Winter Comes to Texas

EMS agencies and first responders leaped from one crisis to another when Texans faced an unprecedented winter storm in the midst of the historic COVID-19 pandemic last February. These challenges stress-tested entire systems to continue providing lifesaving care during the storm while adjusting to the care changes, setting up mass vaccination sites, and continuing our mission during the COVID-19 pandemic. This article details some of the challenges we faced and what we learned.

Montgomery County Hospital District (MCHD) EMS is a tax-supported agency in southeast Texas. We provide our 1,100-square-mile service area with 9-1-1 advanced life support service. MCHD conducts approximately 75,000 responses a year with 30 ambulances and is supported by a network of first responder agencies that operate at both BLS and ALS levels. During the one-week period that began Valentine’s weekend, we saw our number of calls and hospital transports double under the challenges of a massive winter storm.

The COVID Landscape

It’s hard to describe how profoundly the COVID-19 pandemic has affected both our communities and the way we provide out-of-hospital care. Like many systems around the country, MCHD was strained with the challenges of a postholiday surge in sick COVID-19 patients. In December and January, approximately 15% of our workforce was unavailable secondary to contracting or suffering a high-risk exposure to the virus. 

This was not an isolated MCHD problem—our hospital system, consisting of six acute care hospitals in the county, also reported reduced staffing, increased COVID-19 admissions, and full ICU capacities. By this time, almost 10 months into the pandemic, MCHD EMS was operationally and clinically up to speed with the changes required to safely manage operations. In the months leading up to the Valentine’s Day event, we were working on our pandemic recovery plan for 2021 and beyond as well as clinical, operational, and financial plans for our future. 

Major Event Preparations

Discussions of preparation are best split into sections. We maintain a general baseline readiness year-round. There is also event-specific preparation that occurs in the lead-up to a predicted event. The best example is the hurricanes we are accustomed to preparing for on the Gulf Coast. Some of the general readiness plans we had in place in February were:

Power integrity—This is one of the most important aspects of public safety and healthcare delivery. Power redundancy is a critical component of preparedness because it’s an essential utility for response missions. As this event illustrated, every power grid has vulnerabilities on both the supply and demand sides. MCHD has backup generators capable of supplying power to our administration building, alarm office, facilities, and fleet departments, along with all our stations. This proved vital, as nearly all our buildings were on generator power for some portion of the event from February 14, when we initiated our incident command system, to February 19, when power was fully restored. 

Regular generator testing and preventive maintenance programs will ensure your equipment is functional when you need it. Furthermore, check in with area hospitals and response partners to assess their resilience to any disruption in utilities.

Staff—MCHD utilized its incident command system and brought in additional staffing for the event. As in our hurricane events, getting our crews safely from their homes to stations can be a challenge. We implemented a disaster staffing plan to bring in extra crews before the event. This posed the unique challenge of how to socially distance and maintain operational readiness with double the usual staff at our stations. 

To mitigate the risk of COVID-19 exposure, we encouraged mask-wearing in the stations, spaced out crews when possible, and load-balanced with our larger regional stations that had more room to distance. Prior to the event, our facilities team delivered both food and sleep provisions to each station. These extra cots and provisions are kept ready for these types of events. We distributed space dividers to each station to give crews added privacy for communal living and social-distance barriers when increased space was not an option. 

We used crews that were on downtime and adequately rested to staff additional units. Prior to the storm we placed ambulances at each regional station, increasing the fleet with four additional units across the district. These units were used by downtime crews during peak hours and placed out of service early enough to allow rest prior to scheduled shifts.

Water integrity—When the power went out to millions of Texans during the extremely low temperatures, pipes froze and broke, causing loss of water pressure. This directly contributed to two of the six hospitals in our area going on internal disaster status for most of the response period. Losing a third of our transport hospitals required a pivot in strategy. Thankfully, we’d previously implemented alternative destinations in our system, which included transporting patients directly to satellite emergency departments. These relationships proved invaluable to our operation. 

Fuel—To remain mobile any system requires an accessible and sustainable source of fuel. During this event a power outage in the majority of our county affected the ability to fuel our vehicles. MCHD maintains on-site fueling capability at our central administrative building and regional stations, which helped keep our trucks on the road. It’s vital to be able to regulate the temperature of the diesel fuel supply, as it gels at 15ºF, making it unusable. Recently we’ve used these fuel pods during routine operations, so they’re on site if needed for an unexpected incident.

Intelligence—To maintain an efficient system, we had to know how our first responders and hospital partners were operating. During our response to COVID-19, we initiated weekly conference calls with both first responders and representatives from our hospital partners. This allowed us to better predict their ability to care for patients and kept an open line for us to share ideas and combat systemwide challenges. 

Due to high hospital EMS wait times several weeks before the storm, MCHD started a twice-daily operations report on hospital ED volumes and wait times for EMS. This policy detailed a stepwise escalation in responses to long wait times that culminates with staffing of our medical command (MEDCOM) and using a centralized load-balancing system. This functions like air traffic control for units transporting patients to area hospitals directed by medical control. 

The hospital report is done at 0600 and 1800 daily by our alarm chief, who directly calls the hospitals; this provides information that’s much more accurate than the existing regional system, which depends on hospitals to provide timely/accurate information on ED volumes and capability.    

Communication—This includes both internal and external stakeholders. During the COVID-19 pandemic, we minimized face-to-face meetings to mitigate exposure risk. We developed new forms of direct communication, including frequent employee and board Zoom calls to update everyone on plans and elicit feedback. MCHD EMS also utilized the GroupMe instant text messaging application to communicate in small command staff groups, along with Rave alerting and mass e-mail communications to the entire organization.

Lessons Learned

Staffing—We brought in fresh crews that were resting the evening before the onset of poor weather on February 15. It was invaluable to have them ready, but the first few days of this event had record responses, and the large demand for service was complicated by both increased turnaround times at hospitals and icy roads. The constant attention to detail required when driving in wintry conditions, coupled with the sheer number of responses, created an ongoing fatigue challenge for our crews. 

An option to consider when utilizing a disaster-staffing plan is to consider adjusting shift start and stop times—for example, a work/rest cycle based on 12-hour increments, rather than 24. 

Water integrity—While we had cases of drinking water stockpiled at our stations and headquarters, we did not anticipate the loss of water pressure and integrity. This can be mitigated by storing extra potable water at stations for washing and drinking; access to portable toilet facilities; and dispensing wet wipes to employees for personal hygiene.

Winter precipitation—In our area we are not accustomed to snow and icy roads. It is not something we regularly train or prepare for. In response to this event, we did two things that helped manage the conditions. 

For our crews we distributed Hugo Grips 4 Ice over-shoe snow cleats. Utilizing these reduced slips, trips, and falls, which is the most common employee injury source. To mitigate the driving risks of the precipitation, when road conditions deteriorated our on-duty deputy chief implemented our “ice activation” driving plan. It highlights included: 

• A dispatch script that advised 9-1-1 callers we were experiencing delayed responses secondary to hazardous road conditions; 
• Elimination of street-corner posting; 
• Cessation of lights-and-sirens responses to reduce speed and provider stimulation. 

Our peers to the north who are more accustomed to these conditions may view such measures as routine, but we had to develop these plans quickly and were able to avoid any reported employee injuries or major fleet incidents by implementing them.

MEDCOM—Our centralized medical command was essential during high-demand times. It not only allowed efficient transport load-balancing between hospitals but also allowed direct involvement of the clinical staff and medical directors to make disposition decisions and avert some hospital transports altogether. 

With the loss of power and ability to heat homes, we saw an increase in exacerbation of otherwise-stable chronic diseases. Our county Office of Homeland Security and Emergency Management set up several warming centers staffed with MCHD EMS paramedics 24/7. These providers were a medical resource for those with chronic medical conditions (e.g., diabetes, hypertension, chronic COPD) and allowed evacuees to be treated at the shelters with blood glucose checks, BP checks, and supplemental oxygen from their home or MCHD-provided oxygen concentrators until it was safe for them to return home. 

MEDCOM staff were able to communicate with patients directly in the field utilizing our Pulsara platform. Patients were treated in place and put on a list for follow-up by MEDCOM clinical staff or sent with the medic unit or alternative transport to an alternative destination (warming center, clinic, relative’s house, etc.).

System response integrity—As one part of a larger system of healthcare delivery, EMS systems rely on our hospital and first-response partners to support us in the journey each patient takes. MCHD EMS utilized a tiered response configuration that placed more reliance on our first-responder fire departments to make initial responses and patient contacts on less-urgent calls without dispatching medic units. This was accomplished by alarm and MEDCOM staff through surplus call triage and prioritizing resource allocation. The process was successful, and our agency will continue working with other organizations to develop optimal response configurations, increase provider training, and improve the documentation/quality process. 

We also communicated with regional independent freestanding emergency departments on their ability to take increased EMS patient loads. This was a departure from our usual practice and overall very successful. We are now working to evaluate the inclusion of some of these nontraditional assets into our routine transport determinations.

Conclusion

During the Texas winter storm response of 2021, EMS systems faced the dual challenge of an ongoing COVID-19 pandemic and unprecedented storm event causing major utility outages throughout our state. Here are some take-home messages from our experience on what works.

Every agency must have baseline readiness plans for power and utility integrity and staffing, to include facility preparation for extra staff. During any disaster, having an ICS in place with medical command will reduce undue load on the healthcare system. The incident command system relies on good communication both within organizations and among external stakeholders. Have these relationships and contacts with the regional OEM, hospital partners, and first responder organizations sorted before the day of the storm. 

As in every disaster response, success relies not only on preparation but also flexibility in both how we respond and how we deliver care. We would like to thank our regional hospital partners and first responder organizations for their support during this disaster, along with our medics and the staff that support them to provide excellent EMS care to our citizens in Montgomery County.  

Robert L. Dickson, MD, FACEP, FAEMS,  is EMS medical director at Montgomery County Hospital District (MCHD) EMS and an assistant professor of emergency medicine at Baylor College of Medicine in Houston. 

James Campbell, FACPE, is chief of EMS for Montgomery County Hospital District.

Jacob Shaw, NRP, is operations assistant chief of Montgomery County Hospital District EMS.

James Seek, LP, BAAS, is division chief of Montgomery County Hospital District EMS’s clinical department.

Kevin Crocker, LP, FACPE, is division chief of quality and process improvement for Montgomery County Hospital District EMS.

Sean Simmonds, NRP, is EMS preparedness and safety coordinator for Montgomery County Hospital District EMS.