ML20054J101

Testimony of C Maxwell Re Organizational Response of Four Hosps Closest to Plant.Recommends Future Planning Efforts

ML20054J101
Person / Time
Site:	Indian Point
Issue date:	06/15/1982
From:	Maxwell C PARENTS CONCERNED ABOUT INDIAN POINT, PUBLIC INTEREST RESEARCH GROUP, NEW YORK, ROCKLAND CITIZENS FOR SAFE ENERGY, UNION OF CONCERNED SCIENTISTS, WEST BRANCH CONSERVATION ASSOCIATION
To:
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h!y name is Christopher WLw ell. I am currently Director of

!Sspiratory 'lherapy at Conmtinity General Ostoopathic Hospital in Harrishttrg, Pennsylvania. I also sorve as Ad,junct Faculty, Allied Health, !!arrisburg Area Ocntnunity College.

Afy tr: tining is in respiratory care and in the care of the critically ill, particularly in the area of mechanical ventilation of patients in acute respiratory failure. I raceived an Associate in Irtters, Arts and Sciences fran the Pennsylvania State University in 1975 and a Bachelors in Ilealth Care and Adninistration frcm _

Ottawa University in 1981. I mceived my training in respiratory care at the Advanced P.espiratory 'Iberapy Program at the University of Chicago IIcopitals and Clinics in 1978. I also attended Advanced pmgrmns at Tuf ts University and at Georgia State University. I am currently both Certified and Registered by the National Board for Respiratory 'Iherapy. I wn a ramler of the American Association for Respiratory 'Iherapy and of The Society of Critical Care Medicine.

Kly paper "llospital organizational response to the nuclear accident at Three hfile Island:Inplications for future-oriented disaster planning" American Journal of public !!ealth March,1982, is attached to this written testimony. The paper uns prepared following the 1979 incident to b cr M

40 illust rate the lack.of nxxiical preparation for area-wide evacuation. 1ho 00 g paler dercribes organizational r s;mnse of th" four clos"st hospitals to (u

-o tho plant.

'the paper also nuker, reconnendat ions for future planning of fort v.

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IMring the 'INI incident I was insido the 10 mile risk zone and had the O$ opportunity t o observe disant er res;rnse and the preparation of crash (D O.O plans for t he travurent of inst i t ut innalimi pat ient s.

_s AntERICAN e JOURNAL

" Health regrim, 1

1 Hospital Organizational Response to the Nuclear Accident at Three Mile Island: Implications for Future-Oriented Disaster Planning CitRisroeliER h1 AXWEt.t., llA, RRT Abstract: The 1979 nuclear accident at Three h1ile capacity, but retained bedridden and critically ill pa-Island (Thil) near liarrisburg, Pennsylvania, caused tients within the risk-zone, No plans existed for area-severe organizational problems for neighboring health wide evacuation of hospitalized patients. Future-ori-care institutions. Dauphin County,just north of Th11, ented disaster planning should include resource files of contained four hospitals ranging in distance from 9.5 to host institution bed capacity and transportation capa-13,5 miles from the stricken plant, Crash plans put into bilities for the crash evacuation of hospitalized pa-effect within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of the initialincident successful- tients during non-traditional disasters. (Am J Public ly reduced hospital census to below 50 per cent of Health 1982: 72:275-279.)

fntroduction response plan involving the area within a two mile radius surrounding the plant. The county to be discussed (Dauphin)

From htarch 28 to Apnl 4,1979, the nuclear accident at had an evacuation plan (updated in 1978) that included a five Three Mile Island (TMI) caused particular stress on the mile radius around TMI. This area contained three nursing surrounding health care system and found it ill prepared to homes and no hospitals. As evacuation plans were expanded deal with community-wide evacuation. Area hospitals found during the incident, the five mile radius was increased to 20 existing dhaster plans inadequate and developed evacuation miles, which included 14 hospitals and 62 nursing homes.

plans both spontaneously and in concert with local emergen. Ilospital disaster plans generally include the managment cy management agencies. Crash planning was hampered by of an influx of trauma cases and provide for the limited the technical complexity of the accident and by conflicting emergency evacuation of patients. A flood, conflagration, or information from the media, from TMI, and from the Nucle- bomb threat can result in the transfer of patients and the ar Regulatory Commission (NRC). During the first three short-term curtailment of operations. The evacuation of a days, governmental direction to hospitah was very liinited hospital, however, is very rare, and has been an event (undoubtedly due to the lack of a precedent); however, at the restricted to a limited area.11ospital organizational response height of the crhis,150 governmental agencies participated to the nuclear accident at TMI provides an opportunity to in ad hoc emergency activities. Following a meeting with review disaster planning-planning that, after TMI, can no local emergency management olliciah 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> after the longer be restricted to fire, flood, and trauma. Ilospitah initial release of radioactive material from TMI, area hospi- must now include the possibility of area-wide evacuation of tah developed both coordinated and individualized response facilities and must plan for the transportation of bed ridden strategies. and critically ill patients to host institutions during arca-wide At TMI, the emergency measures required by the NRC emergencies.

as part of its beensing procedure insluded an emergency Dauphin County Hospitals Addrew repnnt requests to Chnstopher Mamell. IIA. RRI.

thrector, Respiratory Therapy Commumy General Osicopathic Dauphm County bec Figure il contains four hospitak llospital. l'O llos Min. 4100 l.ondonderry Road. if arrnburg. PA that were in the immediate rhk tone. l.oeated in liershey, 17105. The author as aho Adjunct I aculty, Albed llcalth, liarriv the Milton S. IIershey Medical Center of the Penn9 1vania burg Area Commumiy Cottege. 't hh paper, submitted to the Journal June 29.19HI, was revhed and accepted for pubhcation October 19 State Unhersity tilMC) was the closest to TMI 19.5 miles 39x1. NNF.L Community General Osteopathic flospital ICGOlli Editor's Note: see aho related editorial p 2t7 thn inue. I10.o miles NNW); liarrhburg flospital tiill) (10.5 miles AJPH March 1982. Vol. 7'2, No. 3 275

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COMMENTARY census hgures t Alarch 2M-Apnl 2.197W are deladed m Iable

1. Estimates of concurrent area wide spontaneous evacua.

tion vary from 20-35 per cent' to W per cent

• of the total population. by h1 arch 31, more than 200.tMM) people had fled PMC CGOH C "'"*"" the area?

HMC Other strategies to reduce inpatient census included the DAUPHIN canceiiation or aii but emergency surgery and the restriction N"H of admissions to hfe-threatening emergencies. Together COUNTY these methods allowed hospitals to stabilize their census at a

.I N manageable lesel should total evacuation hase become nec-I

\ '- - essary. It is important to note that those patients retained in the hospitals were unable to be easily moved or were in

\ ', critical condition, including those at all hospitats requiring l

9", 7 . .. life support systems in Intensive Care Units.

i ti N*w, StaDing N

s Predictably, the conflictmg responsibilities to family and to work resulted in escalating staffing problems as the FictmE 1-Imtance from and location of Dauphin County ilmpl-crisis continued. Nursing and ancillary support staff w ho had tais from uti young children felt considerable pressure as it became evident that the problem at TA11 was unlikely to be resolved NWn and Polyclinic hiedical Center iPhtC) t 13.5 miles NW) quickly.* hiany elected to leave the area to protect their families. Some workers and managers moved family mem-are all hicated in greater llarnsburg. lhe combined bed bers to points outside the risk zone and then returned to the capacity of these four hospitals is 1.561.

lhe author considers information from these hospitals hospital for extended periods of time. The calculated dis-charge of ambulatory patients to their families decreased the to be representative of disaster planning during the accident, need for full staffing and this,in conjunction with scheduled The time frame of the acute phase is h1 arch 28 to April 2, reduced weekend staffing, allowed many nursing and techni-1979. Recoscry from the incident is generally considered to cal staff members to leave the area. liowever, by the fourth have begun April 4. Ilospital organizational response may be f

' divided into five categories: census reduction, staffing, ad- day of the incident, some hospitals were forced to consoli-date remaining patient units. One institution offered over-ministrative response, emergency /cntical care sersices, and time pay for any hourly rated employee working Starch 30 hospital evacuation and transportation.

through April 3. The staffing crisis was not restricted to professional or technical staff. Physician staffing reached critical levels at at least one institution, with one Emergency Department physician noting that only six of more than 70 Census Reduction doctors remained available.'

IlhtC experienced the potential exposure of medical All area hospitals adopted a common strategy to cope students to radiation during the crisis. Students in the with impendmg evacuation. The pnmary strategy-the dis-medical and health professions have,in the past, proven to charge of ambulatory and stable patients to ilm care of their immediate families-quickly reduced the area. wide census be valuable assets during disasters; however, they were a 1

cause of considerable controversy during the Thti incident.

from an average of 80 per cent to less than 50 per cent of lihtC's Dehtuth noted the " grave concerns" of the medical capacity.u The discharge of ambulatory patients also freed school teaching faculty toward the encouragement of medi-hospitals to treat potential victims of radiation.' llospital TABLE 1-Hospital Census Change during Acute Phase March 28-April 2,1979 Census Distance and

• Ovecton tmm Marct' Apol .

Capacdy TMt 28 2 change Hosptai 350 9.5 mi NE 300 87 - 71 Hershey Me6 cal Center -58 176 10 0 mi NNW 148 62 Community General Osteopatnic Hospital 479 10.5 mi. NW 405 259 -36 Harrisburg Hospital 27

$56 13 5 me NW 537 393 Polychnic Meccal Center lum

, . s COMMENTARY cat students to remain at the medical center.' Another radiation treatment center kicated in the radiology depart.

source notes the anxiety of the medical students? ment; plans were later formulated for the treatment of 75-Following the accident, the unusual nature of the emer- Ith) injured per hour in the tunnel of an underground gency was taken into account, and no hourly rated employee receiving area? HMC also opened an evacuation center at was penalized for being absent (although the use of vacation the flershey Sports Arena, and prepared for up to 5.0tN) pay for unscheduled absences was frequently denied). There arrivals. HMC and PMC were designated by the Dauphin was, however, at least one management level termination County Ollice of Emergency Preparedness as the last emer-due to absence during the incident. gency rooms in the area to provide medical care in a grad,uated shutdown; however one source later reported that last minute services were to be provided by HMC and llH.*

Adininistrative nesponse DeMuth noted that perhaps most crucial to the provi-sion of emergency / critical care services was the turnabout in On the third day of the incident, communication was physician philosophy required to deal with the accident.'

established between hospital administrators and local emer. Hospitals are accustomed to putting the critically ill at the gency management agencies. All hospitals immediately be- highest priority. In previous disasters requiring evacuation gan categorizing patients for possible discharge. The admin. the critically ill have been the nrst to be transferred." During istrative response at one institution ICGOH) involved a the TMI incident, hospitals evacuated the maximum number centralized command (Hospital President) and the following of stable patients first: the critically ill were left until last, delegations: patient discharge evaluation (Director of Patient some maintained on life support and cardiac monitoring Care), maintenance of patient / hospital records (Director of systems, or on osygen support at all hospitals (see Table 2).

Finance) patient transportation (Director of Personnel),

medical support and evacuation supplies (Medical Director),

and facilities security (Director of General Services).

At all area hospitals the charts of remaining patients Hospital Eracuation and Transportation were color-coded as follows to facilitate emergency trans-portation: Although the othcial governmental stand was that there Red - Discharge was no general evacuation (other than the short-lived Gos er-Blue - Ambulance n r s Advisory for pregnant women and preschool children Blue / Black - Ambulance with monitor / respirator within a 6ve mile radius of TMI), hospitals were indeed Yellow - Bus planning for an eventual evacuation effort. While local agencies con piled a list of host counties and mstitutions and Green - Flat-bed trailer monitored their census, mdividual hospitals made their own A problem shared by most institutions-the inadequacy contacts and arrangements. Two recorded incidents of medi-of telephone commanications--had been recognized well cal evacuation occurred: three nursing homes within the Hve before the TMI incident? HMC experienced a failure of the mile radius moved their patients by ambulance on the night entire telephone system that was reported to have lasted as of March 30. and HMC transferred three neonates that were long as ten hours? Experience at TMI also revealed that on life support systems to the Childrens' Hospital of Phila-emergency radio communications carry two signi6 cant delphia on March 31. CGOH made arrangements with the risks: 1) governmental radio communications at the State Capitol interfered with the Dauphin County computer sys-tem, and 2) radio channels are accessible to the general public.' Area hospital administrators had been guaranteed TABLE 2-Number of Patients Maintained on Mechanical Venti-

. . latory Support and Oxygen Therapy from March 28 advance notice of impending general evacuation: this plan to April 2,1979 was discarded when emergency management otheials real- _ _ _ _

ized that the plans had been overheard by citizen radio Number of Patients Number of operators, and were therefore likely to fail.' Hospitals were thus faced with the dilemma of delaymg evacuation until the g gcai ,

on last minute or risk early evacuation and the resulting area Hershey

, 3 - 0 (Neonatal) 17 pame. Medical Center 6 -. 4 (Aduft)

Comfrunity Gea -=' 2 - 3 (Adult) 16

. Osteopathec h.mergencyiCritical Care Sern.ces Hosmtat Hamsburg 3 (Adult) 46 IIMC was under contract to TMI to receive and treat all Hosptal radiation-contaminated workers. In the absence of commu- P nc 4 (Adult) 38 nications. however, the injured would have arrived "com- Center 3 (Neonatal) pletely by surprise."' HMC facilities included a one room AJPH March 1982. Vol 72, No. 3 277

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l COMMENTARY Philadelphia College of Osteopathic Medicme,100 miles SE discharge, patient categorization, and patient-unit consohda-of flarrnburg, to accept all of its patients in the event of a tion. Administrators can expect significant absences from rapid and final evacuation. stati members who have family responsibilities and should in addition to the use of family vehicles and ambu- anticipate a shortage of physiciant Employee call-in sys-lances, projected medical facility transpettation also includ- tems, designated responsibilities, and a planned, structural ed flat. bed trailers and helicopters. The Pennsylvania State response may allow hospitals to stabilize operations until the Police and the Army National Guard based at nearby Fort immediate crisis is resolved. Long-term crises, however,

Indiantown Gap planned to use Jet Rangers. Iluey and will require governmental personnel back-up from many l Chinook helicopters. The State Police listed eight and the agencies and will probably require medical support and Army National Guard 39 available aircraft.'2 Evacuation of transportation assistance.

nc+ ambulatory patients by trailer or by air would have 5. Mass medical evacuation and transportation systems j taken place under truly emergent conditions and, thus, are difficult to arrange during a crash response to an emer-would have been hazardous to both patients and staff. gency and, therefore, are worthy of immediate study by all To deal with an expanding risk zone, emergency man- hospitals. Response should not be restricted to planning for agement officials planned to evacuate the population in accidents at nuclear-generating facilities, but should cover a radial directions away from TMI.2 Some surrounding coun- wide range of situations. Emergency Medical Systems, until ties, however, also planned to block access to some high- now accustomed to getting patients into acute care facilities, ways to control entry into their municipalities.' Dauphin should plan responses to disasters causing influx, evacua-County evacuation routes were due North'; however, ilMC tion, and combined influx and evacuation. Inventories of moved and CGOli planned to move patients SE to Philadel- area transportation capabilities and host institutions should phia. Evacuation plans for the county were published in the be readily available to all hospitals.

Ilarrnburg Patriot News-six days after the initial release.

Key Problems and Recommendations Summary \

1. The overloading of telephone circuits noted in previ. Traditional disasters have included fire, flood, storm, r

ous disasters'and in the TMI incident (2.000.000 calls were and trauma. Virtually all external events are preceded by a placed on circuits designed for half that numbet'), demon- warning and by community activation." Nontraditional di-strate the need to improve area-wide communications sys- sasters may include nuclear power plant accidents such as at tems. A centralized command should integrate area needs TMI nuclear weapons accidents, toxic waste accidents, with available resources.2ilospital communications must be terrorist attacks, or other phenomena without historical linked to designated emergency operations centers. Chan- precedent. In contrast to traditional disasters, all are marked

, nels of communication and hospital disaster response must by the lack of a warning phase, and may involve hospitals l be tested at frequent intervals to reveal potential inadequa- immediately. Nuclear power plant accidents are further cies, characterized by the lack of clearly defined limits of both

2. Further study is needed into the roles of public health time and space-nuclear accidents can escalate rapidly and officials, both physician and allied health personnel, during may involve a continually expanding risk zone. Future-nont'raditional disasters. Gordon MacLeod, then Secretary oriented disaster planning should prepare hospitals to deal of the Pennsylvania Department of IIcalth, noted the ab- with a wide variety of situations, including those which may sence of strong input by public health physicians into most necessitate area wide evacuation.

operational decisions made during ihe TMI incident."Three factors should be addressed: public health physicians need training in the health aspects of radiation contaminated environments, and in area-wide evacuation planning, and REFERENCES emergency decisions made by nuclear engineers should be 1. Chenault WW, Hilbert GD, Reichlin SD: Evacuation planning supplemented by medical advice in the TMI accident. Federal Emergency Management Agency

3. potassium Iodide., a thyroid blocking agent to pre- 73 'N 3'p";"*

h r 'J Special Communication. Three Mile vent tinue uptake of radioactive sodine 131, was not avail- Island-The Silent Disaster. JAMA 1981; 245:1656-1659.

able for immediate distnbution to the involved population 3. Strohl G: Nuclear threat: hospitals need to know. Osteopathic during the accident at TMI.' * " Governmental agencies and llospitals 1979. 21 6.8-9.

private corporations frantically arranged for emergency pro- # U""".s Comminion on Three Mile bland. Report of the

' ' " " ' " ' " " " * " " ** * "" ' "' #"8 '

duction and shipment of the druE to liarrisburg. It arrived Commonwealth of penn91vania 19*t four days after the initial release from TMI. This esperience 5. DeMuth WE. Trautlein JJ: The luck of Three Mile bland.

suggests that in areas of risk, hospitals and other institutions Journal of Trauma 1979. 19:792-794.

should consider stockpiling supplies of potawium iodide for 6 Haglund K: At flershey: medical sptem near " failure" during administration to those who cannot be rapidly evacuated. 't hree Mile bland. New physician 1979; 28:24-25.

. 7. panLo AJ: How I sur ived on "My Three Mile bland', apart th

4. Ilospital administrators should develop contmgency Harrisburg patriot Evening News. Wedneslay. Apni 11.1979,p stalling plans and should analyze methods of graduated 15.

278 AJPH March 1982. Vol. 72. No. 3

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COMMENTARY M. Kati 1H. Pascareth LI: 1%nnmg and devehipmg a communsiy 1) MacLeod UK: Some pubhc health leswns from Three Mile

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innpital dimier program. Emergency Medscal Serseces 197M; ist.ind: a case study m cham. AMulO 19til; lo:IN-23.

7 69-70.72.9.4 14. President's Comminion on the Accident at Three Mde Island:

9 Weidner WA. Mdler Kl., Latshaw RF. Rohrer GV:1he impal Report of the President's Commission on the Accident at Threc

! of a nuclear etisis on a radsology department. Rad ology 19mL Mde Island: The Need for Change: The Legacy of TM t October.

13t717=723. . 1979. New York: Pergammon Prew.1979.

, 10 Kunts E: Itospitals prepared radiation plans in wake of nusicar

! plant acudent. Modern ifcalthcare 1979: 9.16.

I i1. Hlanshan SA: A time model. hospitalorganizational responw to 2 disaster. In.- Quarantelh EL (edt ihmters: 'Iheory and Re- ACKNOWLEDGAfENTS a search. Heverly Hdle Sage Publications Inc.,197N.174-19N The author acknowledges the assistance of Carey Goodrich

12. Nuclear Incident Emergency Medical 1%n (lauphin County (PMCL tMn Wihon (HHl. and John Gddersleeve (HMCL and

O!!we of Emergency Preparedness. Harrisburg, PA 19MO. thanks Chrny Clugh for administrative assistance.

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Christopher Maxwell, B.A., R.R.T.

Community Ceneral Osteopathic Hospital 4300 Londonderry Road P.O. Box 3000 Harrisburg, PA 17105 June 11, 1982 i

Material reviewed includes A. Attachment I, General Evacuation Procedures, Westchester County RERP, Department of Health (including SF 15-17).

B. Responsibility - Public Health and Sanitation Services.Section III, C-6 C. Responsibility - Accident Assessment _,Section III, C-14 D. Responsibility - Protective Response Evaluation,Section III, C-15 E. Responsibility - Radiological Exposure Control,Section III, C-16 F. Testimony, Daniel Hyman, M.D., Commissioner of Health, Rockland County, Nuclear Regulatory Commission Hearings on Indian Point.

a.

Based on this limited information only, my assessment / recommendations are as follows:

Medical facility response to nuclear accidents should be classified as Class Medical Facility Status I Normal II Standby III Alert The Lead Emergency Management Agency should order the following t.edical j

facility response:

l A. Class I - notify appropriate medical' facilities of the possible need for decontamination procedures B. Class II and III - notify medical facilities of situation at power l

plant, C. Obtain current census / transportation needs assessment D. Notify predesignated relocation hospitals E. Determine beds available in host area F. Establish medical transportation stag.'.ng areas G. Name staging coordinator H. Establish radio communications between staging area and emergency management agency I. Determine staffing requirements of medical facilities in risk area J. Request medical support if necessary K. Color code charts by predetermined system for transportation needs (e.g. car / bus / ambulance / trailer / air)

L. Establish evacuation triage ranking as follows:

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Page 2 (L. Establish evacuation triage ranking as follows:) - continued (First) - Maternity Pediatrics Neonates Medical / Surgical Intermediate (Last) - Critically ill

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M. Class III (Only)

1. Discharge to family where possible/ appropriate

2. Discontinue surgery / admissions

3. Restrict non-cmergency admissions

4. Consolidate remaining patients

5.  ? distribute ki to remaining staff / patients

6. Maintain sheltering precautions (windows / air intake, etc.)

7. Maintain hospital emergency room until directed to close by lead age,ncy

8. Emergency management agency designate remaining area-wide emergency facility Other considerations include A. Five mile audible warning system B. Preprepared EBS warnings / instructions C. Evacuation routes for public dissemination D. Destinations / mass care centers E. Inventories of risk facilities / census F. Inventories of host facilities / census G. Inventories of heliport location / telephone numbers 11 . Ambulance service capabilities for 5, 10, 20 mile radius and statewide I. Air medical evacuation / landing capabilities J. 360 degrees evacuation plans K. Estimated time for population evacuation L. Inventories of homebound M. Liason with - medical society

- state hospital association 1

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