Missouri Disaster Medical Team Responds in Joplin

With only one drill under their belts, the Missouri-1 Disaster Medical Team (MO-DMT) deployed to Joplin, Mo., after a devastating EF-5 tornado wreaked havoc on the town May 22.

Just one week before, MO-DMT had participated in FEMA’s National Level Exercise (NLE) in nearby Branson. They practiced setting up portable medical facilities and dealing with mass casualties under a scenario involving a major earthquake on the Midwest’s New Madrid Fault.

At the time, the team had no idea how soon they’d be using the training. The drill, which included erecting and using one of the largest, civilian-owned mobile medical units (MMU) in the U.S., concluded Friday, May 20. Breakdown of that 60-bed facility began after Saturday’s debriefing, but it wasn’t finished because the MMU’s outer shell still was drying from weekend thunderstorms. Then on Sunday evening, the tornado struck Joplin, which is located about 100 miles west of Branson. By Sunday evening, some MO-DMT members were in Joplin, including MO-DMT Deputy Commander Kevin Tweedy, who ran the exercise.

“The drill was invaluable,” Tweedy says. “It was just kind of ironic we did the drill and then had the tornado.”

With 138 dead, hundreds injured and one-third of Joplin shredded by the storm, MO-DMT initially set up their own agency’s 24-bed ED at a Joplin car dealership to help relieve stress on Freeman Hospital West. Freeman was overwhelmed with patients because the city’s other hospital, St. John’s Regional Medical Center, suffered a direct strike.

Over the next three days, MO-DMT personnel treated 100 people, mostly relief workers with lacerations, sprains and broken bones, Tweedy says. The MO-DMT also set up another makeshift ED at Joplin Memorial Hall for St. John’s personnel, who moved there to continue seeing patients.

The delay gave officials in Joplin time to arrange for the 60-bed, portable hospital to be set up in St. John’s parking lot. Crews first had to clear debris, make logistical plans and establish two helicopter landing zones. By Thursday, the MMU was trucked from Branson to Joplin. After setting it up on Friday, MO-DMT teams started moving equipment into what would become a functioning hospital. The multi-pod MMU features an ED with ICU capacity, several operating rooms, several Med-Surg wards, a lab, a pharmacy and multiple communications and power sources.

With a Sunday morning “ED doors open” deadline, MO-DMT and St. John’s personnel arranged MMU supplies and salvaged what they could from St. John’s, including portable X-Ray machines, infusion pumps, multiple crash carts and ICU and ED beds.

The MMU, now named St. John’s Mercy Hospital, officially accepted its first patient only three minutes after it opened Sunday morning. The facility is expected to be used for at least six months during Joplin’s initial reconstruction period. The MMU is reinforced to withstand winds of 100 mph and is both air-conditioned and heated.

Shortly after the MMU was turned over to St. John’s Mercy personnel, members of MO-DMT were demobilized and have used their dual-deployment experiences to help identify problems and ways to improve the already unique MMU, Tweedy says.

Branson-based Taney County Ambulance District (TCAD) purchased the million-dollar MMU in 2009 with the help of a state grant, says Darryl Coontz, executive director of TCAD. Taney County’s MMU is used by the Missouri Hospital Association and manned by MO-DMT personnel. The NLE exercise was the first time it had been completely deployed.

“We never thought we’d have to set it up and have it operational,” says Tweedy, who also works for TCAD.

Hundreds of other EMS crews from across the state converged on Joplin. Five members of the Missouri-based Johnson County Ambulance District (JCAD) arrived at 3 a.m. after driving 180 miles though the night.

“It was really overwhelming the number of agencies that offered assistance and had showed up already that night,” JCAD Operation Manager Cole Harris says.

Harris and two ALS ambulances with a paramedic field supervisor and EMT started work the next morning. They shuttled patients from Freeman to other medical facilities. They also attended to volunteers suffering from minor injuries sustained while they combed through the rubble.

“There were so many agencies and so many units [that] the call load was spread,” Harris says. “That’s why you get in the field, to do something good. When you go down to something of that magnitude and offer help, it is pretty rewarding.”
–Geoff Deitrich & Courtney McCain, EMT-P

Rider Alert
Motorcycle riders can help EMS responders assist them on crash scenes thanks to a new Rider Alert program launched by the Richmond Ambulance Authority.

The program is simple. Riders get free cards they mount inside their helmets that include key contact and medical information, as well as a decal for the outside of their helmets to alert responders it’s there.

“With the carnage that’s occurring out there, this is absolutely the right thing to do,” says Rob Lawrence, chief operating officer of the Richmond Ambulance Authority and chairman of the Virginia Rider Alert Project.

The Rider Alert card is modeled after a successful program in the U.K. called CRASH Cards.

With sponsorship from the Bon Secours Virginia Health System, 15,000 rider alert cards have already been printed and distributed in Virginia. Already the program has expanded to other states, including New York. The program is free to anyone but has associated expenses. It costs about $1,400 to print 5,000 cards, and Lawrence suggests groups seek sponsorship to foot the bill.

“The cards will assist [EMS responders] in ways of thinking about treating the patient,” Lawrence says. “It enables us to make some instant decisions.” He also suspects that merely having the card will make motorcyclists think more about their own mortality, and perhaps, be safer on the road.

Bike Team
Sometimes two wheels are better than four, so the folks at the Westport (Conn.) EMS (WEMS) have instituted a new bicycle response team at their service. Now, whenever there’s a planned event, such as a fair or fireworks, the squad can deploy a team of trained responders on two wheels. “Clearly, one of the big benefits is any time you have a mass gathering,” says Marc Hartog, MPA, EMT-P, and EMS coordinator WEMS. “The bike team gives you an added level of maneuverability you don’t have with a four-wheeled vehicle.” Yet, like many organizations, financing a bike team was a challenge. WEMS, a combined career and volunteer service, gets funding from the town, but they also get money through fundraising by the nonprofit volunteer side of the organization.

The team was spearheaded by Michael Salvatore, NREMT-P, EMS-I, who used his own money to buy a bike and then incorporated that into pitches he made to local service organizations. The Westport Kiwanis Club liked his idea and donated money to purchase two bikes and the associated gear to get the team going. The bikes are equipped with AEDs and medical supplies. Two members have also taken the 32-hour International Police Mountain Bike training course.

“This gets us out in the public,” says Salvatore. “When you’re in an ambulance, EMS is mostly hidden in a garage or sitting in a truck. This makes us approachable.”

Pro Bono
Patient Hand-Off Reports
Often, the patient care report (PCR) isn’t yet completed when EMS caregivers transfer patient care to a hospital emergency department (ED). Hospitals, therefore, usually don’t have the benefit of seeing the information contained in the final, complete PCR at the time they’re making treatment decisions in the ED. The full PCR is often sent to the hospital after it’s eventually completed by the EMS providers.

Although many EMS providers routinely complain that they don’t believe anyone in the hospital reads their PCRs anyway, it’s a vital clinical and ethical obligation on the part of EMS providers to ensure hospital caregivers are given all the relevant information necessary to care for a patient before EMS relinquishes care.

First and foremost, all EMS agencies should be sure to check their state laws, regulations and EMS office policies regarding the hand-off of patient information and the timely completion of PCRs. This is a state-by-state issue. Beyond that, all EMS providers must remember that certain information from the prehospital phase of patient care can be relevant–critical, even–in the ED or trauma center.

For example, such issues as how long CPR has been in progress, mechanism of injury in a trauma case and the types and dosages of medications provided in the field can affect patient care in the hospital. Whether your jurisdiction requires the completion of a full PCR prior to leaving the hospital, you must still ensure caregivers are given all information that is or may reasonably be relevant to patient care.

EMS providers can accomplish transferring information during the hand-off of care in many ways. They can verbally give reports by radio or in-person at the ED. Or they can give “mini-sheets” or field notes to the hospital. Either way, the crew would also be well-served to document that a patient report was given to the hospital, along with the name and title (if known) of the person they gave the report to. Even a chart note such as “verbal patient report given to nurse Smith” might be beneficial should a question arise down the road.

At least one court case that we’re aware of dealt with information given (or allegedly not given) to a hospital by EMS providers. An appeals court in New Jersey ruled that EMS providers weren’t entitled to statutory immunity from liability when their documentation presented to the hospital allegedly failed to record a key fact about the patient’s condition observed during the course of prehospital care.

EMS providers should always ensure that basic information, such as vital signs, history of present illness/injury and treatment provided is communicated to the ED staff prior to handing off care of the patient. And when a complete PCR is finished, send or transmit it to the hospital without delay.

Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information.

Quick Take
Critical Training

As reports of chemical suicides began to grow across the nation, EMS expert August Vernon realized providers needed information about the incidents. The result is “Chemical Assisted Suicides: Threat to First Responders,” a free training program he created that’s being distributed by the Firefighters Support Foundation. In these suicides people typically mix household chemicals to create a toxic vapor. They usually do it in closed cars, but the deadly gasses also put the responders at risk. In some situations, patients leave notes for responders. “I’ve come across first responders, law enforcement, EMS and firefighters that haven’t heard about this,” says Vernon. “As long as people are aware of the threat and maintain some situational awareness, [the suicides] are not going to be a lot of danger to them.” Vernon says the normal reaction for a responder approaching a car with an unconscious patient inside would be to open the door. With a chemical suicide, however, that scenario could be fatal.

“With these kinds of situations, EMS could be the first on the scene,” Vernon says. “They’ve got to be able to make some decisions: Is this victim viable? And should we put responders at risk?” The training program includes a 36-slide presentation, as well as a video. The class explains the process people are using to kill themselves with chemicals and why it’s a growing trend. It also suggests response guidelines. “There have been some responders hurt in these incidents,” says Vernon, operations officer for the Forsyth County (Ga.) Office of Emergency Management. “They need to recognize, identify and protect themselves. “¦ For a lot of these victims, by the time the 9-1-1 call has gone in and units have been dispatched, most of these victims are not viable.”

To read more about chemical suicides, read “Toxic Transport” from May JEMS at

Capnography Helps Save Patient
When Howard Snitzer collapsed outside a Minnesota grocery store in January, rescuers spent 96 minutes performing CPR and defibrillating him before his heart started beating normally.

It was the use of on-scene capnography that kept fire, police and EMS rescuers going when others would have quit.

During the marathon resuscitation session, a medical team from the Mayo Clinic, delivered to the scene by helicopter, received end-tidal carbon dioxide measurements (EtCO2) obtained from the 54-year-old patient. The readings suggested they should keep working him far longer than a normal code.

“Capnography does not save their life, but it tells others not to give up,” says Bob Page, AAS, NREMT-P, CCEMT-P, NCEE.

Capnography measures the CO2 being exhaled by a patient and can tell rescuers whether CPR is effectively moving oxygenated blood through the body and perfusing the organs.

“Before capnography, we really had no way of knowing if we were even close when doing CPR,” Page says. “What capnography tells us is that if cells are perfusing, there may be a chance.”

A normal level of EtO2 is 35—45 mmHg. Snitzer’s level was in the low 30s, according to a report in the Mayo Clinic proceedings. Snitzer was also defibrillated a dozen times during the process before he achieved return of spontaneous circulation. Page says he’s going to incorporate Snitzer’s story into his own lessons on capnography.

“They did high-quality CPR, as evidenced by capnography,” Page says. “They were getting good feedback. The reason we quit is we don’t have feedback.”

To read more about capnography, read “Measuring Life and Breath,” the exclusive supplement to December JEMS, sponsored by Oridion at

In Brief: For more about natural disaster and other MCIs, visit www.jems.com/major-incidents

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