In the early evening of May 22, one of the strongest tornadoes ever recorded in the United States tore through Joplin, MO, destroying homes, taking nearly 160 lives, injuring 1,000, and devastating St. John's Regional Medical Center, one of the city's major hospitals. The storm struck with less than 30 minutes warning, but at the first sign of “Executive Condition Gray,” nurses and other health care personnel began rolling patient beds into hallways and trying to secure equipment.
Within seconds, ferocious winds pummeled the nine-story structure, exploding glass from windows and even sucking some people out into the parking lot. Five patients died in the hospital that night, despite the best efforts of hospital workers, who responded to their training with heroic efforts. When the winds had passed, the hospital was battered and dark, without power or communications.
Dennis Manley, RN, the director of quality and risk management at the hospital, credits the staff for reducing the loss of life and continuing to care for patients in the aftermath. “I do believe you do what you practice,” he said. “That paid off in our case. We do ‘Condition Gray' drills for severe weather. The staff knew what to do and acted appropriately. We had done drills on evacuating patients and setting up an alternate care site.”
Within a week of the disaster, a 9,000-foot mobile Army surgical hospital had been set up within sight of the damaged hospital structure. The hospital's personnel have taken care of patients, in and out of the hospital, in that location since. “We are operating it now, treating patients in the emergency department as well as caring for inpatients and those needing critical care,” said Mr. Manley.
In July, they began moving another, larger temporary hospital to the site. They anticipated finishing the hard-walled temporary structure by the end of August. Eventually a component hospital will provide a place in which to care for patients until a permanent hospital is built, a process expected to take two to three years.
Training also kicked in for James Riscoe, MD, who said he received a text message minutes after the tornado hit, telling him that the hospital had been devastated and was on fire. “I followed the disaster plan,” said Dr. Riscoe, who dressed quickly, and with his 16-year-old son Tanner in tow, went to Joplin Memorial Hall, the city auditorium, where he began to set up an emergency department in the same configuration as the one at the hospital. “I tried to recreate what we had — cardiac there, pediatrics over there, gyn over there,” he said. “That way everyone would know where everything was.”
This was not the first time Dr. Riscoe had responded to an emergency. In 1981, he treated people injured by a skywalk collapse at the Hyatt Regency Crown Center in Kansas City, MO, and in 2010, he and Tanner responded to the Haitian earthquake. All of that, along with training he received as part of the hospital team and as a member of the American College of Emergency Physicians, gave him the background to respond quickly this time. Yet while the training was important, Dr. Riscoe said nothing could have prepared him or the rest of the hospital personnel for what has been called the most devastating tornado in recent time.
“You go through the four stages of grief in about 10 seconds,” he said. “It is hard to see the hospital where you spent so many years destroyed. They say no other hospital in the United States has been destroyed by a tornado. It's an honor we would have gladly passed on.”
The 350-plus-bed hospital had 183 inpatients at the time of the storm, and within 45 minutes, they had all been evacuated. “Some were put in sheets and carried down the stairs,” said Dr. Riscoe. “It was a pretty good evacuation. They took the most critical to Freeman Hospital [also in Joplin]. The walking wounded came to Memorial Hall, and then were transferred to outlying hospitals.”
“No disaster plan totally prepares you for the hospital being gone,” he said. “We worked by the seat of our pants.”
There was no power and no telephones, and water lines dripped everywhere, he said. In addition to caring for evacuated inpatients, he and his colleagues, who all flocked to Joplin Memorial Hall, had to care for the injured who walked in from the street. His son and another physician went to McAuley Catholic High School, where they set up an ancillary treatment center to take care of minor problems. “I knew the principal's number, and I called him at home,” said Dr. Riscoe. Tanner's high school friends came in to help feed people and to get them through the night.
Back at Memorial Hall, “we had to go outside and flag down ambulances that were going toward the hospital,” he said. “We finally got between four and six to stay with us so we could ship patients out to regional hospitals. There was only one real hospital with an operating room functioning,” he said.
Mr. Manley said he was not on site at the time the tornado hit, but soon arrived at the hospital to help with the evacuation. Hospital staff, some of them injured themselves, continued to provide care outside the emergency department of the structurally damaged hospital and then moved to Memorial Hall, where they continued to treat patients until the mobile unit was set up.
“There was no question that we would reopen the hospital,” said Mr. Manley. “All those plans are being made. It will take a while to build and reopen a new hospital.”
Dr. Riscoe said the St. Louis-based Sisters of Mercy Health System, the parent organization for St. John's, is committed to reopening the hospital. “St. John's has always been the heart of the medical community,” he said. “It is the place people come to when they need care and can't pay.”
Mr. Manley said he is proud of the hospital team's response. “We never stopped treating patients from the night the storm hit,” he said.
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Fungal Infections Kill Five in Joplin
The tornado that tore through Joplin, MO, created a perfect storm for a serious fungus in those injured during the May 22 event. Five patients with the infection died.
A local physician first reported that two patients with tornado injuries had suspected necrotizing fungal soft-tissue infections, according to a report in Morbidity and Mortality Weekly Report. (2011;60:992.) The Missouri Department of Health and Senior Services started surveillance for infections at all the hospitals and laboratories serving patients injured in the tornado, and with help from the Centers for Disease Control and Prevention, identified infections caused by mucormycetes (formerly zygomycetes) in eight patients. A CDC field team ultimately identified 18 suspected and 13 confirmed cases of cutaneous mucormycosis.
Patients ranged in age from 13 to 76, seven were female, and all were white. Twelve had sustained lacerations, 11 had fractures, and nine experienced blunt trauma. Wound management included surgical debridement for all 13 patients and removal of a foreign body from six. Wooden splinters were the most common foreign body, found in the wounds of four patients. Ten patients required admission to intensive care, and five died.
The CDC evaluated 48 specimens, including 32 fungal isolates and 16 tissue blocks, and all yielded the mucormycete Apophysomyces trapeziformis. Cutaneous mucormycosis is a rare infection caused by fungi of the order Mucorales, which typically are found in soil, decaying wood, and other organic matter. The infection was also reported after a tsunami in Sri Lanka in 2004 and a volcano in Colombia in 1985. (Lancet 2005;365:876; World J Surg 1991;15:240).
The CDC said health care providers, particularly those in emergency departments who first see patients, should consider environmental fungi as potential causes of necrotizing soft-tissue infections in patients injured during tornados, and should initiate early treatment for suspected infections. Additional information is available at www.cdc.gov/mucormycosis.
‘Like a Bomb Went Off’
Read a moving first-person account of the tornado from emergency physician Kevin Kikta, DO, at http://bit.ly/JoplinKikta.
EDs Receive Lantern Award
The Emergency Nurses Association gave the first annual Lantern Award to 20 emergency departments to recognize superb leadership, practice, education, advocacy, and research.
The 20 EDs recognized were judged on a range of performance and outcome metrics. They were also asked questions about their commitment to excellence and innovation. “By applying for and receiving the Lantern Award, these emergency departments have set themselves apart,” said Ms. Papa. “They have submitted themselves and their practices to the scrutiny of experts and have been recognized for their commitment to quality patient care.”
The Lantern Award was named after Florence Nightingale who was sometimes referred to as the “Lady of the Lamp” because of her actions during the Crimean War when she would work in the night checking on wounded British soldiers as they slept.
Honorees were Aultman Hospital (Canton, OH); Bon Secours Memorial Regional Medical Center (Mechanicsville, VA); Children's Healthcare of Atlanta, Scottish Rite Campus; Cincinnati Children's Hospital Medical Center, Liberty Township, OH; Edward Hospital, Naperville, IL; Medical Center of Lewisville, Flower Mound, TX; Geisinger Medical Center, Danville, PA; Kadlec Regional Medical Center, Richland, WA; Stanford (CT) Hospital and Clinics; Medical Center of the Rockies, Loveland, CO; Northwestern Lake Forest (IL) Hospital; Oak Hill Hospital Emergency Care Center, Brooksville, FL; Overlook Medical Center, Union, NJ; Paoli (PA) Hospital; Sinai Hospital of Baltimore; South Jersey Healthcare Elmer; St. John Hospital and Medical Center, Detroit; University of Kansas Hospital; University of Kentucky Albert B. Chandler Hospital, Lexington; and University of Wisconsin Hospital and Clinics, Madison. For more information, visit http://bit.ly/ENAlantern.