the hospital response after an earthquake carl h. schultz, md professor of emergency medicine...

The Hospital Response The Hospital Response After an EarthquakeAfter an Earthquake

Carl H. Schultz, MDCarl H. Schultz, MDProfessor of Emergency MedicineProfessor of Emergency MedicineDirector, Disaster Medical ServicesDirector, Disaster Medical Services

UC Irvine School of MedicineUC Irvine School of Medicine

IntroductionIntroduction

• Current research suggests earthquakes Current research suggests earthquakes of magnitude 7.0 or larger occur on the of magnitude 7.0 or larger occur on the Jordan Valley segment of the Dead Sea Jordan Valley segment of the Dead Sea Fault about every 1000 yearsFault about every 1000 years

• The last major earthquake occurred in The last major earthquake occurred in 10331033

• Jerusalem located less than 40 km from Jerusalem located less than 40 km from the faultthe fault


• Estimate of worst-case event:Estimate of worst-case event:

– Moment magnitude 7.5 earthquake on Moment magnitude 7.5 earthquake on the Jordan Valley segmentthe Jordan Valley segment

– 30 billion dollars U.S. in 30 billion dollars U.S. in economic losseseconomic losses


• Hospitals are vulnerableHospitals are vulnerable

• 1971 San Fernando earthquake (Los 1971 San Fernando earthquake (Los Angeles, California, USA )Angeles, California, USA )

– 50 of 64 deaths due to hospital 50 of 64 deaths due to hospital collapsecollapse

– 4 hospitals with structural failure 4 hospitals with structural failure were closedwere closed


• 1994 Northridge earthquake1994 Northridge earthquake(Los Angeles, California, USA)(Los Angeles, California, USA)– 8 hospitals evacuated patients8 hospitals evacuated patients

• 6 completely6 completely– 4 of these closed and demolished4 of these closed and demolished

• 1995 Hanshin-Awaji earthquake1995 Hanshin-Awaji earthquake(Kobe, Japan)(Kobe, Japan)– 13 hospitals partially or totally destroyed13 hospitals partially or totally destroyed


• Delayed hospital closures can occur days to weeks Delayed hospital closures can occur days to weeks after eventafter event

– 2 hospitals closed 3 and 14 days after quake2 hospitals closed 3 and 14 days after quake

• Inspections not perfectInspections not perfect

– Red, yellow, and green tagsRed, yellow, and green tags

– Based on objective and subjective criteriaBased on objective and subjective criteria

• ATC 20-1ATC 20-1

– Political and financial considerations are involvedPolitical and financial considerations are involved


• Office of Statewide Health Planning and Development, Office of Statewide Health Planning and Development, State of California, 2001State of California, 2001– 48% of California’s hospital buildings are at high risk 48% of California’s hospital buildings are at high risk

for collapse or loss of function from structural failure for collapse or loss of function from structural failure after a Northridge magnitude eventafter a Northridge magnitude event

– 91% of nonstructural components essential to safety 91% of nonstructural components essential to safety and patient care will fail or sustain serious damageand patient care will fail or sustain serious damage

• Rand Corporation 2007Rand Corporation 2007– 305 acute care hospitals have buildings vulnerable to 305 acute care hospitals have buildings vulnerable to

collapse. ½ will be condemned by the 2013 deadline collapse. ½ will be condemned by the 2013 deadline due to failure to retrofit due to failure to retrofit

– Cost of seismic improvements: $110 billion U.S.Cost of seismic improvements: $110 billion U.S.

Overview of Hospital ResponseOverview of Hospital Response

• Initial assessmentInitial assessment– HospitalHospital– RegionalRegional

• Hospital is functionalHospital is functional– Convergence behaviorConvergence behavior– Personnel (staff)Personnel (staff)– Equipment (stuff)Equipment (stuff)– Facilities (structure)Facilities (structure)– Standard of careStandard of care

• Hospital is non-functionalHospital is non-functional– TriageTriage– Internal patient Internal patient

evacuationevacuation– Off-site patient Off-site patient

evacuationevacuation• CommunicationCommunication• Staff behaviorStaff behavior• Government assistanceGovernment assistance

Initial Hospital AssessmentInitial Hospital Assessment

• Immediate status of environmentImmediate status of environment

– Performed by Charge NursePerformed by Charge Nurse

– Manual ventilation of patientsManual ventilation of patients

• Threats to patient safetyThreats to patient safety

– Evacuate to safer area of unitEvacuate to safer area of unit

• Contact House Supervisor and report Contact House Supervisor and report statusstatus


• House supervisor - makes initial assessment House supervisor - makes initial assessment (hospital intact, partial damage, evacuation (hospital intact, partial damage, evacuation needed)needed)– Assessment from patient care staffAssessment from patient care staff– Assessment from maintenance staffAssessment from maintenance staff

• Activates disaster planActivates disaster plan– Implements hospital incident management Implements hospital incident management

systemsystem• Communicate with hospital director (if possible)Communicate with hospital director (if possible)


• Need basic tool for rapid assessment of Need basic tool for rapid assessment of structural safetystructural safety– Building inspectors may take 6-12 hours to Building inspectors may take 6-12 hours to

arrivearrive– ATC-20-1 ATC-20-1

http://www.atcouncil.org/Merchant2/merchant.http://www.atcouncil.org/Merchant2/merchant.mv?Screen=CTGY&Category_Code=a201mv?Screen=CTGY&Category_Code=a201

• Assess not-structural components (plumbing, Assess not-structural components (plumbing, heating/air conditioning, generators, water heating/air conditioning, generators, water supply) supply)

http://www.atcouncil.org/Merchant2/merchant.mv?Screen=CTGY&Category_Code=a201

http://www.atcouncil.org/Merchant2/merchant.mv?Screen=CTGY&Category_Code=a201

Initial Regional AssessmentInitial Regional Assessment

• Ideal metric Ideal metric – available quickly, identifies all – available quickly, identifies all areas of damage, easily disseminatedareas of damage, easily disseminated

• Traditional approachTraditional approach– Identification of epicenterIdentification of epicenter– Measurement of moment magnitudeMeasurement of moment magnitude

• Richter scaleRichter scale– ReconnaissanceReconnaissance– Systematic verbal reports from responders, Systematic verbal reports from responders,

government workersgovernment workers• Modified Mercalli ScaleModified Mercalli Scale


• EpicenterEpicenter– Point on the earth’s surface overlying the where Point on the earth’s surface overlying the where

the fault rupture begins (hypocenter)the fault rupture begins (hypocenter)– Not the area of greatest shakingNot the area of greatest shaking

• AdvantagesAdvantages– Available quicklyAvailable quickly– Gives general location of the earthquakeGives general location of the earthquake

• DisadvantagesDisadvantages– Not provide specific information on areas of Not provide specific information on areas of

significant shaking and damagesignificant shaking and damage


• Moment magnitudeMoment magnitude– Measures overall energy Measures overall energy

release release • AdvantagesAdvantages

– Gives a general measure of damage potentialGives a general measure of damage potential• DisadvantagesDisadvantages

– Poor predictor of shaking and damage at any Poor predictor of shaking and damage at any one locationone location

– Energy not radiate out symmetricallyEnergy not radiate out symmetrically


• ReconnaissanceReconnaissance– Helicopters, spontaneous reportsHelicopters, spontaneous reports

• AdvantagesAdvantages– Available quicklyAvailable quickly

• DisadvantagesDisadvantages– Large sampling errorLarge sampling error– ? reliability? reliability– Many areas with significant damage are not Many areas with significant damage are not

readily apparent from the airreadily apparent from the air

Initial Regional AssessmentInitial Regional Assessment• Systematic reportsSystematic reports

– Government employees, typically postal workers, Government employees, typically postal workers, provide assessment of degree of shaking and provide assessment of degree of shaking and observed damageobserved damage

– Use the Modified Mercalli ScaleUse the Modified Mercalli Scale• AdvantagesAdvantages

– Gives fairly accurate assessment of damage Gives fairly accurate assessment of damage distributiondistribution

• DisadvantageDisadvantage– SlowSlow– Difficult to distribute the informationDifficult to distribute the information

Modified Mercalli ScaleModified Mercalli Scale


• Any of these measure qualify?Any of these measure qualify?

– NONO..

• What does? What does?

– Instrumental intensitiesInstrumental intensities

• Peak ground velocity and peak ground acceleration Peak ground velocity and peak ground acceleration are plotted as Shakemapsare plotted as Shakemaps

– Available within minutes of an earthquakeAvailable within minutes of an earthquake

– Can be downloaded by anyone from the internetCan be downloaded by anyone from the internet

– Easily interpreted by non-seismologistsEasily interpreted by non-seismologists

Instrumental IntensityInstrumental Intensity


• Shakemaps can depict the degree of ground shakingShakemaps can depict the degree of ground shaking– Can this actually work and can it also assess risk for Can this actually work and can it also assess risk for

injuries and death?injuries and death?– YESYES

• Data? Data? • EpidemiologicEpidemiologic

– Ramirez, Peek-Asa: Epidemiology of Traumatic Ramirez, Peek-Asa: Epidemiology of Traumatic Injuries from Earthquakes. Epidemiol Rev 2005Injuries from Earthquakes. Epidemiol Rev 2005

– Peak ground acceleration was highly predictivePeak ground acceleration was highly predictive– Distance from the epicenter in the Northridge quake Distance from the epicenter in the Northridge quake

was a poor predictor of injury and deathwas a poor predictor of injury and death


• Disaster MedicineDisaster Medicine– Schultz, Koenig, Lewis: Decision-Schultz, Koenig, Lewis: Decision-

making in Hospital Earthquake making in Hospital Earthquake Evacuation: Does Distance from the Evacuation: Does Distance from the Epicenter Matter? Epicenter Matter? Ann Emerg Med 2007 (in press)Ann Emerg Med 2007 (in press)

– No significant difference in distance from the No significant difference in distance from the epicenter for evacuated and non-evacuated hospitalsepicenter for evacuated and non-evacuated hospitals

– Statistically significant difference in peak ground Statistically significant difference in peak ground acceleration measurements between both groups of acceleration measurements between both groups of hospitalshospitals

Study Hospitals Control Hospitals

Distance from

Epicenter (miles)

Peak Ground

Acceleration (gravity)

Condemned Distance from

Epicenter (miles)

Peak Ground

Acceleration (gravity)

Condemned

Hospital 1

0.8 0.80 No Hospital A

2.8 0.49 No

Hospital 2

4.0 0.89 No Hospital B

8.4 0.51 No

Hospital 3

4.0 0.93 Yes Hospital C

12.7 0.34 No

Hospital 4

6.7 0.74 No Hospital D

13.0 0.60 No

Hospital 5

9.5 0.81 No Hospital E

15.3 0.38 No

Hospital 6

12.9 0.59 Yes Hospital F

16.7 0.20 No

Hospital 7

21.5 0.46 Yes Hospital G

17.3 0.28 No

Hospital 8

21.8 0.46 Yes Hospital H

22.8 0.13 No

N

5 miles


• Median distance from the epicenter for Median distance from the epicenter for evacuated hospitals = 8.1 miles (13.5 km)evacuated hospitals = 8.1 miles (13.5 km)

• Median distance from the epicenter for Median distance from the epicenter for control hospitals = 14.1 miles (23.5 km)control hospitals = 14.1 miles (23.5 km)

• Difference in medians = 6 miles Difference in medians = 6 miles

95% CI: -4.8 to 11.9 miles95% CI: -4.8 to 11.9 miles

Not statistically significantNot statistically significant


• Median peak ground acceleration for Median peak ground acceleration for evacuated hospitals = 0.77 g, where 1.0 g evacuated hospitals = 0.77 g, where 1.0 g equals the force of gravityequals the force of gravity

• Mean peak ground acceleration for control Mean peak ground acceleration for control hospitals = 0.36 ghospitals = 0.36 g

• Difference in medians = 0.41 gDifference in medians = 0.41 g

95% CI: 0.14 to 0.55 95% CI: 0.14 to 0.55

Statistically significant (p=0.009) Statistically significant (p=0.009)


• Take home message:Take home message:– Shakemaps are useful way to assess the risk of Shakemaps are useful way to assess the risk of

damage across the entire region of an damage across the entire region of an earthquakeearthquake

– Are predictive of increased risk for building Are predictive of increased risk for building damage, injury, and deathdamage, injury, and death

– Shakemap assessment by hospital personnel Shakemap assessment by hospital personnel and emergency managers in the immediate and emergency managers in the immediate aftermath of an earthquake needs to be included aftermath of an earthquake needs to be included in the disaster plans of all vulnerable regions in the disaster plans of all vulnerable regions where such information is availablewhere such information is available

Hospital Is FunctionalHospital Is Functional

• Prepare for patient convergencePrepare for patient convergence

– Closest hospitals will receive most of the patientsClosest hospitals will receive most of the patients

– Israel has real experienceIsrael has real experience

• Versailles nightclub Versailles nightclub collapsecollapse

• Terrorist bombingsTerrorist bombings

– Earthquakes on larger Earthquakes on larger scalescale

– Credentialing of medical volunteersCredentialing of medical volunteers


• Alternate sites of careAlternate sites of care

– Parking lotsParking lots

– Temporary structures (tents)Temporary structures (tents)

– Areas not used for patient careAreas not used for patient care

• ClassroomsClassrooms

• AuditoriumsAuditoriums

• Early discharge of patients – problematic Early discharge of patients – problematic

• Delivery of supplies/equipmentDelivery of supplies/equipment

– Agreement with vendors, Home Front CommandAgreement with vendors, Home Front Command


• Change in standard of care?Change in standard of care?– Triage based on who receives care and who Triage based on who receives care and who

doesn’tdoesn’t– Delayed closure of lacerationsDelayed closure of lacerations– Use of ventilatorsUse of ventilators– Admission to Intensive CareAdmission to Intensive Care

Units (ICUs)Units (ICUs)

Hospital Is Not FunctionalHospital Is Not Functional

• TriageTriage

Order of patient movement Order of patient movement off unit: off unit: Sickest patients firstSickest patients first– No immediate threat to No immediate threat to

safety (immediate building collapse unlikely)safety (immediate building collapse unlikely)– Efficiency of movement not criticalEfficiency of movement not critical– Individuals use great deal of resourcesIndividuals use great deal of resources– Order of floor evacuation not matterOrder of floor evacuation not matter


• TriageTriage– Order of patient movement off unitOrder of patient movement off unit

• Healthiest patients firstHealthiest patients first– Immediate risk to safety (building collapse Immediate risk to safety (building collapse

possible)possible)– Efficiency of evacuation importantEfficiency of evacuation important– Can move more patients with less Can move more patients with less

resources (some can evacuate themselves)resources (some can evacuate themselves)– May need to leave trapped patients behindMay need to leave trapped patients behind– Evacuation lower floors firstEvacuation lower floors first


• Internal patient evacuationInternal patient evacuation

– Movement of patientsMovement of patients

• Used gurneys, backboards, sheets, Used gurneys, backboards, sheets, wheelchairswheelchairs

• Did not use specialized devices and would not Did not use specialized devices and would not use them if availableuse them if available

• FLASHLIGHTS CRITICALFLASHLIGHTS CRITICAL

• Elevators will not workElevators will not work

• Evacuation routes must only use stairsEvacuation routes must only use stairs

• Take patients charts and medicationsTake patients charts and medications


• Control of hospital evacuations Control of hospital evacuations

– Traditional modelTraditional model

• Emergency Operations Center (EOC) controls all Emergency Operations Center (EOC) controls all aspects of patient transferaspects of patient transfer

• Transportation assetsTransportation assets

Ambulances, helicoptersAmbulances, helicopters

• Destination decisionsDestination decisions

– How many patients go to which hospitalsHow many patients go to which hospitals

– Northridge modelNorthridge model

• EOC provides vehicles to hospitals per their requestEOC provides vehicles to hospitals per their request

• EOC and hospitals share destination decisionsEOC and hospitals share destination decisions

Off-site patient evacuationOff-site patient evacuation


• Northridge model (Schultz et al: New England Northridge model (Schultz et al: New England Journal of Medicine, 2003)Journal of Medicine, 2003)

– 1066 patients evacuated totally, 818 in first day1066 patients evacuated totally, 818 in first day

– How many people answering phones would it How many people answering phones would it take for the EOC to coordinate the transfer of 800 take for the EOC to coordinate the transfer of 800 patients in the midst of chaos?patients in the midst of chaos?

– Efficient use of time?Efficient use of time?

– Other demands during first critical 24 hoursOther demands during first critical 24 hours

– Use of shakemaps?Use of shakemaps?


• OutcomeOutcome– EOC able to mobilize transportation assetsEOC able to mobilize transportation assets

• Used ambulances, buses, county vehiclesUsed ambulances, buses, county vehicles• Very effective at this taskVery effective at this task

– EOC can coordinate movement of some patients but EOC can coordinate movement of some patients but not allnot all

– Hospitals can and will move patients on their ownHospitals can and will move patients on their own– Hospitals belonging to systems will be most effectiveHospitals belonging to systems will be most effective– Recognition of hospital role should be part of disaster Recognition of hospital role should be part of disaster

planplan

CommunicationCommunication

• Most forms of communication fail Most forms of communication fail during a disasterduring a disaster– Telephones (damaged or over-utilized)Telephones (damaged or over-utilized)– Cellphones (towers damaged, battery back-up Cellphones (towers damaged, battery back-up

fails, over-utilized)fails, over-utilized)– Satellite phones (batteries not charged)Satellite phones (batteries not charged)– Microwave radios (repeaters down, power Microwave radios (repeaters down, power

out)out)

CommunicationCommunication

• Forms of communication that function Forms of communication that function during a disasterduring a disaster– Pay phonesPay phones– Fax linesFax lines– Certain types of internet linesCertain types of internet lines– Ham radiosHam radios– Police, fire, and ambulance radios (not Police, fire, and ambulance radios (not

compatible in the U.S.)compatible in the U.S.)

Staff BehaviorStaff Behavior

• Concerns regarding commitment of staff. Concerns regarding commitment of staff. Will they remain on duty and will Will they remain on duty and will replacements arrive?replacements arrive?

YES.YES.– Studies by Quarantelli demonstrate basic Studies by Quarantelli demonstrate basic

volunteer nature of societyvolunteer nature of society– Article in JAMA after the Northridge Article in JAMA after the Northridge

Earthquake documenting staff dedicationEarthquake documenting staff dedication


• Hospitals reported staffing Hospitals reported staffing shortages after the Northridge shortages after the Northridge Earthquake, some more than 50% Earthquake, some more than 50% – Not due to individuals refusing to remain on Not due to individuals refusing to remain on

dutyduty– Not due to unwillingness of staff to come to Not due to unwillingness of staff to come to

work. Unscheduled staff reported to hospitalswork. Unscheduled staff reported to hospitals– Due to inability to get to work or could not Due to inability to get to work or could not

leave familiesleave families


• Solutions to the staffing problemSolutions to the staffing problem

– Establish daycare, supervision for petsEstablish daycare, supervision for pets

• Surge capacitySurge capacity

– Use staff from other hospitals (Kazzi et al: Use staff from other hospitals (Kazzi et al: Prehospital and Disaster Medicine, 2000)Prehospital and Disaster Medicine, 2000)

• Raises issues of credentialingRaises issues of credentialing

• National vs local databaseNational vs local database

• Resolved within 7 daysResolved within 7 days

Government AssistanceGovernment Assistance

• Government assistance critical for overall Government assistance critical for overall response but may not be acute care assetresponse but may not be acute care asset

• May arrive too late to impact initial May arrive too late to impact initial outcomes in a significant wayoutcomes in a significant way

• Biggest impact in supporting ongoing Biggest impact in supporting ongoing health maintenancehealth maintenance

• Attack after earthquakeAttack after earthquake

• Transportation an issueTransportation an issue

United States TeamsUnited States Teams

• Urban Search and Rescue teamsUrban Search and Rescue teams– Riverside County team 2 hours away by carRiverside County team 2 hours away by car– Earthquake occurs at 04:30Earthquake occurs at 04:30– Team not begin activities at site of Northridge Team not begin activities at site of Northridge

Meadows Apartment collapse until 23:30Meadows Apartment collapse until 23:30– Live victims already extricatedLive victims already extricated


• Oklahoma City Bombing 1995Oklahoma City Bombing 1995– Multiple USAR teams dispatchedMultiple USAR teams dispatched– Last survivor recovered from building 18 Last survivor recovered from building 18

hours after explosionhours after explosion– Number of survivors recovered by out-of-state Number of survivors recovered by out-of-state

USAR teams:USAR teams:

– ZEROZERO


• Disaster Medical Assistance TeamsDisaster Medical Assistance Teams– No teams arrived in the first 24 hour (Leonard No teams arrived in the first 24 hour (Leonard

et al: Prehosp & Disaster Med 1995)et al: Prehosp & Disaster Med 1995)– 4 team arrived in the next 24 hours, 3 from 4 team arrived in the next 24 hours, 3 from

CaliforniaCalifornia– Each team can see up to 200 ED type Each team can see up to 200 ED type

patients or 400 clinic patients per daypatients or 400 clinic patients per day– Demand for emergent care back to baseline Demand for emergent care back to baseline

by 7 daysby 7 days

Israeli Home Front Command Israeli Home Front Command Urban Search and Rescue TeamUrban Search and Rescue Team

• January 2006: Nairobi, Kenya building January 2006: Nairobi, Kenya building collapse collapse

• 117 victims found in collapsed building117 victims found in collapsed building

• Israeli Home Front Command forces Israeli Home Front Command forces arrived 23 hours after eventarrived 23 hours after event

• Rescued 2 individuals, one a Rescued 2 individuals, one a volunteer who became trapped volunteer who became trapped after the eventafter the event

Government AssistanceGovernment Assistance• Local solutionsLocal solutions

– Granada Hill hospitalGranada Hill hospital• Staff shortagesStaff shortages• Used staff (MDs and RNs) from UCI Used staff (MDs and RNs) from UCI

Medical Center to support Emergency Medical Center to support Emergency Department CareDepartment Care

• Surge capacity: National database? Surge capacity: National database?

TODA RABAHTODA RABAH

Carl H. Schultz, MDCarl H. Schultz, MD

1-714-456-37131-714-456-3713

[email protected]@uci.edu

the hospital response after an earthquake carl h. schultz, md professor of emergency medicine...

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