`A State of Chaos`: The Joplin Tornado

May 22, 2011, Joplin, Mo. The storms had been threatening all day, and the National Weather Service issued a tornado warning at 5:17 p.m. At 5:41, it arrived. With winds clocked at well over 200 mph, it cut a swath through the city from west to east. Traveling more than 13 miles, it ranged up to a mile wide at times. Later it would be determined the tornado contained three separate vortexes. The eye was estimated at 300 yards wide. Initially rated an EF4, it was upgraded after evaluation of radar data and the pattern of destruction to an EF5, the most destructive twister possible.

Within minutes there were 8,000 structures destroyed. This included 400 businesses, two of Joplin’s five fire stations and eight school buildings, as well as an estimated 18,000 vehicles. As it incapacitated St. John’s Regional Medical Center, one of the city’s two hospitals, the storm came within a quarter mile of hitting the other, Freeman West. After going through Joplin, the tornado shifted path to a southeasterly direction. Traffic along Interstate 44 was disrupted as tractor-trailers were overturned and thrown about. This would compromise the later influx of responders.                                        

‘Armageddon’

This can’t happen twice. That was my first thought after hearing a massive tornado had just struck Joplin. Disbelief was the only emotion I felt. Joplin, a relaxed metropolitan city in southwest Missouri where I serve as the EMS medical director, had just become a victim for the second time in recent history. In 2008, a tornado struck just south of the city, killing 11 people, including an entire family of four. A year ago, in May 2011, it happened again. I was driving home from Kansas City when the call came.

“Keep me informed” were the last words I said before hanging up. I then made multiple unsuccessful attempts to call Joplin. Most of the cell service was out. Finally I managed to reach the ER charge nurse at the hospital where I practice. She told me one of the first patients to come through the door had his intestines in his lap. “Do you know how bad the damage is?” I asked. “No,” she replied, “but we’re getting lots of patients coming in the backs of pickup trucks.” I assured her I was driving as fast as I could. The trip from Kansas City to Joplin, about 250 miles, took almost three hours. During the trip home, I tried to think of what I would do.

I work as an attending physician in the emergency department of Freeman West, a community teaching hospital. We see 45,000–50,000 patients annually in our 40-bed ED. On any regular Sunday, those beds would probably be fully occupied. I knew from the sound of the nurse’s voice that this would be anything but a regular Sunday. She was a seasoned ER nurse who’d worked there for at least two decades. The fear in her voice was evident. In nine years working at the hospital, I’d never heard it.

I serve as the EMS medical director for two ambulance services and the Joplin Fire Department. It’s a position of which I am especially proud because of my previous employment as a paramedic with these services. I knew what their people would be going through and felt I should be there with them. To get home, I had to drive south of Joplin to get around the damage. It was already dark as I changed clothes and, with radio in hand, headed to the local Home Depot parking lot, where a triage area was set up.

Local radio coverage was spotty and lacking facts. Nobody had had any time to assess the damage to make any meaningful reports. “Devastation” was a common word heard. While listening to the EMS and fire traffic on the radio, I pulled into the Home Depot lot. The building itself was nothing more than rubble. At that moment I knew I would be living an experience like virtually none other. As one city council member said, we were in “a state of chaos.”

The paramedics manning the triage area walked up to me with blank stares. I knew the last few hours had been Armageddon for them. As true professionals they had a triage/treatment area set up and operating. A couple of doctors from nearby Miami, Okla., joined them. I was glad to see them there. I only remember seeing a few patients getting treated, and I wondered where the rest of them were. Then I realized this was just the beginning. A fire captain told us one of the two hospitals in the city had been demolished. St. John’s Regional Medical Center had a large medical complex, and I couldn’t imagine how it could be destroyed. At least one nursing home was also completely devastated, and rescuers continued their work there. Days later we learned only six people in the medical center had perished—five patients on ventilators and one visitor.

We spent the rest of the night moving the triage area inside a neighboring business (due to another incoming storm system) and traveling through the area of destruction. I drove to EMS headquarters to speak with the field supervisors and then went to the city emergency operations center to talk with the fire chief and city manager. The EOC was just getting organized. An EMS supervisor manned the phone link with dispatch and relayed information to the supervisor at EMS headquarters. A tally was being made of on-duty crews and agencies from outside the area sending personnel.

After nearly three hours in the field, I made my way to the ED at Freeman West. It seemed as if everyone in Joplin was there. Multiple ambulances crowded the bay, with every conceivable rank of EMS provider walking around. Patients continued to stream in, and a mixture of nurses, doctors and residents met each one. I made my way through the crowd to find the people I worked with on a daily basis. They were in a flurry of activity. Bleeding patients lay on stretchers in the hallway, so I knew the rooms were also full. ER physicians stood shoulder-to-shoulder with orthopedic surgeons and neurosurgeons peering over x-rays on the PACS system. Although the trauma surgeons were initially in the ED, they had now gone to the OR, where multiple lifesaving surgeries were in progress.

Over the next several hours, staff triaged and treated multitudes of patients. When the hospital reached capacity, patients were transferred to others in the area. Some went by ambulance, and many “walking wounded” went on school buses. This continued into the middle of the next day. The professionalism of the EMS services that participated in these transfers cannot be overstated. More than 900 patients were treated that night at Freeman West, many with massive internal injuries, but only 11 lives were lost.

EMS Response

METS (Metro Emergency Transport System) is the primary ALS ambulance service in Jasper County, which includes 90% of Joplin. Thirty paramedics and EMTs operate with 10 ambulances, two wheelchair vans and two supervisor vehicles. Their annual call volume averages 15,000. The Joplin Fire Department assists them in a tiered response system with firefighter/paramedics. The southernmost section of Joplin is in Newton County, home of the Newton County Ambulance District (NCAD). They operate from four stations with a total of 12 ALS ambulances, three supervisor vehicles and three support trailers, and they employ nearly 40 EMS providers. Their call volume averages 8,000 a year. METS and NCAD work closely together, although they have separate dispatch centers. Their cooperation on a day-to-day basis became the foundation of the response to this disaster.

In the first 10 minutes after the tornado’s touchdown, there were nine ambulances and two field supervisors responding. Within 30 minutes, 21 ambulances were mobilized, along with nearly 70 EMS providers and five supervisors. Between ambulances and privately owned vehicles, there were nearly 350 patients transported in the first hour. With one of Joplin’s two hospitals out of commission, patients were taken to the only functioning facility. After the transport of multiple patients, it quickly became necessary to set up triage areas in order to begin treatment of the large number of injured. The triage areas were placed along the path of destruction, and ambulances staged at each area. Injured people, not understanding the concept of triage, began climbing en masse into the ambulances, demanding transport. EMS providers had to quickly curtail this and convince them to accept treatment where they were until transport could be arranged. Ambulances were then positioned to enable crews to quickly access the equipment on board.

The EMS command post was established at METS headquarters. From that location the on-duty field supervisor took stock of his resources. He accounted for all ambulances available for immediate response and found his personnel were not capable of responding to all requests for service. Fortunately, many surrounding agencies were calling with offers of assistance, which were gratefully accepted. The triage/treatment locations remained in service throughout the night; however, they saw only sporadic patients, as most immediate casualties had been transported and patients needing rescue hadn’t yet been found. Initial estimates recorded more than 1,300 people missing. Problematic patient tracking and people who self-evacuated to other cities contributed to this total. As more information emerged over the next several days, the number of missing was adjusted downward until everyone, dead and alive, was ultimately accounted for.

As daylight came, the extent of the damage became apparent. On first assessment, officials estimated at least a third of the city was impacted. The tornado’s path essentially divided the city in two. At the EMS command post, decisions had to be made: Do we continue triage and on-scene treatment or just transport? Where do we stage ambulances for response? How do the multiple ambulance services that came to assist communicate with each other? There was no shortage of problems to be solved.

Because the damage stretched from west to east, effectively cutting the city in two, we decided to create north and south response plans. Since the main EMS headquarters (and EMS command post) was situated north of the damage zone, METS handled that sector, and NCAD, already positioned to the south, covered the south sector. We positioned ambulance staging areas along these geographic lines. Dispatch only had to ascertain the sector from which a call for assistance came and relay it to the EMS officer at the EOC. As far as responses within the disaster area, both services were already involved in multiple rescue operations. Triage areas set up the previous night continued due to ongoing rescue operations and the continuing influx of patients at Freeman West. Medical staff from St. John’s began emergency operations at Joplin Memorial Hall. They constructed a makeshift emergency room there, and patients began arriving. A morgue facility was established at a local university with the coroner and personnel from local mortuaries. In addition to the dead, a total of 146 sets of remains were recovered for eventual identification.

The on-duty EMS supervisor remained at the EMS command post while another was stationed at the EOC. The officer at the EOC received all radio traffic from dispatch and relayed it to the appropriate staging area. The staging officer then dispatched an available ambulance. In all, nearly 100 different EMS agencies from seven states responded to Joplin over the next week. METS and NCAD communicated by shifting all radio traffic to a mutual frequency; however, outside agencies did not have this capability. This made placing the ambulances at the staging areas important. It turned out to be a workable solution for the lack of a common radio system.

Hospitals

As the tornado sirens were sounding, the on-duty ER physician and emergency medicine resident stepped out of the Freeman West ER into the ambulance bay. All they saw was darkness. No defined tornado was visible, even as it demolished St. John’s a quarter mile to the north, but the sound was deafening as they slipped back into the department. Shortly afterward, the patients started coming.

The staff wasted no time in implementing the hospital disaster plan. Doctors and nurses quickly responded to the call for help, and soon the ER was awash in medical professionals. The first patient arrived through the main ER entrance with an obvious evisceration. He went promptly to the operating room as a multitude of additional patients began arriving.

The traditional manner of registering them was quickly abandoned. People just took care of people. They did their best to get names from the conscious and assigned numbers to the nameless. Over the next several hours, they saw approximately 300–400 patients. The surgical suites hosted 22 lifesaving surgeries that night. Many patients required emergency transfers to outlying hospitals. An EMS supervisor was stationed at the ambulance entrance and, along with an ER charge nurse, arranged transportation to those facilities. We only specified which patients required transport and provided a rundown of their injuries. He had a list of accepting facilities and assigned an ambulance for each transfer. In addition, multitudes of “walking wounded” were taken to other facilities by school buses.

St. John’s Medical Center sustained a direct hit from the tornado. Their inpatient census was 183 (low because they were in the final phases of implementing electronic medical records). Inside the facility, nurses began moving patients to the hallways. At the time of impact, most everything in the hospital became projectiles, including IV poles. Nurses covered patients with their bodies to protect them. Emergency lights and exit signs were ripped from their mounts as the ceiling collapsed. Doors tore from hinges, windows blew out. The oxygen delivery system was rendered useless, and the smell of natural gas permeated the structure. After the tornado passed, ventilator patients were quickly transferred to Freeman West and the rest of the facility evacuated. Because the fire-suppression sprinklers had activated, staff had to trek through up to six inches of water. The hospital generators were destroyed, and the rooftop HVAC units landed in the parking lot. Outside, the damage included the hospital helicopter and a state-supplied emergency trailer that had been used after the Newton County tornado in 2008. The trailer was in pieces several blocks away. It took a few hours to fully empty the hospital, but up to four days to fully account for each patient and their ultimate destination. Mattresses were placed in pickup trucks, and nurses rode in the beds holding IV bags as patients were evacuated to Freeman West. Weeks later structural engineers determined the hospital had shifted several inches on its foundation.

Challenges

With so much destruction, there was no shortage of obstacles to face. This disaster had it all: communitywide communication failures (TV stations and cell service were seriously compromised); multiple sites requiring rescue and medical care; loss of a complete hospital, effectively cutting city medical facilities by half; minimal daylight early in the disaster; continuing incoming storms; and a finite number of responders and ambulances overwhelmed with requests for service. Although the local EMS agencies had participated in numerous exercises and drills over the years, no one had practiced for all the challenges this disaster brought.

A big problem was gaining access to patients still in their homes. The Joplin Fire Department was instrumental in initial operations, and was supplemented over the next several days by other agencies adept in search and rescue. This included members of the Kansas City Fire Department and 85 people with Missouri Task Force 1, a federal USAR team from Columbia. After rescue, priority patients were transported to Freeman West, while most of those with mild to moderate injuries went to either Memorial Hall on the north side or the MO-1 DMAT tent, which had a fully functioning treatment facility on the south side.

Roads remained blocked, but clearing those became a priority for the city and the Missouri Department of Transportation. Heavy machinery came in to move the immense amount of debris, including downed telephone and electric poles, parts of houses, cars and everything else congesting the streets. The movement of emergency vehicles throughout the city gradually improved.

Along with outside ambulances came supplies. METS and NCAD quickly amassed a medical stockpile that would be required in the days ahead to treat patients with every conceivable injury. A supply officer was assigned to account for the inventory and its allocation to crews.

The EOC incident command functioned in the basement of the city’s municipal building. Present were representatives from the major players in the response, including law enforcement, fire and rescue, EMS and city services. From this location they managed the disaster in a true unified fashion. They held periodic meetings to update everyone; however, many times the EMS command staff was excluded. This was a detrimental oversight, as it made it difficult for EMS staff in the EOC to communicate important details to field providers.

The next day, an informal meeting was held with the fire chief and city manager. They had questions about how long someone might survive in the debris. They worried that using heavy equipment to search might cause further injury or possibly death to living people. There was no definitive answer to their questions; visions of the recent earthquake in Haiti, with viable patients rescued after prolonged periods in the rubble, were fresh on their minds. They decided to do a daily evaluation of the areas being searched and the numbers of patients rescued. Each property was carefully checked before and during any use of heavy equipment. This approach worked well, and no additional injuries or fatalities resulted.

Long-term challenges for both EMS agencies included significantly increased call volumes. Despite a decreased population due to the destruction, people who remained had significant traumatic, medical and psychiatric conditions that required ongoing care. This, along with the fact that a large number of local physician offices and clinics were destroyed, meant more calls for EMS.

A fully functioning 40-bed psychiatric facility located inside St. John’s was also destroyed. Situated behind the hospital was an alcohol and substance abuse treatment facility; this was now gone as well. While both ERs saw a “healthy” population of psychiatric patients for medical clearance, this was now reduced to one handling them all. Since psychiatric inpatient beds were reduced, this meant more transfers to other facilities around the state.

The View Today

As I write this in March, it has been 10 months since the deadly Joplin tornado killed 160 people and destroyed hundreds of homes. The city is beginning to stand on her feet again. Most of the wreckage has been cleared, and the landscape is now dotted with new structures. A significant number of businesses have been rebuilt, and consumers are patronizing them again. Though the winter was mild, spring storms have now begun in earnest, with thunderstorm and flash flood warnings and, yes, a few tornado watches.

St. John’s Regional Medical Center, now St. John’s Mercy Hospital, continues to operate out of modular structures similar to double-wide trailers. They have a total of 40 inpatient beds (including 10 ICU beds). They see ER patients in 15 small rooms for now, but will soon occupy a “component hospital” being constructed to the south of the modular facility. This will be their home for the next two years as a new permanent hospital facility is built approximately two miles away.

EMS and fire personnel have long since regrouped and are now performing at normal capacity. The tornado destroyed the homes of four firefighters (including the fire chief) and three paramedics with METS. No deaths or significant injuries occurred that night to emergency personnel. There was loss of some fire apparatus and two fire stations. Apparatus have been replaced or repaired, and new fire stations are under construction.

Joplin has survived, for the most part, and will continue to make strides in the years to come—due in no small part to its people and the emergency personnel who serve them.

For the eight biggest lessons learned from the tornado, see the companion piece in the May issue of EMS World Magazine.

Footnote

The day after the tornado, while helping direct traffic through the destruction zone, a young police officer who arrived to help from Riverside, Mo., was struck by lightning. Fellow police officers and EMS providers started CPR immediately and transported him to Freeman West Hospital, where he was successfully resuscitated. He was subsequently transferred to the closest burn center, 60 miles away, but succumbed to his injuries 12 days later. The sacrifice this young officer gave in helping Joplin in its time of need cannot be forgotten.

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