Wednesday, 8 a.m.: In half an hour, a train will strike a bus near downtown Palo Alto, injuring or killing 54 people.
In a nearby Stanford classroom, a rainbow of scrubs — blue, maroon and green, representing doctors, nurses and technicians — are eating bagels and listening to final instructions from Colin Bucks, MD, emergency medicine physician and medical director for the Stanford Medicine's Office of Emergency Management.
“Triage is by nurses only,” Bucks explains. “Thirty seconds per patient. Check heart and respiratory rates, and check your gut. Gestalt is important; go with your instinct.”
Stanford Medicine has been conducting disaster simulations for as long as anyone in this room can remember. Some of the physicians here participated in drills, and then saw preparation become reality in 2013 when Asiana Airlines Flight 214 crashed at San Francisco International Airport, sending 55 patients to Stanford Hospital.
Simulations come in many forms, from simple tabletop mock-ups to full-scale enactments. Today’s exercise is large in scale and includes multiple departments at Stanford Hospital and Lucile Packard Children’s Hospital Stanford.
The focus today is on mass casualties.
8:16 a.m.: Staff disperse to the hospital and ambulance bay. Two large tents are set up in the parking lot and I peek into the first; 30 or so blow-up mannequins lie on a tarp, each with a case scenario affixed to its plastic chest. The second tent will serve as a receiving area, with portable electronics enabling nurses to evaluate and route patients quickly.
8:32 a.m.: The urgent call goes out over the loud speaker: “Attention. Attention. Incoming 40 patient surge. ETA five minutes to the emergency department.” Protocols immediately go into effect to transfer existing patients out of the ED — quickly. When flight 214 crashed, 15 of 20 existing patients were cleared from the ED before the first crash victims arrived.
8:37 a.m.: Right on schedule, the first patients appear. “That one is missing a leg.” “This one has bowel poking out of his stomach.” Bucks has written up each case with chief complaints, vital signs, test results and pathology. The volume of creative writing alone is impressive. Mixed in with disaster patients are community patients who need immediate service, just as would normally occur on a Wednesday.
Brandon Bond is circulating between the tents and the ED. The administrative director of the Office of Emergency Management, he knows disaster, and has a list of objectives for today that includes activation of a command center, coordination with operative services, and effective patient tracking.
“We know that disruptions will happen whether natural or manmade,” he tells me. “We will be central focus for receiving. It is inevitable, so it is critically important that we continue to train and improve our services.”
Inside, the ED is quickly filling with patients, both mannequins, and incongruously, stuffed sock monkeys. “We need to clear alpha three,” a physician orders, and a nurse scoops up a pile of sock monkeys to “transport” to the fast track area. It looks humorous, but is a reminder of the unavoidable artificiality to this exercise. The patients don’t talk, cry, smell or bleed. Most don’t weigh more than five ounces. But the stand-ins enable staff to walk through logistics, and despite stuffed animal patients, the exercise is taken very seriously. Nowhere more so than the command center.
8:55 a.m.: On the third floor of the hospital, in a board room guarded by a security officer, more than 30 members of the executive teams from Stanford Hospital and Packard Children’s are gathered around a table covered with laptops, phones and a tangle of cables. Two large screens show the ED entrance in real time and two screens display the patient roster. White boards are constantly updated with statistics. Every 10 minutes or so, the group pauses in their individual focus to share updates on patient counts, IT concerns, traffic flow, media briefing, and innumerable logistical details. Unanticipated hiccups arise and are noted for future discussion.
That is, after all, the point of this exercise: to work out the wrinkles ahead of time because, as Alison Kerr, vice president of operations for Stanford Health Care comments, “Disasters don’t wait.”
9:40 a.m.: The last “victims” are processed. A pile of sock monkeys sits on a gurney in the hallway, and mannequins have been returned to their tent. Staff reconvene in the classroom for a debrief that is as important as the simulation itself.
On the whole, Bucks said he is pleased, particularly with the number of departments involved. “Disasters come in through the ED, but that is just the front door to an entire house that needs to be coordinated. I have never seen any place that can disseminate information and make decisions so quickly.“
Photo by Rafael Cruz
