Operation Twister - Exercising Disaster Behavioral Response

Functional exercises are invaluable for helping participants understand their roles in disasters. This is particularly true for participants who normally are not included in interagency exercises, such as behavioral health personnel. Triaging following a disaster should not stop at the physical level, but should consider psychological concerns as well.

Every disaster to one degree or another involves behavioral health issues affecting the public and the response communities. Disaster behavioral health responders typically work in concert with healthcare providers, public health, emergency management, first responders, and volunteer organizations. Although disaster behavioral health is gaining recognition as an integral part of the overall public health and medical preparedness, response, and recovery systems, disaster preparedness exercises often fail to integrate a behavioral health response. Personnel responsible for providing behavioral health assistance and the healthcare facilities both benefit from opportunities to clarify their roles and rehearse their responses to effectively address the full needs of patient populations in disasters.

Recently, a functional exercise was held in the District of Columbia that provided a focused opportunity for the D.C. Department of Behavioral Health to respond to a severe bad-weather incident and practice its response plan. The plan included the use of Psychological Simple Triage and Rapid Treatment (PsySTART) for victim screening and integration with hospitals requesting their assistance in assessing the immediate and long-term behavioral needs of the injured patients and their families. As a result of the exercise, some valuable lessons were learned.

Operation Twister

The three-hour exercise, named “Operation Twister,” was sponsored by the D.C. Emergency Healthcare Coalition. Dr. Kevin O’Brien, director of Disaster Behavioral Health Services for the D.C. Department of Behavioral Health, was part of the exercise planning team. The scenario involved severe bad weather hitting the District of Columbia with torrential rain, damaging winds, and eventually a tornado. Numerous incidents occurred, which caused mass casualties involving adults and pediatric patients. Some patients had critical trauma including burns; whereas others were severely emotionally traumatized from the resulting dangers, utility outages, and general disruption to their normal lifestyles.

Several hospitals requested assistance from the D.C. Department of Behavioral Health to manage the immediate and possible long-term behavioral health problems of their patients. The department deployed three members of the Behavioral Health Emergency Response Team to work with the Psychiatry Department staff at a large trauma center hospital that received nearly 100 moulaged victims. The request was made by phone as well as on the coalition’s intranet-based system for information sharing.

The team arrived at the hospital within an hour after the request was received. Once at the hospital, they reported per instructions to the Hospital Command Center, where they were briefed and redirected to the Emergency Department to support the work of the staff from the hospital’s Psychiatry Department. Together, the two teams triaged 29 of the victims with the PsySTART tool. The nonintrusive format took less then 10 minutes to administer and manually record the triage scores.


PsySTART is a strategy for rapid mental health triage during a large-scale incident. This evidence-based concept was originally created by Dr. Merritt Schreiber at the Center for Disaster Medical Services at the University of California Irvine School of Medicine, and is used in numerous communities in the United States including hospitals and the D.C. Department of Behavioral Health. The U.S. Department of Health and Human Services’ Hospital Preparedness Program grant money was used in 2012 to provide initial training in the District of Columbia to hospitals, fire, and emergency medical services, and D.C. Department of Behavioral Health staff members.

Periodic refreshers and new training have been conducted annually since then. The triage tool can be used for assessing both adult and pediatric patients. Patient answers can be written on the questionnaire or entered into a computer database for analysis. The questionnaire’s primary purpose is providing situational awareness of at-risk individuals, and it uses a “floating triage algorithm” that prioritizes those who need to be seen first from those who can be referred for assessment after the initial surge is over. 

Exercise Lessons Learned

The exercise was an excellent overall learning experience according to O’Brien, who served as an exercise controller/evaluator. “It gave our department a chance to rigorously exercise our emergency response plan in coordination with other members of the healthcare community. We don’t get a chance to do that very often.” The value of having a redundant approach for making a request for assistance was reinforced because, for some of the facilities, their phone lines were not functioning and use of the coalition’s intranet-based Healthcare Information System (HIS) was the only way they could make the request for help.

The exercise provided the D.C. Department of Behavioral Health a chance to rehearse deploying their personnel to a hospital, while taking into account the bad weather and potentially dangerous road conditions. O’Brien pointed out in his hot wash remarks that, “Having our staff actually integrate into a hospital operation during a crisis was new for us, and proved invaluable so we could learn how to support and not interfere.”

The exercise also brought to light the importance of having multiple personnel – whether in the Department of Behavioral Health or at a hospital – being familiar with and adept at using the PsySTART tool itself. Although both responders and the hospital had trained personnel using PsySTART, just-in-time refresher training was needed for some of the users to quickly become comfortable using it.

Interestingly, the analysis of the answers these “make believe” disaster victims gave indicated that all of the patients evaluated would require follow-up care – something that otherwise might not have been recognized so quickly. Knowing these results allowed both the hospital and O’Brien’s colleagues to better devise long-term discharge plans for these patients. Plans also were discussed but not implemented for administering the questionnaire to hospital staff and using the results to determine staff support needs. However, exercise time limitations precluded such plans from actually being implemented.

Operation Twister was an exercise that had the usual focus on emergency medical services and hospital performance of patient triage and treatment. However, this exercise also provided a much-needed opportunity for key members of the city’s healthcare system to evaluate their ability to address the behavioral health concerns rather than simply the physical needs of victims and responders to severe weather or any other emergency.

Craig DeAtley

Craig DeAtley, PA-C, is director of the Institute for Public Health Emergency Readiness at the Washington Hospital Center, the National Capital Region’s largest hospital. He also is the emergency manager for the National Rehabilitation Hospital, and co-executive director of the Center for HICS (Hospital Incident Command System) Education and Training. He previously served, for 28 years, as an associate professor of emergency medicine at The George Washington University. In addition, he has been both a volunteer paramedic with the Fairfax County (Virginia) Fire and Rescue Department and a member of the department’s Urban Search and Rescue Team. An Emergency Department PA at multiple facilities for over 40 years, he also has served, since 1991, as the assistant medical director for the Fairfax County Police Department.



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