When Being Prepared Matters

When an Amtrak passenger train derailed in the Port Richmond section of Philadelphia on May 12, more than 200 passengers were injured. The victims were taken to a number of local hospitals. Temple University Hospital was one of them—and its Emergency Department (ED) and trauma team were ready.

On the night that the train derailed, Jill Volgraf, RN, BA, was already in bed. Jill is Temple’s trauma program manager. Her husband was watching a hockey game when a breaking news alert interrupted the game. He woke his wife so that she could check in with the hospital. Jill called the ED and learned that victims were beginning to arrive. She headed for the hospital.

Within 10 minutes of the crash, local EMS teams began calling Philadelphia hospitals to see how many crash victims each hospital was able to take. Temple personnel called an internal “Code White” to keep staff members on duty from leaving until they could be relieved. Shortly after, staff status was elevated to its highest level to provide the measures necessary to call additional staff in to help. A number of nurses and physicians who had learned about the train derailment through the media drove to the hospital without being called.

By the time that Jill arrived, triage was underway. “We had emergency medicine attending physicians and ED nursing staff outside our ambulance bay doors doing initial assessments and deciding where each victim needed to go,” she recalls. “We use mass casualty tags to identify patients with the most serious injuries and those who can wait, so we can triage them and then see immediately which victims are most critical and which are less urgent.” While all this was happening, clinical supervisors were working within the hospital to relocate beds and move the ED patients who were already in the waiting room so that crash victims could be accommodated. “At this point, we didn’t know how many victims we were getting,” Jill explains, “so we were trying to make room in house.” The hospital was close to capacity before the crash. Finding extra beds was a challenge. Hospital administrators decided to open the PACU to take any overflow from the ICU.

ED personnel had notified all of the departments that might be affected, so the staffs in the lab, radiology, the operating suite, and the intensive care unit were all alerted. Several additional members of the physician and resident staff were called in. Depending on the patient’s status, at least one but as many as three nurses were assigned to each patient along with at least one trauma resident.

While crash victims were flowing in, the ED staff continued to care for a near-capacity census of routine ED patients. A charge nurse was tasked with managing these patients, making sure that each one had been fully triaged and was being monitored closely. “We were covering all the bases so that no one was being overlooked,” Jill says.

The majority of the crash victims who arrived at Temple University Hospital that night had broken ribs, pulmonary contusions, and lung issues caused by being thrown around inside the train. They were met by hospital staff that was trained and ready. Thanks to some staffing shifts, additional surgical ICU nurses and trauma-certified burn nurses were called upon to supplement the ED’s trauma staff. Jill was helping out in the trauma bay while making sure that needed equipment, such as transport monitors and chest tubes, was available. “We were going to be ready,” she asserts.

Rising to the Challenge

When it was over, every crash victim had been seen by at least two surgical trauma attending physicians. After the patients were admitted to the floor, two attending physicians along with the resident and nursing staff rounded on them to ensure that no injuries had been missed. “We saw 54 crash victims in less than two hours,” Jill remembers. “As far as I know, we did not miss an injury. I think that’s amazing.”

I’ve been at Temple my entire nursing career,” Jill says. “I’ve always really enjoyed working at this hospital and the experience that I’ve gained from it, but there’s never been a day that I’ve been more proud to say that I work at Temple.”

The Morning After

When Cindy Blank-Reid, RN, MSN, CEN, trauma clinical nurse specialist, arrived at the hospital the next day, there was still a lot of work to be done. Critically injured patients from the derailment had been moved out of the ED within a few hours of their arrival. Some surgical patients were moved to nontrauma units to make room for the crash victims. Other routine patients who had come into the ED overnight and who required hospitalization also needed beds. Then there was the usual movement of patients within the hospital, such as patients due to be transferred out of the SICU to the floor, who also needed beds.

Cindy was struck by the exceptional teamwork. Staff from different areas was reassigned to help wherever they were needed. Nurses were reassigned to the busier units to assist with discharging and transporting patients and to help with admitting post-op derailment patients who had been taken to surgery. Residents were pulled from their usual rotations to assist with admitting and discharging patients on the trauma service due to the sudden increase in volume. Some hospital patients who were waiting to be discharged even offered to give up their beds if they were needed for the crash victims.

A number of the victims needed help contacting family members. This might sound easy enough but, since the advent of cell phones, most people no longer memorize phone numbers. They rely on a contact list stored in their phone. Many of the cell phones that were on the train that night were lost in the crash along with wallets, keys, identification, and money. Without cell phones, victims did not know what number to call. “We had many people here who had no identification, no money, no house keys, no car keys, no idea what their family member’s phone number was, and we were trying to get them home,” Cindy says. “So it was much more complicated than just calling someone to come in and pick up the patient.”

There were also family members who needed help. Some had driven for hours to get to Philadelphia and had already been to several hospitals looking for a loved one before coming to Temple. “For any victims who weren’t here, we made phone calls to other hospitals, trying to locate victims to ease some of the stress on the family,” says Cindy. Some families needed help finding hotel rooms. Interpreters were called in to help victims and family members who did not speak English. For those who were discharged, hospital staff was challenged to find a way for patients to leave without being bombarded by the mob of press and attorneys outside the hospital. Even the Foodservices staff had its hands full trying to feed the large number of staff that had stayed overnight plus all of the crash victims and their family members, police officers, and EMS personnel who were onsite. “It was a very complex task to make sure that everybody got what they needed in a timely manner,” Cindy says.

The saddest moment for Cindy came while she was wheeling a patient to a waiting car at one of the hospital entrances.  One man who was believed to have been on the train had still not been located approximately 16 hours after the derailment.  His son, accompanied by a relative, approached Cindy. The young man was holding a photo of his father. He asked Cindy if she had seen him. Cindy directed the young man to the security officer supervisor at the building entrance who was handling media personnel and others looking for information about the crash victims. “I witnessed the young man asking again about whether there were any unidentified patients in the hospital,” Cindy says.  The security supervisor told him that he was sorry, but that there were no unidentified patients at Temple. He offered to have him speak with one of the hospital staff who could help him try to contact the other hospitals that had Amtrak patients. Cindy recalls that “It was just so incredibly sad to see them searching for their loved one.”

Being Prepared 

Because it is a large, metropolitan hospital, Temple University Hospital is often called upon to deal with large-scale emergencies. Being prepared to operate at this level doesn’t happen automatically. It comes from having a plan and a highly trained staff.

Temple has an emergency operations plan (EOP) in accordance with Joint Commission and Emergency Medical Services guidelines and plays a leadership role in two regional health care emergency management coalitions. A multidisciplinary Emergency Preparedness Committee meets monthly to discuss mass casualty event procedures. “This is where our EOP touches the staff and where we are able to talk about how to operationalize the plan,” says Wes Light, Temple’s manager of Emergency Preparedness and a certified health care emergency professional and certified health care safety professional.

Because Temple is an accredited Level 1 Trauma Center, all of the RNs who care for trauma patients throughout the hospital—not just the ED nurses—receive mandatory trauma education and training. This includes nurses in the operating room, recovery room, SICU and neurological ICU, burn unit, and the surgical floor nurses that care for trauma patients on their units. All nurses during their first year of employment receive 32 hours of education on multiple aspects of caring for a trauma patient—from pre-hospital care to resuscitation through rehabilitation. Every year after that, they receive 8 hours of mandatory trauma-related education, so they are continually updated on the complete roster of trauma topics, including initial assessment, chest trauma, shock, orthopedics, and neurosurgery. In addition, all ED staff is required to complete annual emergency preparedness training. The hospital conducts a mass casualty practice drill along with random smaller mass casualty drills throughout the year.

Lessons Learned

Cindy understands the value of all the education and training. “To anyone who doesn’t like to plan and do drills for what might be a once-in-a-lifetime event, I want to say that you need to do it and to take it seriously because you never know when something like this will happen,” she says. “The lectures, the refresher courses, the simulation lab exercises, and the skills stations we do at Temple all pay off when the rubber hits the road.”

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