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Ready -- or not? Can St. Louis cope with catastrophe? Part III: Seattle surges ahead in readiness

This article first appeared in the St. Louis Beacon, Nov. 1, 2009 - In a city where up to 15,000 people bike to work every day and the government hands out compact fluorescent light bulbs, it's not surprising to find an emergency readiness program touted by the National Center for Disaster Preparedness as one of the most progressive in the country.

As ubiquitous as its renowned rain showers is Seattle's entrenched awareness around disaster planning. It's an attitude evidenced by residents, medical professionals and top government officials. More than three-quarters of the Seattle-area population knows CPR. Residents easily passed a $167 million tax levy to improve emergency preparedness. And the health-care community formed a solid coalition that serves as the centerpiece of the region's disaster plan.

"It's part of our culture. It's in our genes," said Seattle fire Lt. Jonathan Larsen.


As St. Louis found out during the 2006 summer outages, when disaster strikes, people head to the hospital -- whether they are injured or not. Ambulances raced hundreds of nursing-home residents to Barnes-Jewish Hospital in July 2006 after thunderstorms knocked out power to hundreds of thousands of residents. They were joined by about 100 of the worried well, according to Jerry Glotzer, director of environmental health and safety at Barnes-Jewish.

"They didn't need medical care, but they had no place else to go. Hospitals are like beacons of hope," Glotzer said.

Barnes-Jewish dealt with the surge by arranging buses to take people to Red Cross and Salvation Army shelters. Four months later when a December ice storm left much of the area powerless again, most nursing homes knew where to rent a generator and had installed generator hookups.

Seattle learned a similar lesson during its December 2006 wind storm when hundreds of residents fled to the hospitals. That kind of influx multiplied many times over during a mega-disaster would quickly overwhelm any hospital and make it difficult or impossible for health care workers to treat those who really need it. Surges on a hospital are one of the most serious threats to survival in a disaster.

"None are adequately prepared," stated a March 2009 nationwide health-care system evaluation by the Center for Biosecurity at the University of Pittsburgh Medical School.

In 2005, Washington's King County, including the city of Seattle, took steps to shore up its health-care community. Organizers created the King County Healthcare Coalition, which is now considered a model for the nation in terms of local medical emergency readiness. The coalition has developed a system that

  • Sets up structures for decision-making, planning and resource-sharing;
  • Helps health care organizations with technical assistance;
  • Establishes methods to handle the surge of patients a disaster brings.

The structure of the Seattle-King County government, which serves 1.9 million people, maximizes cooperation and minimizes the chances of political discord. Unlike the St. Louis region, with its nearly 2.6 million people headed by eight government leaders from the city and seven counties, Seattle is part of King County, which is its own designated disaster area. The jurisdiction has only one public health department for the city and county. In an emergency, one person -- the director of public health -- is in charge of the medical response.
"We are fortunate that we are one county, one region," said Cynthia Dold, program manager for the coalition. "One of the challenges for other communities is having a clear line of decision-making, consistent information and consistent policies."

Through the Healthcare Coalition, Seattle-King County hospital representatives meet at least monthly; a core group gathers every two weeks.

"Coalition attendance is a big priority. Participation is encouraged and readily paid for," said Pete Rigby, emergency manager for Seattle's Northwest Hospital.

The coalition's success is rooted in frequent, face-to-face meetings, Rigby said. "If I had to say what is ground zero in this concept, it's that we're building relationships."


Walking into Seattle's new $44 million emergency operations center feels like boarding a seismically sound Starship Enterprise. Twenty-seven LCD flat screens dot the desks in the cavernous 14,000 square-foot command center with space for 150 emergency responders. Seven-by-nine-foot projection screens can turn sideways to accommodate the vertical city map.

The center has a continuous power supply that keeps all systems running until the generator kicks in and was built to be 50 percent more earthquake-proof than current standards demand.

"In a disaster, we expect it not only to survive but to stay functional, said Barb Graff, Seattle's director of emergency management.

The center was the pet project of Seattle Mayor Greg Nickels, who visited Kobe, Japan, after its devastating 1995 earthquake. In 2003, he championed a $167 million tax levy to build the emergency center, reinforce reservoirs and Seattle fire stations to make them more earthquake-resistant and stockpile a supply of cots, blankets, fire extinguishers and personal hygiene kits. On the less practical side, $425,000 was dedicated to artwork for the center.

Voters approved the levy in November 2003 by well more than a two-thirds majority two-and-a-half years after a 6.8 magnitude earthquake called the "Rattle in Seattle." The measure increased property taxes on an average $350,000 home in Seattle by $105 a year for the first three years. That lug has since fallen to $77 annually and will expire after 2011 when it bottoms out at $41.

Nearly a dozen buildings similar to the Seattle center now operate in Washington. They join a growing roster of such facilities around the country. Graff and others from Seattle visited several before building their own emergency center.

"Now, we're on the tour," Graff said.


The Seattle-King County area conducted an intensive test of all its communications and emergency systems in May 2003. The area was chosen to become one of two cities to participate in a massive Homeland Security TopOff drill, the largest such exercise since 9/11.

After a year and a half of strategizing, creating fake rubble and procuring used cars to destroy, officials "discovered" that a radioactive "dirty bomb" had gone off, contaminating dozens of people. Amid the triaging of victims, rescue workers dodged simulated sniper fire and sidestepped vehicles engulfed in flames.

"They had fires, they blew up cars. It looked like a moonscape," said Larsen.

"It was pretty cool," noted deputy Seattle police chief Clark Kimerer.

So realistic was the staged event that it actually sent several dehydrated and collapsing rescue workers to the hospital, along with a flood of fake patients covered with "blood" and "burns," created with stage makeup.

"I swear on the day when it actually happened, it felt as real to me as if I had a five-alarm fire," said deputy fire chief Angelo Duggins.

Two hundred forty members of the Seattle Fire Department rescued and transported 300 "victims," working side-by-side with hundreds of others from 100 federal, state and local organizations from the United States and Canada, including 40 Seattle-area hospitals. With the federal government covering $2.5 million of the cost -- mostly overtime -- local governments had only minimal expenses. What they learned was priceless, according to Kimerer -- how to predict which way a chemical will blow in the wind or flow up or downstream -- and how to fly blind when that information is unattainable. Also invaluable was the real-time test of 40 departments trying to co-operate with each other.

"We got a clearer look at how governmental entities work or don't work together with their interactions and communications and decision-making," Kimerer said. "If the real event happens, I think we'll have some real insight,"


"You can't plan for the most cataclysmic event," Barnes-Jewish's Glotzer said, when asked if the entire hospital had an strategy if it were devastated by an earthquake. But Seattle is prepared for the evacuation of an entire medical center. Seattle hospitals have a regional evacuation plan under which any hospital would relocate patients to another regional facility. There is also a scenario in which patients at every local hospital would move to another region.

Seattle's Harborview Hospital is the region's designated "disaster control hospital." That means that immediately after a disaster all rescue workers would coordinate with Harborview, which would act like an air traffic controller. Harborview would use an online system to track the number of beds and specific resources available at other medical facilities. It would then tell rescuers the best place to transport each victim.

Harborview employees take part in four full-scale disaster drills every year -- double the number the Joint Commission on Accreditation of Healthcare Organizations requires. Hospitals there involve every employee in at least one full-scale exercise in the course of one year. They do so by involving everyone on duty in each drill whether or not their unit is a focus of that particular exercise.

"It should never be that you'd run a drill and some people aren't participating. You shouldn't have a department with no role," said Seattle Northwest's Rigby.


Question: What happens when a city gets 100 percent behind teaching CPR to its residents for 37 years? Answer: 78 percent of residents of high school age and over know how to do it, a figure documented by a King County-contracted survey.

Learning CPR to resuscitate someone who's not breathing or whose heart is stopped is one of three important skills to draw on during a disaster, along with knowing basic first aid and how to use a fire extinguisher, according to the Federal Emergency Management Association.

In 1972, the then-fire chief of Seattle had a vision: CPR was not a skill only emergency healthcare workers could master. "Citizen CPR was practically invented in Seattle. Before that, only doctors and nurses knew how to do it," said Lt. Larsen.

Soon, residents were leaning over CPR dummies in community centers and living rooms across the city as instructors walked them through the process. Today, the ability to perform CPR is like knowing how to call 911. It's a skill that's mandatory to have for many jobs, including utility workers and some teaching positions, and a required course in area high schools.

"I don't want you babysitting my kids if you can't do CPR," Larsen said.


Visitors to the Seattle-King County website can find FAQs on the H1N1 virus in 13 languages including Khmer and Tagalog. Pictorial instructions are available for those whose languages aren't covered, and for those who prefer graphic novels, information comes in cartoon form. And that's just one sign of how serious planners are about including everyone in disaster planning.

In 2008, the Seattle Office of Emergency Management won an international Partners in Preparedness Award for its work with the local Chinese community. To serve the deaf community, the OEM created a system for texting information during a disaster.

Water bottles, light sticks and even hand-crank radios are available for the taking at locations where people pick up food stamps, buy bus tickets and send their children to school.

"I'm most proud of our work with vulnerable populations," Graff said. "It's the people who are living paycheck to paycheck or who are having a hard time fitting into the community the day before the disaster that need our help."


Even in cities like Seattle, there is no such thing as "prepared," there is only "better-prepared," concur leading disaster planning experts.

Israel can boast an unheard-of level of readiness and individual preparation, a disaster planner's dream, but one born of nightmares: the city's all-too-frequent rocket attacks and suicide bombings. St. Louis' closest and most recent encounter with a major earthquake was a 6.6 jolt in 1895 to Charleston, Mo., south of Cape Girardeau.

Regardless of any region's experience with terror, the very meaning of disaster preparedness eludes even those who devote their lives to this work.

"We don't have clear definitions of 'prepared' or 'disaster,' and that has hampered the field of disaster preparedness," said Andy Garrett of the National Center for Disaster Preparedness.

Still, cities try to move forward. In a perfect world, what would Seattle's emergency readiness wish list include? "Having an organized, national health-care system," said Dold of the Healthcare Coalition.

A nationalized health-care system like Great Britain's, or one that can be rapidly converted into a unified system like Israel's Home Front Command, can engage all health-care resources under one solid umbrella of command and control, according to Garrett: "This is certainly an advantage when the system is responding to a large or complex disaster."

As Seattle looks to the future, one of its primary concerns is that federal funds, which pay for the bulk of disaster preparedness, will dry up. The Healthcare Coalition is just beginning to grapple with ideas for sustaining their coffers with local funds.

"Disaster is always going to be there," said Dold, "Whether federal money is going to be there, we don't know."


In St. Louis, Nick Gragnani, executive director of St. Louis Area Regional Response System (STARRS), is also concerned that local disaster preparedness is almost completely dependent upon the grants it receives from Homeland Security each year.


Individual preparedness checklist

Pack your three-day kit

  • One gallon water per person, per day; three-day food supply and can opener
  • Battery-powered or hand-crank radio and NOAA weather radio, flashlight, extra batteries for both
  • Cell phone, whistle, dust mask; local map; towelettes, garbage bags and ties (for sanitation)
  • Wrench or pliers to turn off utilities

Add other items including: first aid kit, pet supplies, diapers, medicines. You should also prepare a "Go Kit " of items to keep at work and in your car.
Make a plan

  • Designate out-of-town contact and ensure all family members know how to reach this person and has the means to do so
  • Decide where family will seek shelter if necessary
  • Learn about workplace and children's school emergency plans . Coordinate with neighbors about working together especially to help those who are elderly or disabled
  • Take this readiness quiz

You should also learn how to perform CPR, turn off utilities and locate emergency broadcast radio stations
From FEMA's Ready.gov and Focus St. Louis


"There is always a risk at the federal level that these grant programs will no longer receive support. Every year you wonder what's going to happen," Gragnani said.

If the federal funds keep coming, the St. Louis region will have the money it needs to meet all its current disaster preparedness goals Gragnani said. But some multimillion dollar projects are not even on the current list of goals, such as retrofitting numerous older buildings constructed before today's seismic codes.

Other projects that seem small grow expensive when multiplied by the need. Getting an emergency kit together for those who can't afford one would cost about $30 a kit, according to the chief of the St. Louis Emergency Management Agency, Gary Christman. At that rate, supplying even half of the 166,000 people living in poverty in St. Louis city and county alone would cost $2.5 million, nearly one-third of STARRS' entire yearly budget.

Would St. Louisans be willing to support local sources of funding for disaster preparedness? It's not even clear if St. Louis County will pass the one-tenth of 1 percent sales tax to upgrade the county's 1950s fire, police and EMS radio system on the ballot Tuesday. Last Novemebr, Prop H, a sales tax that would raised money for emergency communications, failed.

But taking preparedness to the next level isn't always about money; sometimes it just requires the time it takes for those who have a role in emergency management to get to know their colleagues. Assembling six times a year with the goal of interoperability through communication and resource-sharing, the STARRS hospital committee, coupled with its public health committee, meet only some of the definitions of a health-care coalition.

"The nucleus of a health coalition," is how DHHS's Kevin Yeskey sees the St. Louis arrangement. More frequent and better attended meetings are one step toward strengthening this fledgling core, according to national experts.

Actual or virtual meetings once a month and phone calls inbetween is a desirable schedule, according to Stan Szptek, the national disaster preparation consultant from Mesa, Ariz., who's worked in St. Louis.

Gragnani doesn't have to be convinced about the importance of the relationship-building he's been working on recently. "Now Debbie knows Greg and Greg knows Ernie and Ernie knows to call Mike and Mike knows to call Joyce. That wasn't the case, before."


It's not enough for just hospital emergency planners to meet. A strong health-care coalition includes regular participation by representatives from nursing homes, home health-care associations and mental-health providers. Envoys from such agencies attend STARRS' hospital committee meetings from time to time, but not on a regular basis.

"Sometimes they're there, sometimes they're not, sometimes they're there more often than not," said George Salsman, chairman of STARRS' hospital committee.

Salsman doesn't think a separate health-care coalition is the answer, pointing to the Missouri Hospital Association (MHA) and its involvement in hospital preparedness: "That piece of the action is already there."

But maybe Salsman needs to be in closer touch with the MHA. Its spokesperson Dave Dillon said, "The Hospital Association doesn't play an up-front role in disaster planning. We're not a lead agency."

So the question remains, who is in charge of health care? And who represents facilities other than hospitals in a disaster?

Representatives of nursing homes, home health-care and other agencies must have a bigger presence during an actual emergency, say national experts. At least 15,000 people live in 248 nursing homes in St. Louis city and county, Jefferson, St. Charles and Franklin counties. In the city, one hospital delegate and a public health representative stand in for all of health care. St. Louis County added a single nursing home representative after the power outages of 2006.

The lack of nursing home delegates is a red flag for emergency preparedness, said expert Bob Abrams, author of "Watered-Down Truth: A Flood of Lies That Was More Deadly than Hurricane Katrina." Abrams believes that many people died during Katrina because nursing home representatives didn't get the facts first-hand at the emergency operation center.

"What happens in an EOC is that the government gets all the intelligence -- real-time information. In Katrina, not only did the government not provide information, they withheld information that could have saved lives," Abrams said.

But no matter how prepared the government and health-care community are, individual readiness is the key to survival. That's the opinion of national and local experts, including Barb Graff, Seattle's director of emergency management. She recently put the issue in perspective at a community meeting, answering the question, "Are we prepared for a mega-disaster?"

"You need to answer your part of we,'' Graff said. "Is every person in this audience prepared? Do you have your own supply of water, food and medication? Does all your family know who's going to pick the kids up and go where? Until you can all tell me that, we are not prepared."

Nancy Larson is a freelance writer in St. Louis. Funding for this series on disaster preparedness came from the Enterprise Journalism Fund of the Press Club of Metropolitan St. Louis.