By Robert L. Dickson, MD, FACEP, FAEMS
James Campbell, FACPE
Jacob Shaw, NRP
James Seek, LP, BAAS
Kevin Crocker, LP, FACPE
Sean Simmonds, NRP
EMS agencies and first responders were tasked with shuffling from one crisis to another when Texans faced an unprecedented winter storm in the midst of a once-in-a-century pandemic with COVID-19. These challenges stress-tested all EMS agencies and first responders to continue providing life-saving care during the winter storm while adjusting to the changes of providing care, setting up mass vaccination sites, and continuing our mission during the COVID-19 pandemic.
This article details some of the challenges we faced, our general baseline preparedness, disaster-specific preparedness, how we communicated and what we learned. The Montgomery County Hospital District (MCHD) EMS is a tax-supported agency in southeast Texas. We provide our 1,100 square mile service area with 911 advanced life support service. MCHD runs approximately 75,000 responses per year with 30 ambulances and is supported by a network of first responder agencies operating at the BLS/ALS levels. During this one-week winter storm surge, we saw our number of calls and hospital transports double while navigating the challenges brought forth by managing a massive winter storm in conjunction with the COVID-19 pandemic.
Disaster management challenges
It would be an understatement to note the COVID-19 pandemic has affected both our communities and the way we provide out-of-hospital care. Like many systems around the country, MCHD was strained with the challenges of providing great EMS care exacerbated by a post-holiday surge in sick COVID-19 patients. In December and January, our staffing levels were affected by the pandemic and approximately 15% of our workforce was unavailable secondary to contracting or suffering a high-risk exposure to the virus.
This was not an isolated MCHD problem. Our hospital system, consisting of six acute care hospitals in the county, reported reduced staffing, increased COVID-19 admissions and full ICU capacity. By this time, almost 10 months into the pandemic, MCHD EMS had become operationally and clinically up to speed with the changes required to safely manage the pandemic. In the months leading up to the Valentine’s Day winter storm event, we were continuing to work on our pandemic recovery plan for 2021 and beyond as our team worked on developing our strategic operational, clinical and financial plans for our future.
Preparing for a weather event
We maintain a general baseline readiness year-round in addition to event-specific preparation that occurs in the lead-up to a predicted event. The best example is the hurricane storm events we are accustomed to preparing for, being on the southeast Gulf Coast. Some of the general readiness plans we have in place include:
- Power integrity. This is one of the most important aspects of public safety and healthcare delivery. Power redundancy is a critical component of preparedness because is it an essential utility for our response mission. As this event illustrates, every power grid has vulnerabilities on both the supply and demand side. MCHD has backup generators that are capable of supplying power needs to our administration building, alarm office, facilities and fleet departments, along with all of our stations. This proved vital, as nearly all of our buildings were on generator power for some portion of the event from Feb. 14, when we initiated our incident command system, to Feb. 19, when power was fully restored. While power outages may be well mitigated by your agency, it is important to note regular generator testing and preventive maintenance programs will ensure your equipment is functional when you need it most. Furthermore, check in with area hospitals and other first responder partners to assess their resilience to any disruption in power/water utilities.
- Staffing. MCHD utilized our incident command system and brought in additional staffing for the event. As in our hurricane events, the ability to get our crews safely from their homes to the station can be a challenge. We implemented the disaster-staffing plan, which brings in extra crews to our stations before the onset of an event. This posed a unique challenge of how to socially distance and maintain operational readiness with double the usual staff at our stations. To mitigate the risk of COVID-19 exposure, we encouraged mask-wearing in the station, spaced out our crews when possible, and load-balanced with our larger regional stations that had more room to distance. Prior to the event, our facilities team delivered both food and sleep provisions to each station. These extra cots and provisions are kept in perpetual readiness for these types of events. Space dividers were distributed to each station to give crews added privacy for a communal living situation while providing added social distancing barriers when increased space was not an option. Crews who were on downtime and were adequately rested were utilized to staff additional units. Prior to the storm, an ambulance was placed at each regional station, increasing the fleet status to four additional units across the district. These units were placed in service by downtime crews during peak hours and placed out of service early enough to allow rest prior to scheduled shifts.
- Water integrity. When the power went out to millions of Texans during the extremely low temperatures, pipes froze and then broke, causing loss of water pressure. This directly contributed to two of the six hospitals in our area going to “internal disaster” status for most of the response period. Losing one-third of our transport hospitals required a pivot in response strategy to maintain the integrity of the 911 response system. Thankfully, we have previously implemented alternative destinations in our system, which include directly transporting patients to satellite emergency departments. These relationships proved invaluable to our operation.
- Fuel. In order for the MICU fleet to remain mobile, our system requires an accessible and sustainable source of fuel. During this event, a mass power outage in the majority of our county adversely affected the ability to fuel our vehicles. MCHD maintains on-site fueling capability at our central administrative building and our regional stations, which helped immensely to keep our trucks on the road. It’s vital to have the ability to regulate the temperature of the diesel fuel supply as it gels at 15°F, making it unusable. Recently, these fuel pods have been in operation during routine operations so that they are on-site if needed for a no-notice incident.
- Intelligence. In order to maintain an efficient system we had to know how our first responders and hospital system partners were operating. During our response to COVID-19, we initiated weekly conference call checkins with both first responders and representatives from each of our area hospital partners. This allowed us to better predict their ability to care for our patients during the disaster and kept an open line of communication for us to share ideas and combat system-wide challenges. Due to high hospital EMS wait times several weeks before the storm, MCHD started a twice-daily operations report on hospital ED volumes and wait times for EMS. This policy detailed a stepwise escalation in response to long wait times for EMS, which culminates with staffing of our medical command (MEDCOM) and using a centralized load balancing system. This functions like air traffic control for units transporting patients to area hospitals directed by medical control. The hospital report is held at 0600 and 1800 daily by our alarm chief who directly calls the hospitals. This provides information that is much more accurate than the existing regional system that depends on hospitals to provide timely/accurate information on ED volumes and capability.
- Communication. This includes both internal and external stakeholders. During the COVID-19 pandemic, our face-to-face meetings were minimized to mitigate exposure risk. We developed new forms of direct communication, including frequent employee and board member Zoom calls to update everyone on response plans and elicit feedback. MCHD EMS also utilized the Group-Me instant text messaging application to communicate in small command staff groups, along with RAVE alerting and mass email communications to the entire organization.
Lessons learned from the Texas weather event
- Staffing. We brought in fresh crews that were resting the evening before the onset of poor weather conditions on Monday, Feb. 15. This proved invaluable to have them ready, but the first few days of this event had record responses and the large demand for service was complicated by both increased turnaround times at hospitals and icy road conditions, making responses challenging. The constant attention to detail required when driving in wintery conditions coupled with the sheer number of responses created an ongoing fatigue event for our crews. When implementing a disaster-staffing plan, consider adjusting shift start and stop times (e.g., a work/rest cycle that is based on 12-hour increments, rather than 24-hour increments).
- Water integrity. While we did have cases of drinking water stockpiled at our stations and headquarters, we did not anticipate the loss of water pressure and integrity. This can be mitigated by storing extra potable water at the stations for washing and drinking, access to portable toilet facilities for stations, and dispensing wet wipes to employees for personal hygiene if low water pressure makes it impossible to shower at the station.
- Winter precipitation. In our area, we are not accustomed to snow and icy road conditions. It is not something we regularly train for or prepare our organization for. In response to this event, we did two things that helped manage the ice and snow conditions. For our crews, we distributed Hugo Grips-4-Ice winter traction, over-shoe snow cleats. Utilizing these reduced slips, trips and falls, which is the most common cause of employee injury associated with ice and snow. To mitigate the driving aspect of the winter precipitation, when road conditions deteriorated, our on-duty deputy chief implemented our Ice Activation driving plans. Some of the highlights from this plan included:
- A script in dispatch that advised 911 callers that we were experiencing a delayed response secondary to hazardous road conditions
- Eliminating street corner posting
- Stopping lights and siren response driving to reduce overall driving speed and provider stimulation
Our peers to the north who are more accustomed to these conditions may view this as routine, but we had to develop these plans quickly and were able to avoid any reported employee injury or major fleet incident by implementing these safety strategies.
- MEDCOM. This centralized medical command was essential during high-demand times in the system. It not only allowed efficient transport load balancing between hospitals but also allowed direct involvement of the clinical staff and medical directors to make disposition decisions and avert hospital transport altogether. With the loss of power and ability to heat homes, we saw an increase in the exacerbation of otherwise stable chronic diseases. Our county office of Homeland Security and Emergency Management (OHSEM) set up several warming centers staffed with MCHD EMS paramedic providers on-site 24/7 throughout the storm event. These providers were a medical resource for those with chronic medical conditions (diabetes, hypertension, chronic COPD) and allowed evacuees to be treated at the shelters with blood glucose checks, BP checks and supplemental oxygen from their home or MCHD-provided oxygen concentrators until it was safe for them to return home. Staff in MEDCOM were able to communicate with patients directly in the field utilizing our Pulsara PATIENT platform. Patients were treated in place and put on a list for follow-up by the clinical staff in MEDCOM or sent with the medic unit or alternate transport an alternate destination (i.e., warming center, clinic or relative’s house).
- System response integrity. As one part of a larger system of healthcare delivery, EMS systems rely on our hospital and partners to support us in the journey each patient takes. MCHD EMS utilized a tiered response configuration that placed more reliance on our first responder fire department partners to make the initial response and patient contact on less urgent calls without dispatching a medic unit. This was accomplished by Alarm and MEDCOM staff through surplus call triage and prioritizing resource allocation. The process was successful and our agency will continue working with our FRO group to develop optimal response configurations, increased FRO provider training, and improving the documentation/quality process involved. We communicated with regional independent freestanding emergency departments on their ability to take some of the increased EMS patient loads. This was a departure from our usual practice and overall was very successful. As for future planning, we are working to evaluate the inclusion of some of these non-traditional hospital assets into our routine transport determinations.
Disaster management takeaway
During the Texas winter storm response 2021, EMS systems faced the perfect storm, an ongoing COVID-19 pandemic and unprecedented storm event causing major utility outages throughout our state. Here are some take-home messages from our experience on what works.
There is an age-old saying, “Prior proper preparation prevents poor performance”
Every agency must have a baseline readiness plan for power and utility integrity, as well as staffing, to include facility preparation for extra staff. During any disaster, having an incident command system in place with medical command will reduce the undue load on the healthcare system. The incident command system relies on good communication both from within the organization and amongst external stakeholders. Have these relationships and contacts with the regional office of emergency management, hospital partners and first responder organizations sorted before the day of the storm.
As in every disaster response, success relies not only on preparation but also flexibility in both how we respond and how we deliver healthcare. We would like to thank our regional hospital partners and first responder organizations for their support during this disaster, along with our medics and the staff that support them to provide excellent EMS medical care to our citizens in Montgomery County.
Read more: Jarvis, Pickett and Vithalani: After-action report – The Texas blizzard of 2021
Listen for more: 5 Texas EMS medical directors recount the operational and 911 triage challenges recent weather posed as power outages afflicted the region
