“…the only way..to respond to a crisis ..is to ensure every member of the staff feels as though they are part of a team.” (Hurricanes, Mass Disasters, Wild Fires)

“President Trump has downplayed the scale of the disaster in Puerto Rico, where the official death toll now sits at 45. But hospital employees, funeral directors, and healthcare volunteers in Puerto Rico who spoke to VICE News put the count much higher. They’re not only overwhelmed with bodies — often whose cause of death hasn’t been determined — but officials might not be accounting for deaths indirectly related to Hurricane Maria, like those due to medication shortages.
VICE News called all 65 hospitals in Puerto Rico listed on the U.S. government’s website. At least one hospital had permanently closed, and others’ phone lines had been disconnected. Many had administrative employees unable to show up to work, while others were running on inconsistent flow of water and diesel to power generators. At most hospitals, however, the morgues were filling up beyond capacity, making the death count difficult to track. (A)

“Nearly three weeks after Hurricane Maria tore through Puerto Rico, many sick people across the island remain in mortal peril. The government’s announcements each morning about the recovery effort are often upbeat, but beyond them are hidden emergencies. Seriously ill dialysis patients across Puerto Rico have seen their treatment hours reduced by 25 percent because the centers still lack a steady supply of diesel to run their generators. Less than half of Puerto Rico’s medical employees have reported to work in the weeks since the storm, federal health officials said.
Hospitals are running low on medicine and high on patients, as they take in the infirm from medical centers where generators failed. A hospital in Humacao had to evacuate 29 patients last Wednesday — including seven in the intensive care unit and a few on the operating table — to an American military medical ship off the coast of Puerto Rico when a generator broke down….
Matching resources with needs remains a problem. The Puerto Rico Department of Health has sent just 82 patients to the Comfort over the past six days, even though the ship can serve 250. The Comfort’s 800 medical personnel were treating just seven patients on Monday.” (B)

“Medicaid block grants have been a centerpiece of Republican health proposals for more than a decade. Proponents, including House Speaker Paul Ryan (R-WI), argue that giving states a fixed amount of money through a block grant or per-person limit with few strings attached gets Washington out of the way and allows for state innovation. Although the most recent block grant legislation did not reach the Senate floor, proponents have promised to continue to push for it.
But one need look no further than the growing health crisis in Puerto Rico to understand why capped federal money and state flexibility will not solve serious health care issues.
Unlike states, Puerto Rico’s federal Medicaid funding is provided through a lump sum of federal funds: a block grant. Over the years, this approach has proven insufficient to address the island’s significant health needs. Even before Hurricanes Maria and Irma, Puerto Rico faced significantly higher rates of chronic diseases such as coronary heart disease and asthma, as well as higher rates of premature births and infant mortality, compared to rates in the mainland United States. The supply of available providers, particularly for specialist services, is below average. (C)

“Florida Hospital Oceanside remains closed indefinitely, more than a month after Hurricane Irma blew through the area and damaged the 80-bed facility located on State Road A1A on the beachside. It’s not clear when — or even if — the hospital will reopen….
“Florida Hospital Oceanside sustained significant damage both to the exterior and interior of the facility,” he continued. “We are in the process of determining the feasibility of renovations and will update you as the situation unfolds.”
Florida Hospital Oceanside is the smallest of six hospitals the not-for-profit Adventist Health System operates in Volusia and Flagler counties, and it is the chain’s only major facility in Ormond Beach. The hospital’s main focus is on providing occupational, physical and speech therapy rehabilitation services to patients. (D)

“Five years ago this month, the lights went out in New Jersey as Superstorm Sandy roared ashore and wiped out electricity for days….
NJHA works closely with a network of agencies from the emergency response, public safety, public health and social services sectors to make sure we’ve planned and drilled for all types of emergencies.
We developed our Weathering the Storm planning guide with detailed checklists of 400-some items that health care facilities must consider before, during and after a weather emergency. For example, it’s not enough to just anticipate for enough staff to care for our patients and residents. We plan for getting them into place ahead of time, providing them space to sleep and shower, fueling up their vehicles and securing law enforcement escorts if roads are closed. We even plan to make sure our staffs’ family members and pets are cared for — so that they can focus on being there for their community….(E)

“On Oct. 1, the deadliest mass shooting in modern American history occurred in Las Vegas, Nevada, killing 59 people and injuring over 520 others. In the wake of the tragedy, hospitals and trauma centers across the region swung into action — and in the aftermath, witnesses, doctors and patients are describing scenes of intense, bloody chaos as medical staff performed one of the biggest life-saving efforts in recent American memory. Many people are wondering what it’s like inside a hospital after a mass shooting, and the stories that are emerging after what’s now being called the Mandalay Bay Shooting are as horrific as they are heroic.
Nevada has only one level-one trauma center, a 24-hour trauma care clinic capable of coping with waves of critically injured patients. The University Medical Center just last week dealt with 15 trauma cases in one night. After the tragedy in Las Vegas, it was sent hundreds of cases, arriving from the Route 91 Harvest Festival in various states of injury by any means necessary. The narratives emerging from within the UMC and other hospitals and medical centers around Nevada, all of whom responded immediately as news of the massacre spread, are deeply distressing, so this is not the account for you if you’re struggling to deal with a traumatic reaction to the events of Sunday night. But more than anywhere else, perhaps, the inside of a hospital responding to a mass shooting gives lessons about the real impact of gun violence on American people. These are stories that need to be heard. (F)

“Those injured in the mass shooting on the Las Vegas Strip will undoubtedly be confronted with medical bills, and some area hospitals are stepping up to ease those patients’ financial worries.
On top of various donation drives, University Medical Center, Sunrise Hospital and Dignity Health-St. Rose Dominican will assist shooting victims to pay varying amounts of their hospital costs.
“At Dignity Health-St. Rose, our focus remains on the immediate medical and supportive care needs of the injured as well as their long-term healing process,” said Jennifer Cooper, Dignity Health-St. Rose Dominican spokeswoman. “St. Rose does not intend to bill or require payment from any patient victims of this tragic event.”
To recoup some of the cost, the medical group will look to other avenues to pay for the shooting victims’ care. “St. Rose will bill third-party payers (if any) and will be accepting contributions from donors in the community to address the financial and other burdens placed on these patient victims,” Cooper said.
UMC officials said they will work to help those who were uninsured so they will not have a financial burden. “Because we have had an outpouring of support for our patients, we are closely coordinating uninsured expenses with generous donors,” UMC spokeswoman Danita Cohen said.” (G)

“Air Force Maj. Charles Chesnut was asleep when Stephen Paddock opened fire on a crowd at a concert outside the Mandalay Bay hotel in Las Vegas just after 10 p.m. on Sunday.
About 90 minutes later, he was woken up by an alert to avoid the city’s downtown area.
Despite that warning, Chesnut, a general surgeon assigned to the 99th Medical Group at Nellis Air Force Base, met his commander and headed toward the scene.
He arrived at University Medical Center of Southern Nevada around midnight, as treatment for the first wave of patients was wrapping up.
But his work was just beginning.
“Within two hours after the incident, all the resuscitation bays [at the hospital] were full, and six patients were being operated on by trauma surgeons,” Chesnut said in an Air Force interview.
Air Force Col. Brandon Snook was another surgeon working at the University Medical Center during the aftermath of the shooting.
“Days like we experienced at UMC are the toughest ones, when you have multiple patients injured while multiple patients are continuing to come to the hospital,” said Snook, a surgeon from the 99th Medical Group.
Chesnut said that doctors treated over 100 patients, most from gunshot wounds, as well as some patients who were trampled. (H)

“They streamed in in droves, arriving any way they could: via ambulance, crammed into the backs of trucks, even on foot. Many were in desperate need of care, their bodies punctured by high-velocity gunshots more frequently seen on the battlefield than on the Las Vegas Strip.
After the worst mass shooting in modern U.S. history, victims shot at a music festival on the Strip on Sunday night quickly filled Las Vegas’ hospitals on a scale that many medical personnel said they had never before witnessed — in both the sheer number of patients and the extent of their injuries.
But thanks to regularly held mass casualty training sessions at their hospitals, attending to the victims went as smoothly as possible, they said….
Sunday night’s massacre by a gunman who unleashed a rapid-fire barrage of bullets from the 32nd floor killed at least 58 people and injured almost 500 others, pushing hospitals to the brinks of their capacity.
At Sunrise, which treated 214 patients, “probably a hundred percent” had gunshot wounds, Scherr said. A lot had bone fractures and injuries to their extremities, he said. Others were in more dire condition.
“It’s the art of triage in mass casualty to find the sickest patient and to treat that patient first and get to the less acute patient a little later,” Scherr said.
The sickest arrived first, in ambulances, he said. Then other patients started coming in in makeshift emergency vehicles: trucks and cars driven by ordinary people.” (I)

“In situations where it’s not clear if a shooter has been subdued, medical staff have to make choices about protecting their own safety. Emergency workers, the New York Times reports, went to the site of the shooting to help triage patients and get them to hospital while wearing ballistic helmets and protective clothing to avoid being shot themselves. Paramedics are also trained to avoid attracting attention; Amber Ratto told The Guardian that she and her colleagues turned off their vehicle lights and worked in darkness so as not to attract attention and risk further injury for their patients, or death themselves…
Medical staff went beyond their limits. The Chicago Tribune reports that pediatric surgeons operated on adults and obstetricians diagnosed trauma patients, while some surgeons were performing five operations simultaneously. One surgeon, Jay Coates, told the Associated Press, “I have no idea who I operated on. They were coming in so fast, we were taking care of bodies. We were just trying to keep people from dying. Every bed was full. We had people in the hallways, people outside and more people coming in.” Many patients came in unidentified, so names were assigned at random. Staff worked shifts back-to-back, and volunteers showed up to provide them with water and food.
Supplies were under constant pressure. UMC didn’t have enough X-ray machines; at one point, the supply of chest tubes ran critically low and a nearby hospital ran them over on the back of a pickup truck, according to the Tribune. The New York Times reported that they also faced critical shortages of IV tubing, fluids, blood pressure cuffs and blankets. And medical staff were also operating under extreme psychological pressure. Stahl wrote that “probably the hardest thing I saw” was the police officer who died at his hospital…” (J)

“The UNLV School of Medicine has also played a vital role in the response. The school sent 76 residents and fellows to assist the hundreds of victims, most going to UMC.
There were 30 emergency medical residents, 28 general surgery residents, eight orthopedic residents, three plastic surgery residents, three surgical critical care (fellows) and three acute care (fellows) used from UNLV.
Fildes, who also serves as the chairman of the department of surgery at the UNLV School of Medicine, said the UNLV students augmented the hospital’s response.
“On any given night if you were to come and visit us at the trauma center, we would have a dozen or so victims of car crashes, gunshots or stab wounds,” he said. “But to have over 100 at once, you have to have the ability to amplify your staff.” (K)

“Officials said Las Vegas emergency responders spent years training for a mass casualty event before the music festival massacre.
Las Vegas Review-Journal reported that emergency crews responded within five seconds, and used knowledge learned from past mass casualty events to prepare for such an incident
“We knew what to do,” Clark County Fire Department Chief Greg Cassell said. “It was much grander than we ever envisioned. However, we were able to handle it because of our people, our training, our professionalism and our equipment and our relationships.”…
Drills for hospitals, hotels, schools and malls were put into place, “Because that’s where historically these things are taking place,” according to Chief Cassell.
Chief Cassell said responders transported almost 200 people to hospitals, with a wide range of injuries such as high-powered gunshot wounds, sprains, trampling injuries and cuts.
Chief Cassell praised everyone involved who risked their lives to rescue people. “They performed wonderfully under fire, literally under fire, taking care of patients that were right there in front of them in a drastic, very bad situation,” he said.” (L)

“In the days after the shootings at the Route 91 Harvest festival in Las Vegas, many stories emerged of bystander courage. Volunteers combed the grounds for survivors and carried out the injured. Strangers used belts as makeshift tourniquets to stanch bleeding, and then others sped the wounded to hospitals in the back seats of cars and the beds of pickup trucks.
These rescue efforts took place before the county’s emergency medical crews, waylaid by fleeing concertgoers, reached the grassy field, an estimated half-hour or more after the shooting began. When they did arrive, the local fire chief said in an interview, only the dead remained.
“Everybody was treating patients and trying to get there,” Chief Gregory Cassell of the Clark County Fire Department, said of his personnel. “They just couldn’t.”
The experiences in Las Vegas have implications for the nation. Emergency medical services have changed how they respond to mass attacks, charging into insecure areas and immediately helping the injured rather than standing back. Still, every minute counts, and bystanders can play a critical role in saving lives, as shown in the aftermath to the shooting on Oct. 1 outside the Mandalay Bay Resort and Casino.
“The city functioned as a trauma center,” said Dr. Sean Dort, a surgeon at Dignity Health-St. Rose Dominican Hospital’s Siena campus in nearby Henderson, Nev. “What really makes this unique is the volume.” (M)

“The types of injuries you’re talking about responding to in a mass casualty event are the types of injuries we see here every day, it’s just that there are substantially more of them,” said Miller, a trauma surgeon at University of Louisville Hospital. “So when it comes to preparing for something like this, it’s always in the back of your head.”
Not only is University of Louisville Hospital the only Level 1 adult trauma center in Louisville—it’s the only Level 1 trauma center in a 70-county area spreading south into Kentucky and north into Indiana. The “Level 1” designation indicates the facility is capable of providing the highest level of surgical care for trauma patients, and University of Louisville Hospital is staffed 24/7 to deal with traumatic injuries–everything from car accidents to workplace explosions.
And in the event there’s a mass shooting or any large-scale disaster in the region, this sterile space would quickly be filled with patients, and extend into a nearby hallway and other areas.
Level 1 trauma centers are equipped to handle major trauma, like gunshot wounds. Level 2, 3 and 4 trauma centers have fewer capabilities.
In Kentucky, hospitals and first responders have contingency plans if something were to happen. The people with the most traumatic of injuries – like a gunshot, knife wound or severe burn – would go to University Hospital. If children are involved, they’d go to Norton Children’s Hospital downtown, where there’s a Level 1 trauma center for kids. And Miller said other hospitals in the area would take on patients with less severe injuries.
“This isn’t a single hospital response to this [a mass shooting or other disaster] – this is a community-wide, and a regional, sometimes state-wide approach,” Miller said. (N)

“The initial chaos requires quick, creative incident mitigation solutions, while recovery requires long-term
The massive fires in Northern California have stressed the area’s emergency response system beyond its very limits. Since the night of Oct. 9, thousands of public safety personnel have been working steadily to save tens of thousands of lives.
“Several observations are emerging from this incident even as it continues to unfold:
Chaos reigns supreme in the first moments. When the fires began racing down toward the populated areas, crews scrambled to rescue hundreds of infirm people from nursing homes, hospitals and other medical facilities in the path of destruction. EMS crews reported that patients were being loaded into ambulances, busses and private vehicles as buildings began burning. Local communications began to fail as radio towers were destroyed in the fire zone. The 911 dispatchers were overwhelmed by calls for assistance, both from affected areas as well as the rest of the system. Additional resources will not arrive soon enough to assist during the first moments, requiring rapid out-of-the-box thinking for incident mitigation.
The EMS system must continue functioning. Calls for service continued to flood the system even while fire victims were being treated. We were able to staff up quickly, sending literally every piece of rolling stock into the field to expand coverage and fill gaps created by the fire situation.
Major incidents require planning for the long game. Within the first few hours, the number of EMS vehicles on scene grew exponentially. It became apparent that many were not needed at the time, but that there would be long-term needs for transportation during patient relocation and general repopulation of the community. Several strike teams were demobilized and went home fairly early.
Closing a hospital during a disaster has major ramifications for the EMS system. Beyond the initial evacuation needs, the remaining hospitals have been inundated with patients both in and outside the affected areas. The threat of evacuation of at least one of these facilities kept it from admitting patients to the floors. As a result, the number of inter-facility transfers rose dramatically during the initial phase of the incident. Moreover, re-opening a hospital is incredibly challenging and takes much longer than anticipated. (O)

“On June 12, 2016, a shooter opened fire on Pulse Nightclub in Orlando, Fla., killing 49 and injuring 58 more. At the time, it was the deadliest terrorist strike in the U.S. since the September 11 attacks and the nation’s deadliest mass shooting. All of the victims were rushed to Orlando Health, where CEO David Strong’s team was charged with not only caring for dozens of critically injured patients, but navigating the aftermath of unprecedented tragedy..
He says the only way an organization can be prepared to respond to a crisis such as the Pulse shooting is to ensure every member of the staff feels as though they are part of a team. Only with a strong sense of duty and community can a hospital handle the seemingly insurmountable task of providing necessary patient care. This kind of environment is established from the top down, and Mr. Strong made it clear that teamwork extends beyond clinicians.
“It takes a team. That day, there were security guards, nurse techs, nurses, physicians that were working well beyond what they would typically do. There were administrators getting supplies — it took a team,” Mr. Strong said. “It takes a team every day in healthcare. We think about the outstanding clinicians, but if the operating room isn’t cooled properly, then the operation can’t occur. It confirms that in healthcare, a good functioning team is essential in making things great.”” (P)

(A) Not even hospitals in Puerto Rico know how many people have died, by Alexa Liautaud, https://news.vice.com/story/not-even-hospitals-in-puerto-rico-know-how-many-people-have-died
(B) Puerto Rico’s Health Care Is in Dire Condition, Three Weeks After Maria, by FRANCES ROBLESO, https://www.nytimes.com/2017/10/10/us/puerto-rico-power-hospitals.html
(C) The Insufficiency Of Medicaid Block Grants: The Example Of Puerto Rico, by Vikki Wachino and Tim Gronniger, http://healthaffairs.org/blog/2017/10/12/the-insufficiency-of-medicaid-block-grants-the-example-of-puerto-rico/
(D) A month after Irma, Florida Hospital Oceanside still closed in Ormond Beach, http://www.news-journalonline.com/news/20171012/month-after-irma-florida-hospital-oceanside-still-closed-in-ormond-beach
(E) The New Jersey health care community played a critical role during Superstorm Sandy and its aftermath., By Aline Holmes, http://blog.nj.com/new_jersey_hospital_association/2017/10/weathering_hurricanes_what_san.html
(F) What Is It Like In A Hospital After A Mass Shooting? Trauma Centers Now Need To Be Prepared For Large Scale Attacks, by JR Thorpe, https://www.bustle.com/p/what-is-it-like-in-a-hospital-after-a-mass-shooting-trauma-centers-now-need-to-be-prepared-for-large-scale-attacks-2781862
(G) Local hospitals working to help shooting victims with medical expenses, by Mick Akers, https://lasvegassun.com/news/2017/oct/11/las-vegas-hospitals-help-shooting-victims-expenses/
(H) ‘The kind of thing that happens … in Iraq or Syria’: An Air Force surgeon describes the response to Las Vegas shooting, by Christopher Woody, http://www.businessinsider.com/air-force-surgeon-describes-response-to-las-vegas-attacks-2017-10
(I) Las Vegas Shooting: Hospitals Tested by ‘Wave After Wave’ of Wounded, by Miguel Almaguer and Elizabeth Chuck, https://www.bustle.com/p/what-is-it-like-in-a-hospital-after-a-mass-shooting-trauma-centers-now-need-to-be-prepared-for-large-scale-attacks-2781862
(J) Extraordinary recounting of the rush to save lives at a Las Vegas hospital https://www.washingtonpost.com/national/health-science/as-the-wounded-kept-coming-hospitals-dealt-with-injuries-rarely-seen-in-the-us/2017/10/03/06210b86-a883-11e7-b3aa-c0e2e1d41e38_story.html
(K) Hospitals: ‘No training on earth that will prepare you for this’, by YASMINA CHAVEZ, https://lasvegassun.com/news/2017/oct/07/hospitals-no-training-on-earth-that-will-prepare-y/
(L) Officials: Las Vegas responders trained extensively for mass casualty event, https://www.ems1.com/mass-casualty-incidents-mci/articles/332978048-Officials-Las-Vegas-responders-trained-extensively-for-mass-casualty-event/
(M) After the Las Vegas Shooting, Concertgoers Became Medics, By SHERI FINK, https://www.nytimes.com/2017/10/15/us/las-vegas-shooting-civilian-first-aid.html
(N) In Wake Of Las Vegas, Louisville Hospitals Say They Try To Prepare For Mass Shooting, By Lisa Gillespie, https://wfpl.org/louisville-hospitals-say-theyre-prepared-for-mass-shooting/
(O) 6 takeaways from the California wildfires, by Arthur Hsieh, https://www.ems1.com/fire-ems/articles/334298048-6-takeaways-from-the-California-wildfires/
(P) Orlando Health CEO David Strong on the details of crisis response few people anticipate, by Leo Vartorella , https://www.beckershospitalreview.com/hospital-management-administration/orlando-health-ceo-david-strong-on-the-details-of-crisis-response-few-people-anticipate.html

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