A surgeon in the U.S. Virgin Islands recounts the experience
Editor's Note: This editorial is an account written by AAOS Fellow Jeffrey M. Chase, MD, who rode out Hurricane Irma in his house on the U.S. Virgin Island of St. Thomas. Irma, a category 5 hurricane, with sustained winds of 180 MPH and gusts up to 220 MPH, roared across the United States and British Virgin Islands (BVI) on Sept. 6, 2017. It was the strongest Atlantic Ocean hurricane in recorded history. Prior to menacing the Virgin Islands, Irma had flattened the islands of Barbuda and St. Maarten. The U.S. Virgin Islands sit just south of the BVI (Tortola, Virgin Gorda, and Anegada) and is made up of three main islands: St. John, which is slightly south and east of Tortola; St. Thomas, which is a few miles west of St. John; and St. Croix, located 30 miles south of St. Thomas.

Dr. Chase submitted this report in mid-September, shortly after Irma struck St. Thomas.

The eye of Irma crossed right over Tortola; St. John and St. Thomas were in the lower eye wall. I live on the east end of St. Thomas and although our home faces northeast toward St. John, it also has significant southeast exposure. Therefore, as the storm raged, we did not get the calm of the eye. We got wind the entire time, first from the north and then from the southeast. I was bunkered with my family in the lower level of our poured concrete, steel-reinforced house, with most windows protected by roll-down hurricane shutters. The house sits about 50 feet up from the water, with a reef in front. Our group included my wife, my 23-year-old stepson and three of his college friends who were not allowed to stay in their dorms, my 7-year-old twin girls, our dog, and my physician assistant (PA), Lisa Feather, who'd only been on the island for 3 weeks.

It started out as a pretty mundane storm, and we played Monopoly and card games and listened to music. But as the intensity picked up, the generator failed and the shutters and doors began to rattle. The most south-facing room (my stepson's bedroom) had a metal door, and the south-facing window (one of only two without hurricane shutters) was covered with plywood screwed into the concrete with multiple Tapcon screw anchors. As the metal door began to bend and fail (pressure changes during hurricanes cause a pressure differential that will blow out windows and doors), we grabbed a strap, tied it around the doorknob, and took turns resisting the outward pull of the door. We also were just feet away from the plywood-covered window and watched over the course of a half hour as each Tapcon gave way, until the plywood flew off. We had prepared for this with a ditch plan: We had moved the mattress to the next room, and decided that if the plywood gave way we would abandon the room, throw the mattress against the door between the rooms, and brace it with our bodies. That is what we did until the storm died down, around dusk.

We had no idea if the roof was on the house. We could see through small windows in the bathroom that our pool's deck railing was gone, the deck itself was severely damaged, and our reef periodically disappeared under 25 foot or higher waves. As the storm let up, we gingerly emerged from the house through the metal door that had held (as had the window where the plywood flew off). What appeared before us, was in a word, Armageddon. There was not one leaf on any tree or bush, our gutters were gone, our flagpole and our neighbor's tree were lying against our roof, and his gate, fence, and satellite dish were in our yard. The concrete wall between our houses was toppled over. Our large tree had fallen as well and blocked the path to our exit gate. After ensuring there was a safe path to our upstairs main living area, we got everyone inside, checked in with our neighbors on marine radios to make sure everyone was alive and OK, and went to bed, mentally and physically tired.

Fortunately, I was not on call that night. Otherwise, I would have been required to be at our hospital, the Schneider Regional Medical Center. However, I was on call for the next day, and was due to check in at 8 a.m. The phones were not working, so my PA and I decided to drive to the hospital. We had prepared an emergency medical kit consisting of bandages and suture supplies, sterile gloves, various medications, and casting and splint material, in case we encountered anyone on the way who needed treatment.

As we headed out, it was immediately apparent that our world had changed. The scene was post-apocalyptic, with most of the electrical poles down and lying on the road at various angles, often with parts of roofs and other structures dangling in the wires. Some poles were on the pavement, others were supported by wires, and some seemed magically to be suspended in the air. At the top of the hill at the edge of our neighborhood we recognized one of the family practice doctors, Mark Livingston, MD, who had been at one of the hotels during the storm attending to the guests, walking around and checking on people.

Together we came across a 40-ish, 280-pound gentleman sitting in his pickup truck with a dislocated shoulder a few hours old. After we assessed him, we decided to try reduction on the spot, since the roads to the hospital were likely blocked. Fortunately, I had lidocaine in my supplies, so I gave him an intra-articular injection and we laid him down on the tail of his truck. I figured we would use beach towels for traction/counter-traction but none were around. My PA grabbed 2 pool/beach noodles and said, "Let's use these!", so we did, with Dr. Livingston providing the counter-traction, me providing the traction, and Lisa helping to manipulate the arm.

After slight muscle fasciculation the humeral head reduced back in, much to the patient's relief. (I have dubbed this maneuver the "Feather pool noodle method" after Lisa). We used some rope that was in the back of the man's truck to make a sling and on we went. We made a quick stop to check on a few boats, including that of the general surgeon on call (still floating) and mine (on a trailer but moved 4 feet to within 2 inches of a wall), with most of the crafts in the boatyard on their sides.

Carefully avoiding debris and wires, we managed to make our way to the hospital. What awaited us was beyond comprehension. The water and wind, once unfettered, had saturated most of the hospital. We walked through water in the emergency room. The digital portable X-ray machine and an ultrasound machine were the only imaging available; the PACS was down. The large window on the medical ward nurses station (on the fourth of five floors) had broken. The doctors (including the orthopaedic surgeon on call, Brian Bacot, MD, FAAOS) had to protect the patients by leaning on the fire doors to prevent the wind and rain from entering their rooms. After it was determined that the structure was uninhabitable, the doctors assisted the patients' evacuation down the stairwells to a safer area.

To make matters worse, Hurricane Jose was on much the same path as Irma and was headed our way as a category 3–4 hurricane, expected to arrive in 2 days. Fortunately, a Navy ship had been rerouted to St. Croix just prior to the storm and their helicopters were ferrying the patients either to St. Croix or Puerto Rico (20 miles to our west). A Disaster Medical Assistance Team (DMAT) team from San Francisco and Sacramento that had been sent by U.S. Health and Human Services was there to assist the emergency room doctors and the hospital's executive team in coordinating all aspects of the disaster.

DMATs are part of the NDMS (National Disaster Medical System). They deploy for 2 to 4 weeks to disaster areas, often set up temporary emergency triage centers, and staff these centers with physicians and ancillary personnel. It was very evident that members of the DMAT were comfortable in their roles and abilities and were expertly coordinating with our executive team, who did an amazing job, especially in the first 48 hours. In addition to evacuating all inpatients and emergency patients requiring admission, an EMS crew had to go and find every dialysis patient, bring them to the hospital, and relocate them off the island—no easy feat, but within 48 hours, all dialysis patients were accounted for and evacuated. As president of our medical staff, I attempted to contact our physicians to make sure they and their families were safe but landline service was down and cell service was very minimal. 

Fortunately, there were not many serious orthopaedic injuries. A few fractures (distal radius, olecranon, and pelvis), a few extremity and finger wounds, a 3-day-old dislocated shoulder, and lots of scratches and abrasions. There were four fatalities on St. Thomas, one of which was caused by a piece of glass shrapnel slicing a man's neck (unfortunately, a father of one of my children's classmates).

We are on the path to recovery. Jose went north of us. The roads improve every day. As I write, there is still a nighttime curfew. My office had some water damage but we are open during non-curfew hours, and aid is flowing in by private boats and planes from St. Croix and [until it was devastated by Maria] Puerto Rico by an amazing community of people with the means to arrange and pay for it. We are finally hearing from our friends and colleagues in St. John and the BVI, my children's school is scheduled to open next week, people have food and water, and the DMAT temporary emergency room is about to open.

The medium-term plan is for the Army to set up a longer-term temporary facility, including operating rooms, while the hospital, we hope, gets torn down and a new one is built. The current hospital was heavily damaged in hurricane Marilyn in 1995 and was patched up; over the last 2 years it has become evident that the physical plant was crumbling, and almost everyone agrees the current hospital should not be "repaired," if it is even physically possible. Empty cruise ships have come to evacuate tourists and those who need to leave the island because they have lost their homes and jobs. Commercial flights are supposed to resume in a few days (the airport was heavily damaged and is not TSA secure yet). Although we have heard and seen social media reports of widespread looting and criminal activity, especially in the first few days following the storm, that has not been the case on St. Thomas. We have come together wonderfully, people are respectful and patient with each other, and it has really been great to see what this community is at its core.

Although we all thought we were prepared for hurricane season—with shutters, supplies, generators, etc.—there are things I have learned that apply to orthopaedics as well. First, prepare for the absolute worst. In retrospect, the dialysis patients should have all been brought to one central area (the hospital) prior to the storm. This would have greatly facilitated their evacuation and saved a lot of time and effort. Second, a facility should be built that has hurricane-resistant windows or shutters, and it should be constructed so that if one area is breached the breach does not affect the entire facility. Third, from a nonmedical perspective, make sure you have essentials besides food and water, such as a handheld marine radio, a chainsaw with extras chains, and empty barrels to hold fuel for generators (it's not easy to get fuel after a storm). Most importantly, be prepared to adapt to changing situations and resources.

I have been inundated with requests from friends, colleagues, and strangers who want to donate medical supplies. I refer them to our incident command center at the hospital to better coordinate efforts. The acute need for many things has passed, but as we recover I am sure we will require significant support. I would like to thank all my colleagues and friends who have reached out to me and offered their help and support, including members of the AAOS and our local orthopaedic group, the Caribbean Association of Orthopaedic Surgeons, of which I am honored to serve as president. Your support has made the last week much easier to get through.

After submitting his initial account, Dr. Chase forwarded this postscript on September 28.

The eye of Hurricane Maria, another Category 5 storm, passed just south of St. Croix and directly over Puerto Rico in the last few days. St. Croix is experiencing what St. Thomas did a few weeks ago, including evacuation of their hospital, and Puerto Rico is experiencing similar devastation but on a larger scale. St. Thomas, which received category 2–3 winds and a tremendous amount of rain that caused significant flooding, is slowly recovering. My daughters' school resumed classes today and curfew hours are decreasing.

On the morning after Maria passed, a police officer showed up at the door to my house with a patient who had an anterior shoulder dislocation, about 6 hours old. After injecting the patient's shoulder with lidocaine and intramuscular Toradol and oral diazepam, Lisa (who had been staying in our home since the storm) and I placed the patient supine on my kitchen island and attempted a shoulder reduction but we were not successful. We then laid him prone and attached dumbbells to his wrist until he relaxed enough for reduction to take place (the so-called Stimson method).

Two Category 5 hurricanes, two shoulder dislocations, and two unusual reduction scenarios and techniques later I am hoping this hurricane season will now end uneventfully.