Jennifer Silvey-Cason: Pediatric Evacuations During a Disaster (2/7/25)

Okay, welcome Everybody. It is February 7th. It's Friday. Yes. And today we have someone that we've been waiting for quite a while. I met Jen Tilvey Cason at one of the Florida meetings months ago and I begged her, I said, please come on the program and talk about pediatric disasters, specifically what to do when you have to evacuate pediatric patients, which we all know too well in the state of Florida. I see our state medical director, Angus Jamison is on. I know he was busy with that. Dr. Augustine on the west coast was heavily involved in that. So this is going to strike a chord with many of us. And so without any further ado, Jen, you're very decorated. You have a very decorated career, won many awards. Please give us a further introduction and thank you so much for joining us today.

Awesome. Thank you so much, everyone for having me. Again, my name is.

Thank you.

Disaster Gen. I get. I was coined that title because I'm the disaster manager for UF Health Jacksonville. We have two hospitals here that probably over 800 beds, three standalone EDs, 160 plus clinics, and a couple urgent cares. So and probably that I think that surrounds maybe four or five counties that we have a footprint in just right here in North Florida. I've been with UF Health for about 18 years. I'm a paramedic. I was a volunteer firefighter for Jacksonville Fire Rescue for many, many years back in the late 80s, early 90s and started doing emergency management probably about 25 years ago. I absolutely love what I do and I'll go ahead and start with my slides here.

So again, this is kind of a what our campus looks like. We have two very large. We're a level one trauma center. We have three helicopters. So it was 2022, Hurricane Ian hit southwest Florida. I'm part of the incident management team for the state of Florida for Region 3. And I was deployed down there as a liaison officer to Cape Coral and Lee County. While I was down there, I met some incredible men and women, fire rescue, police and at Lee Health and heard the story of how Lee Health had to evacuate many, many little babies, little babies to newborn babies. And I'm going to show you this video. We did a pediatric evacuation. It took about a year to plan. I involved our fire rescue local, Jacksonville Fire Rescue. I have a great relationship with them. I involved our Jacksonville Sheriff's Office, Department of Health, Florida Department of Emergency Management and Healthcare Coalition and a few other community partners, along with just about everybody. And in the hospital that would be involved in a total evacuation. You know, many hospitals do Their annual or quarterly fire drill, and they evacuate. And I really wanted to take that a step further. Really, what would that look like for our hospital? So here's a little two minute video, and then we'll go into a little bit more detail about it.

Okay.

Oh.

All right.

So I'm gonna get our observers over here on this wall. This is again, a level three evacuation. This is so exciting. We are evacuating. We're doing a pediatric evacuation exercise of our NICU babies.

Our NICU babies are special, special group of babies. Some of them are innovated, they're on constant drips, they're on medications. And we are evacuating, doing a total evacuation, a level 3 evacuation of that unit.

Once they went down the stairs, they made their way to the alternative care site.

And here at the alternative care site, they were able to. To continue patient care. They were able to track their patients. If the caregivers aren't here, they were able to call their caregivers and let them know the situation that's going on. You send messages to the incident command, to your director? Correct. But we had pharmacy, dietary, respiratory, transportation, laundry. Folks, nao down here.

A couple of things we noted.

We just finished with their evacuation. In case of an emergency evacuation, we have a three day supply of everything we can possibly need for our babies. We had a combination of many, many departments and units. And we're about to start a hot wash and talk about some things that. Some great things that we saw that went really well and also some things that we can put into our plan to improve. Give her a round of applause, everybody. The next group that's going to be evacuating is going to be our L and D group. So there'll be some mannequins as babies. They will also have humans playing the role of laboring moms coming with the wheelchair. Now we will have moms who have delivered and they will have their babies. Some of them are going to be non ambulatory, which means they can't walk down the stairwell. So they will be placed on a med sled and they will be left lower down the stairs.

Very unprecedented hospital down in Fort Myers during hurricane Ian. Actually had to evacuate during a hurricane. Their NICU babies. I think this baby coming.

Oh.

So for the past year, we've been chatting with them about their lesson learned. And we came back going, you know, we should really do this. Taylor Swift. Taylor Swift. All right, let's back up, get a little room. Make sure you watch the elevators. Is demi low?

Where is she?

Can I get something for pain.

Okay, Mama.

It's okay.

We've got positions on the way.

So I'm really proud of this team.

And how this is pulled together.

I want to say thanks to Jen.

For everything she's done actually coordinating this so far.

This has been a good job, so nice job.

This is a team. This is a team. No other hospital has done this type of exercise to this extent. And this is just going to make us stronger, make our plans and policies stronger, and make it a safe environment for our infants and our staff.

We planned this exercise. Like I said, it took us about a year to plan. No other hospital has even ever tried to do an evacuation exercise like this. And we had a total of over 40 either real humans being evacuated and the use of mannequins. Again, this became, you know, an idea back in 2022. As we move through the year, I would bring in, we would have planning meetings at the hospital and I would include our EMS providers and our community partners and we would talk about the types of evacuation. Of course, you know, we're going to do a horizontal evacuation, incident driven and event driven. But I went back to the evacuating departments and I said, okay, if you had to totally evacuate horizontally, where would you go? What would you do? Who do you need to talk to? And then I said, if you had to do a total evacuation out from out of our building to outside. And that's when I had our fire rescue guys really talk about the proper distance and good locations if they had to evacuate outside. And then the last plan they had to come up with is if they had to do a total evacuation, a vertical evacuation out of one building into another building and set up an alternative care site, what would that look like? So throughout the year, they would come back with different ideas and responses. Then we did, as we came into January 2024, in March, we did a tabletop. So I brought everyone in, all of our community partners, all of our departments and units that would be involved in this exercise. And we walked through each step and a lot of great things happened during this tabletop. 1. You know, it was great for some of our hospital leaders and staff to realize that, yes, fire rescue is coming, but their main purpose when they first get here is to put the wet stuff on the red stuff. We have to evacuate and get our patients to the alternative care site and then they will come and help us. But first they need to take care of that. So that, you know, really opened up some opportunities. We also discovered once we got to the alternative Care site, what type of things are you going to need there? Because you may be there an hour, you may be there a day, but you may be there longer than that. So that opened up conversations of medication. How would you store it, how would you order it? Documentation and joint commission really looks at some of those tasks that we were doing. But they were also looking at how are we tracking those patients, how are we communicating with caregivers maybe who weren't at the hospital at the time. And then how are we communicating with transportation if we had to transfer them out. So great things came out of our tabletop as we went into May and June again, we really started to look at that. Now that our hospital incident command is activated and with the hospital incident command and fire rescue.

Making the decision to evacuate, what type of communication forms, meaning incident command forms, do not only the incident command leaders need to be completing. So a lot of training and education with that, but also with the units that we're evacuating. And then here we get to the full scale evacuation. So that was our nicu, our picu. And with our picu, I actually had a special needs.

Let'S say a special needs patient. And I had someone play that, a young girl who was a good friend of mine. And I told her, I was like, I, I want you to have autism. Be very stimulated and almost panicked when you get to the alternative care site. And it was really good to see some of the best practices that they brought forward and that forward thinking of the Child Life program and different things that they had put into their plans to help with some of those type patients.

These are some QR codes, these are two of the exercise plans that we wrote. It goes through our capabilities and expectations. But the QR codes to really enable you to kind of look at those documents and I'll give you a second if you want to take a snap, a picture of that. But this was a great exercise to not only strengthen our partnership and relationship with fire rescue, but also with units who never really had a conversation before. What if, what if we had to evacuate? What if we had to open up an alternative care site? What would that really, truly look at? So conversations. And then the. One of the best things was the involvement of our physician groups. In the past they would play. But we have a great Disaster Medical Officer, Dr. Caro at our hospital and he really was able to bring in those physician groups and, and get them more involved and intrigued to where now they call me and they're like, Jen, when can we do another exercise? And I'm like, absolutely, let's do it. So some of our best practices, we, the, our NICU and mother baby and L and D units really came up with a great idea to have evacuation book bags. Now in each book bag they would have a different type of supply for their patient types that they serve right. They came up with a list, they were able to work with dietary and following joint commission guidelines, where they came up with a way to where they would constantly be checking expiration dates and keeping the book bags in a good safe place. Another great best practice was the patient MMR sheet and using and then really finding the value in the ICS forms. Ics. It is a thought process that I'm really pushing here at the hospital and it's great to have buy in at the hospital from my C suite. My CEO and COO and CNO really speak that disaster language and that ICS type thought process before disaster strikes and during disaster strikes and then great checkout price processes. They came up with a great plan to where as they were evacuating the little one, before they went down the stairwell, they would check the armband. When they came down the stairwell, they would check the armband. And when they got to the alternative care site, they would check the armband. So this really decreased the chances of someone being lost or not being where they should be. Some other great ones, our special needs I told you about, we actually had, of course you could probably tell she was an actor, a laboring mom. So as she was on the med sled and they were lower lowing her down eight flights of stairs. So pretty, pretty good ways I whispered to her to kind of go into labor. And because of the conversations they had with their physician groups when they established that alternative care site, they had a plan if a mother had to was going into labor that they would have the medications and or supplies they would need for that type of person. And then the use of radios. You know, all of the hospitals, no matter how, you know, old, they were built years ago. Testing out those lines of communication to where they can communicate with each other was vital, Very, very vital. So this is my information and we'll talk a little bit more. I will.

Put this down and stop sharing my screen so we can have a conversation. But you know, this was such a great opportunity for our hospital.

I don't know if you guys recognize but Dr. Elias, he's the medical director for Jacksonville Fire Rescue, he was very involved with our planning and on the day of the exercise and they Jacksonville Fire Rescue actually helped Us establish a few other best practices that we've now put into our plan.

Fantastic. Wow, that's a lot of work. And the amount of planning that went into that.

Makes us realize, I think, how important that type of planning is. I would like to bring in. I'm not sure if Dr. Augustine, are you available? Or Dr. Jamison, because I know that this area impacted both of you significantly. So there's Jim. Hey, Jim, can you make some comments on Jim's briefing?

Can you hear me okay?

Yes.

Perfect. Yeah. Hi, Jim. I was in the region during Ian, but I was not serving as the medical director there at the time. There was a significant evacuation that occurred in the surge areas, which was new for us. It was not due to wind, and it was in combination with three other campuses that were being. That were being evacuated at the same time. I think that is the key issue. What we learned is about coordination of resources when you have that many coming in. And the state of Florida now is doing training for a new group of command officers who can assist beyond the state staff. And, Peter, that's going to be an addition for all of us for future. What we're learning is that it is surge and not wind that is the biggest threat. And it's going to knock out our power, water, sewer, all those things that we forget. And our communications links. When you lose power for too long, we lose our Internet. So, Jen, you have done a great job. Thanks for leading this. Peter, this is real for all of us now. And Angus will talk about what happened in Pinellas during his evacuations this past year.

Thank you.

Thanks, Jim. Appreciate it. Angus, are you. Are you available to make a couple comments? Thanks.

Sure.

You know, we live in Florida and we have these storms and they're just going to keep coming. And if this isn't something that's high on your radar, it really needs to be. I happen to be at the ESF 8 desk at the State EOC during Ian and some of the Lee county issues.

That was an intense operation initially and then a very prolonged operation.

I think a lot of us don't realize how vulnerable a hospital's infrastructure is and how quickly conditions can deteriorate.

I'll just share a couple things I've learned over the course of a few of these. One is, like, if your hospital doesn't have a well for water, talk to them about it.

You might not know this, but it takes four different kinds of water to run a hospital.

That sounds like a goofy statement, but there are four kinds of water that it takes to Run a hospital, you need functional water for things like cooling and cleaning and flushing toilets. You need potable water for eating, you need sterile water for medications, and you need deionized water for things like dialysis and laboratory studies. And without all four of those, your hospital grinds to a halt pretty quick. For example, in a large hospital, one of ours in St. Pete.

Their cooling tower, just to do AC inside the hospital, evaporates roughly 3,500 gallons of water per hour. So if you lose water to a hospital, think about what kind of tanker shuttle operation it would take to keep that hospital habitable. It only takes a few minutes in Florida for a hospital to become really an unpleasant place without environmental controls. And so if your average fire engine carries, say, 500 gallons in their tank, and you need 3,500 gallons an hour because your municipal water system is down, how far are you driving to get to a source of water? And how many fire engines do you need to keep that hospital running? Because that's the alternative, right? You keep the hospital running or you evacuate. So all of these discussions really should be had upfront with your hospitals. And this will happen at some point if you're anywhere near the coast. And it is absolutely the flooding and the infrastructure issues, rather than necessarily just the wind, that are going to be your problem. So power, water, basic infrastructure will bring a hospital offline very quickly, and then they'll be looking at you to move hundreds, maybe thousands of patients. And so you also want to make sure that you have some knowledge and expertise about what it takes to keep a hospital in business. Starlinks, water, all the things that you need.

Jen, you want to comment on all that? So that's, that's, that's very. I mean, I think I need a Xanax right now, but go ahead.

You know, I, I read an article last year where the state of Florida, during those two, three hurricanes, over 400 facilities were evacuated. So just what. Dr. They were saying that, you know, that surge, they're coming. And so those are the conversations that, you know, hospitals one need to have with their people. This is not the normal surge on a Friday night. This is going to be a surge of high acuity or any type of acuity. And it's about staffing, it's about shelter in place, it's about supplies and tracking those patients that are coming in. Let's say you're the receiving hospital. And then, you know, with that, you may have an influx of staff coming with those patients. So credentialing and, you know, having a Shelter in place, area for them to sleep. All of that has to be in those conversations when you are making those plans.

Great, great comment. Let me bring in Dr. Pepe who has written books on this topic, who has been to many a disaster. Paul, what are your thoughts after hearing what Jen's presentation? After hearing Jen's presentation.

It's perfect and it's the right thing to do. And then some of the tabletops I thought were stupid. And then I found out that if you bring in and have a scenario where something goes wrong or it's a problem for the different sectors, you know, within that whole thing, you know, is a really great. Because then you learn about their roles, who they are and I think that's, it's just a fabulous concept that what she's doing.

Thank you.

The main thing I wanted to say is that tell them a little bit about the competition with the other patients. So having a, recently had a preemie grandchild in the ICU and you know, knowing all the sensitivities there, etc. But then you've got, you know, the person in the, the icu, the elderly person or the, you know, who need to get out real quick because it's, they're hard to move, etc. Tell me about a little bit about the competition about the evacuation period. Right.

Yeah. Because you know, if we, even if we look back to Hurricane Katrina, it's like who, who do we evacuate first, who can we wait on and then who is going last? And that, that competition comes in with that thought process and having a plan to answer what type of acuity having your, your disaster. We have a disaster medical officer, Dr. Caro. Have him in those conversations and those plans with your incident command.

Yeah. And I think it's great for just not him as an individual, but maybe one or two people so they don't feel totally alone in that decision because that's a tough. A good example is we wrote a paper about Katrina. So thanks for bringing it up and it was interesting. Like who do you take first? The 75 year old who's up and kind of joking and he's got atrial fibrillation. Right. Or the 55 year woman in with altered metal status who's a diabetic, you know, like so it's more complex in these situations than we have in trauma. So I'm. Yeah, I just want people to think about that as well. It's going to be a tough one and you know, that's in a dynamic. So this is great. So thank you so much.

Okay, great, great comment. But Paul, I think that the highest donors go first. Just kidding. Dr. Augustine. Dr. Augustine, go ahead.

Yeah, I was going to add something this year. Milton gave us this new challenge. And I don't know if Marshall Frank is on or Dan o', Leary, but we have the initial evacuation of facilities and those went, you know, from Charlotte county up to Pinellas, maybe higher. And then you, you filled facilities all the way down into Miami. And then afterwards those EMS systems that are in those evacuated counties can't remove their patients. So we had a hell of a time trying to figure out where patients were going to go in the aftermath of the hurricane who had acute emergencies. Yeah, we, we need to spend more time thinking about that on the back end of what Jen is describing, which is simply the evacuation of facilities. But once facilities are evacuated, you have a community that's back up and now they have people having drownings and mis and strokes. And now you got a flying to place for them when you filled all the local facilities that are still in service. So a new opportunity, definitely.

So, Jen, let me ask you, that was a great comment from Dr. Augustine as well. And I have a comment now is not everyone has a disaster gen in their region.

Right.

So what are the other regions doing? I hear from Angus that, you know, that there are people. So are there people coming online in each region that are the disaster gens that can help each region out?

So I think what's really helped this past year was the fact that I'm getting out there and I'm showing this video and I'm talking about it. A lot of hospitals are afraid to have those conversations, unfortunately, and they're afraid to do these types of exercises. And I have put my, my name out there and I said, look, I will come to your hospital, I will meet with your people, I will help you design and plan and conduct these type of exercises. But it's going to take, you know, leaders and physicians like yourselves to kind of really encourage those conversations between fire, rescue and hospitals, but also asking the hospitals, hey, what is your plan? What if. Who, who are you inviting to your exercises? And just, you know, getting everyone involved. So I have been, I'm actually going down to Lake City this next week. They're doing a family Assistance center exercise. That's my other subject matter expert that I'm in. I'm in is Family Assistance Centers. So it's just getting out there and really starting to encourage hospitals and more hospital emergency management people to have these exercises.

Just to chime in on that. Florida Hospital association is actually hosting an emergency management conference in Lake Nona April 8th and 9th. And both Niki Shimko and I will be on a panel talking about these issues to the Florida Hospital association to try to continue to raise their awareness of how prepared they really need to be and how difficult this can be.

Yeah.

I sent this video to Jim, John Wilkus, and I encouraged him. I was like, john, we really need to push this. And my family assistance. I was like, we really need to get hospitals on board with this. It can't be a knee jerk reaction.

Right.

Can I interrupt for a second?

Hey, yeah, go ahead, Paul.

Sure. Angus, real quick. I'm sitting there says waiting for hosts to start the webinar.

I gotta go to the other thing. All right, bye, Peter.

Okay, see you. Thank you.

Okay, thanks, Paul, again, thanks a lot. Let's stay in touch. We'll talk later. Okay, thanks a lot, Peter. Okay. We should have her on Eagles Maine sometime in the next week or 200.

Yeah.

My info. Okay. So thank you.

I will, I will. And so, Jen, I also think that, you know, now that there's a lot of, a lot more EMS fellowship program starting. You know, Marshall just started his. We are starting our fellowship in South Florida in July thanks to people like Terry Cohen, Scott Alter, Charlie Ingram. So we're going to have up to six fellows in the coming years. But starting off with, I think three, it sounds like it would be nice to have the future up and coming medical directors knowledgeable. So I would pitch to the Met, to the fellowship directors to integrate you into the education. I know we have the center for EMS now, Florida center for ems. That'll get you in there as a speaker and because, you know, listen, I'll be honest with you. I don't know if I had to guess. Let me ask you the question. If you had to guess, in the state of Florida, how many hospitals are ready today for an evacuation, what would you say the number is, percentage wise?

I can tell you offhand that I honestly know Lee Health and UF Health, two places.

Wow. A lot of work to do. A lot of work to do. But this is amazing. You've done truly amazing work. Now we understand why you have had such a decorated career. We're happy that you're in Florida. Thank you so much for joining the webinar. I will get this recorded. You can see on the right hand side. Everyone, for your knowledge, we have the Dr. Pepe's webinar. There's a link. There's the CME code. And so, Jen, give us your final thoughts. You have a lot of EMS leaders here from Canada, the United States.

What's your final comment to us as EMS leaders?

Prepare, prepare, prepare. Practice, practice, practice. But the most important thing is building those partnerships and relationships with people. You have to have those conversations and you have to build those relationships. And you can't be afraid to exercise.

Great points. It's a lot of work, but you've proven that it's, it's possible and that it's life saving. So definitely disaster. Jen, thank you so much for joining us today.

Thank you.

On behalf of my co host, Tanra Smita and the rest of us in Florida, thank you very much. And everyone, have a great weekend. And we'll see you on the other side with Dr. Pepe's webinar. Thanks, everyone.

Thank you. Thank you, sir.