DMAT San Diego CA-4 *   *       *       *
A Level 1 Disaster Medical Assistance Team.
affiliated with the National Disaster Medical System
Founded 1991
Co-Sponsored by: UCSD Medical Center & International Relief Teams
Mailing Address: 200 West Arbor Drive, San Diego, CA 92103-8676

DMAT CA-4 Information Line: 619-543-6216
eMail address of Newsletter Editor, Jake Jacoby:     ca4cdr@san.rr.com
DMAT CA-4 WEB site: http://www.dmatca4.org

January 2003 Newsletter
* * * *  Volume 12,  Number 1  * * * *

CONTENTS
Calendar Of Events..........................................Page 1
CA-4 Responds to Guam...................................Page 1
DMAT in the Micronesia Mall...........................Page 3
List of members who deployed to Guam..............................Page 5
Member of the Year Ballot........................................................Page 6
* * * *
CALENDAR
Next Team meeting --
Wed., January 22, 2003 @ 1800 hrs.

Training Presentation: 
"Newest Communications Cache Items,"
by Peter Diehl
Where?  CA-4 Operations Center
8540 Production Avenue, Suite B, San Diego
Location is in Miramar Area, 1.8 miles E of I-805 exit at Miramar Rd. Turn N  on Production Avenue, 1/2 block on the left. (Remember, we have no mail box at the Ops Center, so never use this address for mailing purposes)
* * * *

* "Disaster 2003 Conference," Sponsored by the Florida Emergency Medicine Foundation. At the Rosen Center, Orlando, FL.  February  6-9, 2003.            Contact web site: http://www.femf.org/conferences/conferences.html
* "2003 NDMS Conference,"  Reno Nevada, March 8-12, 2003.  At the Reno Hilton, Cutoff date for hotel reservations is Feb. 5, 2003.
web site:
 
http://oep-ndms.dhhs.gov/NDMS%20  Conference/ conf2k3/conf2k3.html


 * * * *
CA-4 responds to Guam after
Super Typhoon Pongsona mauls the island
*
Q: What do Super Typhoon Pongsona and DMAT San Diego CA-4 have in common?
A: They both hit Guam in December 2002. They both took three days to get there.

   December was the last month of 2002 for CA-4 to be up first for disasters. The 30th of November however greeted us with a call from NDMS advising us that we were being  placed on ALERT as of the morning of Dec. 1st, and we would need to have a daily roster ready each night of people who could deploy for 14 days.  Also, we needed to get a truck and have our gear loaded and ready to go. We would be maintained in that situation for 10 days, and then the next set of teams would go through the same ALERT phase for the month.  This was to be an operational demonstration of the ability to get a team out the door in these times of heightened preparedness for a terrorist attack, the shape of which would not be known until it occurred.
   So the truck was loaded on Dec. 1st, the roster was prepared, and changed nightly, and there we were, when, on  Dec. 8th,  Typhoon Pongsona (pronounced "Bongsonwa," for those of you not fluent in Korean) happened. Pongsona was a Pacific typhoon which had formed several days earlier in the central Pacific, and which had been predicted to "turn to the North,"  but never  did make the turn until it was bearing down on the island of Guam. It was then that it slowed and gained strength to the level of a Category 5 hurricane, with wind speeds sustained at 150 mph, and gusts to between 184 and 212 mph., just as it struck the island. According to tracking reports, the eye wall essentially passed over the entire island, taking 12 hours to make the pass. Typhoons with sustained wind speeds of 150 mph  or greater are called Super Typhoons. They are equivalent to Category 5 hurricanes in the Atlantic and eastern Pacific. In the opinion of many,  this was the worst Typhoon to strike Guam in the last 50 years.  In its wake, the storm left broken walls at Guam Memorial Hospital, the only civilian hospital on the island, affecting care in the ICU, pediatric wards and elsewhere throughout the hospital. ICU patients had to be transferred either to the ICU at the U.S. Naval  Hospital in Guam. The Emergency Room was unable to function, and patients would  have needed to go the ER at the Naval facility, which itself sustained some damage but had no power or water.  This,  ,plus extensive infrastructure damage and  housing losses, and thousands of Guam residents in shelters, led to  a declaration of disaster  by the Governor, Carlos Gutierrez, resulting in the activation of the teams then on ALERT: DMATs CA-4 and OH-1. The initial request was for the DMATs to do hospital staff relief/augmentation at Guam Memorial. However, 10  nurses and 5 Respiratory technicians from the MA-1 based International Medical Surgical Response Team (IMSuRT) were instead activated for that mission. The mission for the DMATs would be determined once we got there. The 2 airports at Guam ( The civilian one and the military one at Andersen AFB) were not open immediately after the typhoon, due to damage to the navigational aids in the area, and these took 24 hours to be replaced, by the US Coast Guard. A FEMA-chartered flight left Oakland, CA  early Tuesday morning, Dec. 10th, with FEMA folks and an NDMS assessment team, to start working with the local community in responding to community needs. The CA-4 basic load was moved to Miramar Marine Corp Air Station, palletized by the CA-4 logistics section, led by Larry Griffin, and included Ed Snyder and Dave Holland, and loaded on a Southern Air commercial cargo charter 747, joining the loads of the MST and  OH-1.  The load left San Diego on Wednesday night, Dec. 11th after a 6 hour delay at Andrews Air Force Base for a mechanical problem. In the meantime, the Ohio-1 team, members of MA-1 and individuals from other teams that were augmenting the two teams, traveled commercial to San Diego, to enplane the chartered ATA (American Trans Air)  L-1011  passenger flight to Guam. Departure was from North Island Naval Air Station, San Diego, at around 9 AM on Thursday morning, Dec. 12th, and was mostly consumed by trying to quickly figure out what time it was in Guam when it was X  time in San Diego, and vice versa. And 3 movies. The flight to Honolulu took around 6 hours, only stopping long enough for refueling and some really quick shopping at the airport  Then another 6 hour & 45 minutes flight to Guam, arriving on Friday Dec. 13th around 2:30 PM local Guam time.
    It was there that the members of the teams learned the true definition of an old  word in English. The word was "hot."  It was all understandable, seeing as how I had  spent my time on the flight looking at a map that showed Guam to be due north of New Guinea, and on  the 13th parallel North latitude. I quickly calculated that since  the 90 degrees of the northern hemisphere was approximately 6,250 miles long, (1/4th of the 25,000 mile circumference of the earth), that each degree of latitude represented around 70 miles, and therefore we were only 13 X  70, or around 900 miles from the equator. I was of course relieved to know that it was  winter in Guam. What's it like in summer?
   Upon arrival at Andersen AFB, we were introduced to the concept of how important air conditioning was to people on the island, as we were left on a bus for around 45 minutes,  rather than being allowed into the air terminal, because the air conditioning was off, and the building was quite like a sauna, from the typhoon rains, which appeared to have permeated everything.  Personal gear was loaded onto trucks and taken to busses and we finally made it to our billeting destination, the Hilton Hotel.
   The destructive force of the typhoon was visible every where. Trees were down. Palm trees, familiar to me from growing up in South Florida, were missing their crowns. Of those that still had them, many were a dead brown color, instead of the familiar green. Before we left, we were told only 100 hotel rooms were available on the island, and we would likely be sleeping in tents. From the outside, the Hilton looked ok... except for the uprooted trees lying around on the periphery.  Upon entering the halls, it was a different matter. Many rooms had sloshy wet carpets. But hey, it is a disaster area.
    After a night's sleep. the deployment was evolving. We would be setting up a tent clinic function somewhere, to make up for the decreased availability of  doctor's offices which were without power  and water, if undamaged. Pharmacies were in the same predicament. People could not get refills on their scripts, since the pharmacies had them. Many  doctors' offices were not open,  and so people couldn't get new scripts written. And many people had lost their meds when their homes were destroyed   in the storm..  Thousands of people with diabetes and  hypertension were without their meds and in stressful circumstances. CA-4 would be on the north side of the island, and OH-1 was to set up a similar clinic on the southern end. The assessment teams had found some prospects and were negotiating the details.Meanwhile the Critical care nurses and the RTs from the IMSuRT were already starting to work at the Guam Memorial  Hospital.  A load of adult and pediatric ventilators and many needed medical supplies were brought by the USPHS, to aid Guam, and these were being moved to Guam Memorial.  
   By Sunday morning, Dec. 15th, a site had been found. The Micronesia Mall. The largest mall in the Marianas. It was chosen  due to proximity to bus lines, since there was gasoline shortage on the island from a fire that burned over 5 days in the harbor, consuming 3 gasoline storage tanks. And it had power.
   We were ready to start. Our logistics folks were out at the Air Base, where our basic loads had been stored in a warehouse that FEMA was running. We requested supplies and a single tent to get started in, and it was delivered by 10:00 AM, opening time at the  Mall. We were bussed over and started to put the tent up and get the interior ready for an influx of patients. We had no idea what the response would be. Apparently. there had been some radio spots about our opening, and people shopping in the mall would likely come over and check us out just out of curiosity..  But before we could get ready, the first patient showed up, an asthmatic with tight wheezing. She would be the first of many asthmatics we would see during the week. The patient cleared nicely with 3 RTs. She was so delighted to have had her asthma treatment right there in the mall.   Patients continued to find their way to us, and by closing time at 2000 hours, we had seen 50 patients. This was a good beginning. Of course we had already started to see things that we had not anticipated. The number of nebulizers we had was inadequate. How will the flow work with respect to getting the patients their medications?  And, more importantly, "What will happen the next day, when word gets out?" we wondered.  We started to do things that would become routines, both in the morning, with a team briefing covering special circumstances for the day; and at the end of the shift: packing up all the pharmacy storage boxes, and carrying them upstairs to keep them secure in the FEMA Disaster Field Office (DFO) which was directly above us on the next floor. Now this  was convenient, for it meant we could use their copier in a pinch. And maybe even their internet connection? We would see about that. 
   The next day, a small crowd of around half a dozen patients , were already starting to gather as we arrived at the site. More diabetics without their meds. Lots of children. Glucophage was being used heavily on the island, either as a single agent or as part of a two or three drug regimen for diabetes. How is it that there is only one oral hypoglycemic on the cache? Hmmmm. There are really three different kinds of oral agents, each works a different way and they are additive. Some diabetics are  hard to control and could wind up needing hospitalization if they don't get their meds just right.... First pharmaceutical  item to list for the After-Action report....Case of endophthalmitis from a tree branch injury to the cornea came through and had to be transported.  And the first of many chest pains. By the end of the second day,  79 patients had been treated and released or transported. . Pretty good days work, I thought. Busier than day #1, but we kept the flow going. The pharmacists were great, meeting with each patient and explaining the instructions to the patients, and making recommendations as to what substitutions they could make to what we had ordered, based on the contents of the basic load. The nurses and EMTs were really adjusting to the unfamiliar location. Seemed like everyone was pitching in to help somewhere. There were Paramedics working as pharmacy assistants, due to the high demand for prescription meds.  There were nurses doing that as well.  Wherever there was a potential back up, someone pitched in. We had never really made up specific operational plans to encompass this, but it just seemed like everyone was attuned, and things were smoother than the first day.  A visit from the Governor, Carlos Gutierrez, was a welcome boost to morale, as people were noticing the DMAT 's contribution to health care on the island.
  There were other bugaboos. A  list of forbidden food places at the Micronesia Mall  Food Court was issued. Some of the team had already eaten at a couple places on the list. Oh well, we shall see..I am glad we took several  cases of MREs to the mall. And  imodium.They came in handy.

   Day #3 at the mall:  Upon arrival , over 30 people were waiting to be seen, and this was an hour before we were scheduled to open. The volume just kept up all day. So many kids. Families of three, four and five, all being seen. Wheezing. Puncture wounds. Skin infections, Cellulitis; and abscesses. Wound care. Fevers. A patient with  Hansen's disease, on therapy, came through, with an unrelated complaint.  More wheezing. Diarrhea. And always, whenever I went for a break it seemed as though a chest pain rolled in. When there was no ALS medic unit available for the cardiac transport of a patient with  EKG changes, we just sent one of our medics on the Guam FD BLS unit, which would otherwise have not been authorized to do the transport, due to the I.V.  Just grabbed a "Go" bag in our Thomas Bag, and all the ACLS meds were there. Our  nurse practitioners seemed like they were really primed for the load. The ECG machine was working. It doubled as a monitor.  The glucometers were getting a work out.. I wished we had our I-STAT cartridges, but it seemed that the diabetics weren't very sick, despite the high blood glucoses. They seemed to respond to insulin and fluid, I  suspect they weren't used to getting it.  It was unbelievable, but at the end of the day, we had seen 179 patients! Can't remember how many we had to transport.  This was the day that Jon Blumeyer and Deanna Polk's photo was on the cover of the Guam Pacific Daily news. {Go to: www.guampdn.com,  find the photo section for Typhoon Pongsona, look for the date and check out their photo. This led to an even busier day the next day, when we saw 203 patients. I am  sure we could not have seen any more than that, which is quite a load for a 9 hour shift, even with two docs and two NPs. A series of visitors made their stops at our site: the Base Commander from Andersen AFB; the Hospital Director of Guam Memorial;  and  the FEMA person who approved our mission number;
   As we worked hard, so too was the rest of the community, getting their pharmacies open, fixing up their hospital,a and getting their doctors' offices   reopening.  Word had it on the street by day # 6 that we had been appreciated for what we did, but now the doctors and the pharmacists  were back to work and restarted their income streams.  It was getting time to leave. Our last day open was Saturday, Dec. 21st. We finished our last patients, and immediately started to pack up and  shut down the clinic operation.
The team however, had still more surprises. A group of the team , led by Deanna Polk, who was responsible for the words, broke into song to the tune  of "Winter Wonderland," entitled "DMAT at the Micronesia Mall." [See below for words.] A giant poster roll of paper was used to thank the people of Guam who had accepted us and   trusted us  to take care of their health needs during the aftermath of Pongsona.
Final patient totals over 7 clinic days: 933 patients (33% pediatrics); 1091 prescriptions were prepared and distributed, and 21  seriously or critically ill were transported to Guam Memorial Hospital.
Our last day on the island was one of getting our now smaller load palletized, and then some free time to tour the island. And tour we did, all the way around in groups. We got to see many of the small beaches and bays, the 17th century Spanish fortress and its cannon on the SW side of the island; the small towns and villages around the south side, and the large palm groves in the central southern area. We stopped at several sites of the War in the Pacific Museum, and got the magnificent view from atop Nimitz Hill, where we also saw our only brown tree snake. It is truly a beautiful island. The flight home seemed to go faster than the flight out, but isn't that always the case?
   This was an exceptional deployment, in that we finally got to see patients instead of just standing by. And the patients were for the most part in dire need of medical care during that week, while their community supports were recovering.  There is still along way to go for the island to recover.  It will take weeks and months for homes to be rebuilt,  for the power to come back on, for the water supply to become potable once more. But nothing will erase the scary memories of the people who had to live through the sounds of their roofs being torn off, their homes being torn apart, with no place to run to in the middle of the storm.   Those  frights will affect the population for years to come. Although typhoons are a way of life there, this was a bad one. But the spirit of the islanders was truly remarkable.
     Of course the real mystery of the deployment has still not been solved: how did my two XLARGE  DMAT shirts go to the Hilton Hotel laundry and come back as SMALLS, without someone who wears SMALL getting  2 XL's back? Seems to refute Newton's 4th Law of the Conservation of Laundry.
   I am extremely proud of all our team members, who stepped up, in many instances for the first time, and did an awesome job. Everyone  pitched in and worked hard, often out of their job descriptions. We were really glad to have had the opportunity to work with some outstanding members of the MA-1 team. We just have to figure out how to get them to move to San Diego and be permanent members of our team. Also many thanks to those who were on the roster for awhile and who might  have gone if the dates were different. Also to those back here in San Diego who supported the team's activities as part of the Home team. 
   Now to get ready for April.
        -----Jake Jacoby

* * * *
DMAT in the Micronesia Mall
words by Deanna Polk
(To be sung to the Tune of "Winter Wonderland.")

Got a call 'bout the typhoon,
We were up,
Got here real soon,
With FEMA upstairs
But who really cares
DMAT in the Micronesia Mall

Got a room at the hotel,
So damn hot, thought it was hell,
The mold was a fright
We can't sleep at night,
DMAT in the Micronesia Mall

In a minute we can start an IV
Do some blow-by with a paper cup.
Someone's got to lance another boil,
Let' s pray to God that we don't all throw up.

Pretty soon time to bug out
Here it rains like a drain spout
With patients in line,
We've had a great time,
DMAT in the Micronesia Mall

Therese and Jake have been some awesome leaders,
Chipper is our little mascot pup.
Pray to God we don't get any bleeders
'Cause who knows if the ambulance will show up..

Later on--on the airplane
What the heck we're all insane
The things that we saw
Our hearts in it all
DMAT in the Micronesia Mall
* * * *
Deputy Commander's Column
This is an eMail which went out to the team recently, adn is being reprinted for those who do not get our eMails.:

Dear Team:

Happy Holidays!  Hope you have all enjoyed a few restful days with your family and friends.

Congratulation to DMAT - CA4 and our good friends from MA - 1 who augmented  CA -4!   Our "Micronesia Mall - North Team"  provided care to 933 patients over 7 days, 339 (36%) of these were children.  The team stabilized 55 patients who were serious or critical. Twenty-one of these patients were transferred to Guam Memorial Hospital following initial evaluation and stabilization in the DMAT CA-4 tent.  The DMAT pharmacy was very busy with 1093 prescriptions filled by hand.  In addition to the provision of clinical care, the team collected valuable information for the  CDC that will aid future deployments.

The CA-4 logistics team provided superb support and kept the clinical arm of the team well supplied and functioning. The MST kept the teams well informed, supported the mission and provided the structure, equipment and pharmaceuticals necessary for the success of this deployment.  Our friends from FEMA and Andersen Air Force Base, Guam Memorial Hospital, U.S. Naval Hospital, Guam and the management of the Micronesia Mall all helped the teams in their special ways, to provide important medical care to the people of Guam. That makes us all "one big successful team"  in anyone's book.

Ohio I, augmented by DMAT members from Hawaii, Texas and CCRF were equally busy in the South and also staffed Sick - Call.  We have enjoyed working with all these DMAT members and consider this deployment and the experiences we have shared to be unforgettable and very special.  We certainly look forward to working with these members again.

A special personal thank you to all of the DMAT CA-4 and MA -1 members who joined forces with our team.  Your professionalism, talent, flexibility, care and concern for your patients and for each other, marks each of you as extraordinary individuals. It has been an honor to have worked with you.

Thank you also to the CA-4 members who volunteered to go but were not assigned this trip and to those members who helped us to get out the door and return safely.  We all recognize the tremendous support of our families, friends, coworkers  and employers who help each and everyone of us  be able to deploy. We are well aware of the efforts you have all made in support of this deployment and the impact on work and family in this Holiday Season.  Your kindness was felt by the people of Guam.

Wishing you all the Peace and Blessings of the Season,

------Therese Rymer
* * * *
List of Members who deployed to Guam:
Rymer, Therese (CFNP)[Dpty CDR}
Soderbery, Robbin (LVN) (Admin Officer)
Jacoby, Irving "Jake" (MD)
Kreitenberg, Art (MD/Ortho/Trauma)
Duval, Arlyn (CNP)
Prepas, Roberta (CNP)
Wahrenbrock, Zona (RN)
Spuhler, Kevin (RN)
Bunnell, Les (RN)
Hicks, Toni (RN)
Keely, Jeffrey (RN)
Mehlman, Elizabeth Leia (RN)
Polk, Deana (RN)
Hyman, Sara (RN)
van den Hout, Carla (RN)
Dieffenbacher, Mona (RN)
Martinez, Sylvia (RN)
George, Greg (EMT-P)
Rod, Ricky (EMT-P & RN)
Ruiz, Salvador (EMT-P)
Blumeyer, Jon (EMT-P)
Lang, James (EMT-P)
Sohmer, Michael (RPH)
Pregent, Susana (RPH))
Holland, David (Safety Officer)
Welsh, Mary (RN)
Griffin, Larry (Logistics)
Snyder, Ed (Logistics)
Markland, Jo (EMT-1)
Thoreson, Jack (EMT-1)
Fitzgerald, Beverly (EMT-1)
Steinberg, Craig (RPH) - augmented OH-1
Bartlett,Geoffrey (Commo) [MA-1]
Boomhower, Robert [MA-1]
Drake, Catherine RN [MA-1]
Holst, Robert EMT-P [MA-1]

Whelan, Brenda, RN [MA-1]

1 Due to shortage of MDs, Jake Jacoby was rostered as MD, and Deputy CDR Therese Rymer was the Deployment Team Leader.
2 Due to personnel shortages, CA-4 was augmented by 5 members of MA-1.
3 Due to personnel shortage, there was no lab tech deployed.
4 Due to shortage of supervisory nurses, Zona Wahrenbrock went as Supervisory nurse, while Robbin Soderbery was rostered and functioned as Administrative Officer.


Congratulations
To Greg and Shawn Mann on the birth of  Elizabeth Elaine, born on Nov. 23 at  10:24AM  @ Fallbrook Hospital. Elizabeth weighed in at  6 lbs. 1 oz. and  was 18" "tall."

* * * *

Condolences 
To Peggy Perkins, on the passing of her mother, November 17, 2002, in Salt Lake City. This has been a difficult year for the Perkins family, as Chuck also lost his father in the past year. Our prayers are with you.
To Elaine Sapiro, on the passing of her father, in New York, January, 2003.




* * * *
VOTE for the DMAT San Diego CA-4 2002 VOLUNTEER OF THE YEAR Award
Selection time for DMAT San Diego CA-4 VOLUNTEER MEMBER OF THE YEAR for 2002 is running out. Nominations were solicited via eMail and at the last meeting. The following 2 CA-4 members received  the most nomination support . Once again,  we will have a formal vote for the Winner, so that this will reflect the true will of  our team.

GUIDELINES:

*Only fully paid up members in good standing are eligible to  vote.
*Only fully paid up members in good standing are eligible to be considered.
* There will be ONLY ONE member selected as Volunteer of the Year from our team. No joint selections are allowed by NDMS.  There will be no ties.
* You may only vote once. You may only vote for one nominee.
* You must cast your vote even if you already submitted a NOMINATION Form.  The election for Member of the Year is based on the number of actual votes the nominees receive at this stage in the selection process. 
If you wish your vote to be anonymous, you must place your ballot in a plain white envelope which is then placed into the mailing envelope and sent to the DMAT Business address noted below. DO NOT  ADDRESS IT TO THE OPERATIONS CENTER,  as there is no mail box there. When received, the blank inner envelope with your ballot inside will be removed and counted anonymously. You MUST have your name on the OUTSIDE MAILING ENVELOPE so we can track which members  are voting. Votes may also be dropped off at DMAT Ops Center, you will be asked to sign list at time of voting.

* Winner of the Volunteer of the Year Award from CA-4 will be sent to the Annual Meeting of NDMS in Reno, Nevada by the team, and will have the following costs covered; Airfare,  hotel room, Conference registration fee, mileage to and from the airport in San Diego, and airport shuttle cost in Reno.
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OFFICIAL BALLOT  (vote online)