Background: On April 8, 1998, an F5 tornado touched down in two counties of Alabama producing a wide path of destruction. The presence of a regional trauma system in this area presents an opportunity to evaluate the effectiveness of the system in responding to the victims of this natural disaster.
Methods: Emergency room logs and the regional trauma system database were searched for all patients treated for injuries sustained from the tornado, and medical records were reviewed for demographic information, mode of transportation to hospital, injuries, treatment, and outcome. Fatalities were identified by means of the coroner’s office.
Results: A total of 224 patients were evaluated at nine area hospitals, of whom 63 (28%) required admission. There were 32 deaths: 30 persons were dead at the scene, and 2 patients subsequently died at Level I trauma centers. Among patients with nonfatal injuries, 39% were managed at Level I facilities, 46% at Level III facilities, and 15% at nontrauma facilities. Forty patients (55%) seen at Level I facilities required admission compared with 15 patients (17%) at Level III facilities and 8 patients (29%) at nontrauma facilities; Level I facilities also had the highest Injury Severity Score. Of patients requiring admission, 83% were transported by emergency medical services; these patients also had the highest Injury Severity Score.
Conclusion: The regional trauma system facilitated appropriate and efficient triage to system hospitals, routing the most severely injured patients to the Level I centers without overwhelming them with the more numerous, less severely injured patients.
Tornadoes are the most violent and one of the most lethal wind-related disasters in the world. Every year, an average of 800 tornadoes are reported in the United States, resulting in approximately 80 deaths and over 1,500 injuries per year. 1 The intensities of these storms tend to be greater in the United States than in any other industrialized region in the Western Hemisphere. 2 Tornadoes can produce enormous damage over a broad geographic area with diverse injuries to the inhabitants of the region affected. Numerous studies indicate that the most serious injuries and deaths are the result of persons becoming airborne, struck by solid projectiles, or crushed as a consequence of structural collapse. 3–8 The number and severity of injuries as well as the wide area over which victims may be dispersed frequently present significant challenges to the emergency medical systems caring for the injured.
There have been numerous studies wherein risk factors for injuries resulting from tornadoes have been reported. These studies indicate that the type of dwelling, 3,5–7,9 presence in a motor vehicle, 9 type of tornado warning received, 5,7 sheltering precautions taken within a dwelling, 3,5–7,9 and age 3,5,7,9 are among the factors that impact the severity of tornado-related injuries. However, the effectiveness of medical systems in reducing morbidity and mortality has been largely unaddressed. Several authors have discussed inadequacies in the timely delivery of prehospital and hospital care after tornadoes, 10–12 noting that limited contact between emergency medical service (EMS) providers and receiving hospitals significantly contributes to this problem. 12 After a series of tornadoes in Kansas, communications were generated by multiple EMS agencies rather than from a central point. 10 Ambulances were directed to the closest treatment facility, without consideration of the facility resources available to care for injured patients. Additionally, EMS personnel had difficulty in communicating with hospitals before transport because of radio frequency overload. 10 Poor radio communication between the hospital emergency department and the centralized nonhospital disaster-control staff was cited as a significant problem after a series of tornadoes in North and South Carolina. 11
Numerous studies have shown that approximately 20% of trauma deaths were potentially preventable, and the most frequent cause of preventable death was a delay in surgical therapy. 13 Thus, delays in the transport of injured patients to appropriate health care facilities may be an important factor in the outcomes of patients injured in tornadoes and other natural disasters, like any other trauma situation. Although the effect on patient outcome has not been addressed in the literature, an organized trauma system with an integrated communication component may significantly enhance the ability to care for injured patients after disasters. Such a system exists in the Birmingham, Alabama, metropolitan area and was used after a recent tornado.
In October of 1996, a regional trauma system was implemented in the Birmingham Regional Emergency Medical Services System (BREMSS) region, one of the six EMS regions in the state. BREMSS serves Birmingham and a contiguous six-county area covering 7,264 square miles and including 1.2 million people, 24 area hospitals, and approximately 160 EMS providers. This is a voluntary system in which all hospitals in the region were invited to participate. Ultimately, 10 of the 24 hospitals in the region joined the system. Each participating hospital was required to meet certain facility, personnel, and equipment standards as outlined by the American College of Surgeons Committee on Trauma. The resource capabilities of each hospital were verified by a site review team.
On April 8, 1998, severe thunderstorms quickly developed over Mississippi, Arkansas, and southwest Tennessee. During the evening, some of the more powerful storms generated tornadoes that caused massive property damage and loss of life along a path from northeast Mississippi through central Alabama into northern Georgia. Hardest hit were Jefferson and St. Clair counties in the Birmingham, Alabama, metropolitan area. The F5 tornado that touched down in these areas produced a 17-mile long path of destruction that was up to 1 mile wide (Fig. 1). Given the impact of tornadoes in the state of Alabama, 1 an understanding of the ability to respond to such disasters is paramount. The objective of this study is to summarize the injuries and deaths associated with this event, to examine the Birmingham region’s response to an F5 tornado, and to evaluate the performance of the Birmingham Regional Trauma System (BRTS) in appropriately triaging patients to area hospitals.
From the Center for Injury Sciences at the University of Alabama at Birmingham and the Section of Trauma, Burns, and Surgical Critical Care (A.K.M., G.M., L.J.L., A.J.T., L.W.R.), and Division of Pediatric Surgery (W.H.), Department of Surgery, and Department of Pathology (G.G.D.), School of Medicine, and Department of Epidemiology (G.M., L.W.R.), School of Public Health, and Injury Control Research Center (S.H.), and University of Alabama at Birmingham, and The Children’s Hospital of Alabama (W.H.), and Jefferson County Coroner/Medical Examiner Office (G.G.D.), Birmingham, Alabama.
Address for reprints: Gerald McGwin, Jr., PhD, University of Alabama at Birmingham, Department of Surgery/Epidemiology, 700 S. 18th Street, Suite 609 EFH, Birmingham, AL 35294-0009.
Submitted for publication July 12, 1999.
Accepted for publication January 12, 2000.
Supported in part by grant R49/CCR403641–11 from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention-National Center for Injury Prevention and Control to the University of Alabama at Birmingham, Injury Control Research Center and grant DTHFH61–99-X-00039 from the U.S. Department of Transportation, Federal Highway Administration to the University of Alabama at Birmingham.
Poster presentation at the 59th Annual Meeting of the American Association for the Surgery of Trauma, September 16–18, 1999, Boston, Massachusetts.