As the only pediatric hospital and Level 1 trauma center in Mississippi, the University of Mississippi Medical Center pivoted quickly when a twister wreaked a path of destruction across the state.
Editor's note: Thanks to Alix Tromblay, MD, Mohammad Sheikh, MD, Johnathan Princiotta, MSN, Hannah Dearman, RN, and John McCarter, MD, for their contributions.
On the night of March 24, 2023, central Mississippi was ravaged by a Category 4 tornado that ultimately claimed the lives of 22 victims statewide and injured 143 others, many critically.1 A Category 4 storm has wind gusts of 166-200 mph,2 typically creating forces that destroy well-built homes and can throw automobiles and even tractor-trailer trucks long distances. As the tornado stayed on the ground for 59 mins, it caused damage in several Mississippi towns and surrounding rural areas, devastating the town of Rolling Fork.3
Rolling Fork is a town with a population of fewer than 2,000 - 40% under age 20 - and a 50% unemployment rate.4 Many residents live in mobile homes, and few of the traditional homes and apartments were built to withstand a tornado of such magnitude. In Rolling Fork, 51.1% of the homes were lost, and 60.7% businesses were destroyed or sustained major damage.5
This tornadic devastation created a mass casualty event for the state of Mississippi. One of the greatest potential failures of a medical facility is a lack of preparation and proficiency required to care for such an event. As the only pediatric hospital and Level 1 trauma center in Mississippi, the University of Mississippi Medical Center (UMMC), located in Jackson, urgently began preparations for the inevitable surge of injured patients.
PEM-FOCUSED DISASTER RESPONSE
At approximately 9:30 pm, transfer requests began to come into Mississippi MedCom, the major emergency referral center for Mississippi which provides hospital transfer assistance and online medical control for about two dozen counties throughout Mississippi.6 One was a call from an emergency physician at Baptist Memorial Hospital in Yazoo, near Rolling Fork, reporting that 3 children had arrived in critical condition, one receiving CPR. All would need to be transferred to UMMC, an approximately hour long journey by ambulance. Shortly after this initial notification, MedCom staff received a call from EMS on scene that the number of children with serious injuries could be much greater and transfers might continue through the night. This uncertainty was worsened by the storm occurring at night.
UMMC’s pediatric emergency department (PED) has 17 general use patient rooms, 2 trauma bays, and 7 “fast track” rooms. We also have the space to place several stretchers in the halls and tightly fit an extra stretcher into each trauma bay. At the time of the initial call from MedCom, a total of 20 patient rooms were filled. With less than an hour of warning, there was a clear need for available rooms to receive tornado victims and to prepare our staff. At 10 pm, our provider staff consisted of 2 PEM attending physicians, one of whom had recently completed a master’s degree in emergency management, a pediatric and a family medicine intern, a second-year pediatric resident and third-year EM resident, a PEM fellow, and a nurse practitioner. We had a full complement of nurses and ED techs, as well as available x-ray and CT techs, and respiratory therapists covering the hospital. Led by the attendings, the physicians and nurse practitioner quickly met to discuss plans and prepare for the incoming patients.
The initial concern was opening as many beds as possible. We first decided that the admitting pediatric floor teams should be contacted quickly to hasten the disposition of current patients. The PED charge nurse called charge nurses on the floors and the PICU. These services were made aware of the impending mass casualty event and were asked to receive current PED patients who were already dispositioned for admission but were still awaiting lab and imaging results or who had not finished treatments that would usually be performed in the PED. The request was well- received and enacted. At the time of the arrival of the first victim, just before midnight, we had cut the PED census to 9, clearing 55% of the beds occupied at initial notification, and were ready to receive up to 20 patients with our current resources.
Next, we determined that all present and available staff and ancillary services, including environmental services, hospital police, and a variety of therapists and techs would be needed. This included 12 nurses in the PED, but 3 had shifts ending at midnight, which was now the expected time of arrival of the first patients, delayed by the limited transportation availability and the scope of the disaster. Two of these nurses volunteered to stay if needed. Additionally, 3 off-shift nurses volunteered to come in. A respiratory therapist who would normally “float” throughout the hospital was stationed in the PED, and we had 3 technicians for prepping, and keeping one-to-one observation on patients at risk for self-harm or elopement. The nursing supervisor agreed more staff from within the hospital could be moved to the PED if necessary. Our PED was staffed to handle more patients than we had available beds.
The physicians and nurse practitioner decided to divide into “medical” and “tornado” teams. The PEM fellow and the third-year EM resident would lead the care of the injured patients. The family medicine intern, the second-year pediatric resident, and the nurse practitioner would primarily care for the incoming medical patients and all the remaining current patients. The two attendings would primarily focus on the injured victims of the tornado and provide guidance and supervision of all other patients as needed. PED staff coordinated with the adjacent adult ED about suggested surge preparation, resources, coordination of care, and potentially sharing resident physicians. Ultimately, this team formation and division of responsibilities proved successful, as each team was able to better focus on their patients.
Two of the anticipated trauma victims soon arrived. The first victim we received had a severe head injury and was intubated, followed 10 minutes later by another child with a severe head injury who was still alert and speaking, accompanied by his mother. The next 2 patients arrived in a single ambulance an hour later, with no family members located. They also had severe injuries but were able to tell us enough demographic information for our social worker to begin to locate family members. Of course, this was greatly hampered by the devastating conditions in Rolling Fork. The fifth and final patient arrived a few minutes later, before 3 am. Despite the dire predictions, we received 5 injured victims that night. Sadly, the child who received CPR was pronounced dead at the Yazoo emergency department.
Having a surplus of available rooms, increased staffing, and the optimized division of responsibilities, we were able to provide for each pre-existing and trauma patient without sacrificing quality care. At no point did our PED feel overwhelmed. We did not receive the number of patients we had feared, so we had more than enough resources and contingency plans. However, as we worked, we did recognize other preparations and procedures that could have been beneficial.
LESSONS LEARNED
Streamline policy: Per hospital policy, any patient admitted to the pediatric intensive care unit must be accompanied by a resident or fellow to provide a detailed verbal report to the awaiting PICU care team and a smooth transition of care. In one instance that night, both the fellow and the EM resident were transporting victims to the PICU simultaneously. Within this short time frame, 3 additional patients arrived. This left the single attending and the “medical” team with trauma patients requiring high levels of care and potential resuscitation, while also caring for all of the non- tornado victim patients. In retrospect, the PICU could have suspended this acceptance policy by having a PICU physician or nurse practitioner come to the PED to assume care and receive the patient report. Perhaps a report over speakerphone could be given the entire PICU care team after the patient and provider arrived.
Sign-out: Once the initial victims arrived, the pediatric and family medicine resident and the nurse practitioner noticed a significant issue. As the residents and both attendings began treating the trauma patients, the “medical team” realized they had not received adequate information for the patients previously under the care of the “tornado team” residents. Some of these patients did not have their PED course planned to disposition. Ultimately, all patients were provided quality care, although discussing plans with the attending physician during the victims’ critical periods was difficult. This could have been improved at the initial staff meeting by discussing more thorough plans of care for each patient with all providers. This would have allowed all members of both teams to be informed of each patient. Additionally, this would have allowed more efficient care for all present patients.
Visual through-put: A third improvement would be the use of a large dry-erase board. We would include a row for each patient, with columns for a brief list of active conditions, needed labs, x-rays, CTs, other studies, and consults from the trauma surgery, neurosurgery, and orthopedic surgery, with check boxes to indicate if these tests had been ordered and resulted and which consults had been requested and completed. We would also indicate which patient needed these services the most emergently. This would greatly increase efficiency and limit multiple phone calls to these services. The consultants and techs could serve multiple patients during a single trip to the PED instead of being requested for individual patients multiple times. The consulting surgical subspecialties have responsibilities in both the pediatric and adult hospitals at UMMC, so the “batching” technique would be especially helpful to all.
EM TAKE-AWAYS
Despite receiving multiple trauma victims who required care simultaneously, we found that our preparation was highly successful. This provided an efficient and stable environment in what otherwise could have been both overwhelming and potentially unsafe.
- Mass casualty situations frequently overwhelm a health care system. Although there were certainly areas for improvement, prior expertise, quick thinking, and teamwork-oriented care were keys to our pediatric emergency department’s successful response.
- Simply meeting as a provider team to discuss a plan, working closely with nursing and ancillary staff, and putting the plan into action, led to good and effective care.
Our hope is that through our experience of the Rolling Fork tornado, others can learn ways to better prepare for the next mass casualty event.
References
- The Associated Press. Mississippi death toll from March tornado climbs to 22. May 5, 2023.
- NOAA’s National Weather Service. (n.d.). The Enhanced Fujita Scale (EF Scale).
- Sorace S. Mississippi tornado given EF-4 rating, tore deadly 59-mile path of destruction, weather officials say. Fox News. March 26, 2023.
- U.S. Census Bureau. (n.d.). Explore Census Data.
- Cajun Navy Ground Force. Cajun Navy Ground Force: Swift intervention to protect and stabilize elderly and disabled victims of natural disasters. April 19, 2023.
- About MED-COM. (n.d.). University of Mississippi Medical Center: Center for Emergency Services.