As Hurricane Iselle moves toward Hawaii, and Ebola rages in parts of Western Africa, I am reminded of all the “what ifs” that the natural world can throw at us.  Last year, I volunteered to join an amazing group known as the Disaster Medical Assistance Team (DMAT), which is designed, equipped and trained to handle many of these “what if” situations.

The Hawaii team, known as DMAT, is coordinated through the Healthcare Associate of Hawaii and is composed of more than 125 doctors, nurses, paramedics and other support staff who can stand up a mobile care facility in a matter of hours.  These modules are stored in large shipping containers and pre-deployed throughout the state.

The team commander is Toby Clairmont, a former Navy corpsman, nurse, and hospital administrator.  Members come from all over Hawaii, and often work in hospitals, emergency rooms or EMS for their “day job.”  In a disaster, the team comes together to fill the gap between the medical First Responders, such as paramedics and firefighters, and the hospitals.

Toby Clairmont

DMAT Commander Toby Clairmont, right, and Aiko Holmberg standing by at the command post on Ford Island in a recent exercise as part of RIMPAC 2104.

Courtesy: Healthcare Association of Hawaii

Last year, when Super Typhoon Yolanda (also known as Haiyan) struck the Philippines, it destroyed much of the local infrastructure in its path.  At that time, a medical team from Mammoth Medical Missions out of California responded and likely saved hundreds of badly injured residents with emergency surgical and medical care.

One of the core functions of DMAT is to offer medical surge capacity.  On any random day, most of Hawaii’s hospitals and emergency rooms are busy, sometimes even full.  Where then, do you put 50, 100 or even more patients who may be affected by a public health emergency, natural disaster or catastrophic accident?  In a matter of hours, the DMAT team can set up a mobile MASH-like care center able to receive, treat and stabilize patients with a variety of illnesses and injuries.

The team recently fully mobilized in mid-July for a three-day training and readiness exercise as part of the military’s RIMPAC 2014.  The Healthcare Association of Hawaii Emergency Services coordinated the participation of hospitals statewide and Hawaii DMAT to respond to a fictional hurricane hitting the island causing numerous injuries and fatalities.

The command trailer and treatment tents were set up on Ford Island in Pearl Harbor in the evening, and the “victims” began arriving the next morning and this continued for two days .  Making the most of the training opportunity, the volunteer victims, who ranged from high school and college students to hospital employees, were made up in full moulage, which simulated horrendous traumatic injuries.

Disaster Medical Assistance Team

Emergency responders used makeup to simulate horrific wounds during a recent DMAT exercise at Ford Island.

James Ireland

All the patients reported to a make-up tent before the exercise, much like you would see on a TV or movie set.  Fake blood was applied to many of the patients, while others were given burns, protruding bones and various impaled objects that might be flying around in a hurricane.  When I spoke with Dr. Sara May, who went to the Philippines after Super Typhoon Yolanda as a member of the Mammoth Medical Missions team, she recounted that many of the injuries they saw were secondary to flying debris.  She told me that the number one cause of injuries she saw was from corrugated metal roofing material that had gone airborne.

In the training scenario, just as in an actual emergency, the victims were initially brought to a triage area where their injuries could be assessed as immediate/critical (red), moderate (yellow), or minor (green).

From triage, the patients were carried by litter to one of three treatment and stabilization areas — red for the critical, yellow for the moderate and green for the minor.  Each of these treatment areas, like the triage area, were staffed by one to two physicians, two to three nurses, and usually two to three paramedics and other support staff.

I worked as part of the immediate treatment team along with another doctor who usually worked at Kaiser emergency department, a nurse from the Straub burn unit, an ER nurse from Maui Memorial Hospital, a Honolulu paramedic, and two military medics.

The patients would initially come in two or three at a time, then up to five or six, about every 30 minutes throughout the day.  Simulated injuries included sucking chest wounds, open abdominal injuries, open fractures and severe burns.  In all, we saw about 60 simulated critical patients that day that had been triaged as immediate.  In keeping with the scenario, patients received simulated IVs, were placed on ventilators, had chest tubes inserted and received medications.

Once stabilized, we quickly transferred patients out to one of 19 participating hospitals throughout the state by both ground and air ambulances, including military aviation.  This is why coordination with the DMAT command and receiving hospitals is key.  In this training, as in a real disaster, it is unrealistic to think only one hospital, such as the designated trauma center, could handle 20 or more patients all at once.  Rather, each hospital is given a small number of patients at a time, maximizing resources and ultimately survival.

The Hawaii DMAT team has two other very important missions that are worth mentioning.

First, the team has an agreement with the Centers for Disease Control, or CDC, to move patients in Hawaii who may need biological isolation.  DMAT has a plastic isolation capsule that can safely hold an infected patient for movement in a ground or air ambulance.  The need for this capability was spurred by the outbreak of SARS, the Severe Acute Respiratory Syndrome caused by a coronavirus, which led to an outbreak in 2003.

If someone infected with SARS had landed at one of Hawaii’s Airports and was quarantined by the CDC, they could then be moved safely to a designated hospital in the containment system.   Such a system could also be used for a patient with Avian influenza or MERS (the Middle Eastern Respiratory Syndrome) which is also caused by a coronavirus and kills about 30% of the people infected.

Ebola is currently being investigated by the CDC and other health organizations due to an outbreak in Western Africa.  This virus is of particular concern because it kills up to 90 percent of people infected and there is no vaccine or widespread treatment available.  While the chance of someone infected with Ebola coming to Hawaii is extremely rare, the DMAT team would use this equipment if transportation was necessary.

The other DMAT mission I wanted to mention is medical support of the Coast Guard for regional emergencies — and by regional, I am referring to just about the whole Western Pacific.  When a complicated medical rescue mission is accepted by the Coast Guard, DMAT physicians, nurses and paramedics may accompany the flight with advanced medical equipment to stabilize and treat the patient or patients until brought back to the hospital.  One recent mission went to Chuuk for a patient with paralysis from decompression sickness, or the bends, after a diving accident.   There have also been recent missions to Midway for a patient with a bowel obstruction and to Kiribati for a victim of a shark attack.

With the incoming storm, I hope the team isn’t needed, but I am grateful they are there for our community and am proud to be a member.

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