Drills, Team Spirit Helped Minneapolis Pharmacies Respond To Disaster

Main Category: Pharmacy / Pharmacist
Also Included In: Aid / Disasters
Article Date: 15 Aug 2007 - 2:00 PDT

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Thanks to disaster-preparedness drills and employees' team spirit, the pharmacy departments at the two Minneapolis hospitals most involved in treating victims of the recent bridge collapse met the challenge, managers said.

"Our preparedness plans up until a couple years ago were almost exclusively focused around trauma to people," said Charles B. Cooper, pharmacy director at Hennepin County Medical Center, site of the only trauma center in Minneapolis.

As a result of those plans, Cooper said a week after the Interstate 35W bridge over the Mississippi River collapsed during the evening rush hour, Hennepin's pharmacy had a list of "orange alert" drugs. The department, he said, ensures that its supply of those drugs can meet the likely needs of the emergency room (ER) when facing a sudden influx of patients.

"We had everything on that list," Cooper said.

Although initially, he added, no one realized there was a second supply of succinylcholine in another refrigerator.

Hennepin treated 24 victims in the first 20 hours after the bridge collapse, according to the Minnesota Hospital Association.

Cooper said most of the early arrivals were people in need of surgery.

University of Minnesota Medical Center, Fairview-University Campus, the hospital association said, treated 25 victims.

Only two or three of those people underwent orthopedic surgery, said Scott Knoer, pharmacy director for the medical center's University campus, which lies on the river's east bank.

Emergency responders onsite at the bridge, he said, "sent the worst and the first [patients] to Hennepin." The two hospitals treated half of the 98 disaster victims, according to the association's figures.

Joseph B. Stanek, who directs University of Minnesota Medical Center, Fairview pharmacy's disaster-preparedness efforts and heads up the department on the Riverside campus, said a citywide drill this past May was the center's best preparation for what happened August 1.

Organized by the Minnesota Department of Health, the citywide drill known as Operation Snowball III allowed participants to practice several procedures, including requesting the federal Strategic National Stockpile, coordinating communications from multiple locations, and reporting the situation.

With actors portraying patients, Stanek said, the drill tested participating hospitals' ability to handle a sudden increase in patient load, including pharmacy departments' ability to supply needed medications.

Knoer said his hospital in the hours after the bridge collapse "went through things we don't generally stockpile," such as morphine, cefazolin, lactated Ringer's injection, and tetanus toxoids products.

"We did have enough . . . but if we had had a lot more [patients]," he said, "we probably would have run out of tetanus" toxoids products because his hospital does not routinely administer many of those vaccinations.

The prospect of running out of pharmacy personnel that evening, however, was quickly dismissed by the managers.

"Staff was amazing," Knoer said. "It was 'How can I help? What can I do?' Nobody panicked. Nobody wanted to go home. . . . And I had I don't know how many calls from people" asking if they could help.

Cooper, who was in San Francisco when the Minneapolis bridge collapsed, said the toughest task for his department that evening from a managerial point of view was screening calls from staff members who wanted to know how they could help.

Even with disaster-preparedness drills, he said, "you're never really sure how difficult it would be to get people to come in to work. You always hope and assume that they would be willing to come in. But these people didn't wait for a phone call. They were already inbound."

John Pastor III, Knoer's assistant director of clinical pharmacy services, said nearly all of the victims treated on the University campus had a trauma of some sort.

The medical staff, Pastor said, wanted a tetanus toxoid product administered to any patient whose vaccination history was questionable and who had a penetrating wound, an open fracture, or an injury in which a large chunk of skin was missing.

"Most everyone that had either an open fracture or a significant traumatic injury to their skin got some type of an antibiotic dose right in the emergency department," he added.

Pastor, who spent most of the evening in the ER, reached the hospital ahead of Knoer.

Both men headed back to work after receiving an "orange alert" page.

Stanek, who had worked late that day, said he had just exited the parking garage on the Riverside campus, on the west bank of the river, when he heard NPR announce that the I-35W bridge had collapsed. "I was not even a block away, turned around, and came back," he said.

From San Francisco, Cooper called his inpatient manager, who that evening had the designation "supervisor on call" and received the hospital's "orange alert" page.

Cooper said the inpatient manager came in right away and worked in the incident command center helping to coordinate activities and communicate information to the pharmacy staff about the status of inbound patients and requests for help from the community.

"It was kind of a helpless feeling," Cooper said, "because you're a couple thousand miles away watching."

After watching a cable news broadcast, Cooper called the main pharmacy and learned that six people in the department had returned to work in the first hour after the bridge had collapsed.

One of those, the lead clinical pharmacist, was checking the filled-to-capacity intensive care units trying to figure out where some of the patients could be transferred to create space for incoming disaster victims, he said. Two people had gone to the ER to help triage patients and determine their medication needs.

Knoer, whose drive to the University campus would normally have taken 20 minutes but instead took an hour, said he learned on arrival that Pastor had stationed himself in the ER after following a pharmacist who went there to deliver supplies.

"We had four pharmacists in the ER and three techs running drugs back and forth," Knoer said of his department's ad hoc staffing arrangement for the evening.

Knoer said he soon called the pharmacy department on the Riverside campus to ask its status regarding patients and pharmacists.

This contact between the two campuses' pharmacies, he said, was repeated about every half hour throughout the evening.

"We would have immediately shifted resources back and forth across the river if necessary" using nearby intact bridges, Knoer said.

Stanek, whose hospital has a neonatal intensive care unit and is a large provider of inpatient behavioral health services, said no victims of the bridge collapse came to his facility. The lack of patients from the disaster, he said, might have been a consequence of being on the same side of the river as Hennepin.

"We had people who voluntarily called in on our campus to make themselves available," he said, but their help was not needed.

Knoer said he went to the discharge pharmacy, the satellite operating room (OR) pharmacy, which has pharmacist coverage 16 hours per day, and the newly designated ER pharmacy to check the status at those sites.

When he arrived at the satellite OR pharmacy, Knoer said, the pharmacist and pharmacy technician were checking the patient census in the ER.

The two or three patients who needed surgery were not expected to arrive in the OR suites before 10 p.m., he said. After the pharmacist and technician found out that their assistance would not be needed, he said, they left at the end of the work shift.

"When it was clear that we wouldn't have a large volume in the OR," Knoer said, "we didn't think it was the best use of resources to keep" the satellite pharmacy open.

At Hennepin, a level 1 trauma center, Cooper said six or seven OR suites on the fourth floor had been opened in the first hour after the bridge collapsed.

Tammy Londo, the pharmacy technician who replenished the automated drug-dispensing systems in the OR suites, he said, "was probably the busiest person we had . . . because she was running around all night long."

On a normal weeknight, Cooper explained, a pharmacy technician replenishes the automated drug-dispensing systems later in the evening, after the second-shift surgeries have finished and the OR suites are free. With the systems' inventory levels low at the time the bridge collapsed and the supplies of pharmacy-filled medication syringes also low, the technician had to stay ahead of the new patient load as well as prepare for the next day's surgeries.

"She did a real good job to make sure that everything was in place," Cooper said of Lando.

Assisting that effort were a couple pharmacy technicians who came in to help with the disaster response, he said. They quickly started replenishing stock supplies of critical drugs where needed.

Pastor, who oversees the clinical pharmacists and pharmacy team leaders on the University campus, said the pharmacy department initially had too many people working in the ER.

The ER is one flight up and about 200 yards from the central pharmacy, he said.

"One of my learnings was, I was glad I was there" in the ER, Pastor said. "I've got a very engaged staff that all want to help out. And my sense is that if I wasn't there, they would have not taken it upon themselves to maybe go back to their work areas at an appropriate time."

Pastor had the intensive-care-unit pharmacist, pediatrics pharmacist, and cardiology pharmacist stay in the ER.

There, he said, the pharmacists' mode of operation was different than in day-to-day practice.

"For the most part, we didn't have a name, we didn't have an age, we didn't have a weight, and we didn't have any allergy information on these patients" when they arrived in the ER, Pastor said. "So they came in the front door and they were 'trauma number 1,' 'trauma number 2,' trauma number 3,' and down the line." He and the other pharmacy personnel working in the ER quickly established their home base near the site of the automated drug-dispensing cabinets, medication refrigerator, and other pharmacy inventory.

"If something was needed," Pastor said, "the person coordinating things in the emergency department just said, 'I need a pharmacist in room 2.'"

Pastor or another pharmacist would then go to the room and find out what was needed. Once the medication request was known, he said, the pharmacist quickly interviewed the patient regarding allergies, eyeballed the person's size, and noted whether he or she was an adult or child. With that information, the pharmacist would obtain the needed medication and deliver it to the patient's room.

Doses of morphine and other controlled substances were obtained from the supply that one of the pharmacists had removed from the vault in the central pharmacy, Pastor said. Throughout the evening, the pharmacists kept a written log of what they dispensed, he said, with a typical initial entry being "trauma patient 1 with no allergies, adult male."

"As soon as we had the information about the patient's name, we would associate the name to [the initial entry], and then the next day we went back and took care of the billing adjustment and things," Pastor said. In the end, he said, the record keeping came out perfect.

Knoer said when he arrived in the ER to assess the situation, he found that every person working there had a strip of wide white tape on his or her back identifying in handwritten black letters the person's basic identity-nurse, pharmacist, physician, surgeon, and so on. Above the automated drug-dispensing cabinets was a handmade sign identifying the site as the pharmacy.

"I left at 10 p.m.," Knoer said, "because it was pretty clear that we were well under control."

Cooper said most of the extra pharmacy personnel at Hennepin had been sent home before the end of the evening work shift.

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