Anatomy of a disaster drill: hurricanes, tornados and floods, oh my! Florida is no stranger to natural disasters. It's the man-made variety that has three counties preparing for the worst.

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At 7:30 a.m., Sarasota Memorial Health Care System (SMHCS) in Sarasota, Fla., receives an alert from the county Department of Health that a bomb exploded locally that contained a white powder and that SMHCS will be the first receiver of victims. Dead, wounded and possibly hundreds of people who may be exposed to or contaminated by an unknown chemical substance are on their way.

Instantly, SMHCS goes into disaster mode. They issue a Code Yellow and go into lockdown, securing all entrances to prevent unauthorized access to the facility, and a Code Green to let everyone know it's a mass-casualty event.

Specialized teams prepare for a hazardous materials (HAZMAT)/decontamination (DECON) situation. Alerts go out to pagers and phone calls are made to notify the necessary personnel. Emergency radios are distributed and packets containing specialized instructions are handed out to key personnel, who now switch to the specific jobs for which they are responsible during a disaster event. The DECON showers, the command and control center, and all other priority operations and personnel are in place and functioning in less than 15 minutes. SMHCS is ready.

Victims begin to arrive, some by emergency services and some on their own. Those covered in white powder are exhibiting symptoms of anthrax exposure. They are immediately put through the DECON showers and stripped of their clothing to prevent secondary contamination. Samples are taken of the white powder by the Sarasota County Department of Health, which is coordinating with SMHCS and providing the epidemiologist and other ED personnel. It'll take a few hours to determine whether the substance is anthrax. In the meantime, emergency staff, outfitted in full Level B PPE, must assume the worst, and the decontaminations and triage continue.

By 2 p.m. the county calls "all clear" and the command to stand down operations is given. The drill is over. But for some, it's just beginning.

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Heightened Awareness

Hospital organizations all over the United States are working with state and federal agencies to prepare for inevitable disasters, natural or otherwise. Mock mass-casualty events, such as this tri-county drill held yearly at SMHCS, enable emergency first responders to practice alongside hospital personnel to perfect their techniques and discover areas for improvement.

The SMHCS drills, which can take up to five months to plan, involve coordinating the activities and personnel at eight hospitals including Sarasota Memorial Hospital, Doctors Hospital of Sarasota, Bon Secours Venice Hospital and Englewood Community Hospital, as well as the fire, police and emergency services departments in Sarasota, Manatee and Desoto counties. They are enormous operations, which are designed, conducted and evaluated by Burgess & Associates of Clermont, Fla., SMHCS's contracted HAZMAT training provider.

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Representatives from Burgess observe the drill from several locations, including the command center, DECON and triage, and afterwards participate in the writing of an after-action report.

First responders from all three counties coordinated their own drills to coincide with the SMHCS disaster drill. Additionally, unannounced scenarios took place during the drill to provide additional training, including the discovery of a purse that indicated the perpetrator and bomb carrier were among the victims being treated, as well as the discovery that one of the victims had a weapon.

Though most states routinely experience nature's wrath in a plethora of ways and have methods to respond and survive such occurrences, magnitudinous events such as 9/11 and Katrina revealed a marked lack of preparedness in some areas. Communications breakdowns between first responders and hospitals, an inability to track triaged patients, inadequate supplies and staffs not fully trained for such disasters hampered emergency services and may have cost lives. It was a wake up call.

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"Homeland Security, the State Health Department, even the Joint Commission and all the regulatory agencies realized that hospitals had to play a major role in an emergency," says Jim Bugyis, director of facilities at SMHCS, who has been with the hospital for more than 20 years. "That's when we started going to this level and it's been building ever since."

Natural events such as hurricanes can be tracked for weeks in advance, so anywhere from 24 to 72 hours out, landfall can be fairly well determined. Not so with man-made disasters, says Bugyis. "With hurricanes we might have three to five days to plan, hut with a disaster like 9/11, that time gets crunched to 15 minutes to two hours. You don't know what's happening--you don't know what's out there--so when an event like that occurs, there's a minimal amount of time to organize staff, set up the facility and bring in the people as necessary. It might be two o'clock in the morning, or it might be six o'clock at night."

"Obviously, we have hospitals trained for disastrous events--we can't predict when there'll be a plane crash or a bus accident--so we're trained to some degree," says Bugyis. "But with 9/11--with the volume of people affected--it brought terrorism to our homeland. That's when we started thinking the same thing could happen here."

A Nation Prepared

SMHCS established a multidisciplinary group including clinical staff, physicians, security, environmental services and infection control that meets once each year to discuss the types of disasters most likely to occur in the area and make a hazard vulnerability assessment.

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"Every one of our administrators takes very seriously their response to an emergency. In a drill, no one is treating it as a game," says Bugyis.

"One of the biggest things that came out of 9/11 is continuous communication between the state, the Department of Health, county emergency management and the hospital," says Bugyis. "We used to operate like little islands. We communicated with each other, but there wasn't much coordination."

Today, a Web-based communications and resource management solution from EMSystem LLC in Milwaukee, Wis., enables SMHCS to monitor the availability of beds throughout the state during a mass casualty event. Entire regions are connected electronically to share patient data and track patients. First responder and emergency healthcare communications tools are much improved, and hospital personnel are being drilled under conditions that mimic real-world scenarios including chemical, biological and radiological attacks.

"This isn't a plug for the state, but after seeing what happened with natural disasters in different areas, and even man-made disasters, I think the state of Florida is really on top of what they do. The communications and coordination between different departments in Tallahassee, even at the county level, is quite effective," says Bugyis.

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During Hurricane Charley in 2004, radios carried by emergency personnel failed to work properly, due to range and environmental factors. Afterwards, the state required hospitals to install UHF radio, and provided funding. SMHCS's equipment inventory now also includes 800 MHz satellite phones, which are carried by county personnel, hospital staff, police, fire and EMS, as well as a hard-line antenna that connects to the satellite in the event the phones fail.

In addition, a statewide emergency system, established by the department of health, sends out alerts and communicates to cell phones and BlackBerry personal communications devices.

"Through our HRSA (Health Resources and Services Administration) grants, we received a fair amount of supplies to treat our patients for burns, DECON, nerve gas, or different chemical agents," says Bugyis. "We have the majority of supplies on hand right now, including 10 to 12 burn carts."

Also, several FEMA grants obtained this year will be used to harden the SMHCS buildings so they would withstand hurricane force winds.

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"We were well prepared, but Charley and the other hurricanes in 2004 caused us to re-evaluate everything we had put together," says Jim Hesemann, director of hospitality services, whose job as Emergency Operations Liaison during disaster events has him on the front lines. "We haven't had anything like that since then, but we're ready."

Increased Security

Security during disasters also improved at SMHCS. The open door nature of hospitals, and the density of the human population within, makes them particularly vulnerable to terrorism. It's safe to assume they are as much targets as airports, malls and bus terminals. The Code Yellow alert places security personnel at specific entrances to guard against unauthorized ingress. But SMHCS administrators felt more was needed.

"We looked at the various entrances where a person could access the building, trying to prevent a terrorist event here," says Hesemann. "You might have a terrorist come in here to set off a secondary incident because he knows the hospital's going to get rushed with victims, so we work with local law enforcement to barricade the streets around the hospital so no one can get near it."

Lessons Learned

SMHCS first set up their DECON under tents, however, they found that though the showers could be operational in three to four minutes, it could take up to 20 minutes to assemble the tents. Deaths could occur during that period, so the hospital revised their plans and explored areas where the DECON showers could be set up and fully operational in considerably less time.

"The plan is constantly evolving," says Hesemann. "We incorporate the things we learn from each drill into the action plan for next year. That's how the DECON went from taking 45 minutes to set up to just four minutes."

Immediately after each drill, SMHCS conducts a "hot-wash," which is a debriefing of all the personnel involved to find out what went well and what needed improvement. The list is then prioritized to determine which items have the highest impact on the event. "One year we had everyone on the same radio channel," says Bugyis. "With so many walkie-talkies out there it was mass confusion for a while. This year we moved to different channels and had one or two focal points that all communications would go through. It went a lot smoother."

During the previous year's drill, the command center also encountered difficulties communicating with DECON. This year, SMHCS purchased portable cameras for use in DECON to improve communications.

"We're focused on making sure we're communicating well internally, and externally to our partners," says Hesemann. "We're always working to improve for the next drill. Every year the intent is to get better.

"You prepare for the unexpected," says Bugyis. "Because you can run through DECON drills every day--you can prepare for every hurricane, but there's always that one incident that people say 'that'll never happen here.' Well, look at what happened after Katrina--they made it through the hurricane, but the levees broke. Seeing all those people being evacuated by bus--knowing that some hospital somewhere is being affected--you really have to prepare for a variety of events and just know that someday it may happen and hope that it never does."

By Mike McBride, Editor-in-Chief