By Steve Sanborn

5:40 PM, May 22, 2011

A tornado is an evil. 

At its worst, a tornado wreaks a dreaded, fearful , catastrophic havoc.  A sickness hits the gut at the very thought of a destructive tornado.  And there is no getting around a truth with which many in recent years have veteran experience -- evils befall us. 

Deserved or undeserved, knowingly or unknowingly, prepared or unprepared, the absoluteness of such a force as a tornado comes.

In an unprecedented way, 2011 has seen this stuff of worst nightmares manifested in the fiercest and harshest realities – nationwide more than 520 dead and untold destruction caused by tornadoes.

On May 22, 2011, that reality fell upon Joplin, Missouri – a city of 50,000 people, most of them basically prepared for a tornado – none prepared for what hit them.  Close to dinner time that evening an EF-5 rain-wrapped, multi-vortex tornado cleaved Joplin in two leaving a path of destruction a mile wide and upwards of 22 miles long, west to east (approximately 6 miles in Joplin).  As it closed in, warning sirens could no longer be heard as the sound of nature’s terror overtook them.

In spite of overwhelming shock and awe, the punch drunk survivors who climbed out of the wreckage of such calamity began making choices with their first free breath.  In America, we now have a turn of phrase we often choose to recall at such frightful occasions – “Let’s roll.”

While an EF-5 tornado with greater than a 200 mile an hour wind force destroys everything in its path, it also creates a thousand stories a minute.  Some of the stories are harrowing, some horrid – some defy imagination and possibly physics.  How does one begin to try to tell them?  Is it the hospital that took the direct hit or the restaurant manager who used his own body to save others’ lives, losing his?  Is it the good young man taken out of life through the sunroof of his vehicle or the little girl pulled from wreckage who wanted to know where the good ladies with butterfly wings went?  The good, the bad and the amazing.  Where to begin?

The answer of course is – it doesn’t matter.  The important thing is that people be allowed to grieve their losses and start again. 

The EMS Perspective

For the EMS community, the object now is to learn what can be learned when an entire community is smacked down on the canvas.  This was no multi-vehicle pile-up or serious house fire, or school bus accident.  This is years of living and building, gone for good.  Like Rusty Tinney said, “We’re not asking how to get back to normal. We’re asking what the new normal is.”

Tinney, the director of Newton County Ambulance District, and EMS incident commander on the south and east sides of Joplin, recalls the first few minutes of what to him still seems unreal. 

“The Joplin High School graduation ceremony at Missouri Southern State University was ending as the tornado warning sounded,” Tinney said.   “I immediately left to be close to the dispatch radio and headed south toward Newton County with my son, two daughters and future son-in-law.  All four having EMS training, either as EMTs or ED techs, we drove right through town, where ten minutes later, total devastation hit.  We turned around and drove into the aftermath stopping where Home Depot and Wal-Mart had stood but were now crumbled to the ground.  Hordes of people began walking toward my vehicle for aid.  In honesty, I might not have brought my family into the carnage had I realized what I would see, but I was very glad to have them when we began treating roughly 150 injured in the first hour.  I can’t say how proud I am of their performance.”

Jason Smith, director of EMS for Metropolitan Emergency Transport System (METS) in Joplin, was off duty at the time and called away to a structure fire north of Joplin.  The volunteer fire chief of the Oronogo Fire Department, Smith was about to start fighting fire when the tones went off for the tornado. 

“I immediately jumped into a standby ambulance and headed for Joplin, arriving on the scene about 30 minutes after touch down unable to realize the scope of damage.”

In fact, no one was immediately able to know the size of the area destroyed by the tornado.  Tinney recalls the numerous requests for ambulances from fire, police and even his own crews, each requestor believing, understandably, that he was in the worst hit area. 

“It was simply too difficult for rescuers to see beyond their periphery and assume that other areas were as bad or worse than what they themselves were dealing with,” Tinney said.

Tinney and Smith began to get strategic, quickly relying on the longstanding relationship between the two ambulance services and a 17 year friendship which proved absolutely vital.  Past communications made most of their collaborative decisions that day.  Present communications were down.

“When the worst hits, prepare to have little or no communications,” said Tinney. 

What little radio communication the ambulance services did have was used to direct crews to cease transporting the injured to the hospital – an otherwise natural instinct in normal circumstances.  But few realized right away that St. John’s Hospital had taken a direct hit by the tornado and was effectively destroyed.  And with scores of people collectively climbing into ambulances, crews were immediately inclined to transport them. 

What was needed in the moment, however, was the two ambulance services to stage their crews as triage centers in key places along the path of destruction while METS wheel chair vans carried supplies to the triage points.  With St. John’s gone and the adjacent Freeman Hospital quickly overloading, administering care in this way functioned more efficiently with 20 ambulances along the path of destruction until around 4 am the next morning, when METS scaled down to two triage points.  Pick-up trucks and other private vehicles provided the initial transports from the triage points to the hospital.  Multiple rotor and fixed wing aircraft from varying services landed not far away at the Joplin Airport.

“The disaster was so far outside anyone’s expectation our community disaster plan and normal response mechanisms simply could not be proportionate to the need,” said Smith.  “For the EMS side of the house, it was ‘use what you know and take what you have until a new level of response can be mustered.’” 

Between the two services, the common training,  policies, protocols, skills labs, medical director, employees and most important, past mutual aid scenes, including the May 10, 2008 F-4 tornado in Newton County, allowed us to complement each other naturally and work effectively as one team.  For the first hour, that’s all we had.”

In the first few hours, 1500 patients were treated at Freeman Hospital.  The death toll of 153 is considered more a blessing than a tragedy by Tinney, whose family lost friends in the storm. 

“Had the Joplin High School graduation ceremony taken place at the high school instead of the University, we would have had been in the thousands of fatalities at the demolished high school site.  Seeing the overall wreckage simply leaves one in awe that more were not killed.  It is nearly unexplainable.”

Soon after his initial stop to treat the injured, Tinney moved to a new location, in front of what had been Home Depot, managing a triage center with six physicians, seven nurses and a nurse practitioner.  By 9 pm, new reports of coming bad weather were in.  It was time to move again to a more secure location.  With outside services now arriving to help, Tinney instructed his new resources to scout a location that would offer better protection from weather and possibly electricity and lighting.  Amazingly, not far down the road, Lowes had what they needed.

“Lowes was extremely helpful, giving us all the room they could,” said Tinney.  “They worked with us to set up an indoor triage center and staging area in the parking lot for the arrival and coordination of outside ambulance agencies.  We are really grateful for Lowes’ help.”

By 10:30 pm, approximately 40 ambulances had arrived at the south staging area from other areas and were being dispatched to relieve Freeman Hospital of its patient load.  By week’s end more than 700 patients were transported to hospitals in Missouri, Arkansas, Oklahoma and Kansas. 

Tinney and Smith both gratefully acknowledged the selfless crews that came from as far away as Illinois and Texas. 

“They called us and came,” said Smith.  “We did not have to call them.  Days later when things were under control, they did not want to leave.”

“We had tremendous aid from places I had never even heard of,” Tinney said. “I cannot thank them enough.”

Unique Planning & Timing

Just days before the tornado in Joplin, a statewide disaster training program took place in Branson, Missouri.  The program was a patient movement exercise called Get Fit or Get Hit, sponsored by the Department of Health and Human Services, HHS, which involved patient evacuation for EMS, Hospitals, Long Term Care Facilities, Local Emergency Operations Center (EOC) and Local Public Safety using state and federal resources. 

As noted in the program presentation material, the “exercises allow personnel, from first responders to senior officials, to validate training and practice strategic and tactical prevention, protection, response, and recovery capabilities in a risk-reduced environment. Exercises are the primary tool for assessing preparedness and identifying areas for improvement, while demonstrating community resolve to prepare for major incidents. Exercises aim to help entities within the community gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are addressed prior to a real incident.”

The exercise also included working with Disaster Medical Assistance Teams, DMAT and a Mobile Medical Unit, MMU, a portable hospital made of large tents and semi-trailers. 

Twelve hours after the tornado on May 23, a Disaster Medical Assistance Team, DMAT, arrived from Branson to supplement local medical care while other agencies were in route to Joplin.  DMATs provide rapid-response deployment to disaster sites to provide medical care or augment overloaded local health care staff.  The team is composed of medical professionals and support staff.

The MMU was also quickly moved from the exercise site at Branson to Joplin and set up in only 7 days by the National Guard east of the hospital as a temporary replacement for St. John’s.  A veritable MASH unit, the MMU includes a 60 bed hospital, two surgery suites in semi-trailers, an MRI, CT Scan and Mobile cath-lab.

What was learned?

“Train with your local surrounding agencies, they’re the ones you’ll be working with during the real thing,” said Tinney, strongly convinced that the many positive results achieved by Newton County Ambulance District and METS the week of May 22 came from their years of collaboration.

Yet when it came to the real thing, local Emergency Operations Center, EOC, officials did not include Newton County Ambulance District or METS in their top level strategic meetings, a fact which confused both ambulance system directors since they were directing significant life-saving resources throughout the entire ordeal.  Both believe changes should be made in regional planning to include EMS leadership in future incidents.

There were other lessons learned as well.

“In hindsight we concluded that at the outset of a disaster this big, the best assumption is that everywhere is a bad area,” said Tinney. “That’s easy to say, much harder to know or qualify in an immediate sense.”

In the future for the Joplin area, dispatch will receive initial reports of what authorities on the ground are seeing in their respective areas allowing them to map the layout of damage and decide where resources should be allocated.

Ambulance crews will immediately move to set up triage areas rather than attempt to transport the injured.  This will eliminate some of the initial confusion experienced on May 22. As is always the case in such scenarios, the walking wounded find their way to lights and sirens and stand a better chance of being treated more quickly on the spot.

Tinney also addresses the adrenaline that pushes rescuers to be highly focused and diligent but also possibly somewhat aloof. 

“We listened to the radio traffic several days later to review the events and I realized how much I missed while in the thick of it working on the injured. People were trying to reach me at times when my radio was on my hip and my lapel mike was in my vehicle.  Others listened and began talking about scenarios I was a part of yet had no memory of.  In the moment of emergency it is important to collect one’s thoughts and realize what mode your brain is operating in, sort of a survival mode where you can miss important details and also not store experiences in the long term memory bank.”

Smith cites the need to develop check-off lists as part of a larger disaster plan proportionate to a mass destruction scenario.

The mass casualty nature of the disaster required EMS personnel to man Freeman Hospital in order to coordinate staging areas and patient transport in and out of the hospital.  While this conclusion was arrived at early on, it was not a planning forethought.

Finally, Tinney and Smith agree that a significant positive outcome was the tremendous dedication and devotion shown by all involved with the rescue effort.  Forty-eight hours into the dilemma, neither Tinney nor Smith could get staff and crew members to quit for much needed rest. 

“The hospital staff at Freeman and St. John’s showed immense courage and functioned miraculously with so few fatalities, moving past the greatest obstacles, relocating to Memorial Hall amidst destruction and pushing patient care to a whole new level.”

“We’re humbled to know them and thank them all for working so hard to pull our community through its most trying moment.”

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Rusty Tinney and Jason Smith will participate at the Missouri EMS Conference & Expo Wednesday, July 27, 2011 at the Hilton Convention Center, Taneycomo A, at 4:00 p.m. to review “What went right” and “What went wrong” during the initial and ensuing response to the emergency. This session is open and free to all interested participants including EMS, Fire, Police, Hospital, Flight Crews, Volunteers, and others who want to learn from the experiences or are interested in learning more about how a disaster of such magnitude was handled.

Please visit www.memsa.org or www.missouriemsconference.org for a complete brochure.

Due to many of us being involved in the extended response to the tornado, the Hilton Hotel and Convention Center has extended the discounted room rate of $119.00 to July 8th. After that the rate will will be $179 and up.