Mass Casualty Incidents, Operations

Pre-Planning Contributes to Effective EMS Response During Hurricane Irma

Issue 3 and Volume 43.

Disaster planning facilitates effective hurricane response in Pinellas County, Fla.

Strike team ambulances line up in preparation to evacuate patients in hospitals and skilled nursing facilities in Pinellas County, Fla. Photos courtesy Sunstar Paramedics

In September, Hurricane Irma was projected to hit Florida as a Category 5 storm with significant impacts on most of Florida.

Irma was expected to be a record storm as one of the largest and strongest hurricanes to hit the East Coast. At one point, the forecast predicted that Hurricane Irma would directly hit the city of St. Petersburg and Pinellas County.

Pinellas County lies on the west coast of Florida, and is surrounded by water on three sides. Its low-lying lands make it extremely vulnerable to even a few inches of rain, and a high-category hurricane could have a devastating impact on the county and its residents.

Hurricane Irma would prove to be a new and challenging test for Sunstar Paramedics, the 9-1-1 ambulance provider for Pinellas County, to provide EMS before, during and after a natural disaster.

Pre-Storm Preparations

Sunstar Paramedics has had hurricane plans in place since the highly active 2004 hurricane season. The management team revises the plan annually and felt confident that they were prepared for Hurricane Irma.

When Pinellas County declared a local state of emergency on Sept. 8, Sunstar Paramedics requested that all employees report to headquarters or other strategic locations in the county.

The all-call was broadcasted through the agency’s employee communications channels, including the internal Facebook page, and the company began preparing employees for long shifts in which they might not be able to return home for several days.

Managers sent out checklists with recommended supplies for employees to bring with them, such as air mattresses to sleep at headquarters or the shelters, changes of clothes, and more. Employees were also advised to prepare their own homes and make accommodations for their families and pets.

The first rounds of ordered evacuations in Pinellas County occurred on Sept. 8, starting with coastal, low-lying areas and mobile homes (Evacuation Level A), which affected about 160,000 residents.

By the next day, mandatory evacuations expanded to all residents and businesses in Evacuation Level B—accounting for a total of 260,000 people—including completely evacuating 10 cities on the Gulf of Mexico. In total, these evacuations were more than one quarter of Pinellas County’s population of over 1 million residents and visitors.

Sunstar Paramedics began evacuating four local hospitals. The 18 local fire rescue agencies coordinated the evacuation of special needs residents and 50 skilled nursing facilities that were located in Levels A and B through Sunstar Paramedics’ operations subcenter. All patients needed to be moved to other hospitals and facilities on higher ground and certain patients, such as those who were dependent on ventilators, were transported by ambulance.

In addition to the evacuations, EMTs and paramedics were still transporting patients who were discharged ahead of the storm.

Sunstar Paramedics put out a call for three FEMA strike teams who came from multiple states with 15 ambulances to assist with transports before the storm arrived.

As people were evacuating, shelters had to be opened to accommodate residents who had nowhere else to go. Sunstar Paramedics was responsible for stocking and delivering medical supplies to three special needs shelters throughout the county. This was included in Sunstar Paramedics’ hurricane preparedness plan, so the supplies were kept packaged, quality assured and ready to go all year long.

The management team made the decision early on to rent a second truck to assist with deliveries. This decision enabled employees to deliver all supplies and equipment in a single day, instead of two days, which allowed staff to focus their time on other preparations.

In addition to delivering materials, Sunstar Paramedics assigned one paramedic and one EMT to each special needs shelter with full advanced life support (ALS) gear in case of an emergency. The Pinellas County Department of Health also had medical staff at each shelter for basic medical needs.

While EMTs and paramedics were evacuating hospitals and stocking shelters, the management teams were preparing to feed and house more than 600 employees. Sunstar Paramedics had partnerships in place with seven hotels across the county and a church across the street from its headquarters to provide shelter for some of its employees.

Community outreach coordinator Charlene Cobb began the mission of buying food to feed hungry and hard-working employees.

“While providing a safe work environment and places to sleep were certainly important, feeding our employees three meals a day seemed to have one of the largest impacts,” said Cobb. “Our management team wanted to take care of our employees’ needs, so employees could work through 12-hour shifts with a clear mind and provide the best care possible.”

Cobb and the team stocked up on food from several grocery stores, brought in catered meals, and ordered in pizza before the storm was supposed to hit.

The detailed hurricane preparedness plan was effective in navigating Sunstar Paramedics through the pre-storm phase, although there were still some lessons learned:

Communicate more efficiently: Though the internal Facebook group is well-used during normal operations, it wasn’t the most efficient form of communication in an emergency situation. Sunstar Paramedics is now able to send texts to all employees with important information through Pinellas County’s alert system.

A total of 120 calls were on hold in the dispatch queue as Hurricane Irma battered Pinellas County and EMS operations were down for eight hours.

Distributing staff time and workload: The special needs shelters were much busier than expected. Management recognized the need to have more than one EMT and paramedic on-hand at the shelters, or rotate shifts more frequently.

Addressing family concerns: Many employees were unsure where family members and animals could shelter while they were working long shifts or required to remain at one of the designated employee shelter locations. Sunstar Paramedics had space reserved at several hotels and a church that was serving as a shelter, with room to board some employees’ pets too, but still received an influx of last-minute requests. Management is now looking into the possibility of securing an entire shelter for Sunstar Paramedics’ employees and their families, and working out a contract with a local animal shelter to reserve more space for pets.

Setting expectations for employees: The management team sent out checklists for employees to bring certain supplies before the all-call and distributed reminders, but many employees didn’t have all of the needed supplies. Sunstar Paramedics is planning to add training on employees’ responsibilities for hurricane planning during orientation to better prepare them to plan for working several days and potentially not returning home.

Weathering the Storm

It wasn’t long after Sunstar Paramedics completed pre-storm preparations and evacuations that all Pinellas County emergency services—from police to EMS—were pulled off the road and shut down because sustained winds had reached 45 mph with gusts reaching 90 mph. EMS operations were down for eight hours, which meant all 9-1-1 calls were on hold.

Once cleared by officials at 6 a.m., Sunstar Paramedics began responding to the 120 calls that were on hold in the dispatch queue due to the wind restriction. The initial strike teams that helped with evacuations before the storm had gone to Georgia and Alabama to avoid storm damage. As a result, only Pinellas County assets were available to respond during the storm and immediately after. Sunstar Paramedics and the local fire departments worked cohesively to provide the highest level of response and quality patient care.

Fire chiefs had offered to send over their own paramedics to work on Sunstar Paramedics’ ambulances. However, Sunstar Paramedics actually had more paramedics on duty than the ambulance fleet.

Instead, Sunstar Paramedics sent a paramedic to a fire department that had an EMT and rescue ambulance in reserve help transport patients. Together the agencies were able to respond to all held calls in only three hours, while at the same time responding to new incoming calls. This had never been done before in Pinellas County, and it was an effective partnership.

However, the call volume didn’t decrease with the wind speeds. The Pinellas County EMS call volume rose to 48% above normal and lasted two days after the storm.

A second request for FEMA strike teams was made, resulting in an additional 25 ambulances being sent to Pinellas County to assist with patient transports.

Sunstar Paramedics, local fire departments and the strike teams completed a total of 5,321 transports during the week of Hurricane Irma. (See Table 1.)

To address the higher call volume, Sunstar Paramedics had its fleet of 85 ambulances on the road and responding to calls, and support staff, such as ambulance mechanics and vehicle supply technicians, were needed 24/7 to repair and restock the ambulances for the next shift.

“We anticipated an influx of 9-1-1 calls during and after the storm, but having 85 ambulances available and on the road is a large undertaking,” said Nick Berry, Sunstar Paramedics’ logistics manager who oversees materials and fleet. “We utilized the staff we had available, and we’re grateful for their hard work in making sure all ambulances were fully functional and materials were properly stocked throughout the storm.”

In addition, the emergency operations center (EOC) desk needed to be fully staffed to manage the influx of calls during and after the storm. Sunstar Paramedics employees are specially trained to work in the EOC.

After the high call volume subsided, Sunstar Paramedics had to reverse some measures taken before the storm, including transporting back all patients that were evacuated from the hospitals and skilled nursing facilities. The strike teams were essential in supplementing the EMS system, coming down from neighboring states and completing 255 transports.

During the storm, Sunstar Paramedics also lost power at its South Hub—a key location for service in south Pinellas County. The South Hub was able to move its operations to a local hotel based on its pre-existing agreements. The hotel happened to be in a small area that didn’t lose power and hotel management offered the use of a conference room as a temporary command center as well as storage space to restock ambulance supplies. Ambulances filed in at the hotel’s valet loop and exited along the neighboring street.

After two days of enduring Hurricane Irma and the increased calls that came along with it, employees were feeling its effects. Cobb, along with the management team, organized a massage therapist to provide chair massages and brought in therapy dogs to alleviate employee stress.

The Sunstar Paramedics leadership team arranged for therapy dogs to help alleviate employee stress during Hurricane Irma.

There were a couple of important takeaways and lessons learned during and immediately following the storm.

Taking care of employees: Food and rest are essential for EMTs and paramedics to be sharp while responding to emergencies in difficult environments after a storm. Although in-house treats and large, family style dinners may seem like minor benefits, it made a big difference to employees. Treating everyone equally, regardless of their rank, was another key to success.

Providing family style meals made a big difference to employees of Sunstar Paramedics during their all-call response to Hurricane Irma.

Considering mechanical needs: Sunstar Paramedics’ ambulance mechanics went above and beyond to keep all of its ambulances, as well as the strike teams’ ambulances, in top shape and ready for the next call. However, the all-call didn’t extend to mechanics so some went home during the storm, and some were unable to return because of the weather conditions. In the future, management plans to include mechanics in the all-call and have more support staff on-hand, if possible, to assist with the immense workload that goes along with having 85 ambulances out on the road.

Even though Irma wasn’t as strong as expected, the high winds, rain, flooding, evacuations, & downed trees & powerlines still put pressure on the EMS system.

Assessing the Response

Hurricane Irma proved to be a great test for Pinellas County’s EMS system. Sunstar Paramedics prepared for the storm as if it could make landfall anywhere from a Category 3 to a Category 5, but the storm ended up veering east in the final hours, so its impact was a Category 1 or less when it hit Pinellas County.

Even though Irma wasn’t as strong as expected, the high winds, rain, flooding, evacuations, and downed trees and powerlines still put pressure on the EMS system and tested emergency preparations.

Throughout Hurricane Irma, Sunstar Paramedics alone had two record transport days within four days of each other, and the county’s entire EMS system was very busy.

“The entire EMS system was under tremendous pressure throughout the storm,” said Richard Schomp, director of operations for Sunstar Paramedics. “I think the key to our success was threefold: 1) our pre-storm planning initiatives; 2) the collaboration with local agencies and strike teams; and 3) the commitment from our employees.”

Sunstar Paramedics’ extensive hurricane and disaster preparedness plan was essential to the overall synchronization of the countywide EMS system. But as in all disaster situations, adjustments had to be made, important lessons were learned and resulted in several key takeaways following post-storm assessment.

Solidarity from top to bottom: Top management and executives stayed at headquarters throughout the pre-storm preparations, during the storm, and after the storm, and they also went to the primary employee shelter, as well as both deployment hubs to meet with employees and inspect facilities. Seeing members of the leadership team working alongside employees helped to build and maintain team morale. It also created a strong sense of comradery and desire to help.

Success of the all-call: Putting out an all-call for more than 600 employees can be a daunting task, and managing staff once they’re onsite can be even more challenging. Sunstar Paramedics’ management was aware of what was being asked of employees, and took into consideration that staff had personal lives and challenges posed by the storm. Employees were encouraged to have open conversations during every briefing or with individual managers if they were having trouble or needed to go home. Anyone who needed to leave was able to, but was asked to come back as soon as they could. In the end, very few employees left during the all-call, but employees were glad to know they had the option and understanding from management.

Strike team accommodations: Strike teams who came down to Pinellas County were well fed and sheltered as best as possible, but Sunstar Paramedics will now plan ahead of time to accommodate up to five strike teams, including personnel and equipment.

Employee surveys: Following Hurricane Irma, Sunstar Paramedics sent employees an anonymous survey to allow management to determine what was done well and what could be improved in the future. Employees were asked to rate their satisfaction on a number of factors, including distribution of workload, communication, sleeping arrangements, availability of food at additional locations outside of headquarters and whether employees felt personally prepared for the storm. The surveys highlighted several positive aspects during a challenging time, and are quantitative evidence of Sunstar Paramedics’ dedication to providing for its employees. (See Table 2.)

Figure 1: Results of Sunstar Paramedics employee satisfaction survey evaluating Hurricane Irma response


Hurricane Irma brought together all aspects of EMS in Pinellas County. Sunstar Paramedics, Pinellas County government officials and agencies, local fire departments and the strike teams all worked collaboratively before, during and after the storm.

Interagency relationships, both inside and outside of Pinellas County, were solidified and improved. Each agency has a better understanding of their own contribution and the contributions of others, and have agreed to continue to collaborate to maintain and strengthen a unified EMS system and a united front in the face of any future natural disaster.