From battling bats to devising innovative response techniques, North Carolina EPs shared their experiences.
In September, Hurricane Florence devastated eastern North Carolina, with 800,000 coastal evacuees transported to the Central Piedmont region and to the Appalachian foothills for safety. A conglomeration of shelters, conference centers, tent hospitals and even a vacant former psychiatric hospital were adapted to provide medical care, lodging and social support.
It took lots of people to make everything work: EMS professionals, NPs, PAs, emergency physicians, nurses, DMAT teams, SMAT teams, electrical power workers, engineers, drivers with high-water military vehicles, pharmacists, IT experts, local restaurants and logistics teams to get the appropriate supplies to the right places at the right times. Here are some of their stories.
A Vacant Psychiatric Hospital
‘One of the amazing things about these efforts is how people pulled together. How dedicated they are. How relentless they are in getting every job done. I can honestly say this has been one of the most rewarding experiences that I’ve had in my profession of emergency medicine.’ — Wes Wallace, MD, Department of Emergency Medicine, University of North Carolina.
Wallace said he was camping in Missouri when he got the call to mobilize for Hurricane Florence on Sept. 10. He flew back to North Carolina, and on Sept. 11 was at the site of a three-story, vacant psychiatric hospital set to serve as a care site for medically fragile patients — most of whom needed 24-hour in-home care — plus a few from skilled nursing facilities.
Most of the first 24 hours were spent cleaning, scrubbing and moving furniture to care for patients who would be placed on the second and third floors. The only lab tests available were a point of care glucometer and a pulse oximeter. Two other physicians, Brenna Lanner and Bill Lindners, joined Wallace the next day. Once the tornadoes, wind and rain began, one problem after another quickly surfaced.
The abandoned hospital was in rough shape. Large puddles of water collected randomly on the floors. Soon after the storm hit, all power was lost – but the emergency generator kicked in, which kept power flowing to the ventilators. Another challenge arose as the chillers failed, leaving staff and patients in 90-degree heat with 100% humidity. When the elevators failed, staff had to use the stairwells to get supplies and meds, but they weren’t alone as the stairwells were dotted with bats – some dead, some alive. After a few thoughts about rabies, staff just kept on going, Wallace said. The Army Corps of Engineers arrived the next day to fix the elevators and air conditioning.
The 84 patients sent to the psychiatric hospital were people who faced significant risk of death, or at least had substantial morbidity, if their homes flooded, or if they lost power for even a brief time, Wallace said. These were people with multiple problems: oxygen dependent, some on ventilators, some with tracheostomies, a few with advanced multiple sclerosis, requiring hemo- and peritoneal-dialysis. Local hospitals provided the oxygen, peritoneal dialysis fluids, and medications used in the rehabilitated facility. A local cafeteria provided meals to the hospital staff and patients. Emergency Medicine colleagues quickly and graciously accepted all acute transfers into their EDs. Army vehicles drove through high water to get patients to needed in-hospital care.
After 11 days, and nights that allowed staff only two to three hours of sleep, it was time to shut down the revitalized psychiatric hospital. Every patient expressed gratitude to the staff. Patients made new friends with the medical and nursing staff and new friends with other patients. One patient told Wallace ‘look, this is the most social contact I have had in the past five years. You have been so good to us here.’ On the last day, the staff put together a Halloween ice cream party, complete with costumes and crowned one of the more socially active patients the ‘Mayor’ of the hospital. Everybody sang ‘Hail to the Chief’ as the ‘mayor’ was wheeled in, in his wheelchair.
With thanks to Brenda Lanner, MD, State Medical Assistance Team (SMAT) from Duke University Department of Emergency Medicine and William Lynders, MD, Middlesex Hospital Emergency Department, Chief Medical Officer of Connecticut Disaster Medical Assistance Team (DMAT).
Thinking out of the Box
‘From my point of view, this will be a new standard for us when we are providing medical care during disasters.’ — Jose Cabanas, MD, MPH, Director/Medical Director, Wake County EMS
The center of North Carolina was pummeled by rain and some flooding, but was not ravaged by Hurricane Florence like the coast was. Seven shelters in Wake and Orange Counties were organized to care for coastal hurricane evacuees in varying degrees of health with varying degrees of medical morbidities. Each shelter had DMAT or SMAT nurses and local paramedics, but only three had physician presence. The basic goal was to manage most simple medical issues within the shelters, keeping the EDs free for sicker patients.
Imagine this environment: patients were evacuated without time to gather their medications; many had polypharmacy; some had time-sensitive medication needs, like insulin or anticoagulants; others had quickly depleting small oxygen tanks with them; some needed simple refills of medication. Some patients were evacuated before their planned dialysis in their home area; others had acute or subacute complaints that needed to be addressed.
The Wake EMS system used ingenuity and creativity to manage medical issues for over 1,000 patients, and their triage idea quickly spread to Orange and Forsythe counties.
About 24 hours into the evacuation process, it became obvious that the intensity of need for medical services at the shelters outgrew the abilities that could be provided. To provide a stronger medical structure, Wake EMS assigned medical branch EMS directors at every shelter. But how to provide needed medications and supplies for what peaked at more than 1,200 people, in conditions that were set up as non-medical units? How could transports to local EDs be mitigated or avoided?
On-the-fly, Jeff Williams, MD MPH Assistant Medical Director, Wake County EMS and Cabanas had a brilliant idea: telemedicine and iPads to the rescue! WakeMed Hospitals Emergency Department already had an ED telemedicine system in place using RelyMD. Wake County quickly provided six iPads for its county shelters, which were then programmed for use with RelyMD. Each shelter was provided with a one-page guide on how to use the app and obtain a facilitated consult with a medical provider, pharmacy, logistics and other relevant needs. Just-in-time training was implemented to teach a nurse and paramedic at each shelter how to use the app and carry out telemedicine consults. Information was passed on shift to shift. In the meantime, RelyMD waived their fees for use during the hurricane emergency.
Handling the emergency took involvement with the county, state, public health, local hospitals and emergency departments, hospital pharmacies—and IT. Because severe rain and wind resulted in numerous local power outages, portable Wi-Fi units were deployed to each free-standing shelter. Shelters that were in schools typically had generator power and Wi-Fi. The concept worked and quickly spread to the other shelter systems in Orange and Forsythe counties, and was in use for five days!
With thanks to: Joey Grover, MD, Medical Director, Orange County EMS
When a Tent is Not for Camping
‘Our mobile hospital functioned as a 24-hour primary clinic-urgent care-emergency department, all in one, for nine days!’ — Eric Golike, MD, MPH, Department of Emergency Medicine, University of North Carolina
Eric Golike was one of the lead physicians working alongside multiple physicians, APPs, nurses, EMTs, and medical and x-ray techs at a mobile disaster hospital set up at the height of Hurricane Florence. The team members hailed from various health systems in North Carolina and the Sentara Health System in Virginia, and assembled in a high school parking lot in the rural town of Deep Run, NC.
The field hospital served an area populated by more than 20,000 people in imminent danger of being cut off from the health care infrastructure by flooding, from the Neuse River. In heat, humidity, rain, and wind, and with immense effort, the tent-like mobile disaster hospital was set up Sept. 15 after Florence’s landfall the day prior. They were operational.
Their mobile disaster hospital then became part of the EMS system, taking all 911-EMS calls in the area. The mobile hospital had five acute care beds, multiple sit-in chairs for lower acuity complaints, full resuscitation medications and equipment, portable ultrasound, and an x-ray machine.
The most common conditions treated were storm-related lacerations and injuries, but the hospital also provided 24-hour primary and urgent care, because no one else could continue to offer these services due to severe post-Florence flooding.
Just to keep everyone on their toes, patients presented with heat stroke, pre-term contractions in a breach pregnancy, NSTEMI, respiratory distress, and septic pyelonephritis – among others needing resuscitation and stabilization. Transport to full hospital facilities was conducted by air or ground, depending on the status of local roads and bridges. It was nine days until the flood waters receded, roads were cleared and primary care offices re-opened. Golike noted, ‘In that time, we treated > 320 patients! Not bad – not bad at all!’