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Rios-disaster response-puerto rico
- 1. A Warholian Experience Luis E Rios Jr
- 2. Objectives • Contextual framing of the response to Hurricane Maria Disaster in Puerto Rico • Briefing on the realities, responder expectations and target population expectations • Brief overview of the Operational response at the Governmental level to disasters in general • An overview of our DMAT’s response experience and missions in Puerto Rico • What de-mobe from a disaster response entails • “Lessons learned” during and after the fact
- 3. CONTEXT: 2nd Cat 4-5 Hurricane to hit Island in one month Several storms hit the USA and territories, response spread thin Electrical Grid of the Island: 50 years old with minimal updates Bankrupted Island economy Puerto Rico 1000 miles from mainland open ocean
- 4. Context: Hurricane Maria entering Puerto Rico
- 5. Context: Three storms side by side
- 6. Context
- 7. Context: Power Before and After Early Hurricane season: started with old grid After both Irma and Maria landfalls
- 8. Context: distances from US Mainland 1,035 miles 1.553 miles 1,610 miles
- 9. The Stafford Act: what does it say? Seven titles in the Act. Been formally amended 3 times since 1974. Establishes procedures and process for implementation. Establishes cost sharing maximums, %’s and Congressional recourse. Establishes the rules for command and control and flexibilities thereof. Liabilities, fairness, FEMA responsibilities, payment and repayment time frames among other details. The Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) is a United States federal law designed to bring an orderly and systemic means of federal natural disaster assistance for state and local governments in carrying out their responsibilities to aid citizens. Amended 1988 from the original 1974 passing senate 91-0 Ops Overview
- 10. General Disaster Response Pattern Local Agency Assessment of capacity, capability and vulnerability in face of threat. State & Regional Agency Response to request for assistance; capacity & capability resources; threat analysis – response-assessment triad. Federal and/or International Response to requests for escalation; resource and allocation assessment and assessment of critical needs beyond those resources Ops Overview
- 11. Disaster Cycles are: A continuum regardless of the level of Operations Ops Overview
- 12. Disaster Management process is the same: Followed at each level of response: local, State and Federal as well as International but with caveats……… Ops Overview
- 13. Federal Government response Ops Overview DHHS agencies and Divisions DHS Agencies and Divisions DOJ Agencies DoD branches DOE (Energy) EPA (Environmental Protection Agency) DOT (Department of Transportation) US Treasury
- 14. Fit testing among other pre-deployment tasks: Vaccine records Accountability Psychological force protection Theatre briefings DMAT
- 16. Personnel and Cargo delivery Reception area sequestered from the commercial part of the airport in the Charter area and waited for Port-master release DMAT
- 17. Luis Munoz Marin International Airport to San Juan Convention Center DMAT
- 18. Staging area: San Juan Convention Center DMAT
- 20. MASH style Showers One each: Men and Women Visitor or peeping – tom? DMAT
- 23. First Mission ! Federal Medical Shelter NDMS 7 man Strike team to support a new Federal Medical Station (FMS) at: Hospital Universitario Dr. Ramon Ruiz Arnau In Bayamon DMAT
- 24. Hospital Universitario Dr. Ramon Ruiz Arnau DMAT
- 25. Meanwhile 2nd mission evolves in the mountains: Utuado’s regional hospital DoD squadron: Crew chief looking at terrain Blackhawks for personnel V22 Osprey for heavy cargo Chinooks road out cargo De-board transport and walk to unload Two adjacent LZ’s for personnel and cargo Ground crew to deliver to sites Supplies for Distribution -Done Several hours of grunt work invigorates the soul. Rest-time and visit the hospital DMAT
- 26. Hospital Metropolitano de la Montaña Day mission accomplished; again multi-agency coordinated DMAT
- 27. Then: Comerio Field Medical Station Team split in half Dam above the Municipality of Comerio I’m a refugee too! DMAT
- 28. Community and Individual Psych First Aid took all forms: For ourselves For kids and the community DMAT
- 29. Final Mission of the command half of our DMAT DMAT
- 30. The Acropolis Arena RED Tent Sick with IV fluids, Shortness of Breath, Chest Pain and any other complaint that could need evacuation to a hospital ED YELLOW Tent Non-sick IV fluids, abdominal pain, rashes, suturing, BA when no Psych services and others unlikely to need evacuation Command Desk In-front of the two tents where control via administrators, communications, planning and logistics were stationed DMAT
- 32. The VA managed chronic vent care Hospice O2 and power dependent patients CPAP reservations But all hands on deck when power outages before generator support and death send-offs occured: DMAT
- 33. Support areas included: Cantina ala NYP Outdoor warm but indoor COLD!! Laundromat DMAT
- 34. Components DMAT
- 35. Visit to the Public Hospital Face Job underway Construction and patient –visitor congested with security everywhere Emergency entrance Adjacent to main entrance and an active construction site. Resembled So. FL Waiting room tiny and at midday. A few commodities in the only salvaged portion of triage and registration DMAT
- 36. Volume Census record: ~ 5500 total Volume graphics DMAT
- 37. De-mobilization Send off arch Good byes are hard after closeness in such circumstances. We honored each others contributions upon exit. ESJ Azul R&R After hours of searching the water front SJ district we found the de- mobe site: ESJ rental apartment- condo unit Cleaned up beach Following morning our team together and relax before flight to Atlanta and de-briefing De-Mobe
- 38. Homeward bound….. Our replacements Economy of scale: we took their plane and they took our buses. Exchanged greetings and encouragement, Finally taxing to Take off Security, Port-Master, final accountability before shutting the hatch. Reception in Hartsfield The HQ Brass turn out to welcome us home and congratulate us on a job well done De-mobe & De-brief
- 39. Lessons Learned from deployment experience • Take what you can carry, there are roads but also dirt mud and water to navigate • Be and stay fit; It is easy to overestimate your physical stamina • Prepare for all facets of work, ADL’s and resting. • Go with an open mind and no pre-expectations • Look after each other and respect each others boundaries • Take time for yourself while there, it pays back with dividends • Allow yourself recovery time upon return
- 40. Thank you from the TEAM
- 42. Sources: http://www.worldometers.info/world-population/puerto-rico-population/ U.S. National Hurricane Center NDMS Individual Team databases US Department of Homeland Security, FEMA databases
Editor's Notes
- Welcome to the first edition of Disaster Response. It is my hope we can update you via similar forums on deployments, topics in Disaster and Operational Medicine and “just-in-time” concepts for the “gen-pop” emergency provider and responder diaspora.
- All disasters need framing and updates when situational status changes in order to guide the care expectations and care given. We will look at the theatre and operational level. Pts. understand these realities when changes come about when explained in concrete terms. We’ll look at the GO response predominantly and mention NGO missions. NGO’s, unless attached to GO’s, may not have the infrastructure and logistics to support long range missions. The meat of this talk will examine the NDMS response to PR, and in particular, DMAT FL 4 and appendages: VA, USPHS-Uniform Service Corp and DoD. De-mobilization is not just dis-engaging from a mission. We’ll touch on that itemized process. Lessons learn really apply to operational process and as such are very specific to those subsets. Once the academic process of DM gets codified then EB data in a more generic fashion can be shared and disseminated. Please be mindful of this distinction when we look at some of my items.
- Framing: As we already know Irma had gone through the island before devastating mainland Florida and Jose had skirted the Island in the couple weeks before Maria Several storms had impacted the US mainland and territories before Maria came about and with Maria bringing a staggering cost eventually surpassing $ 200 billion overall. As we’ll see illustrated shortly, Puerto Rico’s power and light grid was knocked off for nearly 100 % of the Island’s population and commerce. Remember that the electrical grid for the island dates back more than 50 years with only supplemental improvement NOT infrastructure updating. For decades, the Island’s economy had been imploding and hovered over the collapse that eventually flowered 2016-17. Remember that a State & Territorial co-pay to Stafford Act related funding can be anywhere from 10 to 50% in certain block items. The Island of Puerto Rico, and even more so the USVI (whose staging platform is actually Puerto Rico), lies nearly 1000 miles from the nearest mainland point of reach. Unlike Texas and even Florida where there is contiguity to sister States.
- The last time a large storm like Maria went through Puerto Rico was 1928, San Felipe II ( also known as the Okeechobee Hurricane), a Category 5 storm that killed 300 people, destroyed 100,000’s of dwellings and the coffee industry saw a near total loss of a bumper crop. This in comparison to the weaker (Category 4) Great 1899 storm, San Ciriaco, that killed > 3000 people and left the Island’s agrarian economy destitute. This last storm cause $ 20 million in US Dollars circa 1899 economy.
- Irma in center, Jose to your right and Katia in the gulf on your left and the leading bands of what becomes Maria at your far right. This clip is after Harvey.
- Saffir-Simpson Hurricane Wind scale, amended 2000’s to exclude storm surge (because of wide variance), is a the most widely used standard measure of hurricane strength. Some of us felino-philes attribute whimsical properties to the categories of course not validated! .Maria hit Puerto Rico as a Cat 4, Irma passing above it had been a Cat 5. San Felipe II, again, in 1928 with a similar trans Island trajectory to Maria was a Cat 5.
- Satellite pictures of night lights over Puerto Rico before and after both Irma and Maria are a graphic illustration of the power grid consequence of these storms. Look out to the East at the neighboring Virgin Islands. 93.9 % of Puerto Rico’s population lives in the urban rims of the island (3,439,190 people in 2018). While my team was there October 22nd to November 7th, only 17% of the Island had any kind of centralized power.
- Distances here illustrated on a flight map shown from San Juan to NYC (1,610 miles SSE), Washington, D.C. (1,553 miles SSE) and Miami, FL (1,035 miles SE) as well as other major airport hub-cities demonstrate the huge logistical movement problem for the theatre. San Juan is the usual staging site for response to the USVI’s calamities.
- In 1979 President Carter incorporated much of the original into an executive order creating the Federal Emergency Management Agency (FEMA). The amendment in 2000 was called the Disaster Mitigation Act but Senator (R, VT) Robert Stafford’s (1988) name stuck. The act has 7 titles covering and authorizing all facets of Emergency Response at this level. Requests for assistance are bottom driven thought the top can suggest. Payment of funds is targeted to 60 days after approval and repayment of assigned portion to 3 years after final assessment of cost. This assessment may be much after the initial response and recovery starts.
- General response to disasters follows a well travelled, escalating process from the local to the federal levels. One requirement of Federal response is the State/territory declaration of a state of emergency with deployment orders for its regional resources because resource needs must exceed the State level.
- In this slide the four “R’s” noted here represent the more familiar Preparedness, Response, Recovery and Mitigation phases of a disaster. The sequence may vary according to situational awareness and segmentation of the theatre.
- Management process is generally the same with detail dictating capacity and capability escalation. Caveats include issues sovereignty, theatre characteristics, funding process, theatre logistics and political overtones. The later alludes to control of operations and chain of command and can be troublesome if not clearly delineated and accepted. I’ll let you ponder on this: “asking others for help does not mean that others take over you home!”
- We could see the power picture from satellite imaging and focused satellite pictures but movement depends on boots on the ground intelligence from Disaster Assessment teams. Topography can change from day to day depending on weather, structural vulnerabilities and traffic footprint. This map illustrates the situational status as of September 26th All of these Departments and Agencies are ordered into activity following a Federal Disaster declaration. Most of their roles are deducible and others are somewhat subtle: DOJ includes FBI and USMS; DOE involved in all facets of energy provision ; DOT owns roads and bridges as well as HAZMAT along with the independent agency, the EPA. When it was reported that > 10,000 federal workers were deployed to Puerto Rico; it’s easier to see who that figure represented. I receive may questions about why DoD aircraft are not routinely used for movement into the theatre. The answer involves risk, training and cost. Most especially cost as a military airlift of non-combatant personnel cost much more than charter services.
- So we mobilized from our homes and work to respective airports and were commercially shuttled to HQ in an Atlanta Hotel for muster and accountability before briefings. This process can be anywhere from < 2 hours (most deployments) to several days as in Overseas, austere and Special Function deployments.
- Next morning, gloomy 04:00 wake up, muster at 05:00, load buses & go at 0:530 and travel to the airport to wait……………………………………………………until ~ noon when charters load and take off shortly thereafter.
- Arrived in San Juan and for security purposes both personnel and air traffic de-board was at the adjunct site adjacent to Luis Munoz Marin Int’l Airport. Unfortunately the customs and port official capacity were not expanded and each transport was individually cleared by one official.
- Loaded on buses and transported < 10 minutes (6.9 miles) away but 3 X longer because of road damage, hazards and traffic re-routing to the San Juan Convention Center.
- Service entrance in the back.: unloaded and entered warehouse-storage facility which would be our staging home until missions were assigned. Usual warehouse area with dust, open vents and utilitarian bathrooms. We slept in cots with an occasional air mattress along side our comrades USPHS-US, DoD elements and a few other adjuvant agency members as well a NGO’s. Lights out at 22:00 and on at 06:00 daily. Food and drink from screened vendors in the convention lobby on a schedule with access to the Hotel across the driveway for change of venue. The hotel housed brass from State Department, DHHS, DHS and as-sundry other agencies.
- Civilian and Uniform services all there for the same goal: to help.
- At SJCC staging, the USA set up these self contained warm water showers for all bivouacked personnel: generator driven, overhead lite, vented and drained. Ran 24/7 to accommodate volume and shift workers
- All members are credentialed in their patient-care as well as team roles: Administrative, Epidemiology, EMT-P, RN, MLP and Physician however equipment, packaging, machines and comfort levels with them may vary. Once cache is delivered, orientation with the contents is imperative.
- The Island response was divided into 4 Divisions, each with their own IRCT (Incident Response Coordination Team rep) and Operations Section Chief and Deputy, as indicated on this map. The map is from November 1st but the mission map was updated periodical (24 hours at least) and the missions varied from domiciliary visits to Federal medical Stations to Federal Medical Shelters to DMAT Fixed support to other contingents (VA, USS Comfort [Combat Support Hospital], Native Hospitals, MedEvac Base) to Mobile Medical Field Units (usually Provider/RN/EMT-P strike teams) i.e., MA-1 in Utuado. The later did field work and supported other contingents when needed and had satellite communication.
- Waiting for the two members fetching the vehicle to drive the 10 miles to University Hospital in Bayamon. The fist of many inter-agency missions partnering with the USPHS-US. USPHS had lead and would staff 24/7 with Nursing, Medical, Pharmacy, Administrative and Logistical staff. We severed as Rapid Response support, Retrieval Teams and Intake. Our mission was 12 hours daytime: 08:00 to 20:00. No admissions at night because of power risks and curfew.
- University hospital was recipient of Federal grant to set up Ebola Treatment unit complete with an bathroom, ante room, negative pressure containment and segregation from rest of hospital. We used it as a 38 bed non-acute care station. If custodial assistance was needed the 2nd cot was for the caretaker. This was a 3 day mission for us. During downtime we responded to calls for field assistance, non-EMS, routed to us from the Public Health hotline: tell them about the 100 ½ yo lady with syncope and 5 hours to coordinate transport to the receiving hospital. Problem arose with pts who were not emergent but needed hospital care and eventually basic EMS picked up with our staff serving as ALS. A pt. for the Shelter: middle-aged man with ESRD in a San Juan Hospital was one candidate for the shelter and had transportation to HD attached. Power was the bane of it’s existence with frequent power lose and heat issues. Closed prematurely after we left for that reason.
- North-central town of Utuado home of Taino ceremonial park with a regional hospital capable of servicing that segment of the of Puerto Rico’s mountain towns. Land access limited and danger of land slides 1500 – 3000 ft above sea level.
- Several personnel from different Departments, agencies and NDMS teams pulled out of staging to accomplish goals; as you saw we all chipped in to mission needs regardless of our job descriptions.
- HQ’d at the Municipality’s City Hall. Bunked in hallways and open office spaces, they used the open and closed spaces to provide medical support to the community. The river rose 50 feet (79.45 ft)over the record flood stage during the winter system in 1992 (29.2 feet), The usual wet season stage is 18 feet. These figures are from hydrographs sited by the Weather Channel based on water pressure estimates of depth of the Rio la Plata which is dammed above the Town of Comerio that is in trough about 1700 feet below the mountain peaks. People left quickly and some of those left behind were pets and livestock. This little guy was in a container outside the FMS and heard whimpering a team member.
- Normalcy, like Trick or Treating that many families had prepared for before the storms had tremendous impact on the most vulnerable of populations. Logistics and local vendors helped us prepare for the day.
- The last mission was the Command and Control component of the Field Medical Station in Manati, a coastal north central city with 2 regional level hospitals and several HD centers. Housed in the municipal coliseum, the floor contained the Station components: ventilator dependent long-term care, O2 dependent care, reserved beds for power dependent OSA, domiciliary patients with simple nursing needs and MASH-style Free Standing ED.in the periphery.
- Patient care areas followed disaster labels modified to fit. The medical care was provided by 80:20 mix of the NGO, NYP and our own Darrell Thomas. Top left is a crash cart ala DMAT. The top center is our ChNYP Chief of staff. The top right are the Coms, Med and Logs. The Green Tent was the fast tract and was actually a table cattycorner to the Triage Desks. We hand intermittent Psych manned by USPHS-US Psychiatrist, Psychologist and Social Worker across from the Green Tables and enclosed. Wax-wane moderate volume of psychiatric complaints warranted the back up. On the next slide you will see an operational vignette demonstrating patient flow.
- We follow a volunteer real patient through the process. Take in the sights and sounds he senses and highlight some staff process. The lab services were donated by a local Lab Company and their staff donated their time and skills. We even had our own troubadour. There invariable someone observing the overall flow from the seating area above.
- The VA contingent was large with 24/7 coverage of PCT’s, Nurses and providers (both physicians and midlevel providers).
- Cantina NOT to replace MIRE (meals ready to eat). Toilet and shower services: inside and MASH shower outside. Laundry though was on your own: grunt style. Red for soap, black #1 for first rise then black # 2 for second rinse and outdoor dryer; usually 2 hours for heavy stuff.
- Lab services outside of RED tent. Pharmacy in the center. Logistics to the left. The Movement or Transport Area lay central between tents and easy access to all clinical areas. Three DoD ambulances and medic driver capable of 4 patient litters. Our nurses or paramedics provided ALS services when needed.
- Gave us perspective on where we were sending and hearing about, their infrastructure and staff. Yours the Peds floor, Med-Surg, ICU’s, OR capabilities, HD, L&D, NICU and sine qua non: the ED. A one hour lunch trip took three hours, 75 % traffic, to complete.
- Averaged about 160 out patient visits a day. The graphic on the right shows the TRYG levels (orange replaced yellow for lack of a yellow marker. Of the ~5500 patients seen, 1200 were under the Command & Control of DMAT FL-4.
- We split and half left the night prior to DoD replacement and half stayed until morning to brief DoD contingent on Command & Control issues. 2 vehicles each group and the first navigated and mapped the destination. A four hour tour: navigator directions proved difficult to discern post-storm. Surreal scene at ESJ Azul: “Hotel California” playing, a disco in full gear and youngsters seeking distractions could be see and heard. Finally peace in-front of the Atlantic’s womb.
- Bused to the airport where we spent 90 minutes going through DHHS clearance before boarding our charter. The newbies had already de-plane and on the tarmac. De-planning at ATL was quick and shuttles to the hotel-conference center efficient. 1 hour de-briefing and psychological expectations in large group format completed and it was SSS, a great meal and a good night’s sleep before the journey back home the next morning.
- These are but a few of the take home messages. I am sure the other Team-mates have more. The most important phrase to remember upon return: “ You did what you could and it is what it is!”
- Thank you for listening and some of you: for making this happen!
- And from the extended family: a salute to you ALL!