldn't be arriving any time soon. Crumpled cars, fallen trees, shattered glass and other debris blocked access to the west side of the hospital, leaving it up to Dr. Anwer and his colleagues to lead an evacuation.

“At first all we could do was stop the bleeding and assess the damage,” said Dr. Anwer, a hospitalist at St. John's. “I saw there was no way the fire trucks could get here and we would have to figure a way out ourselves.”

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The lobby of St. John's Regional Medical Center in Joplin, Mo., shows the destruction caused by the May 22 tornado. Photo courtesy of Mercy Health System.

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Anwer and a nurse made their way from where they had been working on the fourth floor on the east side of the hospital to the west side, which sustained the worst damage. Unable to find flashlights, the pair relied on light from Dr. Anwer's cell phone to navigate through corridors strewn with debris and covered with several inches of water from burst water pipes.

Once on the west side, “we started physically digging people out from under debris,” said Dr. Anwer. Then the real work began, triaging patients and carrying them one-by-one down five flights of stairs.

Other physicians, hospital staff and community volunteers also pitched in to get patients to safety that night. Ultimately, five patients died, but 183 others were successfully evacuated—an impressive feat given the extent of the destruction from the tornado, which packed 200 mph winds and was the deadliest in U.S. history.

“Joplin did a tremendous job with what happened because they were, within seconds, reduced to the Stone Age in terms of medical capabilities,” said Gregory R. Ciottone, MD, director of the disaster medicine section in the division of emergency medicine at Harvard Medical School. “They were able to do a lot of things and save a lot of lives with very broken down and rudimentary equipment.”

How did they do it? According to St. John's chief executive officer, the hospital's ability to dig out and recover from the disaster can be attributed to a combination of trained staff, community involvement, and a corporate parent—St. John's is one of 28 acute care hospitals in Arkansas, Kansas, Missouri and Oklahoma owned by St. Louis, Mo.-based Sisters of Mercy Health System—committed to supporting recovery and rebuilding.

“We were well prepared but you don't really plan on your entire hospital being destroyed,” said St. John's CEO Gary Pulsipher. “Mercy has been very engaged with our efforts, helping us set up a mobile clinic and providing information technology expertise and supplies.”

Calm amid chaos

At around 5:00 p.m. on the night of the storm, the community of Joplin was under a tornado watch, indicating that a tornado may be in the vicinity, but watches are fairly common in the storm-prone area. At most, people expected the darkening skies to produce a severe thunderstorm, said Kapil Passi, MD, program director of St. John's hospitalist group, who had just started his shift in the emergency department (ED) before the tornado struck.

By the time the watch escalated to a warning, hospital staff had only about five minutes to take shelter under desks or doorways, he said. Then “debris began falling and flying; I could feel wind blowing over us. The ceiling was failing and water was pouring down from a pipeline that broke.”

When the shaking stopped, Dr. Passi and his colleagues found themselves in total darkness surrounded by glass, hanging wires and other debris that blocked access to all but one exit. The staff used light from cell phones along with any flashlights that could be found to get about 100 people (25 patients—many on intravenous fluids and antibiotics—plus staff and family members) from the ED into the radiology department and from there to the relatively safe east side of the hospital.

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Memorial Hall in downtown Joplin functioned as a command center where St. John's patients were triaged and transferred to functioning hospitals. Photo courtesy of Mercy Health System.

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The west side was hit hardest by the tornado, which after tearing through the building continued to wreck havoc along a six-mile stretch of Joplin. But the severe winds did irreparable damage to the entire infrastructure: Walls were blown out, the roof was ripped off and the generator and power distribution system were destroyed.

Outside, Dennis Manley, St. John's director of quality and risk management, established a command center at Memorial Hall in downtown Joplin, where patients and others who had been injured inside St. John's during the tornado were triaged and transferred to other area hospitals. At first, the only way to confirm whether a floor of the hospital had been completely evacuated was to wait for a messenger to go to the floor and report back to the command center on foot—all phone and Internet connections were down.

“Communication was a major challenge,” said Mr. Manley. “But no one panicked. Everyone's [disaster preparedness] training kicked in and in the middle of all this chaos, there was an orderly evacuation.”

Many patients who had suffered critical injuries in the tornado were triaged by ambulance or trucks and sport utility vehicles owned by Joplin residents to nearby Freeman Hospital West, part of Freeman Health System, which was in full disaster response mode. Freeman, which is less than a mile from St. John's, suffered water leakage and some roof damage, as well as downed phone lines, but was otherwise functional.

“Patients were coming in two or three at a time, some on ventilators,” said James Harwell, MD, director of the hospitalist and critical care group at Freeman, who participated in triage that night. “It was very challenging during the first few hours trying to keep up with the volume of patients needing [cervical] collars, gurneys and wheelchairs and sorting out the life-threatening injuries from those that could wait.”

Freeman admitted more than 500 patients and doctors performed 22 surgeries in the first 12 hours following the tornado (there were 11 fatalities that night), said Dr. Harwell. The key to keeping up with the influx was transferring the patients who were stable to other facilities so that Freeman physicians could focus on patients with life-threatening injuries, he said.

Other area hospitals, including Mercy facilities in Springfield and Aurora in Missouri and another in Northwest Arkansas, also had their disaster plans in place, said Kim Day, Mercy's central region president based in Springfield.

“We realized very quickly that [the tornado] was very significant,” said Mr. Day. “By the time I called into the hospital in Springfield (about 30 minutes after the tornado struck), the disaster plan was already in place, staff had been called in and they were setting up the command center.”

Getting back to work

John's continued to use Memorial Hall as a temporary ED for a few days following the disaster, but Mercy leaders started working on an alternative solution the day after the tornado. At mid-week, a Mercy team traveled to Branson, Mo., a 30-minute drive from Joplin, where, by sheer coincidence, the Southern Missouri Disaster Medical Assistance Team was conducting a demonstration of a 60-bed tent hospital.

Through an agreement with the National Guard, the mobile clinic was quickly transferred to the St. John's campus in Joplin. By Sunday—exactly one week after the tornado—the clinic was up and running, equipped with full imaging capabilities, an operating room, intensive care and emergency room.

“We needed to plant our Mercy flag back into the community,” said Mr. Day. As soon as the field hospital was set up, vendors donated a catheter lab, MRI machine and two mobile operating units, and Mercy's nonprofit foundation donated a generator, he added. “The outpouring was unbelievable.”

Mercy is now in the midst of planning a more substantial temporary facility with a concrete foundation and steel walls that could open by late fall. The 120-bed hospital will be built from component parts and shipped to Joplin for assembly, said Mr. Day. It will be used until a new permanent facility, now in the planning stages, opens in about two-and-a-half years.

In addition to building a new hospital, Mercy has been helping its Joplin employees deal with the financial and emotional toll of the disaster.

“We recognized on the first day [after the storm] that we had to assess the immediate needs of our coworkers and physicians,” said Mr. Day. The first step for Mercy headquarters' staff was to make contact, by text, phone or in person, with all 2,200 Joplin employees and assess who needed immediate assistance. Hospital administration then set up a temporary office in the Holiday Inn Convention Center in Joplin where employees could apply for financial assistance and receive counseling. About 250 employees suffered significant losses of major items such as homes or cars, Mr. Day said.

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A 60-bed demonstration tent hospital was transferred from Branson, Mo. and functioned fully within a week of the tornado. Photo courtesy of Mercy Health System.

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Through a Joplin employee relief fund set up through its nonprofit foundation, Mercy collected over $1 million in donations and distributed more than $700,000 to employees within the first two months following the disaster.

“All of that money was unsolicited,” said Mr. Day. “People from all over the country just started sending money.” In addition to money, “truckloads of stuff,” from food and clothing to medical supplies, began showing up at Mercy's command center, he said.

One of the most significant commitments the hospital made was guaranteeing that all 2,200 employees could stay on the payroll during the rebuilding process.

“If we couldn't make this commitment a lot of coworkers would have left,” said Mr. Day. About half of the Joplin workforce continues to work in Mercy facilities. Some are at the temporary hospital or the site of the tornado, helping with damage assessment and salvage efforts. Others are being placed at nearby Mercy hospitals or with other employers in the region through a talent-sharing agreement.

As employees get back on their feet, the mood is shifting from despair to hopefulness that something positive will emerge from the tragedy, said Mr. Day.

“It gives us an opportunity to start over and reposition ourselves in the community and better serve it,” he said. “The wonderful part of this experience is that a lot of people are working closely together to get Joplin rebuilt.”

Janet Colwell is a freelance writer in Miami.

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Fast facts

• On the night of the tornado, St. John's housed 183 patients in 367 licensed beds with 25 patients in the ED.
• There were no deaths among St. John's 2,200 employees but 136 lost their homes, including five physicians.
• The EF-5 tornado with 200-mph winds has been deemed the deadliest tornado in U.S. history.
• Sisters of Mercy Health System provided immediate $500 wire transfers to 190 coworkers who lost homes or had other significant losses; provided rental cars for up to 30 days to employees who had no means of transportation; and continues to distribute relief funds to qualifying employees through its nonprofit foundation.
• A temporary hospital built from component parts is expected to open in Joplin in late fall and a new state-of-the-art facility is in the planning stages.

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Lessons learned

While it is impossible to be completely prepared for a tornado as destructive as the one that hit St. John's hospital, physicians and employees who lived through the experience had some insights to share for future disasters:

• Stay calm and let your training kick in. “What I remember is individuals stepping up and working as a team,” said Syed Anwer, MD, a hospitalist at St. John's. Added Kapil Passi, MD, also of St. John's: “Every physician put patients first; everyone was a leader but we worked as a team.”
• Community support is crucial. “Volunteers used pickups and SUVs to get patients in quickly and it helped save lives,” said James Harwell, MD, a hospitalist at nearby Freeman Hospital West. “There is no way EMS could have handled it all.”
• Electronic health records are critical. A new EHR system went live at St. John's just weeks before the tornado, allowing staff to access records of all 183 patients on site during the tornado. “We were able to quickly get the records over to other facilities where patients had been taken,” said Kim Day, central regional president of the Sisters of Mercy Health System, which owns St. John's.
• Disperse supplies throughout the hospital. On the night of the storm, it was difficult to access emergency supplies because they were stored in one central area and could not be easily moved due to debris blocking hallways, said Dennis Manley, St. John's director of quality and risk management.
• Establish a backup command center. St. John's had emergency supplies, including computers and phones, housed in a separate building on campus but it was badly damaged along with much of the main hospital. “We need another command center in a completely different location on the other side of town that is stocked with supplies,” said Mr. Manley.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated