Experts Take New Look at Quake Plans

What will happen if a magnitude 7.5 earthquake ruptures a major fault under urban Los Angeles at midday, and tens of thousands of people try to call 911 at the same time?

Haunted by that specter, a Calabasas physician has spawned a plan that could become a model for reshaping California’s disaster medical-care system. The key to quake survival, says Dr. Arnold Bresky, lies in creating a network of neighborhood emergency clinics that would sprout only during a disaster, making communities instantly self-sufficient.

Bresky’s prospective solution has yet to percolate through California. Most individuals’ and communities’ readiness to handle the injuries--both minor and life-threatening--that a major earthquake would cause remain painfully inadequate, authorities say.

Preparations are complicated by a disagreement between many independent physicians and disaster-planning bureaucrats. Physicians like Bresky believe the state’s plans depend too heavily on sharing resources among local, county and state governments, at the expense of self-sufficient and quick-response assistance in neighborhoods.

“We are in a state of denial,” said Bresky, a obstetrician-gynecologist who has already set up a 10-foot-long trunk at a Calabasas tennis club, loaded with materials like rolls of gauze, splints, antibiotics and quick-setting material for casts. “The only way people can think about this huge problem is to make it small enough to deal with. So they make sure they have a flashlight even though the more critical question is: Do you know how to stop someone from bleeding to death?”

The January earthquake in Kobe, Japan, has added special urgency to medical preparedness issues, prompting disaster-medicine officials to re-examine their plans to deal with future “mass casualty” events in Southern California.

Here’s the math: Los Angeles’ paramedic squads are currently stressed at 750 calls per day. Yet recent mathematical models developed for the insurance industry estimate that a magnitude 7.0 quake along the Los Angeles Basin’s Newport-Inglewood fault in the afternoon would kill 3,000 to 5,000 people, hospitalize 15,000 and send many thousands more to emergency rooms.

Experts were stunned at the disintegration of Kobe’s emergency care system when put under a similar load by the magnitude 6.8 quake that struck just before dawn Jan. 17.

Thirteen of the city’s hospitals and a quarter of all neighborhood clinics were destroyed. The remaining hospitals and clinics in the handsome seaside town of 1.3 million people were crippled by the lack of water, electricity and staff. And roads to most hospitals and clinics were blocked by toppled buildings and cratered asphalt.

The sound of Kobe that first week was the sound of ambulance sirens screaming in place.

Could the same happen here?

“Count on it,” said Los Angeles City Fire Department Capt. Jim Denney, pointing to a City Hall map of the city’s 12 hospital trauma centers overlaid on a map of the area’s major earthquake faults and vulnerable lacework of freeways.

Due to the sheer scope of the expected emergency and the likelihood of widespread fires and blocked transportation routes, help from the city Fire Department’s 65 paramedic units is unlikely to quickly reach many seriously hurt victims, Denney said. And even if victims are able to travel, authorities question the ability of the county’s 79 emergency rooms to handle upward of 20,000 victims in the first day.

The suburban Northridge quake--a temblor that released just one-tenth the energy of the projected Big One under urban Los Angeles--nearly maxed out the entire Los Angeles County hospital system with 1,600 people hospitalized and 10,200 treated and released. Sixty-one people died. When the flood of injured people reached its peak after the quake, only 70 critical-care beds were left in the county.

Said David Langness, spokesman for the Healthcare Assn. of Southern California: “A quake just a point or two higher would have overtaxed our capacity.”

That’s why experts say the most effective emergency planning focuses on decentralizing the delivery of medical care in the first few hours after a major event.

But how? Answers are coming slowly, as individual citizens and some fire departments hammer out innovative but underfunded programs on their own.

* In Calabasas, Bresky has persuaded 40 volunteer physicians to sign a contract obligating them to appear at one of three neighborhood emergency stations after a major quake. The city has spent $14,000 so far to equip the stations at a tennis club and at A. E. Wright Middle School; a homeowners association has put up half the $7,000 to install a third box at Calabasas High.

* In Los Angeles, the city Fire Department trains 600 neighborhood and business volunteers a year in its intensive, seven-week Community Emergency Response Team program. A highly acclaimed approach, it has waiting lists a year long for individuals and two years long for businesses. Yet its funding is under attack by city budget-cutters who are seeking to trim the department’s budget by 25%.

* In Orange County, emergency physician Carl Schultz trains 100 doctors and nurses a year to become walking neighborhood MASH units in the event of a disaster. A more ambitious plan to cache drugs and medical equipment throughout the Southland has been stymied by his inability to glean a grant for a pilot project from government agencies.

* In Northridge, anesthesiologist Steve Cantamout is urging the Los Angeles County Medical Assn. to adopt an satellite-linked identification system that would allow hospitals to grant non-staff physicians immediate working privileges during crises. Cantamout traveled with a Southland medical-relief team to Kobe and felt humiliated by the cold shoulder he received from municipal health officials. He realized that his own Northridge Hospital Medical Center, however, might do the same if it could not verify a doctor’s credentials.

To be sure, city, county, state and federal governments have elaborate plans to bunker down in high-tech emergency operations centers after a major quake to coordinate mutual aid between neighboring jurisdictions.

A call for assistance from Burbank officials, for instance, would go to Los Angeles County health officials, who would request help from peers in nearby counties.

Guiding their effort at the top of the California disaster-management pyramid is the governor’s Office of Emergency Services. It coordinates medical resources through six regional administrators and the Emergency Medical Services Authority in Sacramento.

EMSA, in turn, can seek help from the Federal Emergency Management Agency, which marshals such forces as the nation’s Disaster Medical Assistance Teams--squads of 100 crack trauma-care specialists that mobilize in six hours.

California’s complicated emergency medicine system largely worked well during the Northridge quake. But that experience may not be a model for the Big One.

Said Jeffrey L. Rubin, chief of disaster medical services at EMSA: “We have not had a true medical disaster in this country since the Civil War.” Indeed, the greatest loss of life in a single U.S. day occurred Sept. 17, 1862, during the Battle of Antietam, when 4,800 soldiers died and 18,500 were wounded.

Some physicians say that today’s best-laid plans are little comfort when they consider a large temblor.

“Ever seen the (Office of Emergency Services) flow chart? It’s screechingly funny,” said Dr. Brian D. Johnston, 56, an emergency physician at White Memorial Hospital who has worked on disaster planning for Los Angeles County for years. “I don’t know how anyone can keep it in their head much less implement it.”

Johnston takes a cold-eyed view of his profession’s institutional role in the first half-day of a magnitude 7.5 earthquake.

“People will either live or die--for only a small fraction will what doctors do make a difference,” he said. “If you’re pinned in a building in the middle of Los Angeles with a major crush wound, it’s unlikely you will survive.”

Like most other physicians interviewed, he believes that the passage of stronger building construction codes is the most important role government can play in the prevention of widespread death and injury in an earthquake.

A close second among concerned physicians is the need to heighten individuals’ feeling of responsibility to their own families and neighborhoods. A third is the need to improve communications between hospitals.

Most physicians also agree that the state’s long-term attempt to encourage counties to establish so-called casualty-collection points--open fields, like golf courses, where the injured would be told to congregate--has been a costly, wrongheaded detour.

The physicians complain that the centers could take days to set up with supplies and staff and that the concept ignores the fact that, no matter what they’re told, victims tend to converge on hospitals.

Most doctors prefer an approach in which the state sanctions the creation of casualty centers in hospital parking lots--observing that they could be the best place to stabilize patients before transportation out of the area. Others, though, fear side-by-side medical systems are “a recipe for conflict and confusion,” said Johnston.

Rubin concedes that the collection-point concept, central to the state’s disaster planning, might be flawed.

“We encouraged counties to set up lots of them, but you won’t find many that have done it or stocked supplies for them,” the emergency planner said. “They don’t have the money. That concept might have to be revisited, or scaled down.”

The programs of Bresky, Schultz and the Fire Department are providing state planners with an arsenal of new ideas.

Bresky has executed his plan with no assistance from state government. It calls for dividing his hillside town into seven sectors centered around emergency medical stations like the one already installed at the tennis club. Each sector is divided into blocks headed by captains who must know first aid and carry two-way radios. Bresky plans to stage a citywide drill once a year.

Schultz said his mobile MASH unit proposal in Orange County is predicated on the notion that after six hours, “people start dying who didn’t have to die.”

At weekend seminars, Schultz trains professionals to keep medical supplies in backpacks in the trunks of their cars. After a major quake, their mission would be to dig out of their own homes or offices, check their own neighborhoods, then hike to emergency aid centers set up at five-mile intervals in communities--an hour’s walking distance from every citizen.

There each team would triage and treat 300 to 500 patients the first day, using cached medical supplies, he said.

Schultz figures Orange County would need 140 disaster centers to supplement its hospitals, but frets that a $5-million price tag has prevented its adoption by government. “I figure the program will save thousands of lives and at least $40 million, but there’s inertia and resistance to change,” he said.

He added that Los Angeles County emergency-health officials were interested in his proposal but were concerned about its logistics and liability.

The Los Angeles City Fire Department is preparing volunteers for the Big One in a complex of trailers next to its Sherman Oaks station.

The mission before training leaders Steven Vizcaino and Louis Casas is vast: The fire captains are urging the department to designate the city’s 400 elementary schools as community emergency centers, and want at least 100 volunteers trained in each vicinity to guide their neighbors. That totals five times the number of volunteers than have been trained in the past eight years.

Fire officials boosted the number of disaster trainers to eight after the Northridge quake, but a new round of budget-cutting could reverse that gain. Vizcaino and Casas keep a stiff upper lip while straining to supplement their operation’s $45,000 annual budget for supplies with contributions from businesses and by imploring the U.S. Postal Service to distribute its newsletter free.

While the Fire Department is scratching for postage, the private sector is helping by pouring funds into the county’s emergency communications system.

The Healthcare Assn. of Southern California--a hospital, physician and HMO trade group--has spent tens of thousands of dollars in the past year to redesign and reinforce the $2-million, microwave-based communications system called REDDI-NET that links Los Angeles County’s emergency rooms and trauma centers with paramedics. During the Northridge earthquake, at least 10% of its stations failed as a transmission station on Oat Mountain above Northridge fell over, and many hospitals’ receiving antennae bounced off roofs.

The potential for widening communications failures in a broader crisis twists a sharper focus on the grass-roots solutions of physicians like Bresky.

“We’re saying: Get yourself to the closest box,” he said, referring to his tiny Calabasas clinics. “Walk over! A mile is my goal. Anyone can do that. Anyone!”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

L.A. Trauma Centers

Fire department paramedics transport accident or disaster victims to trauma centers, the 12 emergency rooms in Los Angeles County with surgeons and operating rooms on standby 24 hours a day. The number of trauma centers has dropped in half over the past decade, leaving much of the county underserved in the event of a major earthquake, authorities say. Of the remaining centers, many lie on or near major earthquake faults.

A) Henry Mayo Newhall Memorial Hospital

B) Holy Cross Medical Center

C) Northridge Hospital Medical Center

D) UCLA Medical Center

E) Cedars-Sinai Medical Center

F) Childrens Hospital of Los Angeles

G) Los Angeles County King/Drew Medical Center

H) Huntington Memorial Hospital

I) Los Angeles County Harbor-UCLA Medical Center

J) Los Angeles County-USC Medical Center

K) Long Beach Memorial Medical Center

L) Saint Mary Medical Center