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Emergency Medical Services

THREE DAYS BEFORE KATRINA made landfall, Dr. Maurice A. Ramirez and his FEMA Disaster Medical Assistant Team were ready to render aid, but they were forced to wait five days before receiving authorization to enter Louisiana and establish a triage and critical care hospital at the Louis Armstrong Airport in New Orleans. They couldn’t go in until there was a written request from the governor’s office to either the secretary of the Department of Homeland Security or the President. In most emergency situations, that takes as little as two days. The delay in this case was one example of how an ill-prepared response system was quickly overwhelmed by events.

“The biggest failing in my opinion,” says Ramirez, “is the failure of the community responders and hospitals to educate themselves in a coordinated approach to disaster preparedness.”

On the whole, most hospitals in America are underprepared for a large-scale mass casualty event, says Dr. Todd E. Zalut, a physician at the Shaare Zedek Medical Center in Jerusalem, Israel. “I don’t know how much has really gotten into the heads of Americans about how big these disasters can be,” he says.


One state that has taken planning seriously is Florida. For example, at Health First, a three hospital healthcare system in Brevard County, hurricane preparedness begins with a planning process that lasts three months. Last year Brevard County was hit by three hurricanes—Charley, Frances, and Jeanne—forcing the Cape Canaveral hospital, a 150-bed facility in the Health First system, to evacuate twice, so they know the threat is real.

January through March are designated as hurricane planning months, says Jim Kendig, vice president for safety and security for Health First. During this time, representatives from all facets of the healthcare system, including human resources, security, and facilities, meet to discuss response efforts for the coming hurricane season, which lasts from June 1 through November 30.

In April the hurricane team prints their final recommendations and guides. The materials are distributed to members of the staff, and in May, each director is required to sit down with each employee to go over their roles and the overall hurricane plans for the department.

The plans are designed to allow the hospital to remain self-sufficient for seven days, Kendig says. They require each hospital to stock extra food, water, extra generators, and fuel to ensure that they will be able to run at maximum capacity should a power outage occur. To prepare for the influx of patients and staff and the resulting shortage of beds, each hospital is also stocked with bedrolls.

Although the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does not have a minimum requirement for hospital self-sufficiency, hospitals should strive toward being self-sufficient for up to seventy-two hours, says Dr. Robert Wise, vice president of the standards and survey methods division.

Wise stresses that communities, not just individual hospitals, should prepare for large-scale disasters, because in many cases adequate response is contingent upon community support. To that end, JCAHO has published Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems, which calls for the development of scalable templates for community-based preparedness.


Adequate disaster plans should also include provisions for when critical resources fail. At Health First, one hospital is designated as the command center for the entire system. This hospital will function as the headquarters during any disaster. It has UPS generator power, a Nextel phone tower, radio communication, computers, high speed faxes, and two TVs, one that runs through cable and another that receives its signal through a satellite. Redundancy is stressed for every critical asset.

When you’re talking about mass casualty, “everything has to have a backup,” says Zalut, who has worked with many American hospitals to enhance their communication and triage systems.

This is the type of preparedness that was not present in New Orleans. “They didn’t do the basics of being disaster ready,” says Zalut. “They failed to appreciate the risks...and they failed to appreciate each other and the resources and support staff they could have had.”

The first step in being ready is to identify the threat, establish a base command structure, establish a safe scene, and assess the resources available. Hospitals in New Orleans failed to anticipate their Achilles heel: water pumps and generators. If hospitals had identified these problems in the disaster planning process, it is likely that they would have been able to develop contingency plans to circumvent the weaknesses.


Practicing for these events is one of the most effective ways to prepare the hospital and its staff, say most experts. At Shaare Zedek in Israel, Zalut says that mass casualty drills are held three times a year, using varying amounts of soldiers, typically 300 to 350, who act as patients. The soldiers pretend to have wounds and symptoms.

In the United States, the current JCAHO requirements mandate one paperbased drill per year. In addition, a second drill that includes an influx of simulated patients is also required.

The drill requirements are currently under review, says Wise, who agrees that more drills should be mandated in the future. “Drill to the breaking point,” he says. In addition to requiring more drills, JCAHO is expected to develop a review process to ensure that each hospital learns from the drills and that those lessons are applied toward future training events.

According to Zalut, who also worked in Chicago as a director of emergency medicine, the problem with drills in American hospitals isn’t just their infrequency, it is that they may not be extensive enough. Zalut stresses, however, “there’s a level at which the disaster becomes a megadisaster, and no matter who you are and how much experience you have, you’re not going to do much, you’re not going to be prepared enough.”

In Brevard County various drills are conducted throughout the year, but at least once a year the hospital’s hurricane plan is tested. “The most important thing,” says Kendig, “is to have a plan that is communicated and practiced.”

Marta Roberts is an assistant editor at Security Management.