The recent fires inCalifornia served as a testing ground for a new ambulance strike team concept. Prior to these fires, ambulance strike teams that included private providers had not been successfully deployed to an actual disaster. But the severity and ferocity of these massive fires required a unified system combining both fire-based and nonfire- based private provider resources.
To this end, ambulance strike teams from American Medical Response were deployed throughout the region, and the smooth implementation proved successful and will serve as a template for responding to future disasters. According to David Mintz, CEO of AMR_s Southern Pacific Region, ˙This is a unique example of a public-private partnership, and we_re now seeing the practical benefits of its application under severe conditions.Ó
California, like many other states, has suffered more than its share of disastrous wildfires. (Consider the Berkeley-Oakland Hills Fire, which began on Oct. 21, 1991, in an area overlooking the San Francisco Bay.1This winddriven firestorm charred 1,500 acres of land, destroyed 3,300 homes and killed 25 people.) In fact, much of the Incident Command System (ICS) was created in 1970 in response to a series of wildfires inCalifornia. These fires demonstrated the need for a system to help coordinate a multi-agency response to an emergency.1
Ambulance strike teams, the beginning
Although the concept of strike teams is not new for military, police or fire personnel, it is somewhat foreign to privateEMS providers. When the strike team concept was explored in the 1980s, it met with little success. It emerged again on the afternoon of Sept. 11, 2001, when members of AMR_s Southern Pacific Region, led by industry veteran Dave Austin, met with representatives of the Los Angeles CountyFire Department to formulate a way to work together under certain disaster/emergency conditions. The strike team model they created was similar to one the state had produced nearly 20 years earlier.
Strike teams, self-supporting units at the scene of a disaster, are able to receive, triage and transport patients. ICS describes a strike team as involving the same type and kind of resource. The state Emergency Medical Services Authority (EMSA) draft plan for ambulance strike teams classifies these teams as Type I and Type II. A Type I strike team consists of five ALS ambulances and one team leader, and a Type II team consists of five BLS ambulances and one team leader.2
The state EMSA has repeatedly endorsed the use of ambulance strike teams or medical task forces (MTFs), calling them critical components of a coordinated disaster response. A task force is defined as any combination of single resources assembled for a particular mission or tactical operation. Although AMR andL.A.County had developed the idea more fully on Sept. 11, it had not been practiced or deployed until the firestorms of 2003 raged through much ofSouthern California.
Application of ambulance strike teams during the fires
On Oct. 24 at 1245HRS, AMR received a report from KaiserPermanenteHospital (KPH) inFontana,Calif., that smoke from the Grand Prix Fire had infiltrated the hospital. The facility also reported it needed to close its operating rooms and possibly evacuate its respiratory patients to another Kaiser facility.3Edward Van Horne, operations director forAMRSan BernardinoCounty (most directly affected by the Grand Prix and Old fires), was asked to devise an evacuation plan for the KPH facility, in case one was needed. This led to the formation of the first of 17 strike teams that would ultimately be deployed during the firestorms. When it became apparent that KPH would not be evacuated, the first team was diverted to areas of the community that had been placed under mandatory evacuation.
Evacuation ofMountainCommunityHospital: On Oct. 25, the Old Fire began inOldWatermanCanyon. As the fire tore up hillsides, it took out thousands of power poles, causing the communities surroundingLakeArrowhead to lose their utilities.MountainCommunityHospital (MCH) inLakeArrowhead was forced to switch to generator power. The fire jumped Highway 18 into Skyforest, while another large fire began inCrestForest, just a few miles away. This fire, though separate, was considered part of the Old Fire.
MCH was in peril. The emergency department (ED) had a trauma patient with a significant neck injury, as well as a mother and her newborn baby. Another 23 patients were also in the facility. At theSan BernardinoCounty emergency operations center (EOC), public health officials discussed plans to evacuate the facility. Three strike teams were called on to merge and proceed up fiery Highway 18 and evacuate patients to hospitals on the other side of the mountain.
The composition of the strike teams was determined by the San Bernardino County EOC after conversations with MCH staff to determine each patient_s condition. The acute and some floor patients warranted ALS ambulances, while the majority required BLS. This task force comprised one ALS (Type I) strike team from Victorville and two BLS (Type II) strike teams utilizing AMR ambulances from Rancho Cucamonga,Redlands and Irwindale. Meanwhile,Las Vegas was preparing a strike team, and an ALS strike team fromAntelopeValley responded from more than 80 miles away to backfill for the Victorville units.
The MCH task force, without fire apparatus accompaniment, proceeded up Highway 18, with fire burning onboth sides of the road. The ambulances arrived at 0126HRSthe morning of the 26th, and the evacuation went flawlessly. On arrival, strike team leaders met with hospital administrators. A list of all hospital patients was provided, and patients were assigned to ambulance crews on the basis of their conditions and medical needs. Crews received their assignments (patients and patient destinations), and the patients were transferred to waiting ambulances. Strike team leaders and hospital administrators entered each ambulance and accounted for each patient to ensure no one was left behind.
Patients were grouped on the basis of their destinations and assigned to ambulances. Vehicles carried two or three patients, and some ambulances transported to multiple destinations. They set out in a convoy down the mountain and split up once they reached the city ofHesperia, more than 60 miles away. These patients were ultimately transported to five different hospitals inApple Valley, Victorville,Riverside and Loma Linda. Despite fire damage to repeater sites and a loss of radio communication, strike team leaders ensured that the units stayed together by maintaining visual contact from positions in front of and behind the convoy.
After removing all hospital patients to safety, one strike team supervisor and his partner were called to a local residence to assist in the evacuation of an elderly female and her quadriplegic granddaughter. The streets were empty, unlit and smelled of smoke, and when they arrived at the residence, the providers found the 94-year-old woman and her granddaughter waiting by the door of their darkened home. Faced with a twohour ETA for additional ambulances, the supervisor and his partner were forced to place the patients in the front and back seats of their F-150 and evacuated them to the hospital they had just cleared. Fortunately, the staff at MCH had decided to keep the ED open in case of such an event.
The additional ambulances actually arrived four hours later. By that time, fire and smoke had blocked the planned route of egress, forcing the ambulances and supervisor to take narrow, winding roads down the back of the mountain. The evacuees were taken to an evacuation center in Hesperia.
Evacuation ofBigBearCommunityHospital: By 0725HRSOct. 28, the Old Fire had crossed the second threshold for voluntary evacuation of the city ofBig Bear and evacuation ofBig Bear Community Hospital.4By the timea strike team of 11 ambulances arrived to evacuate the facility_s 21 patients, the fire had crossed the first threshold for mandatory evacuation of the city.
With a mandatory evacuation order in place and the two main roads leading down the mountain blocked, the hospital staff decided to evacuate its ED patients via Mercy Air helicopter. The remaining patients were placed in ambulances and escorted down the mountain by sheriff_s department personnel.
Staff had begun to wheel out the patients with their belongings by the time AMR_s ambulances arrived. The strike team leader requested they stage the patients in one area in front of the hospital while a list of all patients was compiled. Fortunately, one facility in the city ofRedlands was able to receive all patients transported by ground ambulance.
As fire personnel engaged the expanding fires, additional ambulances were needed to respond to areas with diminished 9-1-1 capabilities. On the first day of the Grand Prix Fire, 9-1-1 call volume increased 15%. The 9-1-1 volume was up 36% at the peak of the fires, with all major fire areas reporting similar information. With fire first responders engaged in fighting the wildfires, these ambulances were often the sole responders. In fact, AMR was tasked with providing 9-1-1 coverage for areas it usually doesn_t serve.
By Oct. 26, the California EMSA reported 267,000 acres of wildland were ablaze in the multiple major fires affecting Southern California.2Eleven small facilities, two SNFs, three nursing facilities and one hospital had to be evacuated due to the Grand Prix and Old fires.4AMR had strike teams deployed to nearly all of the major fires inSouthernCalifornia. The total number of strike teams deployed by AMR for these fires was 24, with the majority dedicated to the Grand Prix and Old fires. In total, more than 366 patients had been evacuated by ambulance from 18 facilitiesƒ again, the majority at the Grand Prix and Old fires.
By Oct. 28, six evacuation centers were operating inSan BernardinoCounty alone, housing a total of 1,306 displaced citizens.4TheCaliforniaSpeedway, located in the city ofFontana, had cancelled its events and offered its facilities to the evacuees. Less than 24 hours later, the number of evacuees in shelters would total more than 2,600, and the total number of evacuees reached 40,000 inSan BernardinoCounty alone.4
AMR_sSan Diego operations deployed four strike teams, which evacuated 46 people from one facility in Alpine. TheVentura operation evacuated 13 people from one facility inSimi Valley. During the peak of the fires, 80,000 people had been evacuated from all fire areas in the state.5
Improving the medical strike team concept, lessons learned
Although ambulance strike teams performed as planned during these fires, this may not happen so smoothly in every emergency situation. This response involved only one provider, allowing for continuous leadership and promoting better communication and cooperation between operating units. The incredible efforts of the ambulance crews, communications centers and support personnel made those achievements possible. AMR ultimately deployed strike teams to the three main fire areas inSouthern California.
Although not included in the EMSA draft plan for ambulance strike teams, these fires revealed the necessity of occasionally mixing the configuration of teams based on the needs of facilities requiring evacuation. The teams were more correctly called medical task forces when they were mixed. Most patients who needed evacuation required BLS ambulances. However, when strike teams were needed to provide coverage for areas normally covered by fire-based ALS ambulance personnel, those teams had to be Type I teams only.
An organized response within the State Emergency Management System (SEMS) framework using ICS is superior to an unorganized response. These fires required AMR to provide for evacuation of residential properties, hospitals and other facilities, to cover areas it doesn_t usually cover and to increase the call volume in its usual coverage areas.
The ability to handle a significant surge capacity is essential for disaster planning. During the fire emergencies, AMR_s 9-1-1 call volume increased more than 30%. AMR_sSan BernardinoCounty operations responded with 115 ambulances to more than 4,400 calls, transported 3,100 patients, traveled 100,800 miles and evacuated 307 people from six facilities inSan BernardinoCounty alone. AMR_sSan Diego operation responded to over 1,766 9-1-1 calls during the first six days of the Cedar Fire and transported more than 900 patients.
Establish your own ICS structure and EOC. We found it helpful to have a director of operations staffing our internal EOC and overseeing the formation and deployment of strike teams. The authority proved helpful in the establishment of teams and movement of resources in a timely manner. You must communicate your command structure to all involved personnel and develop succession plans early. Because ICS is the best way to establish rapid organization, it_s important to make sure all command personnel are trained to at least ICS 400. All strike team leaders should be trained at least to ICS 200.
IntegratingEMS representatives at command centers is important. The fact that AMR had a representative at each EOC improved system response. These representatives were able to obtain updates from the EOC and plan appropriately for upcoming operational periods. However, because there were multiple fire areas, it was important that the person responsible for managing resources for more than one operational area was not part of a county or city EOC. This allowed them to receive and manage requests from multiple EOCs. For these fires, the CEO for AMR_S Southern Pacific Region, Dave Mintz, and his staff oversaw the response to all fire areas, while Vice President Randy Skomsvold and Director Edward Van Horne oversaw the responses inSan Bernardino andRiverside counties.
Whose resource is the strike team? This question should stir some dialogue. With operational areas involving multiple cities and counties, some conflict may naturally occur. Strike teams become a state resource when activated by county or state officials and require an experienced manager or director of operations to manage the multiple resource requests from the many EOCs that may be activated. It may be necessary to take a strike team from one EOC_s domain and place it somewhere else where it_s urgently needed. This also requires strike team members to remain flexible and prepared for any circumstance.
Don_t forget basic administrative functions. Many strike team members did not clock in, and their time wasn_t kept well initially. This created a great deal of work afterward. Strike team leaders are responsible for tracking personnel, equipment and patients. This should include tracking of times and communicating them to the intra-agency EOC at the end of each mission. Each service should seek the development of standardized forms, policies and procedures for the management of strike teams.
Plan for redundancy in communications. These fires knocked out one of the primary repeater sites in the SanBernardinoMountains, making the radio system ineffective for theRancho Cucamonga operations. The 800 MHz system operated by the county proved a sufficient backup. A local cable company established high-speed Internet access for the California Highway Patrol and SanBernardino PD command trailers inthe field. E-mail is an essential component of a communications redundancy plan. Make sure your EOC has a sufficient number of plug-in points for phones and computers. Your plan should also include extra phone systemsƒnot cell phones. Cell phones proved ineffective in many fire areas.
We can expect to learn a great deal more about what aspects work and those that don_t. We must encourage all private and publicEMS leaders to continue to improve their ability to implement ambulance strike teams. This development will come only through careful planning and training.
Patrick Lagadec, in his bookPreventing Chaos in a Crisis, writes, ˙The ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives. The event can, in some ways, be considered as an abrupt and brutal audit: at a moment_s notice, everything that was left unprepared becomes a complex problem and every weakness comes rushing to the forefront.Ó5
In any disaster, all deficiencies, large and small, are suddenly revealed. The outcome is sensitively dependent on initial conditions.
James F. Goss is the regional training manager for AMR_s Inland Empire region inSouthern California. He is also on faculty atLomaLindaUniversity,Loma Linda, Calif.
1. Waugh WL, Jr.: Living with Hazards, Dealing with Disasters: An Introduction to Emergency Management. M.E. Sharp,NewYork, 2000.
2. Draft Plan: ˙State ofCalifornia Ambulance Strike Team/Medical Task Forces.Ó April 2003,California EMSA.www.emsa.ca.gov/dms2.
3. Medical/Health Situation Report. Grand Prix/Old/Paradise Firestorm. Oct. 24, 2003.
4. Medical/Health Situation Report. Grand Prix/Old/Paradise Firestorm. Oct. 28, 2003.
5. Lagadec P: Preventing Chaos in a Crisis.McGraw-Hill,France, 1991. p. 54.