It’s hard to argue anyone was ready for what happened in Northern California on the night of Oct. 8, 2017, when a series of wildfires broke out in and around the Napa-Sonoma wine country – but the San Francisco VA Health Care System (SFVAHCS) was readier than most. The fires, stoked by dry conditions and high winds, swept through much of the area, destroying an estimated 8,400 homes and buildings. About 100,000 people were evacuated from the area, and 117 veterans lost their homes or reported fire damage, along with 16 SFVAHCS staff members. All told, 793 veterans in the region were affected by the fires.

At around 8:00 a.m. on Monday, Oct. 9, as the fires were still burning, Mary Ann Nihart, MA, APRN, PMHCNS-BC, PMHNP-BC, associate director of Patient Care Services at SFVAHCS, received a call from Bonnie Graham, SFVAHCS director, informing her she was the incident commander for the VA’s response to the fires. Her first task was to assemble her team and find out what was going on. Nihart had recently participated in the VA’s response to another huge wildfire, in nearby Lake County, so she knew what to do. “You get the phone bank going, and then you have your first call, and that’s when you begin to get the situational information and what you’re going to need to deploy to provide services,” she said. “It’s the acute phase, when we’re evacuating people.”

The San Francisco VA had up-to-date lists of vulnerable veterans associated with each clinic in the area. “When they are shutting off electricity, you’ve got to begin to think about who is out there who relies on a ventilator, who uses oxygen,” said Nihart. “You’re thinking about all of those elements for your veterans.” The VA response team reached out to every veteran in the region to see what they needed, and then issued a call for volunteers.

One of the fires – the Tubbs fire, which burned through several residential areas of Santa Rosa – came dangerously near the Santa Rosa VA Clinic, which serves 9,400 Northern California veterans. The clinic was closed for several days, and Air Force veteran Victor Negron, a clinic administrative officer, showed up for work on Monday to begin monitoring the air quality inside the clinic and help in the response. Negron spent much of the next several days driving around in shorts and a T-shirt – he and his family had fled in the middle of the night with only the clothing on their backs, before losing their home to fire – to make contact with other veterans and inform them of the clinic’s closure.

By Tuesday, the response team had set up phone lines for veterans to call for information and began arranging shelter for those who had been evacuated or lost their homes. One of the most significant issues for evacuees, Nihart said, was medication. “When you get awakened at 2 o’clock in the morning and told you have to evacuate immediately,” she said, “you forget things like your CPAP [continuous positive airway pressure machine] and your medicines.

One of the fires – the Tubbs fire, which burned through several residential areas of Santa Rosa – came dangerously near the Santa Rosa VA Clinic, which serves 9,400 Northern California veterans.
With the clinic pharmacy closed down, the response team entered into agreements with local pharmacies, such as Walgreens and CVS, to provide emergency refills.

 

VA employees load a C-5 cargo aircraft with supplies in response to Hurricane Maria in 2017. The VA’s Comprehensive Emergency Management Program (CEMP), its standardized procedure for disaster response and recovery, is administered by the VA Office of Emergency Management.

 

To avoid too much disruption in the delivery of medical care, the San Francisco VA team called upon a Mobile Medical Unit: a clinic on wheels, accessed through the regional Veterans Integrated Service Network (VISN). “We offered up clinic space so we could send providers out to see veterans with specific needs in some of the shelters,” said Nihart.

The team in the field was in constant interaction with veterans displaced or otherwise affected by the fires, tuned in to their every need even as the fires were brought under control and operations moved into the recovery phase. “You start thinking about recovery about midway through a response,” said Nihart. “You start thinking about the total impact, and what you are going to need to bring people back to a place that is whole.” To ease the burden for evacuees and those who had lost their homes, VA volunteers tapped local resources to secure clothing and Walmart gift cards. Mental health experts and social workers stepped in to offer post-trauma support. “You’re thinking about how you are going to get resources to those folks, to help them get back to a normal state, and about how you can best support them, whether they’re going to need housing or anything else. You know, we’re full service. We’re not just a medical organization. We provide social services – whatever’s needed.”

You don’t think of picking up everything you’re going to need. … A lot of our job is to find those folks when they’ve just been scattered across the county and make sure that they get connected back to emergency medication services.”

 

THE VA’s OFFICE OF EMERGENCY MANAGEMENT

The lightning-fast response in Northern California was possible because the Veterans Health Administration (VHA) is a large, integrated health care system with the infrastructure and expertise to deliver supplies, information, and clinical staff support to a population whose needs and whereabouts can be determined quickly – mostly because their local VA staff already know them and can help direct and coordinate the activities of volunteers who surge in to meet demand during response and recovery.

 

As it is throughout the nation, disaster response and recovery is a standardized procedure within the VA, known as the Comprehensive Emergency Management Program (CEMP). The program is administered at VA headquarters – with field offices placed strategically throughout the United States and its territories – through the VA’s Office of Emergency Management (OEM).

The VA’s emergency response capabilities have evolved since the 1980s, when the first elements of the National Incident Management System began to develop. At the time, VA’s charter assigned it three primary missions: to deliver clinical care to veterans; to conduct research that benefits veterans and all Americans; and to educate the nation’s health care workforce in the best clinical practices. In 1982, a new law, the VA/DOD Health Resources Sharing and Emergency Operations Act, assigned it a fourth mission: to serve as the principal health care backup to the Department of Defense (DOD) in time of war.

Much of the VA’s emergency response work happens out of the public eye, in the form of proactive planning and exercises designed to reduce the impact of a disaster before it strikes.
According to Paul Kim, MD, director of the OEM, this fourth mission was expanded in preparation for Operations Desert Storm and Desert Shield in 1990, when the Federal Emergency Management Agency (FEMA), the Department of Health and Human Services (HHS), the VA, and DOD wanted to position the nation’s health care system to prepare for mass casualties and fatalities. “So, the four of us – VA, FEMA, DOD, and HHS – got together and started doing the planning,” Kim said, “and that’s when the National Disaster Medical System [NDMS] was born.” The NDMS is a federally coordinated initiative to assist state and local responses to the medical and public health effects of major disasters and emergencies, as well as to support the military medical system in caring for casualties resulting from overseas conflicts. “So our fourth mission is that we are the primary backup to both DOD and HHS in times of emergency,” said Kim, “and that emergency could cover a variety of manmade disasters. We’ve responded to the Oklahoma City bombing, the World Trade Center attacks, hurricanes, earthquakes – you name it.”

Much of the VA’s emergency response work happens out of the public eye, in the form of proactive planning and exercises designed to reduce the impact of a disaster before it strikes. These efforts are both strategic and tactical. In the VA’s Caribbean Healthcare System, for example, where more than 90,000 veterans live in Puerto Rico and the U.S. Virgin Islands, emergency management committees – composed of departmental supervisors and partners from local, state, and federal agencies, as well as other community members – meet monthly to identify the probability of certain disasters in the current calendar year, and how efforts and resources might be coordinated.

According to Cosme Torres-Sabater, emergency manager for the VA Caribbean Healthcare System, the region’s biggest risks are posed by hurricanes and seismic activity. At VA facilities – the main medical center in San Juan and 10 outpatient clinics on the islands of Puerto Rico, St. Croix, and St. Thomas – employees undergo periodic training in emergency management and are frequently led through drills and tabletop exercises. “We invite the National Weather Service,” said TorresSabater. “We invite the community medical centers. We invite the Department of Health and other agencies, emergency management people at the municipal or other local level to discuss what happens if we have a major hurricane.” On the heels of these exercises, officials identify areas for improving readiness: personnel needs, supplies such as water and meals, likely equipment rentals, shelter and other spaces.

In the spring of 2017, in San Juan – one of the federal government’s coordination centers for the National Disaster Medical System – the VA CaribbeanHealthcare System also took part in a full-scale, three-day multiagency exercise, which included partners from FEMA, HHS, and DOD, that simulated a Category 5 hurricane striking the region in September of that year. As it turned out, the exercise was well chosen; from early to mid-September, U.S. islands in the Caribbean were devastated by not one, but two Category 5 hurricanes: Irma, which killed seven people and caused more than $2 billion in damage, and Maria – the worst natural disaster in recorded history to affect the U.S. Caribbean islands – which swept through just two weeks later.

The VA Caribbean Healthcare System began its tactical preparations early – a routine practice when a known disaster, such as a hurricane, is approaching. “If we’re tracking … a hurricane or something that we can predict,” Kim said, “we look at our vulnerable patient population. We have nine categories of vulnerable patients we need to respond to quickly: those who are on home oxygen, those who are dependent on electricity. Our critical mental health patients, our dialysis patients, our spinal cord injury patients – those who, if there is an evacuation or the power goes out or they lose critical infrastructure, we’ve got to get to them quickly.”

 

Dr. Paul Kim (right), director of the VA Office of Emergency Management, briefs VA Secretary Robert Wilkie on response capabilities.

As Irma approached, said Torres-Sabater, the NDMS was activated and teams activated the plan devised during the full-scale exercise: Teams from the VA San Juan Medical Center – the only federal health care facility in Puerto Rico – were deployed to the San Juan airport to receive 91 veteran evacuees from the Virgin Islands with medical conditions, who were sent to predetermined public and private health care facilities. Ten days later, as it became clear that Puerto Rico lay directly in Maria’s path, the VA worked with the local Department of Health to evacuate those and other vulnerable veteran patients to Atlanta. Each of the VA’s Caribbean clinics, equipped with backup power, water, and satellite communications equipment, was secured for the coming storm, and closed down two days in advance of expected landfall. VA patients needing special care were kept safe at the hospital in San Juan.

RESPONSE AND RECOVERY

It’s hard to convey the scale of the damage Hurricane Maria did when it slammed into Puerto Rico on Sept. 20, 2017. Torres-Sabater has compared it to a nuclear bomb. The 155-mile-per-hour winds killed nearly 3,000 people on the island, destroyed or damaged thousands of homes, and left most of Puerto Rico without power or water. The winds and floods knocked out 85 percent of the island’s cell phone towers and 90 percent of its phone and internet cables, and blocked roads all over the island. Through it all, however – even as 20 inches of rainfall flooded downtown San Juan – the VA Medical Center remained open, operating on backup generator power. When the storm had passed, all but two VA clinics on the island immediately reopened.

 

A Mobile Medical Unit from the Orlando VA Medical Center deployed to Puerto Rico in the aftermath of Hurricane Maria.

VA’s incident response team sprang into action, activating a distinct Patient Assistance and Family Branch within the hospital’s incident command system. The hospital opened a shelter for employees and veterans, and their families, who’d been left homeless by the storm. Teams of nurses and social workers reached out to veterans who were in need of medicine, oxygen, or other support, and arranged for some to be transferred to the main hospital in San Juan. The team deployed new satellite communications equipment to make and maintain contact with veterans, and enabled some to connect with family members on the mainland to assure them of their safety. With its FEMA, HHS, and DOD partners, the VA ferried food, water, medical supplies, communications, and other equipment around the island.

A priority for the VA, of course, was maintaining or re-establishing the ability to provide medical care in hardhit areas far from the San Juan hospital. With support from the mainland, said Torres-Sabater, “We deployed vehicles that we used as Mobile Medical Units, and we received other vehicles as resources for contingencies. We had a mobile pharmacy unit, and we also received additional tents that we used to create mobile clinics in different areas.” In the northeast, a part of Puerto Rico hit particularly hard by the storm, where flooding washed out a bridge to the VA’s clinic in the town of Utuado, VA and HHS set up a 70-bed Federal Medical Station.

 

David Barron, at right, a nurse with the El Paso VA Health Care System, was dispatched to Houston, Texas, in the wake of Hurricane Harvey to provide medical assistance through the Disaster Emergency Management Personnel System (DEMPS). DEMPS volunteers play a critical role in VA’s disaster and emergency response efforts.

These response efforts, played out in the weeks following the storm, could not have been undertaken with the VA’s Caribbean staffing levels alone. One of the key features of VA’s disaster response capability is the Disaster Emergency Management Personnel System (DEMPS), a program that surges volunteer VA staff in from other parts of the country. From September through December, in Puerto Rico and the U.S. Virgin Islands, a total of 691 VA employees from different disciplines – doctors, nurses, social workers, and others – left their positions to put in twoweek rotations. Throughout its response, the VA’s Caribbean Healthcare System, with the help of DEMPS volunteers and other agency partners, served nearly 1,900 vulnerable veterans with medical needs. Given the damage to the island and the unprecedented challenges, it was unlike any emergency response Torres-Sabater – a former Army officer who has served the VA for more than 17 years – has ever seen. “Being a veteran, and seeing how our employees, regardless of the challenges they had at home, reported to duty to serve our veterans … I am proud to work here and see that devotion.”

A growing number of volunteers throughout the VA, Kim said, are signing up to serve in the DEMPS, which is run by a national coordinator through the OEM. Volunteers – professional VA employees who are paid for their service during an emergency response – undergo training, both online and through hands-on experiences. From just under 3,000 volunteers prior to Hurricane Maria, the number of DEMPS volunteers has grown to around 15,000. “Because of what these folks experience during these deployments,” said Kim, “we have people who come back and say: ‘That was the most rewarding adventure I’ve ever had, and I want to do more of this.’ So we really benefit from the spirit of the VA employee, that their mission is to care for veterans and anyone else in need who may come to us during some of these catastrophic disasters. … It’s always a very emotional experience meeting these folks after they’ve come back from two weeks, or sometimes more, of seeing people when they need us the most.”

 

This story originally appears in Veterans Affairs & Military Medicine OUTLOOK.