I Managed Wildfire Response for a Health System. Here’s What I Learned.

This week, the world watched in weary horror as large portions of Los Angeles went up in flames. As I write this, the Palisades, Eaton, and Hurst fires, along with other smaller fires in the area, have consumed over 35,000 acres, killed 10 individuals, and forced 360,000 residents to evacuate. The media has captured many iconic images, from bewildered nursing home residents awaiting evacuation to families staring in disbelief at the remains of their homes.

I know that look of disbelief — I felt it the first time my healthcare organization evacuated a hospital because the Tubbs Fire was bearing down on it. I felt the same disbelief when I evacuated another hospital during the Kincade Fire and when I joined a medical relief team after the Paradise Fire. During my 6 years as the director of disaster preparedness for Kaiser Permanente Northern California, I never quite lost that sense of shock whenever wildfires and my organization collided, which they did with frustrating frequency. But I did learn some important lessons about what to expect during the first 96 hours and how health systems can and must adapt to wildfire.

The First 96 Hours

Open a command center: When communities burn, the health systems that support them are inevitably impacted. To meet these challenges, a unique organizational structure is required — one that is nimble, scalable, and efficient. That response structure is the Hospital Incident Command System (HICS). HICS helps medical centers function in the chaotic environment of an evolving natural disaster. It provides the framework to ensure that operations, planning, logistics, and finance considerations are addressed, and it aligns with other first responder agencies.

During a wildfire, hospitals should be prepared to maintain a command center for days to weeks, and should plan their staffing accordingly.

Poor Air Quality Is the Scourge of Wildfires

Wildfires blanket entire geographic areas in dense, particulate matter-heavy smoke. This smoke is highly toxic: it’s associated with increased all-cause mortality and asthma/COPD exacerbations. It’s been linked to COVID-19 and influenza cases, and a 20% increase in coccidioidomycosis admissions. One review of hospital respiratory admissions found that wildfire smoke was 10 times more toxic than ambient air pollution; in another study, it was 10 times more harmful to children’s respiratory health. It has also been linked to poor birth outcomes and mental health symptoms.

Health systems should anticipate increased healthcare utilization due to wildfire smoke exposure. Facilities can protect staff and patients by providing N95s when indicated and placing portable air scrubbers at entrances to improve air quality.

Operational Impacts

Expect patient surges and staffing shortages: During a wildfire, medical systems tend to experience patient surges even as their staffing is negatively impacted. Some individuals present for treatment of respiratory, cardiac, or mental health symptoms. Others flee to medical centers as a safe place to shelter or reunite with family.

After the Tubbs Fire, Santa Rosa Memorial and Petaluma Hospitals experienced a 70% increase in acute care visits. Staffing shortages go hand in hand with these patient surges. Healthcare workers may have to evacuate their homes or rescue children from impacted schools. Some have elderly family members to check on; others lose their childcare options. Road closures and traffic jams may make it impossible to get to work.

It often becomes necessary to cancel routine appointments or shift to virtual care. For instance, this week Cedars-Sinai announced that it has postponed non-emergent procedures. Under these circumstances, accurate triage becomes vitally important: under-triage leads to increased morbidity and mortality, and over-triage can overwhelm a health system.

Keep the lines of communication open with patients — explain why appointments have been cancelled and waits are longer than usual. Patients are capable of impressive patience in extenuating circumstances.

(A caveat: health systems sometimes experience a surge of well-intended volunteers who offer their services. Proceed with caution: it’s wise to create a system to vet these individuals. Some may overestimate their abilities.)

Plan for power outages: Power outages are common during wildfires. In a planned power outage, the electrical company deliberately turns off electrical lines; in an unplanned outage, the wildfire itself destroys power infrastructure. In the current Los Angeles fires, nearly 400,000 people had experienced blackouts as of January 8.

For health systems, important considerations include whether a facility is equipped with emergency power, what supplies require refrigeration, and how to relocate temperature-sensitive assets. Most hospitals have emergency generator power, but clinics and pharmacies may be forced to close. Power outages also impact patients with electric-powered medical equipment, such as oxygen or peritoneal dialysis. Faced with blackouts, these individuals may present to medical centers for care.

Worst-Case Scenario

Evacuation: The most dreaded wildfire complication is a hospital evacuation. It’s not a decision to be made lightly, but it becomes necessary if wildfire directly threatens a facility or power outages render it nonfunctioning.

An evacuating medical center must have a system to identify patients and track them. It’s all too easy to misplace a patient during a hectic evacuation. Ideally, patients should be relocated from their rooms to a central tracking area and then into transportation. Rooms that have been emptied of patients should be clearly distinguished from rooms still occupied. When time is constrained, plan to evacuate multiple floors simultaneously.

It can be helpful to assign a sitter to fragile patients awaiting transportation. Pay particular attention to the most vulnerable — women in labor, critically ill patients, newborns, and infants. It may be necessary to get creative with transportation, as ambulance transport is typically in high demand and short supply. In my organization’s two hospital evacuations, we used ambulances, city buses, and even private staff vehicles to move patients. Consider creating “go bags” packed with essential medical supplies in case of decompensation during transport. If possible, distribute departing patients amongst multiple receiving hospitals to avoid overwhelming the closest functioning medical center.

Recovery

For now, it’s a matter of survival in Los Angeles. Fire crews are working frantically to preserve life and peoples’ homes. When the flames die down, the prolonged and often poignant process of recovery begins. Wildfires tend to have a long tail, and untangling the logistical, economic, and psychological impacts is complicated. Los Angeles has joined the ranks of other communities decimated by wildfire, and the impact of these combined blazes will be felt for years.

This perspective is the author’s alone and does not necessarily reflect that of any institutions or companies with which she is affiliated.