Disaster Management for the Disaster Management for the Surgeon with case study:Surgeon with case study:

The San Diego Wildfires of The San Diego Wildfires of 2003 & 20072003 & 2007

University of California-San Diego Burn CenterUniversity of California-San Diego Burn Center

B Potenza MD, FACS, FACPB Potenza MD, FACS, FACPDirector of UCSD Regional Burn Center Director of UCSD Regional Burn Center

The SettingThe Setting

San Diego County San Diego County

Each year there are 700 wildfires within Each year there are 700 wildfires within the county, most of which are extinguished the county, most of which are extinguished with less than 10 acres burnedwith less than 10 acres burned

The terrain of the county includes coastal, The terrain of the county includes coastal, inland, mountain and desert topography.inland, mountain and desert topography.

Urban growth interdigitates with canyon Urban growth interdigitates with canyon and mountain terrain.and mountain terrain.

The ClimateThe Climate

Successive years of little rainfall and Successive years of little rainfall and mature dry vegetation set the scene for mature dry vegetation set the scene for “high risk fire season”“high risk fire season”

Each fall the Santa Anna wind blow from Each fall the Santa Anna wind blow from east to west at speeds of 20-40 mpheast to west at speeds of 20-40 mph

Canyon walls act to funnel these winds Canyon walls act to funnel these winds into concentrated areas resulting in gusts into concentrated areas resulting in gusts of wind exceeding 60 mphof wind exceeding 60 mph

2003 Fires 2003 Fires (336,000 acres)(336,000 acres)

Four fires broke out in San Diego County Four fires broke out in San Diego County during the last 2 weeks of October 2003during the last 2 weeks of October 2003

The Camp Pendleton Fire on the Marine The Camp Pendleton Fire on the Marine Base-8,500 acresBase-8,500 acres

The Paradise Fire in the north countyThe Paradise Fire in the north county

The Cedar Fire in central and east county The Cedar Fire in central and east county

The Otay Fire in south countyThe Otay Fire in south county

Satellite view of wildfires 2003Satellite view of wildfires 2003

2007 California Wildfires2007 California Wildfires

October 20 to November 9,2007October 20 to November 9,2007

San Diego County, Orange County, San San Diego County, Orange County, San Bernardino County, Santa Barbra, Los Bernardino County, Santa Barbra, Los Angeles County all involvedAngeles County all involved

Witch Creek Fire in north San Diego Witch Creek Fire in north San Diego CountyCounty

Harris Fire in southeast San Diego CountyHarris Fire in southeast San Diego County

Fire CharacteristicsFire Characteristics

Fast movingFast movingExtremely hot fire due to the Santa Anna Extremely hot fire due to the Santa Anna winds and the dry vegetationwinds and the dry vegetationTemperatures in excess of Temperatures in excess of

550 degrees Fahrenheit550 degrees FahrenheitMany non burned items were meltedMany non burned items were meltedCanyon fires generated a local Canyon fires generated a local microclimate resulting in an unpredictable microclimate resulting in an unpredictable fire pathfire path

Fire CharacteristicsFire Characteristics

The fires consumed on average 6,000 The fires consumed on average 6,000 acres per hour.acres per hour.At the most aggressive time of the fire the At the most aggressive time of the fire the rate of spread was 12,000 acres per hour. rate of spread was 12,000 acres per hour. Flames as high as 200 feetFlames as high as 200 feetAdvancing fire walls 50-75 feet high; Advancing fire walls 50-75 feet high; moving at 15-20 mphmoving at 15-20 mphEntire front of fire seen to advance .5 Entire front of fire seen to advance .5 miles in 2 minutesmiles in 2 minutes

The fires generated their own The fires generated their own weather climateweather climate

Evacuation from the fire areasEvacuation from the fire areas

Notice the Direction of TravelNotice the Direction of Travel

I-15 Acting as a Fire LineI-15 Acting as a Fire Line

The Wildfire Jumped the I-15 The Wildfire Jumped the I-15 Fire LineFire Line

County Wide Injuries-2003County Wide Injuries-2003

There were approximately 125 minor There were approximately 125 minor injuries and 29 minor burns treated at local injuries and 29 minor burns treated at local emergency departments (including 6 emergency departments (including 6 firefighters)firefighters)

41 patients seriously injured 41 patients seriously injured – 23 patients treated at UCSD 23 patients treated at UCSD

(including 3 firefighters)(including 3 firefighters)

– 18 patients fatally injured in the field18 patients fatally injured in the field-(including 1 firefighter)-(including 1 firefighter)

County Wide Injuries-2007County Wide Injuries-2007

9 fatalities (7 in San Diego County)9 fatalities (7 in San Diego County)

85 injuries (50 in San Diego County)85 injuries (50 in San Diego County)

61 firefighters injured (7 in San Diego 61 firefighters injured (7 in San Diego County)County)

1 border patrol agent injured (San Diego 1 border patrol agent injured (San Diego County)County)

51 patients evaluated at UCSD and 20 51 patients evaluated at UCSD and 20 admitted, 11 to the ICUadmitted, 11 to the ICU

Etiology of Non-Fatal BurnsEtiology of Non-Fatal Burns

Protecting propertyProtecting property

Attempting to escape from the fireAttempting to escape from the fire

Rescue operationsRescue operations

Trapped or surrounded by fireTrapped or surrounded by fire

Radiant heatRadiant heat

Smoke inhalation Smoke inhalation

Etiology of Fatal Burn InjuriesEtiology of Fatal Burn Injuries

Protecting a home, structure or livestock (3)Protecting a home, structure or livestock (3)

Overtaken by rapidly advancing fire while Overtaken by rapidly advancing fire while attempting to escape (10)attempting to escape (10)

Motor vehicle crash and overtaken by fire (2)Motor vehicle crash and overtaken by fire (2)

Smoke inhalation (2)Smoke inhalation (2)

Myocardial infarction while loading personal Myocardial infarction while loading personal automobile with belongings (1)automobile with belongings (1)

Mechanism of Serious Burn Injury-Mechanism of Serious Burn Injury-2003 and 2007 Wildfires 2003 and 2007 Wildfires

Serious Non fatalSerious Non fatal Burns (n=43)Burns (n=43)

Flame injuries 27Flame injuries 27Radiant heat 11Radiant heat 11Contact injuries 4Contact injuries 4Smoke inhalation 1Smoke inhalation 1Combination Smoke Combination Smoke

and Burn 27/43and Burn 27/43

Fatal Burn Fatal Burn Injuries Injuries (n=24)(n=24)

Flame injuries 20Flame injuries 20 Smoke inhalation 4Smoke inhalation 4

ARDS 1ARDS 1

Wildfire Advancing on Residential Wildfire Advancing on Residential AreasAreas

Injury DemographicsInjury Demographics

Ages ranged from 11 -77 years oldAges ranged from 11 -77 years old

Mean age of males was 44 and females Mean age of males was 44 and females was 38 (p < 0.05)was 38 (p < 0.05)

Mean age of survivors was 39.5 years vs Mean age of survivors was 39.5 years vs fatally injured was 42.2 years (p<0.05)fatally injured was 42.2 years (p<0.05)

Advancing age translated into longer Advancing age translated into longer length of hospitalization for older patientslength of hospitalization for older patients

Burn Injuries-survivorsBurn Injuries-survivors

Mean total body surface area (TBSA) Mean total body surface area (TBSA) burned 14.8%burned 14.8%

Range TBSA (1-85%)Range TBSA (1-85%)

Major areas burned Major areas burned – Upper and lower extremities Upper and lower extremities – Face and handsFace and hands

3 of the 11 patients with radiant injury 3 of the 11 patients with radiant injury burns were greater than 25% TBSAburns were greater than 25% TBSA

Operative Care 2003 & 2007Operative Care 2003 & 2007

26 required operative intervention26 required operative intervention

Of these 24 required multiple operative Of these 24 required multiple operative procedures (114)procedures (114)

Escharotomies, tracheostomies, excision Escharotomies, tracheostomies, excision of burn wounds, allograft, amputations and of burn wounds, allograft, amputations and then auto grafting proceduresthen auto grafting procedures

Reconstructive surgery still ongoingReconstructive surgery still ongoing

Representative Burn InjuriesRepresentative Burn Injuries

SurgeSurge

In both fires 80% of the patients arrived In both fires 80% of the patients arrived within 24 hours of the fires startingwithin 24 hours of the fires starting

Often with little information from the MICNOften with little information from the MICN

Most of the information you receive will Most of the information you receive will come from the fire rescue and helicopter come from the fire rescue and helicopter personnelpersonnel

Local news will not be on top of the story Local news will not be on top of the story early on in the disasterearly on in the disaster

Internal Burn Service LogisticsInternal Burn Service Logistics

The burn service was full (18 patients) at The burn service was full (18 patients) at the time of the wildfires, therefore, patients the time of the wildfires, therefore, patients were moved off ward or discharged were moved off ward or discharged All non-burned overflow patients were All non-burned overflow patients were moved out of all burn bedsmoved out of all burn bedsTrauma resuscitation room, anesthesia Trauma resuscitation room, anesthesia pre op holding, burn clinic, ICU were all pre op holding, burn clinic, ICU were all used to triage patientsused to triage patientsBurn patients housed in other unitsBurn patients housed in other units

Prepare for the worstPrepare for the worst

Once you have an idea something is up; Once you have an idea something is up; act quicklyact quickly

Triage the burn service, all intensive care Triage the burn service, all intensive care unitsunits

Make sure the ED is aware of what you Make sure the ED is aware of what you know and may anticipate so they can know and may anticipate so they can triage and be prepared for patient influxtriage and be prepared for patient influx

Act quickly and decisivelyAct quickly and decisively

Prepare your call team for how and where Prepare your call team for how and where you will handle all of the casesyou will handle all of the casesMan up the relief areas if neededMan up the relief areas if neededInform the administrator on call of event Inform the administrator on call of event and if you need to consider upgrading to a and if you need to consider upgrading to a disaster modedisaster modePlan to defend your decisions to get quick Plan to defend your decisions to get quick actionactionInstitutional memory is shortInstitutional memory is short

Why go to a disaster mode?Why go to a disaster mode?

You will need logistical supportYou will need logistical support

Materials and equipment needsMaterials and equipment needs

Personnel needsPersonnel needs

Security concernsSecurity concerns

Public relations assistancePublic relations assistance

Assist hospital personnel on duty and offAssist hospital personnel on duty and off

Assist in regional coordination of activitiesAssist in regional coordination of activities– Mostly done by our ED pre hospital director and staffMostly done by our ED pre hospital director and staff

Lesson Learned from Wildfire and Lesson Learned from Wildfire and Recent Multiple Casualty EventsRecent Multiple Casualty Events

A well planned and workable hospital and A well planned and workable hospital and burn unit disaster plan are essential for burn unit disaster plan are essential for successsuccess

Rapid triage of existing patients to other Rapid triage of existing patients to other units to make room for new patientsunits to make room for new patients

Elective operative cases may need to be Elective operative cases may need to be placed on hold until the situation is placed on hold until the situation is assessedassessed

Lessons LearnedLessons Learned

Patient flow may not remain under control Patient flow may not remain under control of local MICN/base station supervision of local MICN/base station supervision

Patients may arrive at the BICU door Patients may arrive at the BICU door rather than in designated triage areasrather than in designated triage areas

Quickly open your local supply chain Quickly open your local supply chain

Adapt to the situation you find yourselfAdapt to the situation you find yourself

Lesson LearnedLesson Learned

Standard inbound transport of patients Standard inbound transport of patients may be altered in a disaster situationmay be altered in a disaster situation

Triage of patients out of your region Triage of patients out of your region impossible due to local weather and road impossible due to local weather and road conditionsconditions

Heavy Traffic and Smoke Hinder Heavy Traffic and Smoke Hinder Patient TransportPatient Transport

Lesson LearnedLesson Learned

Cross training of staff facilitates ongoing Cross training of staff facilitates ongoing coverage of all phases of medical carecoverage of all phases of medical care

Medical personnel callback numbers must Medical personnel callback numbers must be current in order to secure staffing as be current in order to secure staffing as the disaster continuesthe disaster continues

Some personnel will need to be dismissed Some personnel will need to be dismissed from their work as their family or home is from their work as their family or home is in “Harm’s Way”in “Harm’s Way”

Lessons LearnedLessons Learned

As a community resource the burn center As a community resource the burn center may need to provide outreach telephone may need to provide outreach telephone consultations to hospitals which are consultations to hospitals which are treating burn patients until these patients treating burn patients until these patients can safely be transferred to the Burn Unitcan safely be transferred to the Burn Unit

Lesson LearnedLesson Learned

Back up for burn unit personnel must be Back up for burn unit personnel must be provide to meet the surge capacity as well provide to meet the surge capacity as well as to “run the marathon”as to “run the marathon”

Equipment and resupply lines may be Equipment and resupply lines may be limited in the early phases of the disasterlimited in the early phases of the disaster

They may remain limited due to local road They may remain limited due to local road conditions-know you limits!conditions-know you limits!

Urban Destruction from the Fire Urban Destruction from the Fire 2003 & 20072003 & 2007

Over 3900 homes Over 3900 homes destroyeddestroyed> 650 outbuildings > 650 outbuildings destroyeddestroyed55 commercial business55 commercial business> 100 autos burned> 100 autos burnedAnimal loss unknownAnimal loss unknownTotal acreage burned Total acreage burned approximately 600,000 approximately 600,000 $66 million (2003) in $66 million (2003) in direct costs of the fire, not direct costs of the fire, not including rebuilding including rebuilding homeshomes

Resources Used to Fight the Resources Used to Fight the Wildfire-2003 & 2007Wildfire-2003 & 2007

Fire crews from 90 cities responded to a Fire crews from 90 cities responded to a mutual aid call for assistancemutual aid call for assistance

Firefighters 5,000 (2003) & 6,000 (2007)Firefighters 5,000 (2003) & 6,000 (2007)

10 air tankers10 air tankers

15 helicopters15 helicopters

Over 200 engine companies from San Over 200 engine companies from San Diego CountyDiego County

Police, sheriff and military assistancePolice, sheriff and military assistance

EpilogueEpilogue

Within 1 week the major destruction and Within 1 week the major destruction and damage from the fire was completedamage from the fire was completeIt took another 3 weeks to completely It took another 3 weeks to completely extinguish the firesextinguish the firesSmall brush fires continued to breakout Small brush fires continued to breakout during the fall until the winter rains arrivedduring the fall until the winter rains arrivedBurn operations performed everyday for 5 Burn operations performed everyday for 5 weeks weeks Last patient discharged 2 ½ months laterLast patient discharged 2 ½ months later

In MemoriamIn Memoriam

Steve Rucker Steve Rucker

““Engine Company 6162” Engine Company 6162”

Novato, CANovato, CA

Wild Fire PhotosWild Fire Photos

Day 1 Early Morning Day 1 Early Morning

photos by Jim Samuelson San Diego State Universityphotos by Jim Samuelson San Diego State University

photos by Jim Samuelson San Diego State Universityphotos by Jim Samuelson San Diego State University

photos by Jim Samuelson San Diego State Universityphotos by Jim Samuelson San Diego State University

Photos from “After Action Report-San Diego Fire Department”Photos from “After Action Report-San Diego Fire Department”

Photos from “After Action Report-San Diego Fire Department”Photos from “After Action Report-San Diego Fire Department”

Photos from “After Action Report-San Diego Fire Department”Photos from “After Action Report-San Diego Fire Department”

Crash Landing due to Decreased Crash Landing due to Decreased Visibility onto FreewayVisibility onto Freeway

Photos from “After Action Report-San Diego Fire Department”Photos from “After Action Report-San Diego Fire Department”