New Jersey EMS Task Force Response to Superstorm Sandy

It was Sept. 16, 1903, more than 100 years ago, when an unnamed hurricane made landfall in New Jersey. Dubbed the “Vagabond Hurricane,” the storm struck Atlantic City with 80 mph winds and caused $8 million in damage (equivalent to $200 million today after inflation).

The Vagabond Hurricane destroyed dozens of buildings, piers, barns and boats, scattering debris all along the beachfront. Strong winds downed telegraph and telephone wires all up and down the coastline. Moderate damage was reported from Cape May to Monmouth County, with Atlantic County encountering the most severe damage. One person was killed.

Fast forward to October 2012, when another unprecedented storm took place. But this time, it wasn’t just a hurricane; it was the first of its kind–a “Superstorm” named Sandy, the largest storm ever recorded in the Atlantic Ocean. Sandy led to at least 40 deaths in New Jersey and left damage totaling in the billions of dollars.

The New Jersey EMS Task Force (NJEMSTF), formed in 2004, was ready. The NJEMSTF was born from the Sept. 11, 2001, terror attacks and designed to prepare New Jersey’s EMS for large scale disasters and high impact events by providing three critical needs: project management for major regional EMS planning and preparedness initiatives, the procurement of specialized equipment and resources to support those initiatives, and a team of more than 300 people, trained and ready to mobilize those resources and staff critical areas of operation.

We will highlight some of the major areas of operation, share some lessons learned and best practices, and suggest areas where others can learn and adapt from our experiences.

Framework for Preparedness
On Oct. 21, 2012, nine days before the storm arrived, a computer weather forecast model showed a hurricane hitting New Jersey. Our colleagues and I were in disbelief, and we shared the forecast with EMS stakeholders. Subsequent forecasts continued to confirm the storm’s path and its imminent landfall.

On Oct. 26, 2012, the State of New Jersey’s “Tropical Storm/Hurricane Management Plan for EMS” was activated. This document provides a framework for the effective coordination of EMS resources should the state be threatened with a tropical system or major coastal storm. It was produced in 2008 after it was recognized that EMS agencies and organizations would be better prepared to respond to the overwhelming demands of such a natural disaster if a guidance document was available. When Sandy invaded the N.J. coastline, it had been implemented four times already.

The plan provides:

>> Detailed standard operating procedures when a tropical system (or equivalent significant, major coastal storm) has the potential to impact New Jersey;

>> Procedures for EMS at the state, county and local levels when the National Weather Service issues a tropical storm or hurricane watch/warning for any portion of the New Jersey coast;

>> Procedures for the evacuation of healthcare facilities using EMS resources;

>> Procedures for the acquisition of mutual aid out-of-state EMS resources to support New Jersey operations through the Emergency Management Assistance Compact (EMAC) and the Federal Emergency Management Agency’s (FEMA) National Ambulance Contract;

>> Guidance on the suspension of EMS operations (response) during increased, hazardous winds;

>> Integration of EMS resources within the New Jersey Office of Emergency Management’s (OEM) Contraflow Plan;

>> Regulatory waivers to increase EMS capability and response during such a disaster; and,

>> A statewide EMS communications and demobilization strategy.

Supporting Documents
The tropical storm/hurricane management plan references several other guidance documents that were used:

New Jersey EMS Staging Area Management Plan: This plan defines specific, pre-identified locations that have been designated as regional EMS staging areas able to accommodate large numbers of resources. It also gives an overview of the staging process and identifies the resources and trained personnel that will support the plan.

For Superstorm Sandy, two regional EMS staging areas were established. Before and continuing to operate early in the storm, a facility was set up in Egg Harbor Township, Atlantic County. A second location was established at MetLife Stadium in East Rutherford, N.J., two days after the storm hit. The NJEMSTF deployed staging area management trailers and teams to manage these locations. EMS assets were organized into strike teams, task forces and single resources, and each was deployed to various locations around the state for missions.

New Jersey Helibase Helicopter EMS (HEMS) Management Plan: This plan defines specific, pre-identified locations that have been designated as HEMS helibases where large amounts of rotary wing air medical services can be coordinated during a regional disaster. The plan also provides an overview of helibase management and lists the resources and trained personnel that the NJEMSTF uses to support the plan.

A helibase was established at Trenton-Mercer Airport. Additional New Jersey aircraft were placed into service. It was anticipated that search and rescue missions by air were going to be widespread after the storm passed. As it turned out, most of the missions were done by ground; however, this facility was prepared to coordinate large amounts of medevac aircraft to various locations around the state should they be needed.

New Jersey Multi-Agency Coordination System (MACS) Plan for EMS: This plan provides a flexible framework for establishing multi-agency coordination of EMS resources to support a large scale incident when a regional emergency situation threatens or significantly impacts multiple jurisdictions. This plan establishes a coordinated network for providing information, planning, logistics and other operational support to EMS providers within the region.

Sandy was forecasted to have a statewide impact, so a MACS was established and coordinated the tracking of hundreds of mission assignments. This allowed for the prioritization and assignment of resources to multiple, simultaneous areas of operation to include emergency evacuation, mass casualty surge, continuity of 9-1-1, search and rescue, mobile satellite emergency department and shelter support.

Emergency Management Assistance Compact (EMAC)
Knowing ahead of time that NJEMSTF would be overwhelmed, and following the guidance in the previously mentioned plans, Ken Christensen, the N.J. Department of Health State EMS coordinator activated the EMAC system, the nation’s state-to-state mutual aid system.

The initial request was for 75 ambulances to be deployed to N.J. before the storm. Indiana sent the first wave of ambulances. It had to come from that far away initially because Superstorm Sandy was going to potentially impact the entire northeast quadrant of the U.S. A total of 136 ambulances, as well as staff, and support and specialty vehicles, arrived from Indiana, Pennsylvania, Maryland and Vermont. Not only did these teams bring resources, but they brought experienced EMS providers, which was critical to the success of the operation. Dealing with a catastrophe of this type required “relief” and more staff to fill management roles. Additionally, many of these out-of-state professionals filled critical “leadership positions”–from assisting with staging area and camp operations to staffing critical roles at the MACS. The so-called “EMAC ambulances” remained in New Jersey through Nov. 11, 2012–almost two weeks after the storm hit.

Specialized EMS Resources
Almost every piece of the 100-plus NJEMSTF apparatus fleet was used in some type of capability in regards to the response to Sandy. We’ll touch on two critical resources:

Mobile Satellite Emergency Department (MSED): Through a partnership with Hackensack University Medical Center, the NJEMSTF deployed a “mobile hospital system” four times. The complete MSED system consists of three tractor-trailers and several support vehicles, and is equipped to function as a mobile emergency department.

Mission 1 was deployed to Somerset County ahead of the storm as a result of lessons learned from Tropical Storm Irene. This area of the state was expected to be cut off significantly from river flooding based on rainfall forecasts. Its mission was to be a temporary field hospital to support area communities until flood waters receded, roads were cleared from debris and power was restored. They treated four patients during the three-day deployment, which included the delivery of a healthy baby boy during the height of the storm.

Mission 2 was deployed to Ocean County after the storm as a result of a massive surge of patients flooding emergency rooms. The mission was to decompress hospitals by establishing such a facility. Patients were transported via MABs to this temporary location, triaged/treated and discharged or admitted to a fixed facility. Approximately 150 patients were seen over several days.

Mission 3 was a “mobile hospital” deployed to Jersey City Medical Center to allow for extra capacity so that the damaged areas of the hospital could be repaired after being surrounded by five feet of water. This mission saw 1,301 patients.

Mission 4 was deployed through EMAC to Long Beach, N.Y., in Nassau County at the request of the state of New York. It served as a “mobile hospital” to serve the residents and surrounding communities after Long Beach Medical Center was severely damaged and inoperable as a result of the storm surge flooding. This mission lasted 17 days, and nearly 160 patients were treated.

Medical Ambulance Buses (MABs): The NJEMSTF maintains a fleet of 12 MABs. These resources served as “force multipliers” when it came to evacuation of healthcare facilities, relocation of non-ambulatory medical needs patients, transport of sick people to the mobile hospital to alleviate the jam-packed emergency rooms, a place to rehab and continued MCI operations. During the storm, 10 of these resources were available, and the MABs transported close to 1,000 people since being were placed in-service.

Lessons Learned
As you would expect with an incident of this size, lessons came through during the event and after evaluation.

Incident management assistance should be established early and continue until operations cease. Although New Jersey had an Incident Management Team through an EMAC request, this resource came in several days after the disaster took place. With a catastrophe of this magnitude anticipated, EMS leaders will need additional support for the long-term — especially when the impact is statewide and “all-hands” are continuously operating.

The MSED experienced, at times, a shortfall of available physicians. Once again, in a “statewide” disaster, pulling these types of resources from surrounding, non-impacted states would have solved our manpower shortages.

Understand the scope of practice of all response levels and how they will integrate into the existing EMS system. Although the state doesn’t normally recognize EMT-Intermediates, during the disaster the state acknowledged (via the EMAC) that EMT-Intermediates could practice to the level at which they were trained. This created some confusion within our own EMS system at times and was mitigated with a quick explanation explaining what EMT-Intermediates do.

Critical incident stress management (CISM) is crucial during and after the event. We believe the integration of CISM is paramount to ensure the mental well-being of responders, especially when they are also personally impacted.

Long deployments can stress responders, especially those with personal or family commitments. States sending agencies via an EMAC should ensure that all responders can stay beyond the agreed EMAC request should an extension be granted. This ensures continuity of operations and does not create a hardship for the sending state.

Activate the EMAC system early. This was only the second time New Jersey requested out-of-state EMS resources. N.J. learned during Tropical Storm Irene that activating this system early ensures resources are in position and mission ready when you need them.

Establish inter-state relationships before a disaster occurs. Knowing who your out-of-state partners are ahead of time only enhances the coordinated response when disaster strikes. These previous relationships established can make a big difference.

Healthcare facility evacuations should always take place prior to an anticipated disaster. This is especially true for the most vulnerable locations.

Carbon monoxide illnesses and fatalities need to be included in the plan. A large amount of carbon monoxide illnesses and fatalities took place after Sandy struck. This was due to the incorrect use of generators and damaged utilities. EMS responders should be equipped with personal carbon monoxide detectors when providing 9-1-1 services to areas that don’t have power.

Be careful about what you eat. A number of EMS responders fell ill after eating “donated food.” Although intentions from the public are generally good, EMS crews have no way of knowing if donated food was properly stored or contaminated. It’s best to stick with meals, ready to eat (MREs) products or food supplied from trusted sources. Also, maintaining public health and hygiene are important to prevent outbreaks, such as norovirus.

Fuel shortages in a regional disaster should be anticipated. Have a backup plan with several other potential suppliers should the preferred ones not be able to meet your needs.

The lack of widespread power is accompanied by a widespread loss of technology. If your computer email servers and backup systems are all affected, you’ll have to wait until they are restored. Some EMS leaders were without email services for several days. It’s a good plan to use a backup email during disasters, such as Yahoo Mail or Gmail. Both are alternative options because they have redundant systems worldwide.

Anticipate the need to change or waive regulations. The N.J. Department of Health issued two waivers of regulations during the storm. The first waiver was for ALS and permitted mobile intensive care units (MICU) to be staffed by one EMT and one paramedic, instead of the standard staffing protocol, which requires a minimum of two paramedics. The second waiver issued permitted licensed BLS agencies to use one EMT and one first responder as minimum staffing as opposed to two EMTs per regulation. This increased the state’s capabilities during the disaster where resources were limited.

Establish a plan; exercise your plan and improve your plan. Every time you exercise or use your plan, you will find ways to enhance or improve it.

Planning & Teamwork
In the end, the New Jersey EMS community and our out-of-state partners pulled off an incredible feat. Sure, there were challenges at times; however, because of all the pre-existing relationships, plans, resources, procedures and people that were in place, it all paid off. Today, New Jersey is not just known for its 127 miles of picturesque shoreline and beaches, but it’s also known for its dedicated and prepared EMTs and paramedics, who went above and beyond the call of duty during the largest EMS response in state history.


Hospital Evacuations
Two emergency evacuations of hospitals took place, both in Hudson County, N.J. The night before the storm, Hoboken University Medical Center issued an emergency evacuation order. The Hudson County OEM EMS coordinator Mickey McCabe, with the assistance of the NJEMSTF, mobilized more than 40 ambulances from eight counties, including three medical ambulance buses (MABs) to transport more than 140 patients to other destinations. This was a good decision by hospital administrators, because Hoboken was under water and without power for more than a week. The second hospital evacuation took place at dawn, the morning after Sandy struck. Palisades General Medical Center in North Bergen is located adjacent to the Hudson River; water penetrated their emergency generators and disabled them. Four MABs from the NJEMSTF were deployed to rescue and relocate 83 patients in between tidal cycles.

Continuity of Operations
Shore towns and urban areas were greatly affected. The urban cities of Jersey City and Hoboken both had their EMS headquarters destroyed by storm surge flooding and 10 ambulances were destroyed. This area had, severe fuel shortages and a population of more than 300,000 desperate people and no power. Dozens of the shore communities within Monmouth, Ocean and Atlantic counties also lost their buildings, ambulances and equipment. Houses lay where roads used to be, and remaining roads were buckled and looked like beaches. Call volume into the dispatch center was extremely high. EMTs and paramedics worked tirelessly throughout the storm with the remaining resources they had, despite, in many cases, losing their own homes and personal property. More than 1,000 mutual aid 9-1-1 missions were coordinated from the Regional EMS Staging Areas, the EMS divisions that were established and the MACS throughout the event.

Search & Rescue
Union Beach and the “Bayshore Region”–the Barrier Islands and Atlantic City–and many more locations received mutual aid ambulance strike teams (ASTs) and other task forces to assist with search and rescue operations. At one point during the storm, Mike Bascom, the Monmouth County OEM EMS coordinator made a request for five ASTs to assist with 500 trapped or missing people in the community of Union Beach. In Ocean County, the EMS coordinator, Steve Brennan, also used numerous strike teams to canvas the barrier islands while more than 20 structure fires burned and smoldered. In Atlantic City, residents were trapped in their homes and apartments because they didn’t heed evacuation recommendations. These and other search and rescue missions went on for days.

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