Courage Under Fire

‘This could happen to you’: Lessons learned from explosion in West, Texas

George Smith, DO, who coordinated disaster response following the explosion, urged DOs to amp up their disaster readiness chops.


A few weeks before the fertilizer plant explosion that rocked West, Texas, last year, George N. Smith, DO, led a practice fire drill at the nearby nursing home, where he serves as medical director.

During the drill—intended to prepare health care workers for the possibility of a fire at the fertilizer plant—Dr. Smith asked two aides to use an electric lift to transfer each patient into a wheelchair and move them away from the plant “fire” to the other side of the building.

Dr. Smith had no idea that his disaster readiness plan would soon be put to the test. On April 17, 2013, a fire at the plant caused a massive explosion of the fertilizer ammonium nitrate. Dr. Smith and his staff weren’t able to execute their disaster readiness plan exactly as they had practiced because the nursing home partially collapsed, requiring staff to evacuate patients manually and transfer some out of windows. However, having a plan in place helped Dr. Smith spring into action more quickly and think on his feet.

After evacuating the nursing home patients, Dr. Smith spearheaded West’s disaster response efforts. Under his direction, emergency response personnel evacuated the area and treated the injured in less than three hours.

As the medical director of a local Health and Human Services Department Disaster Medical Assistance Team (DMAT) based in Texas, Dr. Smith had significant training in disaster response prior to the explosion.

“I’m very thankful I had that training,” he said. “I knew what to do. I knew we would be working with the incident command system and that I needed to get to the incident command center.”

Dr. Smith, who still lives in West and practices family medicine there, challenged DOs and medical students to amp up their disaster readiness chops in an OMED presentation Tuesday. The explosion in West, a small town of about 2,800 in central Texas, killed 15 people and wounded more than 200. But Dr. Smith stressed that such a catastrophe could happen nearly anywhere in the nation. Semi trucks and rail cars carry ammonium nitrate to and from all corners of the U.S., he noted.

“How many of you live or work or have a hospital or nursing home within five miles of a railroad or five miles of a major interstate highway?” he asked. The vast majority of the audience raised a hand.

“This could happen to you,” he continued. “This could have very easily been a rail car that derailed and caught all the cars on fire.”

In addition to advising DOs to perform frequent drills, Dr. Smith also recommended they get to know their city’s regional trauma advisor and city and county emergency management directors, as they will be in charge during a disaster.

DOs should also always carry photo ID that identifies them as physicians and make sure their staff have ID stating they are health care workers.

During a disaster, out-of-town officials will likely man roadblocks, and won’t let people in without appropriate ID, Dr. Smith said, noting that in the aftermath of the West explosion, the nursing home’s administrator couldn’t get back to the site because she didn’t have her work ID.

Also crucial for any disaster readiness plan is an emergency communication plan, Dr. Smith noted. The West explosion downed radio towers, so Dr. Smith used a satellite radio in a helicopter to reach the outside world. Physicians should know where they can find a satellite radio or a ham radio operator so they can notify authorities about what happened. In addition, they should make sure staff know where to go if disaster strikes and phones aren’t working, he said.

Treating patients

Treating patients amid the chaos of a catastrophe is perhaps the most difficult element of disaster response, Dr. Smith said. Physicians must consider how they would handle an influx of trauma patients if they are the only doctor around.

“[Physicians are] used to saving lives,” he said. “If I have to spend 30 minutes with you to save your life, you bet I’m going to do that. But in a disaster situation, if I spend 30 minutes saving your life and 40 other people die because I’m doing that, I can’t do that.”

Dr. Smith said it may be necessary to employ the help of others, even nonphysicians, when triaging multiple patients with severe injuries. “You get somebody to hold pressure on a bleeder so you can move on to other patients, because you can’t definitively treat in a disaster,” he said. “You just have to stabilize [patients] and get them to definitive care.”

And if you encounter dead bodies, be aware that the authorities won’t want the bodies disturbed, Dr. Smith noted. That means you can’t give someone’s belongings to relatives, though the police will be OK with physicians moving or touching bodies in order to save lives or treat patients.

Richard E. Jay, DO, said that Dr. Smith’s presentation inspired him to look into getting DMAT training.

“When you least suspect it is when a disaster is most apt to happen,” said Dr. Jay, a family physician in Lovell, Wyoming. “Hearing about Dr. Smith’s experience gave me greater insight as to the amount of preparation that should be done before disasters happen.”

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