Tones. Then more tones. Then more tones. Napa County (CA) was catching on fire”¦fast. Again. In August and September 2020, massive wildfires ripped through Northern California, causing unprecedented devastation and straining public safety resources to the max. Already grappling with the effects of COVID-19, Global Medical Response’s Napa team mounted an EMS response to successfully evacuate the same rural hospital twice in 40 days while simultaneously supporting on-going remote firefighting efforts in ways EMS has not traditionally done. This submission tells the story and revisits some of the challenges and lessons learned of the EMS response to the 2020 Lightening Complex and Glass fire events.
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The Napa County EMS System
Napa County sits 60 miles north of San Francisco in a valley surrounded by rolling hills and vineyards. At 45 miles long, with a daytime population of 150,000, the Napa County EMS system consists of a single county-wide paramedic ambulance provider — American Medical Response (AMR), a REACH helicopter air ambulance, fire-based ALS first response from Napa City Fire and American Canyon Fire, and fire-based BLS response in the remainder of the county from Napa County Fire/CAL FIRE, St. Helena Fire, Calistoga Fire, and numerous volunteer departments.
The system includes two in-county hospitals, Queen of the Valley Medical Center (STEMI, OB, Trauma, Neuro) and Adventist Health St. Helena Hospital (STEMI), and an additional four out-of-county hospitals that routinely receive Napa County patients. On any given day, crews respond to traditional urban 911 calls, remote backcountry recreational emergencies, suburban calls and rural agriculture accidents. The system’s strength comes from genuinely strong working relationships between fire, law enforcement, hospital and regulatory stakeholders.
The Logistics of Evacuating a Hospital Twice in Forty Day
The saying “amateurs talk strategy, experts deal in logistics,” speaks to the primary challenges of any large patient movement or evacuation. When evacuating a hospital, merely having a strategy of sending ambulance strike teams to the hospital isn’t enough. Breaking down hospital evacuation logistics requires management of three distinct pieces: internal hospital organization, receiving destination management, and transportation management. Given that EMS provides ambulances and is used to managing a sizeable number of patient movements in MCI-type situations, it’s natural that, from an EMS leader’s standpoint, the primary focus of a hospital evacuation can get centered on patient transportation.
However, what we’ve seen with these two most recent fires and the 2017 and 2019 Santa Rosa wildfires, is that the first two pieces are often the more challenging. While we, and most EMS systems, have well-defined mutual aid and disaster response systems in place to obtain the necessary ambulances, the process of securing receiving facility beds and managing the internal hospital operations are not well defined.
Adventist Hospital St. Helena sits in the northern-most portion of Napa County. The location is serene, peaceful and in a high fire-danger area. Although the hospital’s typical census is under 70 patients, St. Helena Hospital serves as a major receiving center for cardiac patients and those requiring more complex ICU care than is available in several nearby Northern California counties. This rural hillside location, coupled with a high-acuity ICU, posed significant challenges.
Internal Hospital Operations
EMS engagement is essential as the hospital stands up its internal command team. Hospitals have pivoted in the past decade to using a modified Incident Command System (ICS), Hospital Incident Command System (HICS). Like all operations managed under ICS, unified command when multiple agencies are involved is critical. Adventist Health St. Helena’s use of HICS allowed for ease of integration between hospital and EMS command structure. EMS involvement at the early stages of a hospital standing up is internal hospital command structure — even before a formal evacuation warning or order — allows for real-time knowledge sharing between agencies and provides both EMS and the hospital with the ability to tailor their operations plans to the other’s current situation and capabilities. Additionally, it allows the hospital and EMS to discuss if early decompression of the facility is possible through certain patients’ strategic movement via system resources before a possible full-hospital evacuation.
The ability to navigate the executive-to -executive level between a hospital administrator and an EMS executive officer having command authority can be incredibly beneficial if resources allow. Assuming the evacuation is the result of a larger community-wide disaster, the EMS provider’s highest-ranking officer will likely be committed to overseeing the successful execution of all three elements of the hospital evacuation — internal hospital operations, receiving destination management, and transportation management — as well as the 911 system and any fire standbys. Given this, inserting a deputy into this position can ensure that both the tactical objectives and executive needs are simultaneously addressed. During the 2019 wildfires, the EMS chief officer/regional director of neighboring Sonoma County’s ambulance service responded to fulfill this role.
Receiving Facility Management
Moving patients to a temporary off-site field medical shelter out of the fire danger zone may work well for non-monitored medical-surgical or skilled nursing patients; however, the ability to do so safely becomes increasingly difficult as patient acuity rises. Furthermore, while patient movement to a temporary off-site field medical shelter may get patients out of fire danger, it ultimately requires moving them a second time to another medical facility for the remainder of their hospitalization. Expeditiously ensuring that patients get to a new receiving facility capable of meeting their medical needs and bed capacity is paramount.
To make this happen in an organized and secure fashion, GMR’s All Access Transfer Center (AATC) came to the rescue. As a regional referral and receiving transfer center, the AATC maintains a detailed list of all hospitals in Northern California, including facilities’ capabilities, key leaders’ contact information, and a breadth of historical knowledge of which facilities will likely make the most sense. Utilizing a dedicated emergency transfer line, the AATC was able to work with St. Helena Hospital to obtain a detailed patient list, including of required level of service. With this information in hand, the AATC rapidly secured bed placement of 100 percent of patients at facilities capable of providing the definitive care required by each patient. Utilizing the AATC saved both time and unnecessary patient movements.
While ground ambulance strike teams remain the primary way to move a large number of patients, with 11 critical patients in the ICU and the need to send ICU patients to facilities up to two hours away by ground, air assets’ utilization played an essential role. For the first hospital evacuation, we got lucky. The ICU had just a few critical patients. This resulted in sending two patients out by a REACH air ambulance and one by AMR ground critical care transport.
For the second hospital evacuation, time not on our side. Compounding the situation was the fact that the ICU had eight critical patients who required therapies beyond the paramedic scope of practice. Fortunately, we have a large footprint of air assets in Northern California that could be rapidly leveraged to support this mission. As soon as it became apparent that multiple patients would require air transport, we began pre-staging aircraft at the Napa County Airport, a short 10-minute flight from St. Helena Hospital. Additionally, we established an air operations section chief to manage the multiple incoming aircraft and coordinate which helicopter was transporting which patient. All in all, six critical patients were transported by air medical helicopters.
For all patients leaving the hospital, patient tracking and accountability are critical. Much like a mass casualty incident (MCI), a single transportation unit leader to track each patient as they exit is necessary. Having all patients depart through a single hospital exit point ensures that no one gets missed. Once en route to the destination facility, continued tracking of ambulances can become a challenge. While it is incumbent upon each ambulance strike team leader to know where their resources are, when dozens of ambulances are transporting patients to hospitals all across Northern California, things can get missed. To ensure tracking, we once again leveraged the AATC. When an ambulance departed St. Helena Hospital and arrived at its destination, the crew called the AATC. This allowed the strike team leaders to have additional support and allowed easy communication back to St. Helena Hospital so that they could know where their patients went and that they had safely arrived.
EMS is More Than an Ambulance Provider
If the recent wildfires proved one thing, EMS’s role is more than to be a paramedic transport provider. EMS’s role varies dramatically across the country; in larger urban systems, EMS is frequently viewed as nothing more than a paramedic transport resource to get patients to the hospital while a fire or law enforcement agency handles a more traditional public safety command capacity. The recent California wildfires proved this notion to be utterly false. Far from merely responding to and transporting patients to the hospital, EMS’s role during wildfires is multifaceted, extending to supporting fire-line activities, community evacuations, and continuing maintenance of the 911 system.
Supporting Firefighting Activities
The most traditional utilization of non-fire EMS resources has been to support fire-base camp activities while fire agencies provide staff for conventional fire-line medic activities. In recent years, the sheer number and size of the fires and the subsequently strained resources have forced EMS to pivot to support truly fire-line medic activities and fire-line drop point standbys. While our crews were not out hiking the fire line, they were nevertheless deployed in locations beyond where urban ambulances were traditionally positioned and required to be self-sufficient.
Doing so safely requires training, resources, and experience. AMR Napa field crews began training with CAL FIRE in July of this year to support this new mission. CAL FIRE provided a training class that reviewed basic fire behavior, fire shelter deployment, fire-line safety and incident radio communications. This training ultimately paid dividends as the skills and knowledge gained by EMS personnel who attended were put to use for both the Lightening Complex and Glass Complex fires.
Training aside, GMR invested in additional protective equipment, satellite communications, tools, and four-wheel drive ambulances necessary to deploy paramedics to more remote locations than traditional ambulance posts. These new resources and capabilities enabled us to deploy advanced life support units to remote locations for days on end while safely supporting the fire line.
Getting thousands of people out of, in some cases, densely populated urban areas in a rapid yet organized fashion requires coordination and genuinely strong communication between local government, EMS, law enforcement and fire services. While broadcasting evacuation information is generally a law enforcement task and suppression is a fire-related task, EMS’s role is twofold. First, people don’t stop having medical emergencies and calling 911 simply because the area is under an evacuation warning or order. In more densely populated areas, 911 system volume continues while individuals are evacuating, yet ingress and egress can be substantially more challenging. Pre-positioning resources to respond to the continued barrage of 911 calls is essential and proved critical during both significant fires. In both cases, access was limited and alternate destinations had to be used.
Secondly, some individuals can’t self-evacuate due to a variety of medical reasons. Pre-positioned EMS resources in evacuation zones become essential to ensure the evacuation of medically fragile patients. Finally, as firefighting actives begin to ramp up, there can be a lag time between the use of a local command structure and establishing a larger Incident Management Team. During this lag time, the need for staged EMS resources to support fire activities still exists, yet the command structure may be overwhelmed and not yet have the financial authority to commit to the assets. A pre-arranged relationship with the fire agency that has initial attack jurisdiction allows for the rapid deployment of standby resources absent a more formal incident request.
Building the Right Leadership Structure to Support Day-to-Day Operations
EMS leaders are often adept at creating incident management structures for a single MCI or sizeable special event standby. Building out the right leadership structure to manage a multi-week incident while simultaneously managing a 911 system requires a different approach. To make this happen, we took an approach that involved focusing one manager on solely continuing operations of the 911 system while focusing an additional manager on leading all resources assigned to support evacuation and fire-line activities. Additionally, we brought in dedicated administrative support to ensure that resources were accurately tracked, ICS forms and documentation were completed correctly and promptly, thereby minimizing any back-end accountability issues. Leading the day—to-day operations while your county is on fire or simultaneously coping with any larger disaster requires communication between all agency stakeholders, both internal and external.
Managing a sudden hospital evacuation requires planning and effective execution of internal hospital operations, destination management and patient transportation. With the right leadership, team, and resources in place, patients can be evacuated quickly and safely. When multiple critical patients are present who require transport to regional ICUs, the ability to rapidly leverage numerous critical care air resources can be vital in accomplishing this mission. As wildfires continue to rage across the West, EMS must evolve to support these new missions with additional training, equipment, and community support. If 2020 has demonstrated one thing, it’s that EMS’s role is much more than solely patient care and transportation.