http://paloaltoonline.com/print/story/print/2013/07/12/sfo-airline-crash-puts-stanford-hospitals-mass-casualty-plan-to-the-test


Palo Alto Weekly

News - July 12, 2013

SFO airline crash puts Stanford hospitals' 'mass casualty plan' to the test

From mobilizing surgeons to helping with lost glasses, Stanford executes disaster plan

by Chris Kenrick

Within minutes of Saturday's crash-landing at San Francisco International Airport of an Asiana Airlines flight carrying 307 passengers, employees at Stanford University's two hospitals prepared to execute their long-rehearsed "mass casualty plan."

When the first patients arrived by helicopter and ambulance at 1 p.m., about an hour and a half after the crash, medical teams including eight surgeons and dozens of other physicians had rallied to treat an unknown number of crash victims potentially on their way. Nobody yet knew how many would come or the extent of their injuries.

Ultimately 55 injured passengers were brought to Stanford University Hospital and Lucile Packard Children's Hospital, drawing not only on medical resources but on translators, social workers, chaplains, the Red Cross and government agencies and testing the hospitals' joint plans for a range of disaster scenarios.

"We have to continually be ready and prepared 24/7 for any of these types of events," said registered nurse Melva Scott Averhart, an administrative supervisor at Packard Children's Hospital, who regularly has trained for such "mass casualty" situations over her 36-year nursing career.

Some Mandarin-speaking children arrived at the hospital separated from the adults they'd been traveling with.

And since passengers had not cleared customs on the international flight from Seoul, U.S. agents came to the hospital to check on immigration issues. FBI agents and representatives of the U.S. Department of Homeland Security as well as officials from the Chinese Consulate and Asiana Airlines also showed up.

To "avoid getting caught up in the chaos, there's an organized dance that we do," said David Spain, chief of trauma and surgical critical care at Lucile Packard Children's Hospital and Stanford Hospital & Clinics.

"We have a very systematic, orchestrated way of evaluating patients, finding the most life-threatening injuries first and moving down the priority list," Spain said.

"That's basically what we do every day on an individual patient none of this was new or different. What was different was that instead of doing that for a few patients, we had 55 patients in six hours."

Available floor nurses were sent to help in the Emergency Department. Medical receiving teams were assembled outdoors in the ambulance bay to facilitate rapid intake and return ambulances to the crash site. Patients who had been in the emergency department prior to the crash either were admitted to the hospital or sent home to make beds available.

All told, about 150 staff members mobilized for the disaster.

Stanford Hospital first learned of the crash moments after it happened, when an emergency-room nurse noticed photos on the TV screen in the waiting room.

She told attending physician Eric Weiss, who also happens to be medical director of Stanford's Office of Service Continuity and Disaster Planning.

At 12:06 p.m. Weiss issued a "code triage," paging about 900 employees that the hospitals were on preliminary alert for a full disaster response, said Brandon Bond, who directs the office of emergency management for both hospitals.

Bond had been doing housework in San Mateo when he got the first page and drove immediately to the hospital.

At 12:47 p.m. after learning that the San Francisco Fire Department was "triaging 290 patients" at the crash scene and that at least four were already headed to Stanford Weiss and Bond activated the hospital's "full mass casualty plan."

A logistical command center sprang up in a specially equipped conference room on the hospital's third floor.

"It has a tremendous amount of additional technology and communications equipment, allowing us to monitor the response and communicate with all our public-safety partners," Bond said. Both Stanford Hospital and Packard Children's Hospital were represented in the room full of staff from various hospital departments, all on their laptops tracking bed availability and other aspects of the emergency.

Spain, the trauma chief, had just walked the dog and had lunch with his wife at their Palo Alto home when he received the initial "code triage" standby page.

Flipping on the television he saw fiery photos from the crash and guessed that "we weren't going to get many patients (because) there weren't going to be many survivors.

"Then it said the fire broke out later, that people were able to get off. I called in, and they (the hospital) said we were going to be getting a bunch of patients."

Spain was at the hospital by 12:30 p.m., ready to help ensure that enough staffing was available.

He found that a number of others were already there a trauma surgeon who had been on call and another surgeon who had been caring for patients in the Intensive Care Unit. A colorectal surgeon who happened to be in the hospital came downstairs to help. The head of pediatric surgery came in.

Two other surgeons who recently arrived at Stanford for extra training including U.S. Army Lt. Col. Jennifer Gurney, who has been on active duty in Afghanistan also were on hand.

An additional 10 surgery residents including four who arrived at Stanford as new interns two weeks ago also came to help.

"The biggest challenge was just making sure we kept track of which patient was which, what the results were, what was still pending and what the unresolved issues were," Spain said.

"It's rarely what you know that gets you in trouble it's what you don't know. So we spent a lot of time making sure we knew what we knew about people, and what we didn't know."

Professor Ann Weinacker, chief of staff at Stanford Hospitals & Clinics, described the scene after walking through the emergency department: "There was not a lot of drama. It was almost like business as usual, only there were many more people."

Of the 55 patients evaluated and treated Saturday, 18 were admitted 11 of them to Stanford Hospital and seven to Packard Children's Hospital.

As of Thursday morning, all had been released from the hospital except for two adults, one upgraded from critical to serious condition and the other listed in good condition.

Viviane Vanderwoud, who practiced pediatrics in Brazil and now manages interpreter services at Packard Children's Hospital, was having lunch at a restaurant in Town & Country Village Saturday when she got the "code triage" page.

Since it was a Korean airline, Vanderwoud first assumed she would most need her single Korean interpreter, who happened to be out of the country. (Most of Packard's 38 round-the-clock staff interpreters are Spanish-speaking.)

When it became clear that Mandarin was needed, she enlisted help from an outside agency as well as from the main hospital's staff of interpreters. The South Korean government said 141 passengers carried Chinese passports, 77 South Korean passports and 61 U.S. passports and that the rest of the passengers were other nationalities.

"The good part of having both hospitals so close together is we help each other mutually," Vanderwoud said. "Stanford offered to help us if needed because they have more in-house Mandarin interpreters as staff members."

At 6:30 a.m. Sunday, Packard Hospital social worker Lori Durand was paged to come in to work with the children from the crash.

"Thank God we had interpreters," said Durand, who helped coordinate needs such as clothing, lost glasses and locating responsible adults.

It was breakfast time and nurses were searching for "comforting food, like they'd have at home," Durand said.

Someone remembered that congee, a rice porridge, was available in the hospital cafeteria and brought it up for the kids.

"A couple of kids had lost their glasses. One of the nurses had a similar prescription as one of the children so she let him borrow her glasses for the day," Durand said.

"My partner social worker was in touch with the Red Cross, who gave them vouchers to take to an optometrist to get replacement glasses."

A Chinese Consulate official came to help, and an airline representative offered to try to locate the children's luggage.

Durand said she tried to caution the children against listening or watching accounts of the plane crash, which would hinder their recovery from the trauma.

"We used interpreters to call the parents back in the children's home countries," she said. "Luckily, they'd already talked to their kids and knew they were safe, and we just reassured them that the kids were doing well and being taken care of."

Durand worked with parents to locate responsible adults to whom the children could be released.

"One adult was at another hospital with a couple of other kids he was in charge of. He said, 'Can I send so-and-so,' but the parents had never heard of that person, so we said 'No, we can't just have anybody.'

"Eventually we were able to locate a teacher the father was familiar with, and he said it was OK," Durand said.

All seven children were discharged from the hospital by Sunday night.

In the end, both hospitals were prepared to handle more patients than the number who came Saturday.

"The Emergency Department remained fully open to accept trauma unrelated to the plane crash," Bond said following a debriefing session about the crash response held Tuesday.

Other points from the debriefing session, Bond said, were that "international relations with China remain strong and were further developed as a result of the response."

Medical staff "remained in constant communication with the (Chinese) Consulate," he said.

The hospital call centers fielded nearly 1,000 calls in four hours Saturday.

Bond said Saturday's alert was the largest Stanford hospitals have faced at least since the 1989 Loma Prieta earthquake, and he has been unable to find anyone who remembers what the hospital was like on that day.

"We learn from every response," he said Thursday. "We are developing a comprehensive after-action report, which will result in continuous improvement to our emergency operations plan."

Staff Writer Chris Kenrick can be emailed at ckenrick@paweekly.com.

Comments

Posted by neighbor, a resident of another community
on Jul 12, 2013 at 9:40 am

Good job Stanford. All of the disaster planning and practice exercises paid off. I'm sure a lot was learned about how to improve things for the next time.


Posted by San Bruno?, a resident of another community
on Jul 12, 2013 at 11:11 am

" Saturday's alert was the largest Stanford hospitals have faced at least since the 1989 Loma Prieta earthquake,"

They didn't take any casualties from the PG&E defective pipeline disaster in San Bruno?


Posted by Lydia Kou, a resident of Barron Park
on Jul 12, 2013 at 1:16 pm

Being ready for any disaster or any emergency!

Join the Emergency Services Volunteer (ESV) Program supported by Palo Alto's Office of Emergency Services made of residents. There is a role for everyone who is interested in participating. It is your choice as to decide which role would be the best fit. The different teams are as follows:

- Block Preparedness Coordinator (BPC) Team – helps ensure residents can participate with the City in disaster preparation, response and recovery. This program trains volunteers to staff Block Preparedness Coordinators positions for each block and to functions as the "eyes and ears" following a major disaster. They stay in their block and inform the city of the status of their block. Residents participate with the City in disaster preparation, response and recovery, as well as Crime Watch, since The Neighborhood Watch program is a part of the BPC Program. The next class is July 20, 2013, 10AM-1PM at Cubberley Community Center, Room H-1.

- Neighborhood Preparedness Coordinator (NPC) – Community members serves as the leader of the neighborhood emergency preparedness teams by supporting and keeping all involved, including residents, updated with preparedness and safety tips and fostering resiliency. During emergencies/disasters, NPCs are incident commanders in the neighborhood and coordinates communications with resources to the city, damage and injury assessments, recovery and response. The next class is July 20, 2013, 10AM-1PM at Cubberley Community Center, Room H-1.

- Community Emergency Response Team (CERT) program trains - Community members are trained in basic disaster response skills, such as small fire suppression, light search and rescue, and disaster medical operations. Using the training learned in the classroom and during exercises, CERT members can assist others in their neighborhood or workplace following an event when professional responders are not immediately available.
In a disaster, CERTs will be deployed as either:
-Neighborhood CERTs
-Citywide CERTs
-Shelter & Human Services CERTs
-Public Works & Flood/Storm CERTs
-Logistics

- Emergency Medical Unit (EMU) Team - is a team of Volunteers who have a background in various areas of the medical field. They are tasked to set up and maintain a field medical unit during a large scale disaster. Using their medical knowledge and team skills they will take care of injured people when hospitals are inundated with patients and transport is difficult.

More information is available at the following links:
Web Link
www.paneighborhoods.org

If you have any questions, email us at epvolunteers@paneighborhoods.org


Posted by registered user, Peter Carpenter, a resident of Atherton
on Jul 12, 2013 at 1:20 pm

This remarkable response is worth remembering the next time someone wants to lambast Stanford for not serving the community.

Thank you Stanford Hospital and the Lucille Packard Children's Hospital - Well Done.


Posted by Gethin, a resident of Midtown
on Jul 12, 2013 at 2:02 pm

Congratulations to Stanford for its successful leadership and work providing emergency services such as these


Posted by SF General, a resident of University South
on Jul 12, 2013 at 2:11 pm

Not to downplay Stanford, but SF General has an even better trauma center and burn unit. Plus, by the time the ambulances arrived, they had already set up triage tents and a trauma unit in the parking lot!

A friend and his wife were among the casualties of the crash, the wife still hoitalized in Critical Care at SF General. Well-to-do, they are used to good medical care as a fact of life, but have nothing but praise for SF General's readiness and excellent care and attention.


Posted by Not an issue, a resident of Community Center
on Jul 12, 2013 at 3:48 pm

Well said, Peter. Surprised we did not hear complaints about too much traffic and too much noise from the helicopters.


Posted by Not an issue, a resident of Community Center
on Jul 12, 2013 at 3:51 pm

BTW, SF general-- if you read the weekly story you will see that Stanford also had tents set for triage as well-- the are pictures.
Stanford has better treatment for AS.


Posted by SF General, a resident of University South
on Jul 12, 2013 at 5:54 pm

But not tents for trauma care. What does AS mean and what does it have to do with anything here?


Posted by Not an issue, a resident of Community Center
on Jul 12, 2013 at 6:35 pm

Sf general- 6 pf one, half dozen of another. Would depend how the hospital is set up and the protocol the hospital uses in these cases. Does not mean that one hospital is better than another.
AS= ankle shattering as opposed to MS.


Posted by neighbor, a resident of another community
on Jul 12, 2013 at 7:47 pm

They are both outstanding hospitals -- and they did an amazing job after the plane crash.
No controversy here at all.


Posted by Wayne Martin, a resident of Fairmeadow
on Jul 13, 2013 at 7:07 am

It's hard to have anything but kudos for all of those involved in responding to this crash. As the dust settled, and the various media outlets carried various stories, I got to wondering:

1) What kind of Master Plan does SFO have?
2) What at SFO is in charge when emergencies like this one occur?
3) How does SFO alert outside agencies to request support/resources?
4) How many regional hospitals are partnered with SFO in their Master Plan?
5) What local agency has oversight of the emergency response capabilities of our regional airports?

Relative to this crash:

6) How many ambulances responded to this crash?
7) How long did it take to remove all of the injured from the scene?
8) What was the origin of these ambulances?
9) What First Response capability does SFO have?
10) Will there be a minute-by-minute review of the Emergency Response to this accident?
11) Will there be a review/rating of SFO's response to this accident?

I'm also interested in how the hospital's bills will be paid? Will the hospitals charge the individuals, who then will pay through their insurance? Or will the airline offer to pay all of the bills of those on the flight?

The regional hospitals seem to be ready to handle small emergencies, but what about the airports and other aspects of our regional emergency response "infrastructure"?


Posted by wondering for Wayne, a resident of Walter Hays School
on Jul 13, 2013 at 10:23 am

Uh, any more questions, Wayne? Feel good to post a bunch of questions, and then do nothing about it?

Oh! I get it! You want other folks to do your searches for you! How, uhhh, "nice".

Okay, I'll take #8, origin of ambulances, for 200, Alex:

What is.... hmmm.. the origin of ambulances? Ambulances were first used for emergency transport in 1487 by the Spanish....

Can I Wiki anything else for you today, Wayne? Go to the Stanford or SFO or any number of sites that have info posted about your wonderments?

Curious: did it take longer to type your questions and post them than actually doing the search yourself? Thought so...

And yes, Wayne, some of your answers are not posted to a website for security reasons. I checked.


Posted by neighbor, a resident of another community
on Jul 13, 2013 at 12:06 pm

Wayne:
There is a very sophisticated disaster planning effort in the Bay Area. A little web searching will give you more information.

Hospitals, public facilities such as schools/airports, and all cities/counties/the state are required by law to have disaster response plans. Public facilities must practice them annually (or 2x/yr. or MORE for many entities). Also, 100s of Bay Area neighborhoods have citizen disaster teams (CERTs in Palo Alto) in case of a region-wide disaster when most local areas may have to wait as more critical areas are addressed.

All of the entities that would be part of a real disaster --- health facilities, police/fire, city and county gov't, CERTs, etc.--- are part of annual drills. Hospitals and ambulance crews simulate victims' injuries to practice triage. A central Incident Command center coordinates. You might have seen emergency exercises on the news (often exercises occur in April and October).

We are fortunate that the emergency response personnel and emergency managers in the Bay Area have such good plans. SFO, Stanford and UCSF have particularly long histories with emergency/disaster planning -- and they have a lot of practice.

That's why things went so well. But no matter how much planning and practice you have the reality of a situation is different -- after all, disasters are called disasters for a reason.

The runway response time at SFO was actually good -- but it's a long way from the terminal to the end of the runway. I suspect that issue will be addressed, and that the response plan will be modified to propose new closer satellite FD. That will cost money -- be sure to vote for the bond issue if there is one.

The hospitals set up disaster triage areas to receive patients before they arrived. SU and UCSF did a great job.

The next exercise will no doubt test the issues that didn't work so well, along with practicing new issues. There will be lessons learned from the SFO incident.

However some of the recommendations coming out of this disaster will cost money. Please support disaster response spending.


Posted by Wayne Martin, a resident of Fairmeadow
on Jul 13, 2013 at 12:40 pm

> Ambulances were first used for emergency transport
> in 1487 by the Spanish...

What a bizarre way to read this question. What I was asking was:

Is there a pool or ambulance services that are registered with the Airport, and these ambulance services called as they are listet? Are they all called? Are public ambulances called before private services, or are all treated equally?

What the historical origin of ambulances would have to do with this crash is hard for me to fathom.


Posted by Wayne Martin, a resident of Fairmeadow
on Jul 13, 2013 at 12:46 pm

@Neighbor ..

Thanks for the posting. I was actually aware of some of this information, but had not seen any of the details i was wondering about appear in any of the local/national media reports.

I have not seen many of the Emergency Response Plans on-line, and probably would accept the general claim that there is some "sensitive" information in some of them. However, some overview of these plans should be available for public access/review, it would seem to me. I reviewed the Palo Alto Emergency Plan some years ago in paper form. There wasn't anything "sensitive" in that version, as far as I am concerned.

Remembering back to the Oakland Hills Fires, I'm not as convinced that all of these local agencies are as prepared for "mass emergencies" as others.


Posted by neighbor, a resident of another community
on Jul 13, 2013 at 3:45 pm

Wayne---- the post by "wondering for Wayne" was meant to be funny. Seriously though

1. Yes, the pool of ambulances who respond at the airport is known before a disaster.

2. Ask the PA City Council to see a summary of your local plan. It will identify who responds, who is in charge, how decisions are made. Many entities (cities, counties, schools and colleges etc. put plan summaries online. BETTER YET, sign up for the CERT training and you'll get an intimate knowledge of the local Plan and how the coordination of resources happens.

3. The Oakland Hills firestorm (22 years ago) changed disaster response planning just as many other disaster events have -- whether they are local or not. It's cumulative. 1989's Loma Prieta response, the 1994 Northridge Earthquake and the Malibu Fire in Southern Calironia, etc. led to planning modifications and, of course, 9/11 changed everything for emergency planning all over the U.S.. This airplane crash will lead to many lessons learned.

One issue remaining is getting all of the Bay Area emergency responders on shared radio frequencies. Local voters have been unwilling to pay for this.

It was one of the strongest recommendations after 911 in NYC -- responding firefighters and police couldn't talk to each other and the firefighters climbing up the stairs in the second tower never received the message to suspend operations.


Posted by Wayne Martin, a resident of Fairmeadow
on Jul 13, 2013 at 8:28 pm

@Neighbor:

Thanks for your response, again.

However, I was hoping for more detail--such as links to the emergency plan that spells out the ambulance pool membership, and the alert sequence for emergency transport services.

I decided to do a little googling, and found a nice web-site for the SF Dept. of Emergency services:

Web Link

Which has some information about this office's responsibility for transportation emergencies (including SFO):

Web Link

I will contact them with my specific questions, since they should know the answers.

> sign up for CERT ..

Well, had some of that training as a Company Commander many years ago. Was required to be fully cognizent of all of our Company-level and Battalion-level SOPs (Standard Operating Procedures), many of which involved emergency evacuations in time of combat, as well as providing periodic updates to these SOPs, as required by higher level command.

> One issue remaining is getting all of the Bay Area
> emergency responders on shared radio frequencies.
> Local voters have been unwilling to pay for this.

Am unaware that there has ever been a coordinated SF.BayArea ballot issue to fund "shared radio frequencies". What year was this on the Ballot?

But you are correct about the issue of radio communicatons being an issue. For instance, did you read this article about the problems at 49er Park?

Web Link

In this case, the SF.PD seem to want to use cell phones--and ultimately there is only so much channel capacity when thousand of civilians want to use their cell phones also. So--how much would it cost for San Francisco to fix this problem of adequate communications for its combined Fire and Police Departments?

> Ask your City Council for a copy of the Emergency Plan.

Why would I do that, when I should be able to find it on the City's web-site (as I was able to do for the SF Dept. Emergency Services? I wrote in an earlier posting that there weren't many of these around. Perhaps I was wrong. (Anyway, I was really only interested in the SFO plan for the purposes of this posting.) There was a copy of an older version in our local library at one point, but I doubt anyone on our City Council would have a copy.

If the folks in SF respond to these questions, I will post the answers--even if this topic has been aged into the archive.


Posted by Wayne Martin, a resident of Fairmeadow
on Jul 13, 2013 at 8:38 pm

> shared frequencies (Radio Interoperability)

This topic has been kicking around for several years now. I remember it's being discussed by the PA CC at least five years ago. The following link points to a short memo that seems to suggest that this interopability project is well under way:

Web Link


Posted by neighbor, a resident of another community
on Jul 13, 2013 at 10:32 pm

Again....hats-off to UCSF + SU hospitals for their great response to the plane crash disaster. It shows that "prior planning precludes poor performance." Their preparedness paid off.


Posted by member, a resident of Downtown North
on Jul 14, 2013 at 10:58 am

It was to good to see such cooperation among the different agencies, emergency personnel and hospitals.

This was a good test of emergency response, but it is hardly what I would consider a major disaster where the casualties may be in the thousands.

It would be interesting to learn how we would cope with a larger scale disaster.

Why don't you do a story about this?


Posted by wonderment, a resident of Adobe-Meadows
on Jul 14, 2013 at 11:55 am

Congrats, Wayne, on learning how to use the google machine, and the phone. "wondering for Wayne"'s post must have worked. Nice Jeopardy reference!

Ain't it a wonderment.


Posted by DE-myelinated, a resident of Palo Alto Hills
on Jul 16, 2013 at 4:07 pm

@not an issue--- MS is nothing to be light about. The sufferer is slowly dying, the nerves being stripped of their insulation by the disease. It is totally debilitating, and eventually the patient stops breathing.