Keeping calm in case of catastrophe

A young man groans as hospital staff in full biomedical hazard protection suits wheel him into a decontamination tent. They cut off his shirt as water from outdoor showers rains down on them. They wave a wand-like device over his chest wounds to detect any radioactive materials.  

“No radiation!” one of the staff yells, and they proceed into the Emergency Department (ED) entrance at Penn Presbyterian Medical Center (PPMC), as another patient enters the tent, wailing about a wound on her arm. 

No, there was not a radioactive explosion in Philadelphia. Every March, departments across the hospital participate in a mass casualty incident (MCI) drill, where medical students in the Perelman School of Medicine’s Wilderness Medicine elective pose as patients who were struck by a radioactive bomb.  

Immediately after the drill, representatives from each department meet with Jonathan Bar, MD, director of Emergency Preparedness and an assistant professor of Clinical Emergency Medicine, for a “hot wash,” or a facilitated discussion to identify drill processes that worked well, and any concerns or proposed improvements for procedures in the Emergency Operations Plan.  

Emergency preparedness isn’t limited to these large-scale drills for catastrophic events like this, though. For a small, but dedicated group, it’s a non-stop job.  

A world of make-believe: how to plan for the unimaginable 

When a crisis occurs, as when the COVID-19 virus made its way to Philadelphia in March 2020, it might seem like the events are unprecedented and experts and hospitals are building their responses in real time. In fact, Penn Medicine has a dedicated Hospital Emergency Response Team (HERT), which monitors for threats, plans responses, facilitates drills, and coordinates with agencies across the region before a crisis ever occurs.  

All hospitals have some iteration of an emergency readiness team, but these can vary widely depending on the staff and resources available. Assessing hazards, building plans, orchestrating drills and training sessions, and training staff is a full-time job, and many HERT members do it on top of their clinical service in the ED.  

From the advanced intensive care units, to hyperbaric chambers, to a helipad that can accommodate military aircraft, many Penn Medicine hospitals can provide specialized care to the most critically ill patients, which makes them crucial assets to provide care during a crisis.   

Every HERT includes physicians, nurses, security, and other staff who are the first line in a crisis. They create plans for how every department in the hospital should handle a specific emergency, and teach the rest of the staff if an emergency unfolds.  

“Emergency medicine can be a world of make-believe,” said Jeffrey Henne, safety manager at the Hospital of the University of Pennsylvania (HUP). “No matter how experienced or prepared you think you are, things always come up that you’ve never seen before. Deciding what to prepare for involves a certain amount of creativity.” 

Year-round, Henne works with John Wierzbowski, MSc, MPH, CHEP, corporate manager for Enterprise Business Continuity and Emergency Operations, and other HERT members to monitor for range of threats to the health system.  

“A lot of these end up being nothing burgers,” Bar said. “But being aware of what could happen and making a plan for managing it safely is what’s important.”  

Every year, the HERT compiles a Hazard Vulnerability Analysis, which evaluates possible threats to the health system, and ranks them based on their likelihood and impact. Then, the HERT develops plans and trainings for events with the highest likelihood and highest impact.  

“There are events, like a nuclear bomb hitting Philadelphia, that would be catastrophic for both providers and patients. We would need to know how to continue caring for existing patients while managing an influx of newly injured patients, all the while keeping our staff safe. But the likelihood of this happening is pretty low,” Bar said. “The chances of a cyber attack on our medical records or having an Internet outage is much higher and would hugely disrupt our operations. So, in this case, it’s more important for us to develop a plan for an adverse Information Services event than for a nuclear bomb.”  

When ‘nothing’ quickly becomes ‘something’  

Emergency readiness can sometimes feel like putting in a lot of work for something that never comes to fruition. But, in rare cases, the advance planning makes all the difference.  

In 2014, as the deadly Ebola virus spread to the United States, the HERT at Penn Medicine developed a plan for managing biohazards, including the extremely contagious virus. The plan outlined what personal protective equipment (PPE) staff should wear, treatment protocols for triaging and quarantining patients, and who to contact at local and national agencies, like the Philadelphia Department of Public Health and the Centers for Disease Control and Prevention. While the Ebola virus never made its way to Philadelphia, another deadly and contagious virus did a few years later.  

The plan for triaging patients in tents outside the hospital entrance while staff wore PPE was instrumental in Penn Medicine’s response to the COVID-19 pandemic in 2020. Thanks to their extensive planning for Ebola, PPMC was able to quickly set up tents and establish a triage system for patients coming through their emergency department that kept both patients and staff safe in mid-March, even before stay-home orders had been issued, and cases in Philadelphia were still low. In less than a week, all Penn Medicine hospitals had similar structures and systems in place.  

“COVID-19 wasn’t exactly like Ebola, but we had the processes and systems in place to work from,” said Bar. “We didn’t have to start from scratch, and in situations like a pandemic, that saves lives.”  

Planning for the unknown unknowns 

“People who work in emergency preparedness are catastrophizers,” said Jack Welsh, RN, BSN, a nurse in the department of Emergency Medicine at HUP, and HERT leader. “While in any emergency, there are things we won’t be able to anticipate, we try and dream up all possible scenarios and prepare contingencies for the most likely things to go wrong.” 

Welsh recently developed an emergency response manual for any type of radiation emergency—from a nuclear bomb explosion to an accident with radiological equipment on campus, to managing a patient with radiation toxicity. 

The document assigns specific tasks to staff throughout the health system that should trigger as soon as the event starts. For instance, the plan identifies which individuals in the emergency department are to lead the response, and what tasks to delegate to their respective teams, along with creating a command center where leadership and information are centralized.  

The plan outlines roles for every department that an emergency might touch, including pharmacy, to coordinate medications, laboratory medicine to test samples, environmental services to manage waste, and security and reception to manage patient safety.  

“Most important in any crisis is clear communication,” said Welsh. “If we can establish in advance who is in charge of what task, there’s less confusion during an actual emergency.”  

Welsh also partners with Bar to train staff on managing various emergencies, and they lecture at the local, state, and federal level on best practices. For example, they coordinated a workshop taught by experts in the field to teach staff the best ways to protect themselves in the event of a radiological emergency, how to use a detection device to determine if a patient is contaminated, and how to treat patients with pharmaceutical countermeasures like iodine.  

“While there is a lot to plan for in the event of any given emergency, we also have to be realistic about training staff and using their valuable time,” said Welsh. “We can’t be taking up an entire afternoon with a drill or a workshop, or else staff will burn out.” 

Instead, Welsh and Bar got creative, and host brief skill refreshers every third Sunday morning for staff.  

“We try and make it fun for them to learn so we’ll bring breakfast and train a dozen or so folks on one topic for about 20 minutes,” said Welsh. “We’ll call it ‘Bagels and Bleeding’ and learn about massive hemorrhage management. Then when there is an emergency, these team members can train other staff on these specialized skills.” 

This was the case during the COVID-19 pandemic: a small team of staff had learned about PPE and how to respond to biohazards, like a very contagious virus. In 2020, these individuals were already subject matter experts, and were able to quickly train other team members in proper protocols.  

Incorporating disaster preparedness in large event planning  

Certain large events in Philadelphia require even more preparation, planning, and coordination between dozens of different agencies and organizations.  

“Not only does the planning and coordination required for these events protect the community during the event, but they also serve as rehearsals for unplanned disasters, helping to build relationships and optimize communication with outside partners in advance,” noted Bar.   

In 2015, Pope Francis visited Philadelphia for two days, which required massive preparation at Penn Medicine facilities throughout the city. Employees slept on air mattresses to circumvent traffic restrictions, pharmacists stockpiled medications, and plans were developed in case of a mass casualty incident that would send patients to the hospital.  

Similarly, the team at Lancaster General Health coordinated logistics for nearly two years in advance for their role as the medical provider for the five-day U.S. Women’s Open golf championship this spring. They ordered supplies to treat a variety of injuries and illnesses that athletes and spectators could suffer from, and devised plans to circumvent practical challenges, like how an ambulance would access the course, which isn’t designed for full-sized vehicles. This event also required coordination with Lancaster Emergency Medical Services and the U.S.  Department of Homeland Security to prepare for a possible mass casualty incident.  

Now, preparations are already underway for America’s Semiquincentennial celebration, or 250^th anniversary, which will include a number of large-scale events throughout Philadelphia in 2026. The year-long celebration will include the FIFA World Cup soccer championship matches, March Madness Men’s Basketball Tournament, MLB All-Star Game, and 108^th PGA Championship, in addition to massive Independence Day festivities. 

On top of drills at Penn Medicine facilities, Henne and Wierzbowski will be coordinating training exercises with government agencies, similar to the dense urban training exercises Penn Medicine staff participated in during the summer of 2022.  

“Not only do we want Penn Medicine to be ready for the worst-case scenario in 2026, but we want to use our expertise to teach other health systems and organizations best practices, so that all of Philadelphia is protected,” said Henne.  

Our duty to our community 

Welsh underscored that not only is the HERT meant to engender confidence from the community in the event of a catastrophic event, but also among health system staff.  

“When a crisis happens, it’s scary—we all remember what it was like at the start of the pandemic. But this prep is meant to majorly account for staff safety during an emergency. If we can’t keep our own people safe, we can’t keep our patients safe, we can’t keep our community safe.” 

The HERT also emphasizes the importance of coordination between Penn Medicine hospitals for emergency preparedness.  

“Leadership has been such a great advocate for our work, and they make it easy for us to communicate between facilities to coordinate our response to various threats,” said Wierzbowski. “HUP and Penn Presbyterian Medical Center sometimes have a lot more experiences and resources for emergencies, and it’s hugely beneficial to everyone when we’re able to share that wealth.” 

“Emergency preparedness also makes us better at caring for patients overall,” Welsh added. “Emergency medicine is a volatile specialty on a good day, but it helps to be prepared for the absolute worst case, so that you can be calm and attentive to every patient you treat during a disaster.”  

“On a regular day, the average person isn’t thinking about a crisis, about who will care for them during a catastrophe, but the HERT is always thinking about that,” said Bar. “It’s our duty to provide the best possible care to the Philadelphia community, even on the worst day imaginable. This is what we train for.”