A Supersized Storm

In late October 2012, Hurricane Sandy devastated the Northeastern United States, part of a storm system that caused damage from the Caribbean to Canada. It’s nickname—Superstorm—was well-earned, for the storm was largely unprecedented. Yet despite the destruction—still evident more than four months later, and likely for some time to come—the response from EMS agencies throughout the region was, on the whole, well-organized and efficient. And that was not without precedent.

New Jersey was just one state affected by Sandy, but it was particularly hard hit, and the images of a swamped Jersey Shore—and the twisted wreckage of popular amusement rides along the boardwalk in Seaside Heights, in particular—left an indelible impression. As bad as Sandy was, New Jersey EMS crews were prepared for most of what the storm wrought.

“One of the things we do here in New Jersey, as far as EMS is concerned, is prepare,” says Henry Cortacans, MAS, CEM, NREMT-P and state planner for the New Jersey EMS Task Force, which functions alongside the New Jersey Department of Health. “Preparedness is a way of life, because terrorism is always on our radar. So we’re always prepared—for anything—especially something like this, where we had several days of notice.”

Cortacans says about nine days prior to the storm, National Weather Service computer models showed a hurricane hitting New Jersey. “Usually when you go out in time these computer models are not necessarily that accurate, but this model nailed it. Even six, seven days prior Sandy was nothing but a bunch of clouds; it wasn’t even a storm or anything. The National Weather Service’s ability to accurately forecast one of the biggest disasters in the nation’s history—so far in advance—was, like the storm, unprecedented. They deserve some credit for that.”

As a state New Jersey also has a specific plan for EMS to follow at the local, county and state level when a tropical storm or a hurricane has the potential to impact the region, called the Tropical Storm/Hurricane Management Plan for EMS. Established in 2008, the plan has already been implemented several times, notably when Hurricane Irene struck the region in 2011. The plan, which lists a host of standard operating procedures for response during tropical storms and hurricanes, has been refined each time it’s been used, to the point that it’s pretty much fool-proof.

In the four to five days prior to Sandy hitting the region on October 29, the New Jersey EMS Task Force prepared to respond across the state, establishing two regional EMS staging areas, as well as a heli-base for air medical operations. And for just the second time in state history, New Jersey implemented the Emergency Management Assistance Compact (EMAC), initially requesting 75 ambulances from out of state to come in and assist with healthcare facility evacuations.

“We only got 47 ambulances pre-storm and they came from Indiana,” says Cortacans. “They assisted with facility evacuation and shelter support. After the storm their mission changed to search and rescue, and continuity of operations for devastated locations. There were at least 23 EMS agencies that had major damage to their buildings or ambulances. That’s 23 jurisdictions that you need 9-1-1 service for, plus all the other jurisdictions that just had severe damage, extremely high 9-1-1 call volume, etc. Ultimately, a total of 136 out-of-state ambulances, from Indiana, Pennsylvania, Maryland and Vermont assisted in New Jersey.”

Terry Clancy, N.J. EMS Task Force coordinator, notes an unexpected challenge brought on by the influx of out-of-state support was the differences in scope of practice. “That’s something you have to consider in the planning process. We had EMT-Intermediates who came in from out of state; we certainly embraced it, but that was a challenge for our providers because we don’t have EMT-Intermediates in New Jersey. We had to educate in the middle of the storm about what other state’s capabilities are and their scope of practice.”

Still, in-state EMS agencies were thankful for the help. Those services that were still fully or partially operational were working non-stop for the first couple weeks after the storm hit.

MONOC EMS, which operates a fleet of more than 100 ambulances and serves 15 acute care hospitals throughout New Jersey, faced many of the same problems as every other agency affected by the storm, says Andrew Caruso, director of operations for MONOC EMS and deputy EMS coordinator for the Monmouth County Office of Emergency Management.

“We had secured additional generators for our headquarters in order to ensure that we didn’t lose power to the HVAC system and our communications equipment,” says Caruso. “We sent adequate medical supplies and vehicle maintenance items to all of our satellite stations and filled sand bags to keep water from coming into our facilities. We identified locations that had been affected by Hurricane Irene flooding and raised everything off of floors and relocated staff and vehicles to higher ground. All primary response units and backup vehicles were fueled in advance, but that was challenging because most citizens had the same idea—gasoline was in short supply and stations were becoming overcrowded. Diesel was less difficult to find, but again, the stations were difficult to access.”

Evacuation

One of the primary roles for EMS crews, especially the out-of-state units summoned through EMAC, prior to the storm was evacuation. Cortacans says a final a tally of individuals assisted before, during and after the storm is a long way off, but the New Jersey EMS Task Force oversaw the evacuation of 16 nursing homes prior to the storm. In the 24 hours before Sandy struck, the Task Force assisted in the evacuation of 140 patients from the Hoboken University Medical Center, in Hudson County, and following the storm, once flood waters receded, helped another Hudson County hospital, Palisades Medical Center, evacuate patients who had been trapped by the overflowing Hudson River. In all, Cortacans notes, five state shelters were opened. Thirty-nine hospitals and 196 nursing homes lost power and more than 1,500 healthcare facility residents were evacuated out of all those facilities combined. Statewide, New Jersey suffered 40 Sandy-related deaths, and nearly 1,000 people were left injured or ill. The $38 billion in damage the state suffered as a direct result of the storm includes 300,000 homes damaged or destroyed.

“Once the storm hit, we were faced with the expected obstacles, such as flooded vehicles and facilities, power outages and downed trees, poles and debris hindering our ability to get to calls for assistance,” Caruso adds. “Unlike normal road closures based on construction, downed trees, etc., in this case we were not notified by local police and did not find out about inaccessible roads until our units attempted to pass. Some of the lower-lying coastal areas were subjected to voluntary and mandatory evacuation and some of the neighborhoods had received door-to-door notification, while other residents were notified by radio announcements, television and radio news, social media, etc. Many residents did not leave, either by choice, or because they were not fully informed as to the danger. Ultimately, some of these people were in need of rescue.”

Michael Bascom, EMS Coordinator for Monmouth County and one of the New Jersey EMS Task Force leaders, talks candidly about those rescues. Just a few blocks from his own home, which was severely damaged, another house exploded during the storm due to a natural gas leak. Two victims were rescued and they were only recently released from a burn center.

“We also had several water rescues, with trees coming down on top of boats,” says Bascom. “I had to make the call that rescues were to cease, and you know the heart and brain of most people in our business. They don’t want to stop until they have to stop, and ‘have to stop’ is when trees are falling on your rescue boats and it’s becoming far too dangerous to continue operations. Making that call, where no further rescues are going to be permitted, and then fielding the calls at the EOC from people who failed to heed the orders to evacuate and at the height of the storm are begging for someone to come save them, claiming heart attacks, structure fires—virtually everything—in the hopes that we’ll come through the storm to rescue them. That’s an interesting perspective that many people probably didn’t experience in the storm in you were boots on the ground. If there’s a lesson to be learned for the public, it’s to heed that evacuation order, without question.”

But Bascom also notes a rescue he was directly involved in, after he’d already given the order to suspend rescue operations. “The police chief and I responded in on a possible drowning call. It was just as things were getting really, really bad. Sustained winds over 45 mph. Flood levels were probably about 12 feet. It was unfounded, on the first response. Two hours later we got called back again for a possible drowning, but they give us a different location. We responded with a family member of the person who was suspected to be in the water. The police chief and I pulled up on the scene and the victim was far from the location that had originally been provided. This guy was a boater, a fisherman, who had gone down to check on his boat and apparently fell overboard at some point. He floated several piers away where he managed to hold on to another boat.”

The victim, in his 60s, had been holding onto the side of a boat, in rapidly moving water, for close to three hours, Bascom estimates. It was too dangerous to send rescue swimmers in to get him because of all the other boats and debris floating through the water, but Bascom was able to direct the man to an area where he could support himself on the pier and still hold on to the side of the boat.

“He was in a channel we’re very familiar with, that’s normally 50 yards wide,” Bascom says. “When we pulled up, the water rushing through that channel was probably about 400 yards wide at this point. It had just over flown and engulfed restaurants, night clubs and everything else that had lined the waterfront previously. Obviously this limited our access to get down to the guy, and the operation continued past the period where we had called people off the road, but when you actually make physical contact with an individual, regardless of the conditions, it’s tough to walk away. So, we remained on scene until we were able to successfully rescue this guy, who then refused medical assistance. He just wanted to go home and put on dry clothes. Your typical old salt fisherman. Tough, tough guy.”

Lessons Learned

As smoothly as operations ran before, during and after the storm, considering the circumstances, Cortacans says, there were still unexpected challenges to overcome, and lessons learned for the EMS providers involved.

“We expected widespread utilities disruptions, but to actually undergo and see what 2.6 million households without power looks like was astonishing,” Cortacans explains. “One of our major coordination centers lost power, went to the back-up systems and those were unable to be used because they required power as well, apparently. So they had to go to some tertiary systems, some satellite technology, to get back up and running.”

The loss of utilities also meant the loss of communication, or at least some modes of communication taken for granted these days.

“There was no power, so towers and transmitters went down; people working out of EOCs couldn’t communicate,” explains Cortacans. “And I’m not just talking about radios, but Internet. There was very limited Internet service and it took a while for that to get back in place. Some of our government primary e-mail servers and back-ups are located in New Jersey. If almost all of New Jersey has no power, you have no e-mail. So, many state, county and local government officials that didn’t have a back-up server in a non-affected area had e-mail outages for several days. One of the lessons learned is to have a professional back-up e-mail on Yahoo or Gmail, because if one of their servers goes down they have them all over and you can still get e-mail without interruption.”

Cortacans notes though that mobile devices largely withstood the power and Internet outages. The 3G and 4G networks didn’t go down. Providers were at least able to rely on their mobile devices for alternate e-mail, text messaging and Internet. He also found tablet devices extremely useful in the field and for operations management, particularly an app called Tactical EMS Table, which assists in geotagging operations.

In particular though, says Cortacans, his tablet was useful for keeping him connected with his family while he was working long hours for weeks at a time. He was able to video chat with his wife and three sons before bed when he couldn’t be at home, which was most nights in the aftermath of Sandy.

The utility disruptions were an obstacle for several days or more in some areas, as were fuel shortages. Providers and their families in many cases lost homes or other personal property.

“All of our employees were personally affected by the storm either directly or indirectly,” says Caruso. “Our field providers, communications staff and management team were resilient. They left their homes and families as early as when the storm was coming, knowing there was a chance they wouldn’t be able to get back for several days. A majority of our employees were without power at home. Many did not have running water, cooking facilities, etc. Some had damage to their homes from water, wind and falling trees and poles. Many of our employees actually preferred to come to work, knowing that their homes were in such conditions. They saw work as an opportunity to get their minds off of what they had happening in their personal lives, that was unchangeable, and to do what they got into EMS for in the first place—to help others.”

Flexibility on the state’s part also helped MONOC avoid red tape so crews could respond more effectively to storm victims. “In the two weeks after the hurricane hit, in addition to providing over 2,400 man hours to shelter coverage, MONOC responded to 10,429 requests for service,” says Caruso, “compared to the same time frame in 2011 in which we responded to 8,603 requests.

“To the benefit of the community we provide advanced life support services for,” he continues, “our regulatory agency, the New Jersey Department of Health and Senior Services Office of Emergency Medical Services, provided a waiver allowing New Jersey Mobile Intensive Care Paramedic Units to alter the normal crew configuration of two paramedics to one paramedic and one EMT. This not only afforded us the ability to put more MICUs on the road, but also allowed more flexibility in staffing these units.  During the waiver period, these ‘hybrid’ units were dispatched to almost 300 critical emergencies.”

Two other unforeseen problems, Cortacans notes, had more to do with the aftermath of the storm than the storm itself.

“Be careful what you eat,” he advises. “A number of our EMS responders got ill, particularly the out-of-state ones, because they were eating donated food. While the intentions of the general public were good, we had no way of knowing if that food was properly stored, or contaminated. It’s best to stick with MREs, or food supplied from trusted sources. And also public health and hygiene are important to prevent outbreaks such as norovirus. There was a small norovirus outbreak that sickened a handful of responders.

“We also had a surge after the storm hit of carbon monoxide illnesses and fatalities because people were incorrectly using generators,” Cortacans says. “One thing I thought was really good, the EMS Task Force equips our members with personal CO detectors and they carry them all the time because we typically just respond to disasters. But a good lesson would be for EMS agencies to routinely carry these CO detectors. Some of our members, who were not deployed on an assignment with us but were working with their local jurisdiction, had it on them and would come into residences where these things were alerting them to high levels of CO. Especially during a disaster, EMS crews should all be outfitted with personal CO detectors, especially working in areas with prolonged utility disruptions.”

Other lessons noted by Cortacans, Bascom, Clancy and Caruso were:

• To activate EMAC early, so out-of-state assistance can be on hand at the start of a disaster to assist with surge capacity and in areas where local EMS services are unable to respond, as well as with incident management.
• According to Clancy, it wasn’t just important to establish all the key leadership positions early on, but for leaders to be present in the field, not just the EOC. “We had staff at our command center, our state EOC and we had key state officials in the field, not only at various sites where a lot of the activity was happening, but also when EMAC resources came in to make sure there was a coordinated effort with local resources,” she says.
• Medical ambulance buses are an incredible force multiplier, and one of the most effective uses of EMS funding for mass casualty response.
• Plan, train and exercise. Cortacans notes New Jersey probably has two dozen incident-type specific emergency operating plans, of which 90% have been implemented because state EMS officials value their effectiveness.
• Use social media to communicate with employees and the public when traditional means of communication are interrupted.
• Besides electricity, have a back-up plan for other utilities that require power, such as water. If the water company is out of power, arrangements will need to be made for portable toilets and potable water for hygiene and drinking.

The most important lesson? “Take care of yourself,” says Caruso. “We all know we shouldn’t put ourselves at risk, but in times of disaster it might be easy to overlook the most basic signs that it’s time to have a healthy snack, take a break, sleep, stay hydrated, etc. We must delineate very clear operational periods and enforce them.”

Mobile Hospitals Integral to N.J. Sandy-Response

The New Jersey EMS Task Force is fortunate to have two mobile hospitals at its disposal, both of which were utilized during the state’s coordinated response to Hurricane Sandy.

According to Henry Cortacans, MAS, CEM, NREMT-P and state planner for the New Jersey EMS Task Force, the two tractor trailer mobile units can be deployed and set up with a city of tents to act as a field hospital. Both feature a mobile emergency room and have a seven bed capability. “So we have 14 bed capability if we deploy both, plus we have a third tractor trailer that serves as an operating room with two OR suites.”

During and after Sandy struck, the mobile hospitals were deployed four times, after having never been previously deployed, adds Cortacans. “Before the storm we had a request in Somerset County, which is more inland, to serve residents who were cut off during Hurricane Irene. That area ended up not being totally devastated, and in that first deployment they delivered a baby amidst hurricane force winds.” That initial deployment only saw six patients.

The second deployment came after the storm. As hospitals swelled with patients, both mobile units were sent to the Jersey Shore region. Medical ambulance buses were utilized to transport patients in large numbers to the mobile hospitals, which was deployed nearly 10 days and saw 150 patients.

While deployed on the Shore a request for a third deployment came in, so one of the tractor trailers was freed up and went to Jersey City, Cortacans says. Jersey City Medical Center was underwater and had no power, so the mobile unit acted as the ER for that hospital, admitting patients to the upper, dry, floors, as needed. That operation saw 1,301 patients.

Once the Shore region operation started to wind down, a fourth and final request for the mobile hospital came in from out-of-state. “Long Beach Medical Center in Nassau County on Long Island was almost destroyed, so they requested our mobile hospital,” says Cortacans. “We set up there for 17 days and saw about 160 patients as well.”

Hurricane Sandy, By the Numbers

As with any large-scale disaster, a final tally of the devastation caused by Hurricane Sandy October 29, 2012 is still a ways from being complete, even more than four months later. But some data and statistics about the storm are available, as outlined in brief below.

• An estimated 8.5 million customers in 16 states and Washington, D.C. lost power due to Sandy, most in New York and New Jersey, for periods ranging from a few days to multiple weeks. Reportedly as many as 2,000 people are still without power in those two states as of early February.
• The estimated cost of damage from Sandy ranges from a low of $74 billion to as much as $82 billion, with the majority of the damage taking place in New Jersey and New York. In New York 305,000 homes were destroyed and at least 72,000 buildings were damaged in New Jersey.
• Hurricane Sandy has been blamed for 132 deaths in the U.S., as well as 60 in the Caribbean.
• More than 850,000 people were evacuated prior to Hurricane Sandy making landfall, compared to about 1 million before Hurricane Katrina. At least 100,000 people were displaced by Sandy.
• At its largest, Hurricane Sandy spanned more than 1,000 miles in diameter, dwarfing Katrina’s 415 mile diameter span. Sandy spent about 32 hours on land.
• Winds from Sandy reached 80 mph on land, making it a Category 1 hurricane. Katrina, with landfall winds up to 120 mph when it hit Louisiana, was a Category 3 hurricane at its strongest.
• More than 4,300 FEMA personnel were deployed to assist before, during and after Sandy.

Data and statistics courtesy of The New York Times, Huffington Post, CNBC, Scientific American and FEMA.