In late October, San Diego's elected leaders, public safety agencies, paramedics, EMTs and other health-care professionals managed to pull off one of the smoothest mass emergency medical response operations in history. As the smoke clears, after-action reports may bring deficiencies to light, but overall, few could argue that the firestorm evacuations andEMS response were insufficient. With hundreds of thousands of scorched acres and more than 500,000 evacuees, only 15 fire- and evacuation-related deaths occurredƒtragic, but remarkable, considering the magnitude of the disaster.
The Call Goes Out
The wheels for this massive cooperative response effort began moving days before the fires actually started, with fire officials keeping close watch as the drySanta Ana winds blew in off the desert at speeds up to 100 mph.
˙I got the call about 4:00 in the afternoon on Sunday [Oct. 21] that there was a fire brewing off [Highway] 78 that was starting to gain momentum,Ó says Wayne Johnson, chief operating officer for San Diego Medical Services Enterprise (SDMSE), the city ofSan Diego's ambulance provider. ˙At that point, there was already a fire command and control center doing surveillance of the fire itself. The Fire Communications Center (FCC) got an update around 8 or 9 in the evening from Chief [Perry] Peak. Paraphrasing, he said, ÂI'm driving as fast as I can, and the fire is passing me._Ó
At this point, the fire was still several miles from the city. ˙We were trying to get a handle on where [the Witch Fire] was going to hit in the city and formulate a plan,Ó Johnson says. ˙Once fire resources were allocated, then from a medical standpoint, we needed to determine at what trigger point we would start cutting off first responders, start looking at call triageƒgoing into an emergency dispatch mode.Ó
In the end, the heightened surveillance on the ground and at the FCC paid off; San Diego Fire-Rescue Department (SDFD) personnel were able to accurately predict that the fire would hit the San Pasqual Valley first, and then move into Rancho Bernardo.
San DiegoCounty's Emergency Operations Center (EOC) was also in full motion. American Medical Response (AMR)ƒthe county's designated Disaster Ambulance Coordinatorƒwas activated on Sunday afternoon at 1:30, says Katie Keach, AMR's government affairs manager. ˙AMR operated from the onsiteCommunicationsCenter with a liaison at theCountyMedicalOperationsCenter, a part of theEmergencyOperationsCenter.Ó At the height of the disaster, AMR was responsible for coordinating the response efforts of 19 different agencies.
New Reverse 9-1-1 Deployed
Barely a month after San Diego Mayor Jerry Sanders unveiled the city's new $180,000 reverse 9-1-1 call system, it was put to the test. The system, paid for with Urban Area Security Initiative (UASI) Homeland Security grant funds, uses a 9-1-1 database to initiate calls to specified landline telephones at homes and businesses during an emergency. A voicemail message provided citizens with instructions on how to proceed.
The system performed well, rapidly notifying hundreds of thousands of residences and businesses in advance of the flames racing toward their neighborhoods. However, reverse 9-1-1 messages didn't reach everyone in need; those with VoIP or cell phones didn't receive calls unless their phones were independently registered via the city's Web siteƒa fact many were unaware of.
˙You could have segments of the population who were missed,Ó says Deputy Chief Criss Brainard of SDFD. And much to the frustration of responding firefighters, some people didn't evacuate as ordered. ˙We don't know, quite frankly, [if] every one of them was notified.Ó
Anecdotal evidence suggests this to be the case. Fire-related blogs include reports from families who say they never received the reverse 9-1-1 calls. Despite this glitch, the system proved highly efficient at reaching thousands of people. It's certainly a vast improvement over law enforcement and fire personnel driving through streets using their PA systems (although that still occurred).
Strike Teams Help Evacuate
AMR coordinated the evacuation of more than 1,100 patients and residents of hospitals and skilled nursing facilities, Keach says. ˙The overall smooth evacuation process and low loss of life is evidence that the plans in place and regular drills have elevatedSan Diego's disaster preparedness.Ó
Fifteen ambulance strike teams were called in to assist with the massive evacuation andEMS effort. ˙The out-of-county strike teams and medical task forces were ordered by the County of San Diego EMS Agency's Medical Operations Center (MOC) when MOC personnel, including AMR as the ambulance coordinator, determined their necessity, based on existing and projected increased demand forEMS services,Ó Keach says. ˙The ambulance coordinator is a staffed position in the MOC and was involved in the decision to request the resources. The strike teams and medical task forces were utilized throughout the county to provide 9-1-1 emergency medical services to citizens and firefighters and other public safety personnel on the front lines, as well as to help hospital and skilled nursing facility patients requiring emergency evacuation and repatriation as conditions permitted.Ó
Johnson, with SDMSE, agreed that the evacuations from the skilled nursing facilities and hospitals went well. The challenges didn't occur during evacuation, but on the other side, he says. Where do you house hundreds of ailing and elderly long-term care residents who don't necessarily require hospitalization but need constant care and pharmaceuticals, such as insulin, and more than a cot on a gym floor?
˙I don't think anybody anticipated the mass evacuation of the skilled nursing facilities, to be very honest,Ó Johnson says. ˙That really put a wrench in the evacuation centers because they weren't prepared for what was going to occur there.Ó Many of these patients evacuated with little more than the clothes on their backs, leaving vital medications behind.
˙At that point, I called [Acting EMS Coordinator] Marcy Metz at theCountyEmergencyOperationsCenter and gave her a synopsis of what was happening,Ó Johnson says. ˙Because [Qualcomm Stadium] was an evacuation center, most people were in the mind-set that people were driving there or walking in. What would normally happen is a county physician would go down and write scripts. Ú But these were people who have their medications given to them. I suggested they get DMAT set up at the stadium and at the Del Mar Fairgrounds because it was overwhelmingƒthe number of long-term care patients coming into play.Ó
At some point, the evacuation needs of long-term care patients affected fire-attack operations. Deputy Chief Brainard says when wind speeds decreased, helicopters were called in to launch an aggressive attack on a threatened skilled nursing facility in Rancho Bernardo in northeastSan Diego. They determined it was safer to shelter the residents in place, rather than attempt evacuation.
Brainard suggested it might be beneficial to compile a list of facilities that should receive reverse 9-1-1 notifications before the community at large because these populations move slower and require wheelchair transport. Of course, there's always the possibility of forcing unnecessary evacuations because conditions can change so quickly, he says. ˙There's definitely a cost-benefit analysis. The resources necessary to move 500 non-ambulatory and elderly patients would excessively draw from the overall emergency resource pool.Ó
Sporting Facilities Become Shelters
Dozens of evacuation centers, including at least nine led by the American Red Cross, were established as more fires erupted and then quickly spread, prompting massive evacuations. The two largest evacuation sites were at Qualcomm Stadium in the southern portion of the county and the Del Mar Fairgrounds to the north. In addition to people, the sites provided shelter for everything from hamsters to horses.
˙I found it completely amazing how quickly Qualcomm Stadium was transformed from a sports facility to an evacuation center, where all partsƒfood, clothing, bedding and medicalƒcame together,Ó says Michael Simonsen, director of public affairs for San Diego Medical Services Enterprise (SDMSE), which led the medical operation at Qualcomm. SDMSE is a partnership between the San Diego Fire-Rescue Department and Rural/Metro Corp. ˙SDMSE, combined with our fire department partners, the city and lots of volunteer doctors and nurses, just stepped up and handled what needed to be handled. It speaks to working together for 10 years and every single day making combined decisions on emergency medical response in the city ofSan Diego, as well as elsewhere in the county. When you're faced with an emergency situation, you already have a well-established relationship and trust.Ó
At the peak of the evacuations, Qualcomm housed some 10,000 evacuees. ˙It started out like a special event, with a first aid station and transports as necessary,Ó Johnson says. ˙Then it quickly turned into in-patient care because of the skilled nursing facility evacuations.Ó
SDMSE, in cooperation with many civilian and military volunteers, turned the Club Level at Qualcomm Stadium into a mini ED. ˙When you walked in the door, directly to the left was the triage area; just to the north of that was the bar,Ó Johnson says. ˙They made that the pharmacy. UCSD and Sharp came in and set up pharmaceutical services.Ó
The Club Level also included a pediatric care treatment area, rows of beds for patients in need of medical observation, a break area and an ED led by San Diego City Medical Director James Dunford, MD, and Colleen Buono, MD, an emergency physician at UCSD. ˙They did a great job in kicking that off,Ó Johnson says. The next level down became a makeshift skilled nursing facility, with personnel from the nursing facilities tending to their own patients.
The medical team treated a spectrum of illnesses and injuries that would be typical in any ED, Johnson says. ˙There were probably higher than normal shortness-of-breath complaints from asthma and anxiety, [but] it was really all over the board, from cold and flu symptoms to falls. We even had a couple of dog bites.Ó
SDMSE's partnership with San Diego Fire-Rescue proved beneficial in organizing the tremendous number of volunteers who showed up to lend their expertise and support at Qualcomm. ˙There were some issues with a lot of volunteers showing up, and everybody wanted to be in charge,Ó Johnson says. ˙Our nursing staff was fabulous; they really took charge and started directing people.Ó
SDFD arrived on day one, and in coordination with SDMSE and Medical Director Dunford, established an Incident Command System at the stadium, Simonsen says. ˙It was led by the fire department but was a combined effort.Ó
˙To quote [San Diego] Fire Chief Tracy Jarman, the response never would've happened the way it did without the SDMSE partnership [between SDFD and Rural/Metro],Ó Johnson says. ˙We are so integrated with San Diego Fireƒfrom training aspects to planning to personal protective equipment to integration with command and field staffƒwe're like just another team member out there. It effectively just sort of ran itself.Ó
Lessons Worth Sharing
Reverse 9-1-1 systems work; massive public education campaigns to register VoIP and cell phone numbers would enhance it further, as would earlier notification to long-term care and senior facilities.
Jurisdictions should have an ˙officialÓ system for identifying qualified personnelƒvests, uniforms, etc.ƒ to reduce confusion.
Fire ICS proved effective for organizing volunteer efforts.
In addition to planning for hospital evacuations, jurisdictions must preplan for massive evacuations of skilled nursing facilities and the medical, pharmaceutical and facility needs that accompany these populations.
Communities need fast access to mobile pharmacies, either via DMATs (FEMA) or other means, such as a community hospital. There's no time for government red tape.
Provisions must be made for housing pets and large animals. Many people won't evacuate if it means leaving their animals behind.
Close coordination and communication among all agencies is essential.
Not Another Katrina
Media commentators have unfairly contrasted the smooth response operations inSan Diego to the humanitarian disaster that followed Hurricane Katrina. ˙What people have to realize is that they're apples and oranges,Ó Johnson says. ˙Yes, there were more people involved here on the evacuation scale, but imagine the whole infrastructure ofSan Diego being wiped out. That's much different than a portion of the county. InNew Orleans, there were a lot more [responders] personally affected by the tragedy.Ó
˙What Qualcomm represented was a community coming together to support a community,Ó Simonsen says. ˙San Diego rose to the occasion.Ó
SDFD RESCUES FAMILY OF 10
In the early morning hours of Oct. 22, the Witch Fire, driven bySanta Ana winds and critical fire conditions, threatened to destroy 500 homes in the community of Rancho Bernardo in northeasternSan Diego.
Shortly before 4 a.m., the Witch Fire began consuming houses along pre-identified urban interface canyon rims and from neighborhoods not adjacent to these brush-covered canyons. Additional strike teams were sent to support initial units and were quickly engaged in structure protection in an attempt to keep the fire from crossing the eight-lane Interstate 15 freeway (I-15). With out-of-control fire conditions driven by high winds, the fire breeched I-15 and headed toward several thousand residential and commercial structures.
The city's 9-1-1 Fire Communication Center (FCC) began receiving calls from residents trapped in the fire impact areas. Two engine strike teams (one Type I and one Type III) were dedicated the ˙Rescue GroupÓ and responded to many locations where residents were trapped.
Before dawn, the FCC received a 9-1-1 call that 10 people were trapped in a home. The initial Type I engine was unable to reach the residence due to downed power lines and trees. A second rescue team, consisting of four Type III engines, was able to navigate the obstacles, including a power pole that collapsed after they passed, blocking that escape route.
When the crews reached the home, the physical structure wasn't on fire, but surrounding homes were fully engulfed. The crews removed the entire family, including a one-year-old child, to the safety of their apparatus and a family car. A brush rig escorted the onboard family and child to safety, while the remainder followed in the family car. The family did not require any medical care.
The remaining crews found a large woodpile burning next to the house and barn that, if not extinguished, would have destroyed the home. When they opened the barn, the firefighters found 10 horses inside, standing in smoldering hay. The crews removed the horses to a safe location and called for animal control.
Deputy Chief Criss Brainard is an operations shift commander with the San Diego Fire-Rescue Department andJEMS Editorial Board member.
Countywide fire damage estimates, including the Witch, Harris,RiceCanyon, Poomacha, Horno, Wilcox, Cajon, McCoy and Coronado Hills fires:
Structures Destroyed: 1,621
Structures Damaged: 93
Accessory Bldg Destroyed: 878
Accessory Bldg Damaged: 44
Vehicles Destroyed: 2,018
Vehicles Damaged: 12
Fire-Related Deaths: 15
Financial Toll: $1 billion+
Source:County ofSan Diego and CDF
Agencies (private and government): 19
Ambulance Strike Teams: 15 (75 ambulances, 15 task force leader vehicles and 165 personnel)
Strike Team Counties of Origin:San Bernardino,Riverside,Orange andL.A.
Ambulance Providers: 13, including American Medical Response (San Diego, Riverside and San Bernardino operations), San Diego Medical Services Enterprise, Care of San Diego, Lynch, Emergency, MedCoast, Balboa, AmeriCare, AmbuServe, Priority One, McCormick ER, Alert and MedixSource:County ofSan Diego Disaster Ambulance Coordinator, American Medical Response