Lessons Learned From LA Medical Personnel During Wildfires

Having to meet an increased demand for care during a wildfire crisis requires having a plan in place to protect all patients, but especially those with known respiratory and cardiovascular conditions, according to experts. Coordinating efforts with other clinics and with public health officials can help deploy a faster response when a crisis hits.

Thinking Ahead

“The first thing we should think about is disaster preparation…being ready for whatever might come down the road,” Alex McDonald, MD, told Medscape Medical News. “That means having an emergency response plan for your clinic, having enough supplies, masks, gloves, basic things.”

McDonald is the current president of the California Academy of Family Physicians, and a primary care physician in Fontana, California. He also is an assistant professor of clinical science at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.

Key to that contingency plan, according to McDonald, is “the three Ss” and getting ahead of what a disaster might necessitate. “There’s stuff, space, and staff. You need staff to see patients, space to see them in, and stuff to use in treating them,” McDonald said. “Disasters are overwhelming, but if you drill down on those three things, from a medical point of view, you are in good shape.”

Clinics also can be proactive by setting up “protocols to follow local area air quality and wildfire activity to provide appropriate patient guidance, anticipate changes in health care utilization, and adjust services accordingly,” a California Department of Public Health spokesperson wrote in an email response to questions.

Preparing At-Risk Patients

“Primary care providers should also advise patients with respiratory and cardiovascular conditions, to have a management plan for exacerbations,” John Balmes, MD, told Medscape Medical News.

Balmes is a Professor Emeritus of Medicine at the University of California, San Francisco, and Professor Emeritus of Environmental Health Sciences at the School of Public Health at the University of California, Berkeley. As an internist, Balmes’ subspecialty was pulmonology.

“During fires, children are most likely to present with asthma exacerbations whereas adults may present with either respiratory or cardiovascular problems,” Balmes said.

Encouraging patients to have on hand an emergency supply of requisite medications such as rescue bronchodilators can help mitigate any further health crisis in this population, according to Balmes.

‘Clean Air Spaces’

“Primary care clinics in wildfire-prone areas should make sure that their facilities are clean air spaces,” Balmes said.

Part of the disaster contingency plan, according to Balmes, should also include advising patients with known heart and lung conditions to create clean air spaces in their homes as a prophylactic should fires break out. 

The Environmental Protection Agency describes a “clean air space” as a room where levels of smoke and other particles are kept as low as possible during wildfires by keeping doors and windows shut, and if possible, by running a portable air cleaner.

“Patients should stay indoors as much as possible but also have a supply of N95 masks if they need to go outside,” Balmes said.

Although primary care practitioners typically manage chronic respiratory and cardiovascular disease, Balmes said “they should have a good relationship with a pulmonologist should wildfire emergencies occur.”

During the fires, pulmonologists at Cedars-Sinai Medical Center, Los Angeles, reached out to primary care clinicians in their network to let them know they wanted to help.

“As the LA fires grew, we expanded our available clinic appointments as a way to help our primary care clinics who were managing airway diseases,” Isabel Pedraza, MD, director of the medical intensive care unit at Cedars-Sinai Health System, told Medscape Medical News.

Triaging Patients

Patient schedules took a hit during the fires, according to Jerry Abraham, MD, president of the Los Angeles County Medical Association.

“We saw people coming into the emergency room and taking the place of someone who’d been waiting and who might have been having a heart attack,” Abraham said. “It makes it harder for Grandma to get her stroke treated in the emergency room. It makes it harder to get into the doctor’s office because people are coming in front of them to get their inhalers filled.”

Abraham is also the director of integrated services and public health at the federally qualified medical center, Kedren Health, in South Los Angeles.

In the primary care setting, McDonald said that often in disaster situations, to meet patient demand, clinics will cancel all scheduled appointments and operate similarly to an urgent care clinic, and just take walk-ins.

Mental Health Struggles

Evacuation, property loss, harm to loved ones, and overall uncertainty often lead to mental health concerns such as anxiety, depression, and posttraumatic stress disorder, according to experts interviewed. California health officials also recommended clinicians consider it in their disaster preparations, according to their statement to Medscape Medical News.

McDonald suggested that physicians also consider a patient’s mental health as a risk factor for medical concerns and even sequelae.

“When someone is stressed out and worried, their blood pressure goes up which puts extra stress on the heart, which can either worsen heart failure or increase the risk of a heart attack,” he said. 

“Addressing mental health is a much longer, nuanced kind of conversation,

but it can be addressed even if you’ve got 10 patients coughing and wheezing that you need to get to,” McDonald said. “Just asking a question or two, ‘How are you? Are you taking care of yourself?,’ can be powerful, and then referring them to the appropriate resources.”

Innovating to Ensure Care

Coordinating care with other facilities, deploying clinical staff where needed, and innovating solutions is also important for meeting patient needs, experts agreed.

During the fires, several primary care and community health clinics citywide were closed to patients as facilities were either evacuated or without power. In Pasadena, a federally-qualified medical center was destroyed by the Eaton Fire, leaving thousands without access to care.

In response, the ruined AltaMed facility dispatched a mobile unit to ensure continuity of care for its patients.

Meanwhile, other community health centers impacted by the fires either “offered telehealth services or referred their patients to other locations within their network or to non-network clinics,” according to a statement sent by the Los Angeles County Department of Public Health in response to questions.

“Staff who are displaced from their own facility will just go to another location where they can help out, which helps to meet those immediate staffing and patient needs,” McDonald said. 

Public Health Partnerships

Because public health’s primary role is facilitating population health programs by connecting various organizations with the public, leveraging their systems experience can help address acute patient needs, according to a public health official. 

In Pasadena where the Eaton fire was centered, the city tapped public health officials to manage both clinical and acute clinical operations at the city’s largest evacuation shelter.

“We don’t have a lot of clinical staff, but we stepped up and were able to provide that care,” Matthew Feaster, PhD, MPH, told Medscape Medical News. Feaster is the division manager of epidemiology and disease control for Pasadena’s public health department.

Staff from AltaMed, the ruined FQMC, partnered with the city to ensure the care of the mostly high-risk, vulnerable populations in the shelter, according to Feaster.

“Within a very short period, they had set up full clinical operations in the facility and were providing really significant care inside a shelter, which is, I’m told, highly unusual,” Feaster said.

AltaMed was joined by other area health systems like Kaiser Permanente, and Cedars-Sinai to offer care, according to Feaster.

“It happened in such short order, and it speaks to the partnership Pasadena has with all of our area’s no-cost and low-cost medical providers. Everyone was working very closely together to provide these advanced clinical services at the shelter,” Feaster said, adding that the Red Cross has since assumed operations of that shelter.

“Ultimately, a disaster response is about how you come together as a community,” McDonald, who volunteers at the Pasadena shelter, said.