Lessons Learned From the Joplin Tornado

The tornado that struck Joplin, MO, a year ago this month was a monster by any definition. With winds up to 250 miles an hour and a funnel at times topping a mile wide, it carved the city in half, destroying fire stations and a hospital en route to killing 160 and injuring around 1,000.

As the local EMS medical director, Jim Morgan, DO, got a front-row view of the disaster, response and aftermath. Here he distills eight key lessons learned; for his firsthand account of the entire experience, see [link/iPad pitch].

1) Maintain a close relationship with your neighbors.

When a community’s emergency responders face disaster, chances are they will be overwhelmed with calls for service. Having a firm relationship with organizations nearby can assure assistance. Formal memoranda of understanding are good but don’t replace friendly face-to-face discussions. After a major event, not surprisingly, dialogue between EMS leaders usually isn’t a problem. Carry things a step further with disaster exercises involving agencies that have adjacent or bisecting jurisdictions.

2) Train on the art of triage.

In the early stages of our disaster, EMS providers learned that triage and treatment on scene can be much more effective than transport. With the extent of destruction and loss of a complete hospital (St. John’s Regional Medical Center, one of only two hospitals in Joplin), this was a big decision. It’s rare, but the loss of such a prime medical facility in a disaster is something EMS agencies should plan for. The field triage we used was START, which allows the provider to assess a minimum of vital functions and respond in defined ways to any abnormality. After the initial triage, as treatment continued, we constantly reassessed patients while coordinating transportation.

All agencies that may be involved should discuss a common triage tagging system. The simpler a tag is to access and use, the more likely providers will use it correctly. Our EMS crews quickly ran out of triage tags and had to document patient information in other ways. When stocking tags, have a sufficient number to ensure you will not run out.

3) Integrate an Incident Command System (ICS) and review it regularly.

An ICS will help keep your system structured. There will be less confusion of individual responsibility with a unity of command. EMS agencies generally do not have prolonged scene presences and so do not implement this on a daily basis. Its nuances can be lost on crews that do not plan for it. It’s important to field units to know someone is in charge, and a properly executed ICS assures this.

Also, people and positions frequently change. Regular review of ICS structure with agency personnel is important to reduce confusion during a disaster.

4) Implement regular disaster drills.

Disaster drills are one of the least favorite aspects of the job. They take a lot of time to plan and implement, and never seem to approach situations seen in real life. But the tornado made believers of many providers in our area. Without all those fake-blood exercises, EMS crews might have delayed in setting up triage areas. While the loss of a hospital had not been foreseen, the experiences of this disaster may be useful when planning the next drill. Methods of triage, treatment and transportation must be continually assessed and changed as needed.

5) Formulate plans for patient tracking and supply requisition.

There are many different methods to track patients during a disaster. The easiest is to keep a logbook in each ambulance. This will facilitate tracking patients wherever the ambulance may be, and a provider or reliable bystander can obtain basic information from patients. A minimum amount of data is preferable, so multiple patients can be logged quickly. For patients who can’t speak, documenting an identifying feature along with obvious injuries may help with subsequent identification.

Supplies can be logged at a central dispensing location, along with the names of donating agencies. A designated supply officer can list outgoing materials along with receiving agencies or units. This will help with recovery of reusable equipment after the fact.

6) Insist on active EMS participation in a structured EOC environment.

When a disaster strikes that will require prolonged operations, most communities activate an emergency operations center. This is usually at a central location with access to computers, phones and large marker boards. Personnel manning the EOC consist of law enforcement, fire officers and city officials. In some communities, EMS also participates. If EMS does not have an EOC presence in your area, it should. In Joplin, EMS officials were sometimes not included in key meetings, which was a major oversight. It may require some politicking to get a seat.

Once EMS has representation in the EOC, its duties should be defined. This will depend on the type of disaster and each organization’s needs and manner of dispatch. How EMS operates in the EOC is beyond the scope of this article; however, you should have a method of logging personnel, communicating with outside agencies and medical facilities, and instituting changes in operational goals as needed.

7) Arrange post-incident debriefing.

The tremendous emotional toll of a disaster like this on responders can inhibit their future performance. Any disaster has a variety of inhumane circumstances that affect people in various ways. A post-incident debriefing session lets responders know they are not alone. There are many organizations that can be consulted to provide Critical Incident Stress Management (CISM), or your organization may have personnel who can do it. Either way, providing a CISM meeting can help keep providers mentally healthy and able to continue working.

8) Learn to accept the fluidity a disaster.

Disaster upends a community. It threatens infrastructures and the ways people conduct their lives. For emergency response agencies working during a disaster, circumstances change constantly. A provider can’t afford to get blindsided. Weather, personnel, locations and supplies may be reasons a disaster focus changes. Responders need to learn to adapt, sometimes on a minute-to-minute basis. As time passes, the focus becomes more defined and will subsequently require less change.

Conclusion

This disaster saw a wide range of problems, with many solutions identified over the following months. While tornado prediction is still more art than science, it is the best it has ever been. The destructive force of tornadoes cannot be stopped. What can be done is to respect their power and heed warnings when given. As Joplin rebuilds, it will see more houses constructed with safe rooms able to withstand the harsh winds. What cannot be recovered are the 160 lives lost. The best we can do in their memory is to continue refining and restructuring our responses to do the most good for the most people.

More than a few local EMS providers from the Metro Emergency Transport System (METS), Newton County Ambulance District (NCAD) and Joplin Fire Department lost their homes in this disaster, but they kept their eyes on the ball and continued searching and treating patients as best they could. Fortunately, no EMS or fire providers lost their lives that night, but the ultimate emotional toll is yet to be determined.

Jim Morgan, DO, is the EMS medical director for Joplin, MO. Contact him at erfizz@gmail.com.