Ready, or not? Can St. Louis cope with catastrophe? Part I: Half measures plague preparedness
This article first appeared in the St. Louis Beacon, Oct. 28, 2009- Major earthquake. Devastating tornado. Runaway flu pandemic. No one knows when or if a disaster will strike the St. Louis region. But another question can be answered with a lot more certainty. Are we ready to cope with a catastrophe?
In a word: No.
Two years ago, a Focus St. Louis study concluded: "The region is not prepared." Since then, some progress has been made. But many of the study's goals for limiting loss of life are still unmet. If a major manmade or natural disaster were to strike St. Louis today, rescue workers would struggle to communicate with 1950s-era radio systems, people with disabilities would be stranded and countless poor households would be left without food, water and even the means to find out why the world went dark.
A six week investigation turned up other causes for concern:
- Under the current regional plan, eight top elected officials will have to make decisions together during a disaster -- a "nightmare" scenario according to one local analyst.
- Fewer than 15 percent of employees at three major hospitals participate in disaster drills each year.
- Emergency managers acknowledge they are too overwhelmed to consider the needs of the disabled.
- Little is being done to help those living in poverty to prepare for catastrophe.
Planning for a possible Katrina-like scenario, the region's conglomeration of municipalities, fire districts, police departments and school districts compounds the difficulty of formulating a coordinated response. With 892 government agencies spanning two states, seven counties and the city of St. Louis, the metro region is the second most fragmented in the U.S., after Pittsburgh.
"That becomes tough when you talk about disaster preparation, in terms of having one plan. And if something happens, who's in charge?" asked John Wagner, Focus St. Louis community policy director. "We're more ready than we were five years ago, but if there is an earthquake, people are going to die. If we were more prepared, those casualties could be kept to a minimum."
CHAOS AFTER A CHEMICAL SPILL
On Saturday, Aug. 30, 2008, DePaul Health Center's emergency room in Bridgeton treated a typical Labor Day weekend assortment of injuries, including cuts that required stitches and a few broken bones. About 3 p.m., a man burst into the sparkling new ER waiting room, yelling, "I've got two people, really, really sick in my car!"
This account came from John Mueller, hospital director of emergency preparedness, who provided it to the online journal Industrial Fire World. The Beacon verified it with Mueller.
Two security officers ran out to scoop up a slumped-over, vomit-covered figure from the front passenger side and a half-conscious man sprawled over the back seat of an SUV. Slowly, it came to light that they'd been exposed to a potentially deadly chemical at East St. Louis' RoCorp packaging plant 30 miles away.
"We're thinking, 'Where did this stuff come from? Is this from a weapon of mass destruction?' " remembered Dolph Jeck, a Pattonville Fire Protection District battalion chief who was called to the scene.
By the time the victims reached the decontamination area, they'd already contaminated the emergency room, a medic and the two security officers -- one of whom was in charge of decontamination for the hospital. More than a dozen hospital employees were stripped and scrubbed with soap and water, which is the formula for removing all hazardous chemicals, even nuclear fallout.
A similar snafu was rapidly unfolding at St. Anthony's Medical Center in South County, where other contaminated employees were taken. At the same time, a handful of less affected RoCorp workers went home, further spreading the chemical, found to be nitroaniline, a highly toxic substance that causes vomiting, diarrhea, convulsions and respiratory arrest.
What should have been a calm, contained situation became a bungled operation that shut down two emergency rooms and called into question the St. Louis area's ability to handle even a small-scale contamination episode.
Like many such fiascos, the situation resulted from a cascade of errors: RoCorp didn't keep the employees on site or even call 911; the driver failed to let the hospital know his passengers were contaminated; hospital employees transported the chemical-covered victims from the driveway directly into the emergency room without questioning whether they might be contaminated. Ideally, decontamination would have taken place in the vehicle.
"One of the things we learned is to be prepared for methods of exposure other than what we would routinely think about. It's broadened our scope," Jeck said.
GETTING READY IS A CATCH-22 FOR HOSPITALS
The kind of shoulda-woulda-coulda lessons like those learned from the 2008 contamination episode provide invaluable information for emergency preparedness. Full-scale mock drills are the next best thing.
Two full-scale exercises are mandated each year by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an organization that accredits all the major hospitals in the St. Louis area -- a requirement to receive Medicare and Medicaid payments. One of the two annual hospital drills must also involve other emergency responders in the community.
A $300,000 mock terrorist attack staged in Olivette, but set up as if it were Busch Stadium, in August 2006, provided seven hospitals including DePaul, Barnes-Jewish, Children's, Cardinal Glennon, St. Louia University, Jefferson Memorial and East St. Louis' Kenneth Hall Regional, the opportunity to test their interaction with rescue workers. While the two-day drill provided some dramatic photos, the executive director of the agency that oversees regional disaster preparedness said such exercises are often nothing more than expensive dog-and-pony shows.
"They're good for getting your picture on the news and bringing things out and turning them on and making sure they work," said Nick Gragnani, of the St. Louis Area Regional Response System (STARRS).
Most local hospitals do not drill beyond the requirements. Exercises are disruptive, and it's up to hospitals to pay for expenses like employee overtime costs. Another issue: Drills are designed to expose flaws in the system. After each drill, hospitals create an after-action report with proposals for correcting any mishaps.
Exposing flaws can create a public relations problem because hospitals are businesses that need to put the best face on their public images.
"The process for learning means you have to expose the vulnerabilities," said Andy Garrett, director of planning and response at the National Center for Disaster Preparedness at Columbia University in New York City. "It's one thing if you're a federal agency, but it's tough when you're in a very competitive (health-care) system."
Jeff Hamilton, emergency management coordinator at St. John's, disagrees. "The after-action reports -- that's where you expose your dirty laundry -- we share those with the other hospitals. We would be very circumspect to share anything with the media because we are businesses, but between hospitals, we're pretty good about it."
Barnes-Jewish Hospital exceeds the JCAHO requirements for drills with several additional tabletop exercises, in which officials simply talk through a disaster response plan, each year. It also has once-a-month trainings for eight to 10 emergency room employees. But it's quite likely that during the course of a year, relatively few local hospital staffers will be involved in an emergency exercise. At DePaul Health Center, only 100 to 150 out of 2,100 employees take part in each full-scale drill. The number is about 50 at St. John's Mercy Medical Center, which has 6,000 employees.
The idea of having every employee participate in an emergency exercise is unrealistic, according to Jerry Glotzer, director of environmental health and safety at Barnes-Jewish. "I don't know what hospital does that; that's nearly impossible to do. We have a couple of hundred people participating at each drill," Glotzer said, of Barnes-Jewish's 9,300 employees.
Hospital technician Bob Somerscales, who's worked at Barnes-Jewish for two years, has received online disaster training, but that's it: "I haven't been involved in a drill since I've been here."
FAILURE TO COMMUNICATE PROMPTS NEW STANDARDS
While drills are intended to spotlight shortcomings at particular hospitals, JCAHO inspections performed every three years can also serve to highlight issues within the industry. In 2007, JCAHO discovered numerous and potentially fatal flaws in the hospital emergency preparedness systems across the country.
The main problem? There was no mechanism for hospitals to tell disaster preparedness planners outside the medical realm about their own limitations, such as how long it would be before they ran out of ventillators or bed space. Therefore, they had no backup from the larger community, who without additional information would assume hospitals had everything they needed.
To address these deficits, JCAHO added 66 new criteria to its old list of 21. Every hospital accredited after January 2008 has to meet the new requirements, including these top three:
- A highly detailed emergency management plan, as opposed to the previous, vague emergency operations strategy.
- Participation of all hospital leaders, including medical staff, in plan development.
- Proposal for handling the first 96 hours of a disaster, including what would be needed from the community to endure that period.
Why 96 hours? According to Jerry Gervais, an engineer in JCAHO's Standards Interpretation Group, it's often 24 hours before a region uses up its own resources and those of the state, which it must do before requesting federal assistance. Hurricane Katrina taught JCAHO another valuable lesson that completes the math.
"We learned it takes the federal government up to 72 hours to mobilize after the governor places the call," Gervais said. "So, for the first 96 hours of a disaster you're on your own."
All local hospitals are plugged into the same online equipment-and-bed-tracking network, called EMSystems, which they use not only in emergencies, but every day. This kind of resources-sharing, along with other contingency plans like evacuation, could enable them to handle a disaster of small proportion.
If its 17-story hospital were to crumble in an earthquake, Barnes-Jewish would evacuate most people down stairwells, and transport those who can't walk using med sleds carried by hospital workers, a process that would take about two hours. But no plan is in place for a situation in which every Barnes-Jewish Hospital building would be devastated by a major quake or an explosion.
"At that point, it's like Katrina. You can plan and plan and plan, but you can't plan for the most cataclysmic event. There's no other hospital that could absorb our patients," Glotzer said. "It would almost be like the world coming to an end. At that point, what would be our options? We'd have no place to go."
That raises a question that disaster planners across the nation must grapple with: How much money, how much time, how many resources should be devoted to emergency preparedness and a multitude of contingencies when other other priorties beckon?
SWINE FLU: PREPARED FOR THE WORST
This year local hospitals only had to perform one full-scale drill because actual events, like the H1N1 flu pandemic, count as a required exercise. After it's over, hospitals will create an after-event report as they would following a mock drill.
While swine flu closed multiple camps last summer, shut down four Jefferson County schools for a week this fall and created a surge that had Children's Hospital pitching tents in a parking garage, it has thus far not been the catastrophe it might have been.
But the flu season is not over, especially for a flu that seems to know no season. The virus could simply die out. Or it could mutate, becoming more lethal this year or next, according to Greg Evans, a professor in Saint Louis University's Department of Public Health.
"It's like a roll of the dice. This virus has been a strange virus; it's come much earlier than we would expect a flu virus, so there is also a possibility it will do other strange things as it moves along," Evans said. "The vaccine produced now is directed toward the H1N1 as we see it today but if that mutates substantially, that vaccine would be considerably less effective."
That's the worst-case scenario for hospital emergency planners. According to Hamilton of St. John's, if the virus doesn't mutate but begins to affect more people, they can treat an additional 60 patients in the emergency room every day and admit 80 more. But if it mutates, there's not much they can do to help patients get better.
"At that point, we would just have to treat the symptoms," Hamilton said.
ARE NURSES GETTING WHAT THEY NEED?
With more than 165,000 people employed in health care and social assistance in the bi-state area -- 12 percent of the population -- it's easy to understand what a tremendous resource they would be in a mass emergency. The region's 49,000 nurses may play the most vital role because they provide immediate and ongoing care to patients while the area's 7,500 doctors would be spread thin.
Every hospital has a system designed to call in nurses in the event of a disaster. For instance, a computer program at Barnes-Jewish puts the call out for nurses contacting them simultaneously by home phone, cell phone, pager and e-mail. But some question whether the nurses have the training they need to cope when they arrive on the scene.
Shortly after 9/11, Elsie Roth, a St. Louis University-trained nurse, led a small band of nursing and public health educators to a rigorous two-week emergency readiness training at the Henrietta Szold Hadassah-Hebrew University School of Nursing in Jerusalem.
In this volatile city, whose emergency readiness is known as the gold standard and parents teach children about gas masks along with the alphabet, the five St. Louisans learned a variety of new skills and practices. These include the use of color-coded triage systems, the importance of monitoring the health of decontamination workers and how to deal with psychological issues. SLU associate professor of nursing Joanne Langan, who went with Roth to Israel, has developed an elective course for SLU nursing students on disaster preparedness based on these skills, and another online course anyone can take.
"Health-care workers are going to be counted on to share information because people respect and believe health-care providers. So we've got an obligation to be in the know," Langan said.
But no disaster preparedness classes are required at SLU or any other local nursing school that Langan knows of. At Barnes-Jewish, no such coursework is needed before hiring. While Barnes-Jewish's nurses complete an online course each year with an emergency readiness component, little other nurse-specific training takes place.
Roth is very concerned about the lack of preparedness measures here that are taken for granted in Israel: weekly hospital drills, prearranged child care that enables nurses to come in at a moment's notice, and a plan to staff additional social workers in the ER during a disaster. She also bemoans the dearth of local emergency training for nurses here.
"We're still asleep at the switch here," she said. There are programs for police and firefighters, but nothing for nurses -- the largest population in the hospitals," Roth said. "None of us is prepared and none of us is even talking about it."
Funding for this series on disaster preparedness came from the Enterprise Journalism Fund of the Press Club of Metropolitan St. Louis.
Nancy Larson is a freelance writer in St. Louis.