Everyone Out: Managing an Evacuation

Attack One responds as part of the third alarm. “The Big One” is unfolding: A massive derailment in an adjacent city has resulted in a large chemical leak from damaged rail cars. Command has ordered an evacuation of adjacent population areas. Staging has been established upwind in a school parking lot, but Attack One is deployed to establish an evacuation center in an adjacent high school building. This will be a crisis evacuation on a warm weekday afternoon. The derailment occurred on a bridge, involved multiple chemical cars and, from the initial size-up by the regional hazardous-materials team, is going to be difficult to contain. The Evacuation Center will be receiving large numbers of evacuees who had no chance to prepare or pack and will need sheltering for an unknown period of time.

Incident Command has decided that only one evacuation center will be established, and all evacuees will be directed there. That will make for efficient communications with the teams carrying out the evacuation, allow the public-information officer to update the media and community rapidly, and allow those looking for evacuees to locate them more easily. The local chapter of the American Red Cross will assist in staffing the shelter. The Attack One crew requests two engine and two medic crews to assist in the operation. The high school building, empty for the summer months, is large and effectively air-conditioned and has ample parking. The maintenance crew is present to assist in opening it.

Incident Organization

Evacuation Center Command is established, and the physical accommodations are rapidly organized. Areas are created for sleeping, feeding, rest rooms, pets, smoking and meeting with the media. A quiet classroom with an outside door leading to a small parking area for EMS vehicles is chosen as the medical center. Cots are set up, and several desks are positioned for patient reception and interviewing. The medics contribute basic supplies and assessment tools.

Operations

Evacuees arrive slowly at first, then in numbers that increase quickly. Some come by automobile, some by emergency vehicles and some in the backs of pickup trucks on sheets of plywood. The Attack One crew has arranged for a volunteer to create a census of the incoming patients and families. It will be maintained throughout the operation, so that callers and visitors seeking family members can be given rapid feedback. The media arrive, and an area is created for interviewing evacuees. The school’s library has a number of television sets, so everyone can watch the incident coverage live.

The region’s phone system has failed due to the volume of calls accompanying the emergency. This initially presents a communication challenge to emergency personnel, evacuation center staff and evacuees alike, but the arrival of amateur-radio crews (part of the region’s major-emergency response system) restores some communication, allowing evacuees to establish contact with family outside the region. These operators also provide the Red Cross with communications with their office and suppliers. Emergency personnel have to rely on their radio system for communications with the Emergency Operations Center, Incident Command and Staging.

The Attack One crew evaluates incoming evacuees for medical issues related to the chemical cloud or the circumstances of the evacuation. As with many incidents involving vapor exposures, the victim count increases as the “worried well” express concern about missing routine medications. The evacuees present with issues related to the following areas:

• Separation from needed health equipment. This includes home nebulizers, infusion machines, oxygen enrichers or cylinders and adjustable beds;
• Separation from medications kept in the home;
• Inability to contact or meet the usual home healthcare personnel and resources;
• Injuries, illnesses and anxiety related to the evacuation;
• Requests for medications not routinely used but needed for minor pain control or sleeplessness (the longer the evacuation lasts, the more frequent requests for these medicines become).

The crew requests assistance from Medical Control to manage these circumstances. Hospitals have been stretched to meet the needs of patients with chemical-exposure symptoms and routine emergencies still occurring elsewhere. Incident Command has determined that the evacuation order will be in effect for many hours, as the leak cannot be controlled, and a large “hot zone” around the chemical cloud will remain in place. It will be at least 24 hours before most evacuees are allowed to return home.

It is decided to meet as many of the medical needs of evacuees as possible by sending some nurses and a physician to the center’s medical area. With the cooperation of the Attack One crew, the Medical Director and the additional medical staff, all those presenting with routine medical needs have medical records established, and a local hospital creates a small cache of medications and minor medical supplies to be used for the evacuees. Routine medications (no controlled substances, intravenous medications or injections) are provided. The most difficult task is determining what medications evacuees need to take, as most individuals left their homes without medication bottles or lists. Contacting primary physicians is difficult due to the phone system failure. Medical center personnel find the best tool is the “pill photograph” section of a common reference book used by physicians.

For evacuees using these services, home healthcare agencies are contacted via the amateur-radio operators, and personnel from these agencies are requested to report to the evacuation center to maintain contact with their patients. This allows many evacuees with ongoing medical problems to receive their routine care without interruption.

Each evacuee requesting assistance from the evacuation medical center has a record created using routine patient care reports. Communications gives a block of report numbers to the Attack One crew for use in these encounters. A census of encounters is maintained. (In an unplanned community evacuation, medical personnel can expect to see about 10% of the evacuees per day.) A few encounters result in transportation to the hospital; these typically relate to patients with underlying histories of heart and lung diseases who report chest symptoms. None of these patients require hospital admission, however, and several return to the evacuation center after ED evaluation.

Information related to exposure to the chemical cloud needs to be shared with those in the evacuation center, as well as those visiting local emergency departments, urgent care centers and physician offices. The consistency of medical information released to patients in all these circumstances is critically important. That information is compiled at the Emergency Operations Center using the resources of the Medical Director, the regional poison control center, emergency-department leaders, the regional public health office and even the local veterinarians’ group. The same information sheet is then shared by fax and electronic mail. The medical staff at the evacuation center utilizes the same sheet for those exposed to the cloud in the course of the evacuation.

After five days, the chemical leak is finally controlled and the evacuation order lifted. The evacuation center is closed down. Attack One crew members agree to add another element to their community education message: Your household emergency kit should contain routine medications and a list of all family members’ regular medications and medical equipment.

Reference

• DeLorenzo RA, Augustine JJ. Lessons in emergency evacuation from the Miamisburg train derailment. Preh Dis Med 11(4):270–275, Oct–Dec 1996.