Over that hill, a nursing home in ruins

A mother and her son are at the edge of what was once a familiar city, trying to fathom the mess Tom and Jerri have gotten themselves into. Tom and Jerri Anne Guidry, that is—an older couple and friends of the family. Minutes before, when cellphones still held signals in Joplin, Mo., the Guidrys described the sound of a terrible storm blowing away their home while they curled up inside a closet.

So here's Lisa Cantrell and her 19-year-old son, on a rescue mission, heading into the unknown. Cantrell, who happens to be an experienced health professional—the co-founder and chief clinical officer of the Joplin-based National Association of Health Care Assistants—can't comprehend what she sees. After living here for 47 years, her entire life, Cantrell doesn't recognize the landscape and rubble before her, or the people crawling up from underneath. Matthew, a second-year college student home on summer break, is at Cantrell's side, although she now questions having brought him into such an extraordinary circumstance.

They're about a mile and a half from the Guidrys' home, unable to drive any farther as the streets are littered with unquantifiable amounts of debris. It's well into the evening, wet and chilly. Cantrell is wearing blue jeans, work boots, a tank top, t-shirt and three lightweight jackets. Her shoulder was operated on last month and stiffens up painfully in the cold, hence the extra layers. She's also carrying a first-aid bag previously thrown together for volunteer disaster work. It holds the basics: CPR shield, stethoscope, roll gauze, sterile saline, tourniquets, flashlights, bandage scissors, hemostats and a Swiss Army knife.

The further they move into Joplin, the more overwhelming the damage appears. Entire blocks of homes have exploded. Roofs must be climbed over, sparking power lines avoided. Frightened and muddied dogs run wild. Homeowners stagger around their yards stupefied, putting together enough words to refuse assistance. Cantrell averts her eyes straight ahead in fear of what she may see in the wreckage. The devastation seems to go on forever.

“My God, Matt. This is bad. This is so, so bad.”

There is not much left of the Guidrys' toppled house, and a large tree leans on what remains. The couple is alive, but clearly dazed: Tom steps on nails and broken glass in his flip-flops; it takes him a good minute to identify Cantrell. They all embrace, sobbing in the pouring rain. Meanwhile, tendrils of lightning spread out sideways overhead. The storm is still terrible.

They check on a few neighbors before Cantrell insists on heading home. “Matt, go the very same way, just back to the car.” It feels awful, but Cantrell leaves her son to guide them as she takes off toward Main Street in search of other survivors.

The destruction is surreal. There is more debris than she can climb over in almost all directions. Emergency sirens blare in the distance, yet no vehicles are around. No responders. Where is everyone? Where are those screams coming from? She ascends a small hill in the road, feels like she knows the area but can't discern any landmarks.

An odd feeling: Am I on the right road? This is where the nursing home should be, or where it once stood. Below is the Greenbriar, 120 beds, where Cantrell took her nurse aide training as a senior in high school—reduced to a mountain of bricks and mattresses and twisted wheelchairs, identifiable only by the facility's van resting in a spot it couldn't have possibly been parked.

A few men are on top of the heap, frantically tossing aside sheet metal and wood. People are trapped under there. Cantrell runs down to assist.

I don't know if we're going to get anyone pulled out of this.

FOLLOWING PROTOCOL

“There was absolutely nothing in that building able to withstand the force of the tornado, so it basically imploded on itself,” explains William Mitchell, executive vice president of operations at the Greenbriar, speaking months after the disaster. On May 22, at 5:41 p.m., an EF-5 tornado with 200 mph winds—enough to strip the bark from trees—carved its way through six miles of the city. The Greenbriar succumbed to a direct hit.

This was not the only nursing home to have been damaged, but it was the only one with fatalities: 11 residents within the rubble, one resident who passed shortly after rescue and one staff member—a heroic CNA named Keith Robinson who was found embracing two residents, all three of them deceased. The Missouri Health Care Association attributes 20 total resident deaths to the tornado, a number that includes those who had died from injury in the aftermath, resulting in the city's greatest loss of life in one confined area. And when taking into account the 88 residents and 22 staff members in the building that night, it's still hard for some to believe that more people hadn't perished.

The second badly damaged nursing facility, which is also managed by Mitchell's employer, LTC Consulting, was the 120-bed Meadows Care Center. Together, 240 nursing home beds had been taken out of existence within seconds; although the Meadows was not immediately demolished, it was certainly uninhabitable.

Prior to the disaster this past spring, tornado management protocols had been reworked to be consistent with “all known plans and practices” at both locations, Mitchell confirms. When the threat of a tornado became imminent, all windows within the facilities were opened, doors were closed and residents moved from their rooms and into corridors with staff. “[After] a further review and consultation with the state, we concur that all practical and reasonable precautions were taken, as is evident by the lack of injuries in the Meadows,” Mitchell says. The difference was, as one national safety expert put it, that following protocol in the Greenbriar “was like wearing your seatbelt and being hit by a freight train”—a catastrophe beyond the scope of precautionary measures.

Mitchell says it did not take long for the “arduous interfacing” to begin with the insurance company, which insured both buildings, and determine who pays for what, and how much. A microcosm of that process was finding someone to bid on the work of hauling away all the debris at a cost the insurance company agreed with. “As you can imagine, with such mass destruction, anybody who had a Caterpillar and a dump truck was already employed,” Mitchell stresses. That work wasn't completed at the Greenbriar until about a month afterward. At the Meadows, it didn't happen until this past September. “We were going through an analysis with the insurance as to whether [the Meadows] could be rebuilt because it was only partially destroyed,” he says. “Under state and federal rules, when a building goes 30 days or longer unoccupied, you must voluntarily give up your license and your certification in order to maintain the ability to rebuild.”

The operator then had to go through various governmental bodies to retrieve its licenses and certifications, as well as a Certificate of Need, which places restrictions on new construction of healthcare facilities to ensure a building does not overreach with its projected capacity.

Six months since the tornado, LTC Consulting and the owners of the leased buildings are moving forward with the rebuilding process. But for many involved during and after the disaster, including Mitchell, the grieving process has been masked by busywork, a way for some to avoid thinking about all that they had witnessed.

FIRST RESPONDER

The sun is setting and the men are working to uncover pockets of survivors. “We've got one!” they yell, preceding the discovery of several more residents and staff. Cantrell and another woman have cleared a 20-foot section of the parking lot to rest and triage people. Most sit on the concrete, and a few are placed on salvaged but soaking mattresses. Wielding a black Sharpie marker, Cantrell writes numbers on their foreheads: 1—these people have life-threatening injuries and require immediate transportation; 2—moderate injuries, still a priority; 3—those in decent shape, and the last to be transported.

Many of the residents had their clothing ripped or blown off and are wet from the still falling rain. Cantrell has given away all but her tank top and jeans, and she uses the bottom of her top to wipe faces clean of heavy grit so the marker can write. The first-aid bag has been rendered ineffective due to the injuries she encounters—lacerations, puncture wounds, skin tears, broken bones, mouthfuls of shattered teeth. The head trauma and shock has caused so much disorientation that it's impossible for Cantrell, a former director of nursing, to tell who is confused and who is cognitively impaired to begin with. Nothing can be done to put these residents at ease. Cantrell has served the elderly her entire adult life, but these people—she can't keep them dry. Can't warm them up. “I'm going to run to a couple nearby houses. See if I can get some blankets or anything to help until we get these people to the hospital.”

All of the surrounding homes are in ruin. She forages, but it's an act of futility. Everything—literally, every single thing—is drenched or full of glass shards and insulation. But her search offers necessary respite, along with a moment to think clearly and listen to the hissing of burst gas lines below ground. The air is thick with the fumes of gasoline leaking from thousands of overturned motor vehicles. Explosions vibrate underfoot. Gazing at what was once the medical community, the part of town with physician's offices and nice older homes, Cantrell views a pastiche of uncontrolled fires and plumes of smoke. It reminds her of that bizarre California man who predicted yesterday would be the end of the world. The guy almost had it right. He was just one day off.

Cantrell heads back empty-handed. Since then, an elderly woman has been pulled out and requires assessment. She looks up with the most beautiful blue eyes, the fright in her face, searching for answers: “Is it over? Is it over? Is it over?”

“Yes, it's over. We're going to get you taken care of.” But the words sound hollow to Cantrell. And those sirens, they seem so close but are nowhere, frustrating the rescuers who want nothing more than to get these people to the hospital.

Men with small pickup trucks arrive instead. They back up close to the parking lot, and survivors are carefully loaded into the beds. Cantrell rides with the first group; a slow, painful journey filled with obstacles and dreadful sights.

Just a few blocks away, St. John's Regional Medical Center stands as the dominant landmark it has always been. But something doesn't seem right. Curtains on the upper floors are blowing. A caravan of ambulances has assembled out front. Then, the realization: St. John's had been hit.

TRACKING THEM DOWN

Within three days of the tornado, LTC Consulting located 100 percent of all transported residents—a feat considering some ended up as far away as Kansas City, Mo. (150 miles), and Wichita, Kan. (200 miles). And there were no medical records with any of the residents, as the Greenbriar lost all of its data. The Meadows had partial records, but the majority of them were housed in offices at the front of the building, which was taken off during the storm.

With St. John's evacuating its own patients, most Greenbriar and Meadows residents ended up at Joplin's other main care center, Freeman Hospital, which maintained partial records of admitted persons. Those records were used by Mitchell's staff to track down residents who were then discharged to other nursing homes in the four-state area. “It was like a Sherlock Holmes mystery running everybody down because their records were not kept at the discharge location,” he says. LTC Consulting exercised due diligence by notifying all interested parties as to the status of destroyed records. No one raised an issue.

That's pretty much true of the entire effort—most everyone was agreeable given the enormity of it all. Sure, there were panic-stricken families in the beginning, and the staff tried as best they could to locate residents with haste and accuracy. They were assisted by those health facilities that received residents, uniting in one seamless disaster recovery effort. It left people like Jon Dolan, executive director of the Missouri Health Care Association, outspokenly proud of his member facilities. “I think the state would echo the fact that placements, evacuations and disaster preparedness went exceedingly well,” Dolan says. “The governor should be commended because our relief efforts were handled Joplin for Joplin, and the state for the state, so we did not run into any FEMA or national bureaucratic difficulties that I'm aware of.”

Member facilities within the larger American Health Care Association framework came out in support, along with other independent entities. In what it calls a year of “tragedy and triumph,” the Missouri Health Care Association has collected $130,000 to be distributed among the families of affected nursing home staff members in Joplin to help with utility bills and relocation assistance. It's an employee-centered concept, although even some displaced residents have received 26-inch televisions to “bring their homelike environment back to them,” Dolan says.

There has not been much discussion critical of the nursing homes' disaster protocol and response, which may be a triumph in itself. Some local news reporters have questioned why nursing homes don't have storm shelters to move residents to during a tornado. There is an ongoing argument as to the practicality of this solution, considering the persistent difficulties and risk of injury during a normal transfer of frail and disabled persons.

To shield its staff from the burdensome nature of similar interview requests, LTC Consulting ordered most remaining employees to not speak with journalists. Mitchell says the media's greatest failure has been in how it continues to gloss over the heroism that took place at both the Greenbriar and the Meadows. “Each of those facilities had staff with family members in different locations and when the tornado hit, because all communication was blacked out in the region, few knew what the status of their families was,” Mitchell says. “They all stayed and worked diligently without ceasing until everybody that could be identified or removed from the buildings had been taken out. They kept saying, ‘That is our job and we want to do it right.’

“The best way you can summarize it is everybody can be proud—we can definitely be proud and I think most operators can be proud of how their staffs perform in the time of greatest adversity. You can only imagine what they might be able to do, but then you see what they are really capable of and you say, ‘Wow, that is amazing.’”

Dolan echoes that same satisfaction, taking it a step further by saying his member facilities should strive to “become experts who can help others and never turn away” when a similar tragedy strikes, and to “always look out for others in America as they looked out for us.”

“The other hard message,” he continues, “is that we in the long-term care community need to make sure the attention to us as the little brother in healthcare is there. We need to make sure that from communication systems to generator power to FEMA and others that everybody remembers that little facility behind the big hospital and that it is never forgotten. And in this case, we weren't. We've been treated very well.”

NEVER FORGET

It's taken several months before Cantrell can talk about that night. “I just feel like it has stripped all of the joy from my heart,” she now says.

It started out as a denial of emotional trauma. But during her association's annual conference in June, her favorite time of the year, she became consumed by great anxiety. She skipped the awards banquet—an event she always hosts—to remain in her hotel room.

This anxiety often resurfaces. She doesn't want to socialize or be around people, behavior that affects her family more than anyone else. “It's been the hardest experience of my life,” she says. “I go put gasoline in my vehicle and I can't even do it without crying. Just the smell makes me think about everything from that night.” Cantrell has been diagnosed with post-traumatic stress disorder, although she is beginning to feel better after seeking help. She also says there aren't enough people talking about the lingering psychological and emotional effects in Joplin, though she knows there are others “suffering much in the same way that I have been.”

When her association held a luncheon this past summer for the staff members of the Greenbriar, Cantrell heard them talk about how difficult it was in the seconds before the storm hit to keep residents with Alzheimer's contained in safe areas. Those who normally wander or pace the halls couldn't understand what was about to happen.

Cantrell marveled at those nurses and CNAs and says there are many lessons to be learned. She would never hold them accountable for any minuscule details overlooked in the split seconds before the tornado struck. She is a caregiver just like them. But she also speaks of her own regrets, the things she should have done different, “the next time that I do anything like this.” Put blankets in the car. Write “Greenbriar” on the forearms of those in triage.

It's kind of like those sirens that plagued her all evening. It took awhile to remember that the streets were too cluttered for anyone to advance—they needed chainsaws and bulldozers to break through. In those moments, the emergency responders made do with what they had. And it's all anyone could have ever asked of them.

Long-Term Living 2011 December;60(12):20-25

Kevin Kolus

Kevin Kolus wrote for I Advance Senior Care / Long-Term Living when he was an editor. He left the brand in 2012. He is now senior communications manager at Cleveland Clinic.