Major Incidents, Operations

Preparation, Response and Lessons Learned from Hurricane Harvey

Issue 3 and Volume 43.

Houston-area EMS agencies put to the test responding to Hurricane Harvey’s epic flooding

Rescue boats fill Tidwell Road as they help flood victims evacuate as floodwaters from Tropical Storm Harvey rise Monday, Aug. 28, in Houston. AP Photo/David J. Phillip

Hurricane Harvey made landfall on Friday, August 25, at 11p.m., between Port Aransas and Port O’Connor, Texas. A Category 4 hurricane, it was the strongest to hit Texas since 1961.

Estimated economic losses from the devastation caused by Harvey will be in the $150–200 billion range, making it the costliest hurricane in history. (The previous record was held by Katrina in 2005 with estimated $120 billion in losses.)

After a devastating landfall, Harvey quickly weakened to a tropical storm and stalled over the Southeast Texas region for the next five days, causing catastrophic flooding.

The destruction caused by this epic storm prompted disaster declarations in 50 Texas counties and stressed EMS systems and first responders in a manner not previously experienced since Katrina.

The Houston metropolitan area is made up of nine counties and has an estimated population of 6.5 million residents, making it the fifth largest metro area in the United States.

This article outlines the preparations, expectations, actual operational specifics and lessons learned from three of the agencies responding to the disaster: Montgomery County Hospital District (MCHD) EMS, Houston Fire Department (HFD) EMS, and Harris County Emergency Corp (HCEC) EMS.

Citizen volunteer rescuers evacuated numerous patients from flooded areas, and there was initial confusion when these patients turned up at shelters throughout the county. AP Photo/David J. Phillip

Montgomery County Hospital District (MCHD) EMS

MCHD EMS is a non-fire-based ALS system covering a 1,100-square mile area in the north Houston metropolitan area, with a population of 600,000 residents. MCHD’s 9-1-1 transport service is supported by approximately 900 EMT-B first responders representing 13 fire departments in the county. Montgomery County is the farthest inland of all the agencies included in this article, and several areas of the county suffered major flooding. This cut off access to many patients in southeast Montgomery County and made safe response a challenge.

MCHD: Storm Preparation

MCHD EMS expected significant storm damage resulting in surges of requests for services and patients. All available personnel were brought to their stations and provided cots and food.

Anticipating that flooding or damage might prevent access to stations, MCHD also hired back staff and prepositioned personnel.

Trucks and equipment were strategically placed. To mitigate the effects of possible widespread power outages, diesel generators were installed at all stations. Each station was also equipped with extra supplies and emergency fuel.

In anticipation of the storm making it difficult to access and egress hospital facilities, Medical Command (MedCom) was brought online in the alarm office to provide direct medical oversight for transport refusals and phone consultations with patients that providers wouldn’t be able to access.

For difficulties accessing patients, boat and air resources were secured and coordinated through MedCom to assist first responders.

Phone consultations with Montgomery County Hospital District medical command staff in the alarm office contributed direct medical oversight. Photo courtesy Robert Dickson

The information on road closure was inconsistent & dynamic, requiring intermittent survey by command staff & updating by field crews.

MCHD: Storm Response

There was a minimal amount of patient surge just after the storm, but safely navigating routes to access patients and hospitals posed a unique challenge, including terminating CPR efforts via phone in patients that couldn’t be accessed.

The information on road closure was inconsistent and dynamic, requiring intermittent survey by command staff and constant updating by field crews.

Phone consultations with medical command staff in the alarm office contributed direct medical oversight to patients that the crews couldn’t reach. These contacts were recorded and the medical directors followed up with each patient to assess progression of their symptoms in order to assist in triaging their rescues.

Citizen rescuers evacuated numerous patients from flooded areas, and there was initial confusion when these patients turned up at both known Red Cross shelters and pop-up shelters throughout the county.

Misinformation on medical and care capabilities from multiple shelters, along with difficulty in identifying shelter contacts with correct information, made it imperative to have MCHD crews and supervisors on the ground to make assessments and communicate needs to MedCom.

A command staff update meeting, which included representatives from all departments (EMS, Alarm, MedCom, Communications, Facilities, Fleet and Public Health), was held twice daily in conjunction with the county emergency operations center (EOC). These meetings provided an excellent situational update from all involved parties and the EOC.

In Montgomery County, safe navigating routes to access patients and hospitals posed a unique challenge, despite a minimal amount of patient surge just after the storm. Photo courtesy Robert Dickson

MCHD: Lessons Learned

>>Early work in the county to identify all shelters, including their capabilities and contacts, is important in the aftermath of sorting through the displaced with medical needs is vital;

>>Utilization of community paramedics to coordinate shelter and patients’ needs;

>>Early identification of community resources for displaced chronically ill patients (agreements with local pharmacy for prescriptions, processes for the medical directors to write emergency prescriptions, and access to hemodialysis services); and

>>Improve MCHD’s system to identify access and egress routes so that it can be updated in real time.


Houston Fire Department (HFD)

The HFD is a fire-based tiered ALS/BLS EMS system covering the city of Houston, which consists of approximately 650 square miles and is home to a population of more than 2 million, with millions more from the surrounding area coming into the city for work and recreation. HFD’s staff of nearly 4,000 members use both transport units as well as ALS and BLS first responder units, including SUVs and fire apparatus.

Several major bayous cut through Houston. They not only drain rainwater in the city, but also carry water from north and west of the city to empty into the Houston Ship Channel. Houston has had several major flood events in recent years from heavy rainstorms, and certain areas of the city are known to be prone to flooding in major storms.

The Texas Medical Center, the largest medical complex in the world—home to more than 50 major hospitals, medical schools, and other medical institutions—is located not far from one of the major bayous, creating the potential for significant healthcare system delays, should it become inaccessible.

Calls for service during the storm exceeded expectations in Houston, and at one point the Houston Emergency Center received 56,000 calls for service in 15 hours. AP Photo/Matt Sedensky

Anticipating heavy flooding requiring rescue of civilians, preparations were made to staff dump trucks from the Public Works Department as high-water rescue vehicles.

HFD: Storm Preparation

HFD prepositioned certain assets, including rescue resources and evacuation boats, near areas historically known for flooding. Fire stations in known flooding areas were evacuated ahead of the storm, with their units and personnel being relocated to other stations.

Anticipating heavy flooding and rescue of civilians, preparations were made to staff dump trucks from the Public Works Department as high-water rescue vehicles. Other agencies and resources would be called upon should additional support be needed.

In case of difficulty with access and egress from our hospital facilities, medical direction staff stood by to assist crews with patient transport decisions, protocol deviations and other non-standard medical issues.

Medical facilities would also be established at the largest shelters to relieve stress on the hospital system and prevent transports.

HFD personnel and medical directors prepared to open medical areas in major shelters as they opened around the city, with an eye towards the George R. Brown Convention Center, typically the large-scale shelter in previous city of Houston weather events.

Anticipating heavy flooding requiring rescue of civilians, dump trucks from Houston’s Public Works Department were used as high-water rescue vehicles. AP Photo/David J. Phillip

HFD: Storm Response

Calls for service during the storm exceeded expectations: At one point, the Houston public safety answering point had received 56,000 calls for service in 15 hours (there’s typically around 8,000 in that timeframe).

Areas of the city that had never flooded before were inundated, and floodwaters remained high for days, limiting access to patients and evacuees, and preventing fire and EMS crews from relieving the ride-out crews at the fire stations.

There was a drastic shortage of available high-water rescue vehicles. Stressed water rescue resources required major assistance from the Houston Police Department, the Public Works Department, the U.S. Coast Guard, the Texas Guard, mutual aid agencies and civilian volunteers to assist with rescues.

The George R. Brown Convention Center opened as a major shelter, and required heavy HFD EMS involvement to run effective medical care for more than 10,000 evacuees. HFD EMS medical directors staffed the facility 24/7 in the first two weeks to provide overall medical control, and HFD EMS supervisors maintained the role of transport officer. This local EMS involvement helped protect the hospital system and the limited transport resources available.

Chronic care patients (e.g., hemodialysis, chronic O2, behavioral health, nursing care, etc.) were a major concern in the shelter, as access to resources needed to care for these patients were limited.

Systems were established at the convention center shelter to accommodate these patients without stressing the hospital systems and EMS transportation resources.

Coordination between multiple agencies was challenging. One of the primary difficulties was communication.

HFD: Lessons Learned

>>More high-water rescue vehicles were needed; although it was recognized that improvisation, such as the use of dump trucks, was key to the continued operations;

>>Areas that had never flooded before did, causing a potential re-examination of the way resources were staged;

>>Coordination with multiple agencies involved in the rescue efforts could have been more effective early in the response, but were rapidly improved by embedding liaison personnel and bringing representatives to the Houston EOC;

>>Despite it being a nontraditional role, the heavy involvement of HFD EMS in the medical care during shelter operations at George R. Brown helped protect the hospital system and maintain the limited EMS transport resources for patients who truly needed them;

>>Improvisation and critical thinking, from the command level to the individual firefighter and paramedic, ensured the smoothest possible HFD operations and certainly saved lives during a catastrophic disaster that no city could have been completely prepared for.


Harris County Emergency Corps (HCEC)

HCEC is a non-profit EMS system encompassing 130 square miles in an unincorporated area of Harris County, which is north of downtown Houston. HCEC provides vital 9-1-1 and community healthcare to a medically underserved population of more than 400,000 citizens. Patient care is augmented by six local fire department first responders, most of which are under the HCEC medical control system.

HCEC’s service area contains communities with limited public works infrastructure located in a watershed zone with numerous small creeks and bayous. High-density development in the watershed’s floodplain has previously led to major damage to homes, businesses and vehicles during frequent flooding events over the past several decades.

During significant weather events such as hurricanes, street flooding has significantly limited the ability to access patients in need.

Houston Fire Department EMS personnel were heavily involved in the medical care during shelter operations at the city’s George R. Brown Convention Center, helping to maintain the limited EMS transport resources for patients who truly needed them. AP Photos/LM Otero

HCEC: Storm Preparation

HCEC has a centrally located administrative headquarters and a number of satellite stations in the area. Many of the satellite stations are designed to accommodate flex staffing.

The typical deployment plan is a mix of static and dynamic deployments, depending on call volume and geographic coverage needs. For Hurricane Harvey, additional units were scheduled in anticipation of high call volume and the likelihood of delayed response due to high water road conditions.

The administrative headquarters and each satellite station were checked for operational readiness. All generators were verified to be in proper working order. Reserve ambulances were prepared for deployment to augment the frontline fleet. Unleaded and diesel fuel storage tanks were filled at the administration building.

Liquid oxygen supply was topped off to ensure the system had enough oxygen to operate during extended periods of isolation. The logistics team ensured supplies were distributed to all stations for restocking. Hot meals were prepared and rotated to each crew on a daily basis. Additionally, non-perishable foods were distributed, as each station has cooking facilities.

Most of HCEC’s staff live outside of the jurisdictional boundaries of the 9-1-1 response area. As such, it was important to identify ways to ensure staff members could make it to work as well as have a safe place to rest while off-duty. Hotel rooms were reserved and made available to staff concerned about driving home. This strategy proved invaluable as flooding blocked access to many staff member’s homes. Those who were able to make it to their shifts worked extended hours. Crewmembers were encouraged to bring their issued raingear as well as extra socks, boots and uniforms.

Making sure family members of personnel would be safe was a top priority.

Making sure family members of personnel (even four-legged ones!) would be safe was a top priority; a local pet boarding facility was opened to the staff so communicators and medics could be deployed for extended hours without having to worry.

Unfortunately, Hurricane Harvey fell on a pay week. Anticipating widespread internet failures and bank closures, many redundant systems had been established in advance to guarantee payroll would be issued on time. Manual checks were ordered in case direct deposit became unavailable. Forms that were usually electronic and deemed essential for daily operations were printed in hardcopy in case of power failure. Cash reserves were increased in the event additional supplies needed to be purchased without credit cards. Administrative staff members who weren’t required to be on site were able to log in via remote access and worked from home.

Recognizing medics may encounter unique patient care scenarios including the inability to access hospitals or lack of supervisor support, HCEC provided a secure, HIPAA-compliant video conferencing solution that crews could use for live discussions with HCEC’s medical consult team which includes the medical director and a nurse practitioner. As a redundancy measure, in addition to the cellular network, a backup 800 MHz channel was made available for medical consults.

The IT team made ready spare radios, laptops and mobile phones. They confirmed the Governmental Emergency Telecommunications Service for all essential personnel’s mobile devices. They also ensured redundant power sources were functional, and that the company’s remote servers and backups were working properly.

Several generator tests were completed prior to the arrival of the storm. HCEC has a redundant communications center located at one of its satellite stations, which was also checked for operational readiness.

HCEC: Storm Response

Despite closely following weather predictions, HCEC’s service area received significantly more rain than was originally anticipated. Further, the event lasted several days longer than had been planned. As a result, HCEC’s personnel staffing plan was lean at times. Some of the more notable events experienced during the storm included:

>>Medical control authorized alternate care transportation methods for patients, starting with a mother who had delivered a healthy child but was surrounded by floodwaters;

>>In an effort to improve communications with law enforcement partners, HCEC housed Harris County Sheriff’s Office dispatchers in their communications center;

>>Twice daily EOC conferences were held with all major stakeholders to increase situational awareness;

>>Twice daily email reports and a website were established to notify both incoming and on-duty crew members of road closures and important updates;

>>Multiple HCEC crews deployed with the state’s disaster response team, Emergency Medical Task Force 6;

>>Several stations became isolated due to flooding, but crews were able to evacuate with their apparatus to alternate deployment points;

>>After a short power interruption and a faulty breaker on the recently replaced high-power generator, HCEC experienced extended natural gas generator usage at the administrative headquarters;

>>Due to the inaccessibility of typical food vendors, Walmart generously donated food and supplies to HCEC personnel; and

>>Crews were stationed at several shelters that opened in the HCEC primary service area to help oversee medical care until formal shelter medical operations were established.


HCEC: Lessons Learned

>>Develop relationships with local hotels for preferred room reservations during times of crisis, as many employees were unable to get home, and a hotel rest opportunity was identified as critical “disconnect” time for the heavily worked crew members;

>>Purchase high-water vehicles with the intent of transporting staff to/from stations;

>>Develop improved flexible sleeping quarters at the administration building and key stations;

>>Deploy locked, deep freezers filled with frozen foods to all stations at the beginning of hurricane season to make available for emergency use;

>>Reduce work hour duration of communications staff and increase break cycles;

>>Increase communicator shift overlap so that a better hand-off and briefing is achieved;

>>Install fuel storage tanks at each station to avoid reliance on external fuel supply;

>>Integrate a medical provider into communications who can help dictate preferred hospital destinations based off of known bed availability and road closures; and

>>Practice using secure video conferencing consultation as well as digital disaster patient tracking software throughout the year.