Hurricane Evacuations: The Georgia Response

When it comes to planning for mass casualty incidents, much of our current focus has been on preparing for terrorist acts that could result in multiple traumatic injuries; however, this year, with increasing frequency, local EMS across the United States has been called upon to perform as major hurricanes hit.

These hurricanes have generated patients who were injured in the impact of the storm, as well as those who were sick to begin with and had to be evacuated from hospitals, nursing homes and other medical facilities in the affected areas. One evacuation that occurred in the aftermath of Hurricane Katrina was from New Orleans to metropolitan Atlanta, GA.

AIRLIFT OPERATIONS
As part of the largest airlift ever on U.S. soil, 1,381 evacuees arrived at Dobbins Air Reserve Base from September 1-5. Dobbins, located in Marietta, GA, 16 miles northwest of Atlanta, is the largest multi-service Air Force Reserve training base in the world. Dobbins supports more than 10,000 Guardsmen and Reservists from the Army, Navy, Marines and Air Force.

A total of 19 flights, including military C-9s, C-17s, C- 130s, C-141s, as well as four Delta Airlines 757 commercial airliners and a Beechcraft King Air, made the evacuation flights from New Orleans to Dobbins.

As evacuees arrived and were deplaned at Dobbins, staff from the Veterans Administration (VA) evaluated and triaged the sick and injured. Of the 1,381 evacuees, 366 were sick or injured and required immediate evaluation, treatment and transport to over three dozen metropolitan Atlanta hospitals. An additional 37 patients were transported to area nursing homes. Local EMS provided treatment and transport for these sick, injured, ambulatory and nonambulatory patients.

The patient load included diabetics who had not had insulin, nursing home patients who had not eaten or drunk for several days, ventilator patients, patients who were in need of intubation and airway support, critical newborns and chronic mentally challenged patients who had been without medication for days.

Key agencies involved in the operation were: FEMA, National Disaster Medical System (NDMS), Georgia Emergency Management Agency, VA, Georgia Department of Human Resources-Division of Public Health, American Red Cross, Cobb County Emergency Management, Georgia Region III EMS, Cobb/Douglas Public Health, United States Army and Air National Guard, Georgia State Defense Force and Dobbins Air Reserve Base.

Pam Blackwell, director of emergency preparedness for Cobb and Douglass Public Health, was operations chief for the evacuation at Dobbins.

"Everyone participated," she says. "That was the key to the operation's success."

Blackwell said that they had practiced an event similar to this, but on a much smaller scale, the week before Memorial Day this year. At that time, the military brought in a C- 130 aircraft with recruits on board to simulate patients. The recruits were deplaned and triaged by the VA, but no transports were done.

"I did not know that a few months later we would be doing this for real," she says.

The EMS deployment involved ambulances and medical helicopters from 28 private and public EMS agencies throughout metropolitan Atlanta and north Georgia. Medi-vans were used for some ambulatory transports. Metropolitan Atlanta Rapid Transit Authority (MARTA) and Georgia Regional Transport Authority Xpress buses were used to transport evacuees who were triaged to go to local shelters. Both Marietta and Cobb County Fire and Emergency Services also assisted in the operation.

Cobb County Fire responded with its mobile command center, as well as its medical operation unit. NDMS staff, along with members of the Cobb County Fire and Emergency Services, lived and worked in these specialty vehicles for the duration of the operation at Dobbins Air Reserve Base. Cobb County Fire and Emergency Services acted in a support role at the base, staffing the mobile command vehicle. Cobb County 9-1-1 communications officers staffed the command vehicle in the role of incident dispatchers.

A transportation staging area was established at the Cobb County Civic Center in Marietta. The staging area, operating under the incident management system established over the entire operation, was under the direction of a management team member from Puckett EMS and Metro Atlanta Ambulance for the entire 87 continuous hours of operation. Puckett EMS and Metro Atlanta Ambulance are the contract EMS providers for Cobb County.

Metro Atlanta Ambulance was initially deployed, along with Puckett EMS, but as additional flights were anticipated, mutual aid was requested. According to Pete Quinones, CEO of Metro Ambulance, "What started as only one flight lasted for days. This would not have been possible without the great mutual aid support we had."

Shane Garrison, vice president and chief operating officer (COO) of Puckett EMS, adds, "The real reason for the success of this operation was the commitment from departments that pulled together the resources needed to transport these patients."

The EMS operation developed into a major event as Dobbins received additional flights. At any time during the operation there were 10 EMS units at the flight line prepared to transport patients and a minimum of 20 EMS units in staging. Being prepared also meant prestaging a Rescue Air 1 helicopter on the flight line for expected critical patients; at times, two medical helicopters were staged. At the height of the incident, when multiple flights were expected within a short period of time, 78 pieces of equipment were in staging awaiting deployment, including ambulances, transit buses, ambulatory transport vans, wheelchair units and other specialty vehicles.

As it became obvious that this operation was going to be extended and involve multiple resources, the need to track resources became obvious. Susan Auten, human resources director with Metro Atlanta Ambulance, developed an Excel spreadsheet to track resources that were available for the incident, as well as personnel assigned to those resources. This also served to track responses made by each piece of equipment to the base itself. This became the chronological history of the EMS operation at staging.

The staging area at the Cobb County Civic Center was set up so crews could receive rehabilitation. Many of the crews were on a 24- hour shift, so rest became an important factor between responses. Dr. Chris Wizner, EMS medical director for Puckett EMS, provided staging area responders with a travel trailer where crews could rehab during the incident. Puckett EMS secured three hotel rooms where crews could rest in four-hour blocks, as well as shower and change clothes. Metro Atlanta Ambulance and Puckett EMS provided food. As word traveled throughout the community, citizens and responders' family members also brought food and drinks to the staging area.

"Everyone pitched in," says Puckett EMS's Director of Operations, Doug Norton.

Both Norton and Garrison said that fuel was one issue that had to be resolved. Bringing in mutual aid ambulances meant they had to have fuel, and there was no time for them to return to their local jurisdictions. One local BP service station, owned by Butch Davis, came to the responders' aid.

"Butch reserved 1,000 gallons of fuel just for use by EMS," Garrison says. "When we needed a large fan to cool the staging area, Butch Davis was there again," Norton adds.

As the event progressed, four large tents were acquired and placed into service to shelter crews and operations staff, and portable toilets were deployed. One responder acquired generators through an existing contact with Six Flags Over Georgia, and Marietta Fire Department deployed a fuel truck to provide fuel for the generators and opened its fueling station to all out-of-town ambulances so they would not have to return to their jurisdictions for fuel.

Much assistance came from Cobb County Parks and Recreation, which secured shelter for EMS waiting to be deployed from staging. Both the Cobb County Civic Center and the Aquatic Center were opened for responders.

Cobb County police deployed their mobile command center to the staging area. A camera on top of the mobile command center allowed an officer inside the center to monitor the staging area. Security was beefed up when members of the Georgia State Patrol, spearheaded by Corporal Moody, arrived in force to provide traffic control and escorts, as well as security in the staging area.

MARTA, along with its deployment of buses, sent a supervisor and a maintenance and fuel truck mechanic to keep buses running and to perform minor repairs to ambulances.

Lieutenant/paramedic Kevin Stone and Lieutenant/paramedic Troy Smith, both EMS officers with Gwinnett County Fire and Emergency Services in Lawrenceville, GA, responded as mutual aid to the staging area to assist in a support role, along with a strike team from Gwinnett County. Both Stone and Smith were impressed with the operation as it unfolded.

"It was great to see all agencies, public and private, coming together to achieve a common goal," says Stone. "The relocation of patients from New Orleans could have easily taxed emergency services in metropolitan Atlanta," Smith adds. "However, because responders routinely use the Incident Management System and had a mutual aid plan in advance, overwhelming results were averted."

On Sunday, September 4, Georgia Governor Sonny Perdue visited the operation at Dobbins Air Reserve Base to observe and lend his support.

"During the aftermath of Hurricane Katrina, there were many illustrations of Georgians' generosity of spirit, but the scene at Dobbins Air Reserve Base was one of the most memorable," says Perdue. "Georgians welcomed hurricane victims, offering medical expertise, a warm meal and an empathetic ear. Standing alongside the hardworking volunteers at Dobbins Air Reserve Base made me proud to be a Georgian."

COMMUNICATIONS
Communication was achieved using portable radios on a tactical channel. Mutual aid responders were given portable radios as they arrived. The staging officer dispatched ambulances in strike teams of three ambulances each. As they began transport to hospitals, units advised the transport officer of the number of patients, the facility they were transporting to and when they arrived at the facility. When returning to staging in-service, they advised the staging officer that they were returning. Units from multiple jurisdictions shared the same frequency, reporting their service name and unit number.

Metro Atlanta Ambulance, Puckett EMS and Cobb County Fire and Emergency Services provided spare portable radios to arriving mutual aid responders so they could communicate with the local agency. These portable radios, which had been recently purchased by agencies in Cobb County through a grant from the Health Resources and Services Administration (HRSA), were vital to the operation. At the height of the incident, Nextel radios, Southern Link cellular phones and laptops with wireless Internet, as well as standard 800Mhz radios, were used to achieve communication.

Representatives of the Veterans Administration, NDMS and Grady Memorial Hospital in Atlanta checked the status of each of the 38 local hospitals in the system and secured patient destinations. Strike teams that were deployed from the staging area to the patient triage area were assigned patients and given a hospital destination, and hospitals were made aware of incoming patients. Hospitals received a short patient report from EMS before their arrival at the hospital. Transportation, including check in/check out, was the responsibility of Metro Atlanta Region III EMS, under the direction of Marty Billings. Other Georgia EMS regions assisted this section as well.

CHALLENGES
Information about arriving patients was limited in regard to the number and the types and severity of injuries and illnesses. Also, little reliable information was received about the time the flights would arrive, which meant that EMS and other healthcare personnel had to be able to respond on short notice.

Security became another challenge. Rather than allow any ambulance or bus through the gates of a military base, leaders had to quickly come up with an identifying insignia that would let guards know a vehicle was truly part of the emergency response.

Although communications generally went well, communications between civilian and military participants presented a challenge.

PLANNING
A Mass Casualty Incident Plan had been in place since the September 11, 2001, terrorist attacks, and a lot of planning had been done between the fire and emergency services and EMS in Cobb County.

"We just followed that plan," says Norton. "Drills had previously been completed that included the Emergency Operations Center (EOC), fire and emergency services, local law enforcement, public works and every other county department."

Most of these drills, however, had involved incidents like a terrorist attack or hostage taking.

Local agencies had completed several tabletop exercises and two live drills in the past year. A communications drill was conducted recently in an extremely large parking lot at Six Flags Over Georgia. Local agencies deployed their mobile command vehicles to simulate a mass casualty incident and the communications that would take place during a live event.

ROOM FOR IMPROVEMENT
While all parties agree that nothing really went wrong, they do believe there is room for improvement. Increased security at the staging area early on is one area that could have been improved upon. There have to be mechanisms in place to put things like security in motion.

Garrison says he would provide a large enclosed tent with cots where crews could rest the next time an event like this occurs.

When the first aircraft arrived at Dobbins, things moved quickly. Patients were seen by a healthcare provider within 10 minutes after their arrival on the base. After weapons, including rifles and handguns, were found on arriving displaced residents, things were slowed down and proper searches were conducted to protect healthcare workers and others on scene.

WHAT WENT WELL
Interagency cooperation between public, private, government and military was outstanding.

"All responders checked their egos at the door," says Quinones, adding that planning for this event was much improved over the 1996 Olympics hosted by Atlanta. "This time, we had control over who responded," he says.

Quinones also believes that a strong incident command played a big part in the success of this event, as well as the fact that many of the responders have worked together for years.

Norton says that although Puckett EMS had never really practiced a true recall of all employees, after three hours on the phone, he had all employees available to staff all their ambulances as 24- hour units.

WHAT OTHER AGENCIES CAN DO
"Planning and training for such an event is vital," says Quinones. "A vital element of the planning and training process is communication and walking through the process before the incident occurs."

Training together and having a simple incident plan bring success.

"The days of the incident plan in the three-inch binder are gone," says Garrison.

"The responders on the street need to know what their job is and how to perform it," Norton adds. "You have to plan and prepare for failures in communications and then train for it. Communications is always an issue."

Both agree that agencies have to plan for the local incident and then build on that plan for the large incident. They also agree that the plan should be used on a daily basis so the responder on the street knows how it works when it counts.

It is important to have a cache of equipment and supplies available, including HEPA masks and gloves in large quantities. Knowing how you could move large numbers of patients is also vital.

"We had 10 stretchers that we gave to the Georgia Defense Force to unload patients from aircraft," says Quinones. "You also have to think about alternate transport needs." Both Garrison and Norton agree.

"An event like this means we need to move large numbers of people who are not traditional EMS patients," says Garrison.

Both point out that you need to have ambulances with inverters and know which units are equipped with ventilators.

Another important need is having clearly marked unit numbers on responder vehicles. This makes unit identification clear, especially when operating outside your jurisdiction.

One area that is often overlooked in a typical mass casualty planning session is pets. In this event, many patients and displaced residents were deplaned with pets; therefore, Animal Control is a vital resource that should be on hand. At Dobbins, pets were also evaluated as they arrived, and two dogs were found to have canine parvovirus. One patient had her deceased dog in her purse, because she did not have a place for burial. Once again, preparation and planning are key. Once Animal Control responded, arrangements were made for pets to receive shots on site.

Everyone agreed on one thing: Planning and training, knowing your resources, developing mutual aid resources, and preparing for nontraditional mass casualty patients are the keys to a successful response.