Good morning. My name is Greg Miller. I'm a nurse with Atrium Health Med 1 Mobile Emergency Department. And my name is Christy Haynes. I'm the manager of operations for Atrium Health Med 1. The story we're going to share with you today is a disaster response that we shared where we actually ended up setting up a full functioning emergency department in a family parking lot. Basically what we're going to talk about with this group is how a mobile emergency department actually was requested, the logistics of how that happened to get it there, and other lessons we learned along the way. Operating in a remote emergency department had several challenges. And while we had done this for many years, this was the first big 100% full disaster deployment where we had no support externally. And we were on an island, essentially. And also this is for your own community. You would know a resource like this exists and how to move forward with it. You are going to see a lot of video clips without audio and several photographs. These photos and videos are either minor Christy's property, or we have written releases from the patients that are photographed to use their photographs on file. So to set the stage of how this deployment happens, we have been working for well over a year to plan a planned disaster, we like to call it. The World Equestrian Games were coming to Trinidad, North Carolina, which is about an hour from Charlotte, where we are actually based. And there are essentially 100,000 people were expected to come into a small community that in current state had a six to eight bed ER, very little community support. So we had planned for a full year. It's the most complex setup that I've ever been a part of with the mobile hospital. As you can see from the picture, we actually had multiple tract controllers there, we had the mobile hospital and additional multiple tents that we had set up for this deployment. Again, it was a very elaborate setup. When we got the call to deploy to the hurricane, we had been on site about 12 days. And these were 12 very rough days, it was very hot, very dusty, as you can see, we're in a gravel dust kind of parking lot. So we had already started seeing patients at the point when we got the call. So I had been working one day, and it was not uncommon to get called down to the administration area, they would have a question, or there'd be a visitor that had questions, a dignitary. And I got a call saying that the Secretary of Commerce from the state of North Carolina was actually in the office area and wanted to see me. So I went and left by myself, Christy was up at the hospital, she was actually acting as the charge nurse at that point in time, and also our Assistant Vice President was there, Robin, on site. But I went on down by myself and walked in the door, and the Secretary of Commerce told me that we are moving MedOne to the coast. Hurricane Florence had just come through, and they needed a resource for a community that did not currently have a functioning hospital. For me, I had a bit of panic at that moment. We had worked for over a year for this, the immediate panic in my moment was, we're in a contract, we can't leave, we're dedicated, this was a planned disaster, we can't do this. And I actually said those words to the Secretary of Commerce, we can't do that, we're in a contract. And he said, the Governor says you will move this asset, and they actually were threatening to close down the World Equestrian Games if we did not move the asset. So at that point, I panicked a little bit, and I called Christy and Robin down to the site, and we started discussions on what the next piece was going to look like. And when Greg pulled us in, I had a little moment of panic as well, because I was also on day 12 of hyper-focus on how to make this event work, and to treat everybody that came through our doors. So our Assistant Vice President Robin kind of pulled us back in and said, you will make this happen, and kind of guided us along that route. And we had about four hours of planning to be able to come up with a full plan of what we wanted to do, and how we were going to continue to support the World Equestrian Games, as well as take half of our team out to the coast in the aftermath of Hurricane Florence, which was at that point in time anticipated to be a Category 5 hurricane when it hit the coast, and anticipating total destruction. So during this time, we were trying to figure out how do we make this work, and thankfully we had a great partnership with the state. They supplied additional support units that we made into patient care facilities. We moved them down into a sheltered area to provide additional support away from the storms as they came through. And then we had the hard task of deciding who do we take, and who do we leave behind. You know, the teammates that were putting their heart and soul into this event also wanted to be able to get out the door to the disaster, but we couldn't take all of our senior leaders on the team out the door. We had to leave some behind because these are austere conditions as well that they had to work in. So Robin graciously took another leader within our mobile medicine division and put them in charge of the World Equestrian Games, and then I and Greg worked together to kind of divvy up our staff and leave some strong leaders behind, but also bring a strong group of emergency nurses out the door to help see these patients that we knew we were going to encounter in a few days. The big important thing of that is the next morning after we had pulled out, the first patient they saw at 6 30 a.m. was a cardiac arrest patient. Thankfully they had raw skin, had a positive outcome, but this is how important the decision making in these four hours became is to make sure that we could meet the needs of this equestrian event and those out of the coast. So we made the difficult decision on who to take and who would stay behind. In addition to the staffing portion, we had to coordinate how to get that complex compound out of the parking lot that you saw before. So the picture in the beginning of the presentation didn't show all the other assets that came in behind us, so that took a lot of coordination with the administration at the equestrian event as well. There were a lot of tensions that arose on kind of like a turf war of what equipment and supplies would stay behind and what equipment and supplies would go on with the mobile hospital to the coast. But once we got it all figured out and we left, the tensions subsided and we all started working as a team again. One important comment that I remember that really hit home as we were packing up because of all the dust, the heat, the humidity, the hard work, a retired military veteran actually came up to us and said these conditions we're working in and the work that we're having to do right now is something worse than what I saw in Afghanistan. You know, we weren't, just the conditions were quite awful while we were trying to do this and accomplish it and we were very exhausted at this point. Exactly. And the picture you see here, to break down this asset only to have to pack it back up, and we had to pack very compact because we were taking everything we had with us on this deployment, food, everything else. About the easiest you can do this breakdown was six hours and we worked for six hours at least without stopping and we actually left the site that night around 8, 9 p.m. when we drove back in the dark to get back to Charlotte. We did make the decision to go ahead and go back to Charlotte that night. We needed to restock all the water tanks, all the fuel for the generators and trucks, and quite honestly for safety the team was already exhausted, so we felt like it was a safe decision. We would go, we got back about 9, 30, 10 o'clock I believe to the warehouse. The next morning we met at six o'clock and prepared to be on the road at seven o'clock. During the hours that we were sleeping, the storm did come in and as you're going to see here in this video, which there is no audio hopefully, this is us actually pulling out heading to the coast of North Carolina. In this compound we had 36 people traveling in all these vehicles that you're watching. That included trauma surgeons, ED physicians, EMS and disaster fellows from the emergency department, of course nurses, paramedics, we had respiratory health. We did make a decision for this deployment to take a behavioral health specialist that was also trained in pastoral care because we knew we were going to face things that we as regular nurses probably were not equipped to handle. The emotional aspect of what these people were going through having lost everything they had. The other thing that was very unique is we usually do not travel with lights and sirens on in this convoy. They're usually only used as a safety mechanism when we are on the side of the road or when we're trying to get through intersections. Usually we get to the intersection and we turn all that off, but because of the urgency of the situation and the fact that we had to get there and in addition the fact that we were carrying a huge pharmacy with us, the North Carolina Highway Patrol did escort us. There was one in the front and one in the back, so that was a unique experience. If you can imagine being on the roadway in my interstate and look up and see an 18-wheeler coming with a lot of lights and sirens flashing at you and they went on and on as you could see. It was rough and Christy and I think we're lucky enough to be in an SUV and I was thankful for that. I don't enjoy riding the big trucks in that situation. So we traveled for about two hours when we received word from the state that we were not going to be able to go to our destination that night. The feeling of, I don't think defeat is the right word, but just the somber feeling amongst the team of knowing that we weren't going to get to the community that we were ordered to serve was really tough for the team. So we stopped in Raleigh and you can see our convoys parked here in a parking lot that was designated for responders to stop in. It was also challenging because every one of our vehicles was crammed full with equipment and supplies and we used those as lodging quarters once we get on site, but we weren't able to sleep in this area because you couldn't get into any of the vehicles so they were so full of our equipment. So that was another thing that was difficult for our team is to not stay in the camaraderie with all the other responders. We actually had to go over to a hotel to stay for the night. We got back up the next morning at six o'clock and got on the road at seven o'clock again. We had the highway patrol escort us. What should have been about a two and a half hour drive out to the coast took us between five and six hours to get there because the road conditions were so poor. We had to take so many detours to avoid the floodwaters. We traveled down roads that were closed to the public. We actually, I think, went the wrong way down the road at one point just to be able to get into the community of Burgaw. So it was quite the experience to travel down the road. As we traveled and we got closer to the coast and to the community of Burgaw, we began seeing citizens of those communities coming out to their front door steps of their homes or businesses. As they're trying to clean up in the aftermath of the storm, they would stop and wave and cheer us and cry. And we knew at that point that we were headed in the right direction and we were taking on a task that we probably had never experienced before, many of us. There were several teammates on the team that had the experience before, but most of us, this was the first time that we had seen anything quite like this. Exactly. So we traveled and we actually got into the town of Burgaw. Christy and I actually pulled into this Family Dollar parking lot about two o'clock in the afternoon, 205, I think is the exact time. While we were on the road down there the entire time, we were on the telephone with our state emergency operations center deciding where they were going to put us, what kind of spaces we need. To set this mobile hospital up, you've got to have a firm surface. It's very heavy. You've got to have a space large enough to really set up all the equipment and tools that you're going to need. Originally, we thought we were actually going to a Piggly Wiggly parking lot across the street from the Family Dollar. And even when we pulled in there, that was the thought. But that grocery store was able to get some power and open. So the decision was that was not the best decision. So we went directly across the street to the Family Dollar parking lot, which ended up being very important because as you'll hear later in the presentation, the Piggly Wiggly saved our lives, literally, in some ways. So again, we got there about five after two in the SUV. We always go scout, make sure the track controllers can get through. Particularly with this situation, there were several power lines that were down or very, very low that were still energized. So we had to make sure the track controllers could clear underneath those. So we were headstrong, ready to get to work as hard as we could go. When we pulled into the parking lot, that's not exactly what we encountered. No, we pulled into the parking lot and there were quite a few of the city officials. Fire EMS was there. And perhaps one of the most memorable moments in my career so far with the mobile hospital team was when a paramedic walked up to us and she hugged my neck and started crying. And as we were trying to reassure that we were here to help, this is what we do, we didn't realize until that moment the impact that we were having on this community. The paramedic relayed to us how in all of her career, she never thought that she would be in a position that she had to leave patients with treatable conditions in their homes to die because she had nowhere to take them. She talked to patients that had heart attacks, that the local hospital was closed, the floodwaters were so high that they couldn't get patients out of their homes to tertiary care facilities or higher level care. And so she would give them comfort measures and she would have to leave them to go take care of the next patient. And I can't imagine in my career that being faced with not being able to take care of a patient, not to be able to get them the resources they need, not in the same age. And so we started to grasp the reality of what this community was actually going through. And this was, we already had motivation, but this was one more piece of motivation that got us to work very quickly. Exactly. And the guys that drive these trucks, a lot of their background is not medical, and they were energized, ready to get started. And I think it brought us all to a common, let's take a breath, this community needs a lot right now. So it was very, very impactful. Actually, it's still emotional to talk about it to this day. The first truck and trailer pulled in the parking lot at 2.19 p.m. and we started the setup of the complex. Now for the entire time I've worked with the mobile hospital, we've advertised we could see a patient within 45 minutes of arrival. And that is very true. We could have seen a patient within 45 minutes of arrival. The struggle with that is you get one chance to lay a lot of your resources down. The electrical grid is very important. So you can make the decision just to connect the one mobile hospital trailer, but you would have to shut down at some point to connect everything else to the power grid. So we felt like that we would open at 5 o'clock. That was our plan moving forward and we worked very hard in very, very hot, humid conditions to make that happen. Physically, at about 4 o'clock, all the truck and trailers were in place, the doors were open, we had the beds inside the hospital, and we were ready to see a patient. Christy was in another trailer working on the pharmacy and I'll let her share what that happened, but we had to open sooner than we planned. So if you think about the massive amounts of medications that we had to take, the pharmacy doesn't pre-sort them for us. So we were in the midst of trying to sort out about $80,000 worth of medications so that we could get prepared to see our patients. And we had a little tunnel vision trying to get the bed set, the hospital ready. And when Greg radioed myself and said, Christy, your first patient's here, I immediately radioed back and said, we're not ready. And I can appreciate his bluntness with me because he said, well, what do you want me to do with the patient? And at that point it was game on. It was time to adapt and overcome any challenges that came our way. And that's exactly what we did. So within the first 30, 15 to 30 minutes, the hospital was completely full. Word spread like wildfire that we were there to take care of the patients that hadn't had the access to a hospital in about two days, I believe it was. Here in the slide, you can see that the hospital had put up hand-painted signs saying that the hospital was closed and where they were to go for care. And we'll talk about a patient that did deliver a baby and she actually talked about how she went to the hospital and saw this sign and said, what? I'm delivering a baby. I have to go to the Family Dollar parking lot. But it worked. It got patients to where they needed to be. We noticed very quickly that members of the community were kind of coming around and scoping out the compound and trying to figure out what they could and couldn't get from this setup and understanding what the resources were. And a question you're probably sitting asking yourselves is, why was the hospital that you're looking at closed? And the simple answer was all the staff left. This was a Category 5 approaching and they ended up, they were short to begin with depending on tons of contract labor in the facility and those contract laborers left. So they didn't have the resources or staff. There was some damage to the hospital, but it wasn't to the point that it was totally inoperable. But it was mainly the resources to staff it were not available, including physicians and etc. So as soon as we started seeing patients, we started realizing that we had a few gaps. And the first one of those was pharmacy support. The first evening, the patients we were seeing lots of wounds, abrasions, lacerations, things of that nature that had been left unattended for a few days. All these patients needed antibiotics. And we started to realize quickly that there was no pharmacy in the area available to give the medicines. And we realized we did not have the bandwidth or the supply to be able to use all of our medications for outpatient dispensing. We had to keep all we had for the first dose, like ERs typically do. Early on with the state, we were able to work out a resource and the picture you're looking at here, actually Walmart was able to bring in their mobile disaster pharmacy and set up directly in the parking lot with us. This was about four days in this resource got here. But that was a gap that we immediately realized and started the ball rolling. This asset actually rolled out of Alabama to get to us. So immediately we started to realize that there were gaps. And we were getting told at the same time that the roads around us were becoming impassable, that the water is actually rising. So essentially at this point, we were on a deserted island and what we have is what we had available. The second thing the next morning we realized is we were gonna need a lot more space than what we had available with us. The mobile hospital has 14 treatment bays. Two of those are up in what we call the OR, which is a full functioning OR. It's an aerospace, so it gets very tight very quickly. We started seeing patients early that morning and there was a curfew in effect in this area. So from 8 p.m. I believe until 7 a.m., people cannot be out without as a life-threatening emergency. The next morning, patients came and more patients came and more patients came. By noon, we had 20 patients awaiting triage. And we were working on getting some tents set up. That's what you see in this picture here. We knew we needed those tents added and that was the original plan. We just didn't realize how fast this was gonna happen. So when I say we have 20 patients waiting, in an ordinary day, these patients would be sitting in a waiting room. You would still have eyes on them to keep them safe. That was not the case this day. There was a little bit of shade around the perimeter of the parking lot and that's where patients and staff were having to go frequently. It was so hot. People that were already sick and dehydrated had to have shade. So we ended up plugging up portable air conditioners at times just to blow on a crowd of people underneath some shade trees. And that was very hard. The guys worked very hard and got us one tent up fairly quickly. And that became our triage tent moving forward with that. The other thing we started to realize is that we were gonna have extra staff on site to help us. We knew the 36 people we brought were not gonna be enough. So we did reach out to the state and I was very pleased that within hours, they had full disaster teams responding to us from across our state with more building space to sleep, with more tents spaces than we had available. So it really was an amazing feat to see all these teams coming together for a common goal to help the community. And the people you see here are actually from the disaster response teams in that area. I'm gonna go ahead and start with the patient story. This actually didn't happen until day five, I believe. It was the day Christy left and it actually went home. And you see a brand new newborn infant in the mother's arms. For most ER nurses, at least if you're me in my emergency department career, that was a fear I had and something I run from. If they're having a baby, they're going to L&D, they're gonna be able to manage that. Absolutely, we want no part of that. But this is a young lady who presented to MedOne. She had went to the local hospital. She really was in an area that wasn't severely damaged. She had no idea that the hospital was closed. So she built some labor. She went to the hospital and I will say she had put off going to the hospital a little while. She was in full-blown labor, I believe her contractions were about every four minutes when she got to us. And we knew there was no stopping this delivery that the baby Ava storm was gonna come. The reason this is important to realize is it'll help you start to think about some of the struggles we had early on in the process. So in our response team, in the first five days, we really hadn't done any surgery. Traumas were able to be flown from the scene that they were severe enough. They were going directly to a trauma center, which is what needed to happen, we knew that. So our trauma surgeon actually had left the site. He had went back to Charlotte and they did not replace him with another surgeon just because we really weren't utilizing his resource to its max capacity. With him, our CRNA also have went back. We were not doing any anesthesia cases. We were able at this point, the weather had cleared, it was gorgeous skies, the air transport was getting to us very quickly if we needed that backup. But obviously you can't put a patient that's in active labor in a helicopter and fly her to Wilmington to deliver her baby. We also did not have any OBGYN physicians with us. We had our ED fellows who of course had recently done their fellowships and training in OB and they were very comfortable with that aspect. For a normal, uncomplicated delivery. Baby Ava wasn't quite ready to come and she was not a very easy delivery. Actually the mom pushed for several hours, was struggling, was having trouble delivering the baby. And we realized that we may be in a C-section situation. At that point in time, I made a call to the state emergency operation desk. And what's important to realize in these situations is the people that are staffing that emergency operations center, the person I spoke to was actually pulled in from Georgia and she was a transportation secretary from Georgia. So when I said, I have an emergency care at the Med One Memorial Hospital, I need an OB physician to back me up immediately. She's like, okay, what can I do to help you? So I got to the appropriate desk, was able to share what my struggle was. We knew there was a local provider on site and she knew that there was an OBGYN physician very close to us. She physically could not get there because of the waters around us. The state was able to send a state patrol helicopter that went and picked up a physician, dropped her directly on the site. And quite literally, as she walked in the doors, baby Ava was born. And the mom was able to reposition, actually she was able to squat and that gave us what they needed to deliver baby Ava. Also during this time with the situation, we were back there working and the lights went off. And I didn't think a lot about that because there's two sets of light switches, one in the back where we were and another in the front. And it's very common that someone will accidentally flip those light switches off and on. But I did go on the radio and I radioed our logistics supervisor, Ed. And I said, Ed, the power's off. Is everything good? The lights are out inside the OR. And I could hear a change in his voice as I could tell he was sprinting. He went to our generator, which we always have redundancy. And this power had came back on within about eight seconds. Our first and primary generator had had a fire. We were working the generators so hard with all these extra air conditioners, all the equipment we were powering in the heat outside, the generator did overheat and actually they had a minor fire. So then there's another thing you have to start planning very quickly. I called back to the state desk and said, we have a problem. And they were able to get us another generator as well as another state disaster team sent another generator in because one generator could not carry the load of all these heavy air conditioners, all the things we were having to use. So it was very, very lucky that we had that redundant generator. Otherwise we could have had more drama in the birth of baby Ava Storm. And I think her name's very unique. The mom actually chose that name, Ava Storm, based on the storm that she was born in. And we'll probably talk about this a little more later, but since this event, we were invited back to Ava Storm's first birthday party. And then when she actually came home from the hospital, waters had receded and we were in the process of disbanding and closing at day 11. And they brought baby Ava by to see us and say, hey, and to thank us. So again, it's another emotional moment to really think about that, the bond we were able to make and the difference we were able to make with this family. And throughout this deployment, we realized that getting our patients to tertiary care was gonna be problematic, especially when we first arrived. Our transport options were very limited. And this included not just patients to tertiary care, but those that needed to go back to their shelters that they were staying at or their homes. A lot of them had lost the vehicles that they had. So we had to work with community leaders to figure out how we can get these patients to the places that they needed to be. And they did start some shuttle services that allowed us to move patients out of Med One when their care was completed. We also found that there was an inability to utilize local EMS. You have to remember that the EMS providers in this community had been working for, at this point, a week straight without any relief because a lot of people had left in anticipation of the storm being so severe. Also, the floodwaters, even though they had receded enough for us to get into Burgau, within a couple of days of being there, the storm had stalled further west of the state. The waters were coming back down and had risen once again, making us landlocked. And we couldn't get our patients out to the closest hospital by ground. So we started utilizing air transport. And at the conclusion of the deployment, we had flown over 30 patients out of our compound to other facilities in the region. And one thing that was unique in the transport, baby Ava, of course, we were not gonna keep the brand new baby there. So her mom actually was flown out to Duke University and the NICU team actually came to get baby Ava. They sent two separate aircraft because of space. One thing that was unique is Ava was healthy. She was safe. Her sugars were good. She was not in any distress whatsoever. So her mom left first and right behind her, the aircrafter landed to get baby Ava. It was unique because NICU teams were so used to having the IVs in place and all these things for sick babies. And I think it was really challenging for some of those teams as well. They didn't really need the IVs. Of course, our protocol, they did start an IV on Ava, but it was a learning experience, not only for us on that site, but I think for some of the transport teams in the area to realize that they may be transporting people that literally could set up at times in their aircraft. But that's what we had available. There were some military aircraft in the area flying, but there was really no good way to secure patients in those, so we did choose to use medical aircraft for all the transports out. We learned a lot of lessons throughout this deployment. One of the most important ones I felt like at that time was how to feed our team. I actually was pregnant during this deployment. And if you can imagine in the first trimester being a little bit picky about what you can and cannot stomach. We go out the door with an amazing amount of food, good food that feeds our team very well, but because of the size of the deployment, we ran through our resources within the first few days. I had to make sure that the team understood that if you have any special dietary concerns or needs, we would not meet those. A good example is our trauma surgeon is a vegetarian and he wanted to go so bad, he wouldn't tell us that he was a vegetarian, but he packed his own protein. So he was able to meet his own needs and he was amazing throughout the entire deployment, not just from that standpoint, but at day three, because the state had sent us so many additional clinicians to help with this deployment, we had to ask them to bring in food as well because they had not sent enough sustainment for us or for all of those extra personnel. We thankfully did the piggly wiggly, they were able to step in pretty quickly. The Salvation Army was amazing, they brought us some food, but it was less than desirable food. It was very bland, hamburger-ish type patties. So if you can think about working in a hundred degree weather 16 to 18 hours a day, sleeping in trailers with 12 other people, which means you're not getting great sleep, you want some good food to nourish you and to get you re-energized for the next day ahead. So the piggly wiggly did step in and help us get some good home-cooked meals for our team. Other lessons learned were the staffing. So I've mentioned that already with our resources being limited. Once they sent ambulance buses, we had three of those large ambulance buses show up. They were a godsend, they were amazing amount of help for what we were trying to accomplish. But again, the food went out very quickly. We were using two showers now at this point for 55 to 60 teammates or clinicians and staff members to shower, which if you can imagine, that means hours upon hours of taking turns showering before and after your shifts. Living and sleeping quarters, we had to relay to the state that we needed additional vehicles. Ours weren't meeting those needs at that point when those additional buses came in. And then connectivity issues were a huge concern for us. And we found out very quickly that when, we knew this going in, is that when a big storm comes in and there's a lot of devastation, everybody uses their cell phones because their landlines aren't working if you even have a landline. So we use satellite connectivity in those situations. Well, a lot of our teammates have figured out the password to the Wi-Fi and we're trying to take care of their own needs relating to their families, trying to do their homework on their hours off. And it quickly bogged down our system and we had to go around and make sure that we were kicking everybody off. And that created some high tensions, but that was so that we could send images back to radiology via our PAC server, make sure that we were connecting with physicians back home for consults and whatnot. And then there were several other lessons learned as well. Yeah, one of the big other things is we were lucky that we were able to plug into a fire hydrant because as Christy said, 50 showers a day is a lot of showers. And we're very lucky that the vehicle you're actually looking at does have a water filtration system. So we were, I wouldn't have used that for potable water, but we did have the ability to shower. But what we realized quickly is we did not have a way to get rid of all that wastewater. We did request an additional bathroom trailer from the state, which was quickly delivered to us, which was very helpful. Prior to that, 36 people were trying to use three bathrooms. And if you can imagine the tension that was happening there, that wasn't always excellent. So the other thing was emptying all that wastewater, finding a local company that could support that need. We were in a very rural area, Wilmington on a good day is about 45 minutes to an hour away. So there was some support in the area, but getting it staffed and getting the people back to their homes to operate those kinds of businesses, obviously was not a priority. We were very lucky though, that all that did happen. A lot of the local firefighters did work on a lot of those pieces with us and made that effectively work. Specialty providers. So I talked a little bit earlier about who we took out the door and sort of how we made those decisions. It's always a hard decision deciding what do you staff? What do you take and what do you not? So our anesthesia choice, we usually will take a CRNA and we're lucky that we have four CRNAs that are a part of the team that are very, very active. They actually have worked to make sure anesthesia equipment's always in operational status. But when we bring people like the CRNAs on the team, we share with them that you very well may not be getting anesthesia. You may be drawing blood, you may be doing housekeeping kind of duties. So the CRNA Brian went with us and he was starting as many IVs and doing as much as his basic nursing care as he was anesthesia. I think he had one anesthesia case in the five days he was there that I remember. OBGYN, we did realize that was a gap. By the third day, after baby Ava was born, so it was actually day eight, there was a local OB position that had came on site and offered services and we had a phone number to call to reach out because OB-GYN is such a specialized resource. Now it is important to share that we did deliver two other babies on this deployment, so a total of three, but that was a gap. We did elect to take the trauma surgeon with us out the door. Again, we weren't sure exactly what we were going into and what kind of injuries we may end up seeing. But after realizing that the surgeon was not 100% needed, he did go back to Charlotte on day five on the first crew swap. But what was unique about this trauma surgeon, he became housekeeping and bed control. Anytime he saw a spill, he had his broom and his mop and that became his role. And it was quite funny, after his first minor OR case, and it's a simple IND that he had to pack, he said, who cleans up this mess? And jokingly, Christy, I believe said, you do. And after that, to see him transition and become a full-time housekeeper, literally when he was not needed as a surgeon, and he had his radio. So he would radio to the triage tent, we have one bed available, two beds available. And really everyone on the team has to be very, very flexible in what they do. Radiology is another unique specialty. All the nurses on the mobile hospital have been trained to do X-rays. With that being said, we're not the experts at doing X-rays. And I think the first day, some of the ED providers that were there were used to requesting these elaborate specialized positions and things like that, that we were not able to meet that need. So radiology is a high importance, and we ended up making sure that's always a priority for us to go out the door with. Radiology staff, now we are able to transmit images back to a radiologist to read those. One other comment I'm gonna make here, because I'm afraid I'll forget to mention it later. After this deployment, several of the ED nurses that work with these providers in the trauma center on day in and day out said that this deployment changed the young providers. Before they were used to practicing preventative medicine, they would CT everything, X-ray everything prior. After this deployment and realizing that their resources would not always be available, they said this changed their practice long-term, that they were able to be more assessment-based intervention and diagnostic versus just mass ordering a lot of tests that weren't 100% necessary. Another struggle that we came into actually on the second day of the deployment, lots of local physicians were there on site. These were family medicine physicians that were coming, they wanted to be a resource, they wanted to help. We were still acting under the direction of the state and our local hospital system that we're a part of atrium health. We just couldn't let any doctor come in and practice that we could not verify their credentialing. Yeah, they say they're a doctor, but there was no way set up at that point in time to verify credentials. We did get that by day five, but we were very lucky in the circumstance. There were shelters all around us and we did have several paramedics with us that were traveling and one of the guys was specialized in community paramedicine. That was his full-time job. He actually suggested to the family medicine doctor, he said, hey, why don't you and I jump in a car? Let's go out to the shelters. Let's see if there's some minor things we can treat there to keep them out of the MEV-1 area, to keep those beds from sick patients. That worked phenomenal. They were able to go take care, set up a small area to do minor things in the shelters. They could do screening top exams for the chronic medical conditions. Lots of people were out of glucometer strips. So something as simple as being able to check blood sugars, get them insulin. Lots of times they were using insulin that had not been refrigerated, things of that nature. So that was a huge resource. So you could always find a way for local resources to help and not turn them away and make them angry in a situation, in a disaster like this. and that actually worked very well for us. This is a great picture here of just showing one of the procedures that occurred with one of our ED physicians on this deployment. And if you take a close look at this, you can notice there's a lot of supplies being used. This is a very minor procedure. And so this was a good reminder to really think about what we were doing for our patients, making sure they were getting the best possible care, but not overusing critical resources. We depleted IV catheters, IV start kits, blood draw kits, very, very quickly. We went through a lot of medications quickly. So about day three on site, we had to have an additional cache of medications and supplies flown in to us to be able to meet those needs. So this actually brought us back to preparing better for the next disaster deployment and making sure that some of these high use items, we have a higher quantity stock in them, but also working with our physicians and fellows to make sure that they're only using the supplies that they actually need. We can use additional staff to open more supplies if they're needed and not just opening the whole gamut of them just because you might need something. So we did. Thankfully, we were supported by our organization back home and they were able to fly us a lot of supplies via helicopter to sustain this mission. The next challenge that we had was media. And really we did not take a public information officer out the door with us. That would have been one of the 36 beds we had available and one mouth to feed. And we felt like initially our focus needed to be on the clinical providers and making sure we were taking care of patients clinically. I had previously spoken to the media on deployments and that's something I'm comfortable with doing. The struggle with this deployment was they were showing up right in the middle of the critical moments when we had 20 people waiting for triage, when we had a hospital full of patients that needed help and the clinical staff were needing my support more than media in my opinion. I first tried the approach of if I ignore them long enough, they'll just leave and they won't have to worry about me. That is not the case. They would sit and they would wait. And we had national reporters. I do believe at one point in time we had ABC, the show is actually on the Evening News with David Muir at one point. So high level media interviews. And they weren't always kind in what they were asking. You know, we were doing a hero mission and one of the questions that they asked me is do you think it's ridiculous that the local hospital closed and that you're having to be here? And quite honestly, that statement angered me and I was pretty much done with that interview when that happened. But they were asking things I was not prepared for. But again, I would always recommend make sure you have someone on the site that has had some experience in talking to the media, just some basic pointers in doing that. And again, it was every 15, 20 minutes for the first couple of days that media was on site and they were not taking no for an answer. We also had to make sure we had releases signed from any patients that they wanted to get photographs for. So we had to make sure that paperwork was available. Initially, it was not. We had to have that email back to us. So it wasn't a problem. It was just one more thing to take time when the patients were needing that time a lot worse at that point in time. By the third day, security is a very, very important factor. I won't speak to that in just a moment, but we had ALE on site with us. We had two officers 24 hours a day, and they became the bulldogs. When they saw the media, they knew where to put them, and they kept them at bay. So they weren't just getting in our compound and filming things that they should not be filming. So on top of seeing over 100 patients a day and mostly in a 12-hour period, staffing took up a lot of our time and our resource of trying to prepare how we were going to maintain this mission. One of the big challenges with staffing was the state was sending us individuals to work with us that had not been trained through Med 1. They provided excellent care, but they also, we didn't understand their clinical capabilities. We didn't know where exactly we could put them, and with any organization, you learn that pretty quickly, but that was a challenge for us. We also were having to tap into resources from our own healthcare organization of teammates that weren't formerly trained with the Med 1 team, which provided some other challenges. With this conglomeration of people from all over the place, not just within our organization, but outside, the leadership on site started to notice some budding romances and relationships that we don't typically see with our full-time teammates. So that put in another curveball for us to deal with and to make sure that we were leading the team properly and keeping these things from occurring on the compound. Logistics that surrounded crew swap-out was quite complicated as well. If you think about exchanging 30 to 40 staff members every five days, getting transportation available, we contracted with a company, and the company actually showed up in the wrong location one day during crew swap-out. So they were supposed to show up at Charlotte at six o'clock to pick up the new crew and then take them over to Burgall. Well, instead, they accidentally went to Wilmington and were at Wilmington at six o'clock in the morning instead of at Charlotte. So that put that crew swap-out very late that day. And if you can imagine, after five days of working, the staff is ready to go home. They've missed their families. They're tired. They're exhausted. We do make teammates go home after five days if we have the ability to get them home. Many of them don't want to go, even though they are tired and worn out. But we make them go because of the mental health well-being is the top priority for our team. A lot of times, they'll come right back after a five-day rest period. But we find that that's extremely important. The other thing that you have to think about when you're staffing something like this is your staff is always on call. So our shifts were 7A to 7P and 7P to 7A. But you always had to make sure that staff realized they were subject to callback. And that can be a challenge. They can be a little huffy and say, I'm not on duty right now. But we have one unique situation that I think is important to share with the group, one of our providers. So when the first baby was born, the physician, as Greg was talking to you, it was a difficult delivery. The physician that was actually working in the hospital needed some additional support. So we did wake up the other fellow that was sleeping in the trailer to come help. Of course, it's an emergency situation. So she gets up and comes straight into the hospital. Well, some of the pictures that made it on different news media outlets, she's in a tank top. So we learned a lesson from that. And we actually had to institute a policy that you're not allowed to wear a tank top while deployed. And clothing has to be of a certain nature. It can't have certain advertisements on it. Because of the fact that we never know when we're going to be on camera. We have to present ourselves in the most professional way possible, even in these austere conditions. The other thing I spoke a little bit about that's very important for us is security. So as Christy said, we had a full cache of pharmacy with us, including narcotics. All the good stuff, I guess, is a good way to put it. Every deployment we go on, early on, you'll start to see the community start to check out what we are. You'll have a few patients that we'll present just to test the waters, to see can they get a prescription or can they get something that they would not have been able to get in an ordinary day. They're usually pretty sad. The answer is no. We're just as strict as any other emergency department. So security becomes very, very important. As you can see from this photograph, we try to position our vehicles so that the vehicles make a barrier. But in this circumstance, people were coming from all directions. You can see directly across the street. It was that piggly wiggly. And people are curious about what we are, how we operate. So we did end up, after this picture was taken from the air, get some fencing brought in and we become a full fenced in security compound. After Walmart was able to get the pharmacy there, they did fence us in 100%. And as I said, in this circumstance, the state does provide our security resources for us. And it was the ALE. And at first, I sort of, the ALE, what are they going to do? Are they going to keep me safe? I could not have asked for a better security team. They were nothing short of amazing. And I will tell you, nobody would have gotten past those guys. They were bears and they protected us. And still to this day, I'm friends with a couple of those guys, at least social media wise, that helped change us. At the same time, one of the ALE officers ended up wanting to pursue a medical career because of this. He was able to see what we do. He was so intrigued by that. So it was a very, very important role for the security function and we were very blessed to have that. On day 11, we received a word from the state that the local hospital was going to reopen. They wanted us closed between noon and one o'clock in the afternoon, which we were, it was a bittersweet moment. We were excited to be able to pack up and go home, but we were sad to leave this community. And we quickly realized the community was equally as sad to see us go. They really did become dependent upon us. As we were closing our doors, we did stay the rest of the entire day just to help redirect any patients back to the local facility. I actually had to escort several families over there to follow up with their vaccination records to make sure that they were getting their follow-up medications as needed. And we have a lifelong impact on those who have served and we've kept in communication with several families. Baby Ava Storm, her family is amazing and they reach out to us each year to let us know when her birthday comes. We have a teammate that joined the team after this deployment. Her parents actually live in Burgaw and came and brought the team cake in the middle of it, not knowing that their daughter down the road would join this team. So it's a huge impact. We just had a long conversation about that last week. We saw almost 1,000 patients in 11 days. Again, we averaged 100 patients during the daytime hours. We did have patients at night. Those tend to be a little more critical or needing some more resources because they did have the curfew while we were there. Demobilization took a day and a half to break down and pack up. We always have to make sure that we're ready for the next disaster deployment. So we can't just shove things in every vehicle. We had to make sure assets were returned, like the generator, the restroom trailers, the extra lodging, and the tent structures that we had the state bring in for us. So it took us about a day and a half and then we headed home. And I will share one personal story. I actually stayed the entire time. I was supposed to leave on the day that we found out we got our demobilization orders. So it really wasn't worth it at that point in time to go home. But the night before, one other gentleman, Ed, had stayed the entire time. He's a supervisor and is very, very committed to the mission and has a hard time leaving the asset, just like I did at this deployment. But we decided to leave the compound one night and simply go to McDonald's to get a cheeseburger to eat. We were tired. We were grouchy. And people, they just like to ask us a lot of questions and that kind of thing. So we went over to McDonald's. It was so impactful. We were sitting at a table and we had our dinner and there was not a single person that entered that restaurant that did not come over and thank us with tears rolling down their faces that night. Specifically, one patient came in that we had flown out. She had had a cardiac issue and had actually had a stent and came back. And just her weeping over our table as we had dinner. As Christy said, it is a lifelong impact. It's a memory that I will never, ever forget. So we got packed up. We broke down the asset. As Christy said, that took a day and a half. And on that second day, we did decide to make the trip the next day. So that night, we did go to Wilmington. We did get a hotel. And everyone, I believe, did get their own hotel room, if I remember correctly. The hotel had been closed and we were the first guests back since it reopened. We each went in our room and had big, huge dehumidifiers. But we didn't care at that point. We were just ready to have a decent shower and a little bit of privacy. So we traveled the next day. I think we left Borgo around 9 a.m., if I remember correctly. We did have to delay that just a little bit because of media. When you depart, that is usually something you have to think about, is the media likes to capture you leaving and all the goodbyes that you have. So we had traveled several hours and we had stopped at a state rest area on the interstate to use the restroom. Someone made a decision to turn a truck off that was stubborn and the truck did not want to crank back. So all the guys were tinkering, working on that truck. Actually, we were at a point of deciding to leave the truck there and we had unloaded the critical equipment into another trailer. Well, I got a cell phone call. And it was the state calling me back from the Emergency Operations Center and I realized who it was and I grabbed Christie and we went over sort of in the woods. And it was the state calling to request us to redeploy to another hospital at the coast. This hospital needed specifically OR support. Some equipment was damaged and a part of their OR was unusable. So here we are at day 13, I believe, for some of us on the road and we're broke down and already frustrated. And we're now needing to turn around and go back to the coast. So at that point, Greg looked at me and Greg didn't mention this in the beginning, but during this deployment, Greg was the director of Med One and has since taken a position elsewhere, but still is a nurse with our team. And he looked at me and said, Christie, you're the manager. So am I going to deliver this news or are you going to do it? And I took a deep breath and I said, I will take care of this. So Greg and I walked down the hill to the team together and they were waiting for the orders to go back home. And they knew because they saw us sitting there, they saw our shoulders go down and we got the word that we were probably going to go on another deployment. And so I relayed to the team who was ready to get home. They're ready to sleep in their own beds, ready to take a shower in their own showers and said, guys, we're probably going to have to go to another deployment. I know this is not what we planned. Many of you have been here for an extended period of time. So who needs to go home? I can start working on staffing and you could see everybody's face of, oh my goodness. But not one teammate there that day said they wanted to go home. Every one of them said, if there's another mission, we're ready. They knew it was going to be a lot of hard work, but every one of them was calling their family saying, hey, we're probably going to go somewhere else. And we were lucky that at the last moment that mission did get canceled. They needed a lot more surgical capacity than what our asset had to offer. So we did get canceled. But again, as Christy said, the fact that we offered to send a couple of SUVs on to Charlotte with people and not one person said, I want to go back home. Yeah, it was an amazing experience to see everybody step up and ready to go to the next. So the current state of bed one, since this deployment two years ago has changed quite a bit. We now have our second mobile emergency department that is in use. We have one, the one that you saw throughout the pictures is currently deployed. The second one is ready to deploy when a disaster occurs. We're always waiting and watching. As we film this presentation, there are two tropical storms out in the Atlantic. One that's predicted to become a hurricane and either today or tomorrow. We're watching, we're ready. We're always packed and ready to deploy. We now are taking in COVID safe measures, not only for our patients, but our teammates, which means additional planning of lodging or sleeping quarters, restroom, bathroom trailers, shower trailers, additional dividers for our lodging quarters. So we're working on that COVID safe environment and always ready to deploy at a moment's notice. And as far as references go, again, I reiterate these photographs and videos were either mine or Christy's pictures or team members that gave us permission to use those photographs. So I'm going to jump back two slides, actually. The trip home. So once we did arrive in Charlotte, this is what we were greeted to, with some yelling, which I'm going to mute that so you don't have to listen to that. All of our hospital administration wanted to have a party for us. They wanted to celebrate this mission. And we learned very quickly. All the team wanted was to go home. We already had to sign duties. We had to refill all the water tanks, as Christy said, because there was actually another hurricane at this point, Hurricane Michael was forming. So if you're in an administration in any way and you have a disaster response team, just a lesson learned. The last thing your staff is going to want when they first get home is a party, food or anything else of that nature. If they're going to want to get their stuff, get their bags, they're going to want to head home. And as Grace said, it was greatly appreciated by the team that the administration was there to celebrate us coming home. It was, we didn't want to hang out and have cake and food afterwards, the teammates really, and us included. We were exhausted. We wanted to get our job done and we wanted to go home to our families. Exactly. So that concludes our presentation. Again, this was a very life-changing, special mission for us. As Christy said, I've since left the team, but when I accepted my new position in a different healthcare system, my criteria in accepting was I could remain a part of this team because it's a life-changing team and it means so much to me that we can serve the mission that we can. If you have questions, you're welcome to email Christy or myself. We'll answer anything that we can for you. Christy will be your primary contact because she is still full-time the manager of MevOne now. And it's Christy, K-R-I-S-T-Y dot Haynes, Haynes at atriumhealth.org. Am I right in that, Christy? That's correct. All right. And it's been our pleasure to speak to you guys today. I'm sorry we're not in Vegas. We were looking forward to having Christy's birthday party in Vegas while we were there. So thank you for watching our presentation. Again, it was a very special mission for us and we're proud to share the story. Thank you.

disaster response

emergency department

mobile emergency department

Hurricane Florence

staffing

logistical issues

pharmacy support

lessons learned

community impact