Hawaii, Missiles and what healthcare can teach us about emergencies

The funny thing about something truly terrifying is that it doesn't create the kind of panic we see in movies. People tend to get quiet.

I was on a flight once into Pittsburg in the middle of summer. A squall line of thunderstorms popped up as we were on our approach. While I can't be 100% certain, as a pilot it felt to me like we missed our approach 3 times. Regardless, there was certainly some dramatic maneuvering, bouncing, dropping and climbing. At one point the passenger next to me leaned over and asked: do you think we're going down. No one screamed. Some people were obviously praying. And my palms sweated through the page in the book I'd been pretending to read for 15 minutes. I looked up at the fight attended who was buckled into her seat and saw a look I don't care to see on someone's face again. We made it to ground and I sat in the boarding area to see the pilots when they came off the plane. They looked like they had been run through the rinse cycle of a dishwasher.

That was, up until last week, the most scared I've ever been.

Last week we were on the Big Island of Hawaii. Around 8:15 in the morning, we were walking towards a beach trail to meet some colleagues at a nearby resort. I heard my phone make the disarming tone it makes for an amber alert and thought: that's strange to have a missing child in paradise. I looked at my phone and saw the message that's already made its way around the internet and through news cycles:

“BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.”

We could see people around us going through a similar range of reactions. Reach for phone, do a double take, pause for a minute, then walk quickly and quietly somewhere. Anywhere.

We headed towards the ground floor of our hotel. We quickly ruled out going to the room. Getting in an elevator didn't feel safe and the room itself was on a top floor and had an sea-facing wall of glass. We tried to get as close to the interior core of the hotel as we could.

A woman looked at us and said: This has to be a joke or hack, right? I told her I thought it looked like an official message and those would be hard to hack. I don't even know where I am, she said. I was out on a run and my family is at another hotel.

All around us people continued to walk quietly and purposefully. Many were headed to their rooms or to rendezvous with loved ones elsewhere. There was no screaming, no running, no outward panic.

The hotel's PA pierced the silence. We have received an inbound missile threat. Everything will be ok. Please take shelter in your rooms.

Having already ruled that out, we made our own plan. This resort, like many in Hawaii, is largely open-air. There were virtually no solid walls on the ground floor. By the elevators there was an emergency fire exit with one of those alarm will sound signs. That felt like the safest place to be and, besides, we'd already gotten the alarm to beat all alarms.

Cori suggested we check to make sure we could get out. Smart! She went in and tried to open the door from the other side. No dice. How could that be? We turned the handle and the latch retracted. She closed the door and tried again, this time it opened. In we went.

We sat on the stairs, a few up from the ground floor landing but not all the way to the next level. I was looking around to see if there was a better spot. What happens if this door blows inward? ... and then my mind drifted to the scariest though I'd had all day: what if we don't die. What if we survive a nuclear blast? We'll be burned and injured. I'm wearing flip flops, so that will make traveling by foot hard. We won't have cell service or wifi.

I messaged my parents:

We’re at the hotel in Hawaii. Just got a ballistic missile alert. I’m sure it’s noting. But we’re all headed inside. Will keep you posted.

Decided it wasn't worth correcting the typo.

We both refreshed twitter. Refreshed again. Kept refreshing. We started to see mentions of an error. Then a tweet from Hawaii Emergency Management Agency said it was an error. I could feel my heart rate slow and my hands stopped shaking. A few minutes later it was official - it had been an error.

We exited our make shift bunker and joined the other guests starting to come back to life. Conversations restarted, people went back out into the sun and there was a general air of shell-shock.

The hotel's PA confirmed the false alarm. A few minutes later, our phones buzzed again. Same tone, same disarming feeling. This time it was the official all clear.

We're still processing. In the hours and days after, there were some small attempts at humor and some news reports were quick to point out humor is a natural reaction to trauma. But mostly, it was the event that we all acknowledged and didn't talk too much about.

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Over the rest of the week Hawaii Public Radio ran many stories about reactions. They played audio recordings of people describing what they did. Some called loved-ones, some sat with their families and prayed, some sought any form of shelter they could find. HPR also ran stories featuring childhood psychologists with tips about helping children process what had happened.

I'm a designer with a rather myopic focus on healthcare. I've spent my entire career working in or around hospitals. And while our healthcare system is far from perfect, there are some lessons our emergency response system might borrow.

Over the last 20 years, simulation has become an integral part of training physicians, nurses, and first responders. Fortunately, true disasters are fairly rare. So emergency room teams regularly conduct simulations to drill things like a mass shooting, plane crash or natural disaster. It was pretty clear to us that neither our hotel or local agencies had done any kind of simulation. The accidental alert was unfortunate but it could be a prime opportunity for everyone to think through what should happen. Does going to rooms make sense, or should there be a central gathering point? Is the messaging helpful or confusing? What do people need, how do they behave and what systems do they need to put in place to account for those reactions?

Healthcare has also had the tragic opportunity to learn from some sad errors. For a long time, it was too easy to mix up an oxygen line with a vacuum line. We still worry about and put systems in place to try and prevent drug-drug interactions. Things like bar codes, 'break the glass' firewalls in electronic systems and color coding have helped a lot.

Here's the screen the Hawaii emergency team was using the day of the accidental alert.

Setting aside that it looks like a webpage from 1993, there's very little to distinguish a drill from the real thing. Any user interface designer would have a field day reimagining this screen. And that's an opportunity. Hawaii should hold a series of challenges; call it Design for Hawaii or Code for Hawaii, or whatever they like. But get smart, skilled people in the room to work on these challenges.

We're also in the midst of an awesome trend of co-designing new approaches to healthcare with patients and families. The idea is to bring the people with the most lived experience to the forefront of reimagining processess, services, and treatments. What would it look like if state and federal agencies engaged the people of Hawaii? What actions did they take? Where did they feel equipped and where did the feel unprepaired? What ideas do they have for future alerts?

Lastly, we're just starting to talk about truly integrated healthcare delivery. We're starting to understand that physical pain and trauma is often accompanied by mental anguish. Both require attention, treatment and acknowledgment. Hawaiians and visitors will be on heightened alert for some time —not just because of the false alarm, but because of the world we find ourselves in today. An integrated approach would acknowledge the caustic effect of heightened stress. Perhaps we might even come to think of our current state of diplomacy as what healthcare calls a never event.

Nick Dawsonhawaii, emergenc, alert, design, design thinking, healthcare, missel, ios, iphone