American Academy of Pediatrics
LIVING IN AN EARTHQUAKE ZONE?
Disaster Planning for a Pediatric Trauma Center
James M. Betts, M.D., FAAP, FACS
Surgeon-in-Chief
Director of Trauma Services
Children’s Hospital & Research Center at Oakland
Children’s Hospital & Research Center at Oakland was designated by the County of Alameda,
California as a Pediatric Trauma Center in 1986. Since that time we have processed approximately 1000
patients per year, the vast majority being single patient arrivals with injuries suffered primarily from blunt
trauma, such as auto-pedestrian accidents, and falls. With Oakland, California having the distinction of
being the city with the fourth highest homicide rate in the United States several years ago, there are a varied
number of gunshot wounds in the pediatric population who come to our center as well. Our designation is
for children less than 15 years of age. However, we do receive older teenage children and adults. Our
system is part of an integrated core trauma center coalition, with three adult trauma centers, and our
hospital working together as a two-county EMS authority trauma system, and for quality assurance crossreview of patient care. Although we primarily serve Alameda and Contra Costa, California counties, with a
total population of approximately 2 million people, our catchment radius is well beyond those environs,
having formal protocols for field transfer by ALS air ambulance of trauma patients as far away as 200
miles from our center.
As part of this East Bay, Northern California system we have worked closely with surrounding
EMS authorities, fire, police, and rescue, in developing a plan to handle more than one casualty who could
be directed to our institution for care. Our county’s formal multi-casualty event protocol involves the triage
and transport of six or more critical trauma patients from any one incident. In this protocol the triage of the
most critical patient to the most appropriate institution would warrant standard ATLS triage evaluation and
treatment for each of these individuals. Six critical patients at one institution could stress the resources of
that trauma center, but not necessarily exhaust the capability of that center to appropriately care for those
patients. At our hospital there are two levels of patient care activation, one for the less critically injured
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child, and a higher level of response for those children more severely injured. For each level of activation a
full ATLS evaluation is performed in the Emergency Department. This level of support is standard for a
designated trauma center. Our institution is unique in that we have the capability of an immediate response
by an attending pediatric surgeon for critical trauma patient evaluation. This requires that an attending
pediatric surgeon is immediately available 24/7/365 for trauma and critical surgical patient evaluation and
treatment. The commitment of the institution, the county and the pediatric surgeons to this level of
response places our institution in a unique position to evaluate, not only single, but also multiple trauma
victims arriving simultaneously. There also is a complement of surgical residents rotating through the
pediatric surgical service who respond and are available 24/7/365.
Despite this level of support, and the commitment of the county and hospital to fund immediate
surgical and attending pediatric anesthesia response, the West Coast and especially the San Francisco Bay
Area harbors a natural geographic phenomenon which will create a calamitous event overwhelming the
capability of all local trauma centers to care for the resulting trauma victims. Earthquakes are a routine part
of our daily existence. The Hayward and San Andreas Faults lie on both sides of the San Francisco Bay,
with the Hayward Fault located less than half a mile from our institution. It has been predicted that within
the next 25 years there will be a temblor equal to or greater than the Great San Francisco Earthquake of
1906, resulting in massive destruction, and the death and injury of thousands of patients. Given the
seismologic and geologic timetable, that event could occur at any time. With such overwhelming numbers
of individuals who could be injured as a result of this catastrophe, routine evaluation, triage, and treatment
of patients would no longer be possible. Austere medical care would be necessary, and the practice of
trauma surgery and critical medical care as we practice, would be impossible to maintain.
A prelude to this calamity occurred in the Bay Area on October 17, 1989. It was a Tuesday and
the day of the third game of the 1989 “Bay Bridge” World Series between the Oakland Athletics and the
San Francisco Giants. The game was to be played in San Francisco. At approximately 1704 hours, a 7.1
Richter Scale temblor occurred with an epicenter south of the Bay, located at Loma Prieta. The shaking
lasted between 15-19 seconds and was felt fairly violently throughout the area and at our hospital.
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Although structural damage to our building was not major, there was a hospital within this quake zone
which could not continue to care for patients. In Watsonville, CA, the hospital was shaken off its
foundation, requiring complete patient evacuation and eventual condemnation of the building. In the South
Bay, the city of Santa Cruz had its main street businesses severely damaged with multiple buildings left
structurally unstable. Miraculously only one individual was fatally injured with the collapse of the front
portion of a building. In the western part of the bay in San Francisco, multiple buildings, especially near
the water’s edge in the so-called “Marina” district where the footings are on un-compacted silt, numerous
structures collapsed. A section of the Bay Bridge connecting Oakland and San Francisco failed. An
individual traveling west-bound on the upper deck of the bridge panicked, turned her car around and drove
against the traffic toward the East Bay, passing over the collapsed section and plummeting to the lower
deck, resulting in her death. In the East Bay, the worst area of involvement was concentrated along a .8
mile segment of elevated double-decked highway. This so-called Cypress Freeway was constructed in the
late-‘50’s and was not structurally designed to handle the stress of the lateral and vertical motion of the
temblor. The footing of this portion of the highway was not on solid bedrock, but rather was on clay,
which amplified the seismic waves of the earthquake. Sections of the highway collapsed on top of one
another, with this section of the highway elevated some 50-75 feet off the ground. Portions of the highway
collapsed to the ground, as well.
The aerial coverage of this disaster was extraordinary, as there was significant fixed-wing and
helicopter surveillance for the “Bay Bridge World Series”. As our hospital readied itself for an onslaught
of victims, and TV coverage was restored, we could view the section of collapsed freeway, the resulting
fires, and the early response of emergency vehicles to that site. Our hospital mobilized medical staff,
stopping elective surgery, called back surgeons, nurses and support personnel, and set up stretchers in the
parking lot of the institution. However, after one hour’s time from the earthquake, no patients had arrived
with injuries as a result of the temblor. A phone call was made to the Emergency Medical Services, fire,
and police dispatchers, inquiring as to whether or not there was a delay in the transport of patients, and
what activity was taking place at the site of the collapsed freeway. We were informed that there were
victims at the scene and it was requested that a pediatric transport and care team be mobilized to go to the
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site. A pediatric surgeon and an attending emergency department physician, an emergency room nurse and
a pediatric respiratory therapist, all with appropriate transport equipment, were taken to the scene by police
escort. It was now one hour and 45 minutes after the initial event. The October air was cool, but not
uncomfortable, and the sun was beginning to set.
The scene at the collapsed structure was horrific. Forty-four individuals perished in the structure.
There were sections of the freeway which were seemingly undamaged, and others where the entire upper
highway had collapsed onto the lower, with partial collapse of the lower highway and its columns to the
ground. Those who were initially evaluated, treated, and triaged away from the scene, were done so
rapidly. All along the .8 mile long section there were groups of fire-rescue teams searching between the
two decks for victims. A field triage hospital had been set up by the adult trauma center in the county.
This was staffed by trauma surgeons, emergency physicians, nurses, and other support personnel. The
scene was attempted to be secured by law enforcement. During the immediate time after the earthquake
and through the night, looting of cars, some abandoned by their drivers, and some with victims who had
perished without being completely crushed by the structure, was wide-spread. As the pediatric team
arrived, we were directed to a section of the highway where two children were trapped in a vehicle. By this
time it was dark, the temperature had fallen, and there was an eerie silence, and acrid smell to the entire
scene. An Oakland Fire Department heavy rescue fire unit was positioned at the location of the trapped
children. Their car was on the lower deck of the elevated highway, which itself was 60 feet above the
ground. The upper deck had collapsed onto the lower deck, crushing the front portion of this vehicle. As
we approached this location a seasoned paramedic was descending the fire ladder. Her face, demeanor, and
tone in her voice trembled with terror of one who had witnessed the horror of this event. She stated that
there was a child trapped with both of his legs crushed, although he was still alive. Ascending 60 feet with
a pediatric emergency transport pack to the level of the compromised lower deck I could not have imagined
the scene before me. Upon reaching the vehicle, it was obvious that there were two adults in the front seat
who were fatally injured by the tons of weight of the upper deck, and concrete crossbeam, which crushed
the front of the vehicle and their bodies. The team already at the scene included a trauma surgeon and
emergency department attending from the adult trauma center, a physician’s assistant, a paramedic, and six
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heavy rescue firefighters. We were all working in an area not more than 4 ½ feet tall. Less than 20 feet
away from this single vehicle there was an airport shuttle van carrying six people which was crushed by the
weight of the upper deck to a height of not more than 2 feet. All inside the vehicle instantly perished. In
our vehicle there had been two children in the back seat, a six-year old boy, and his nine-year old sister.
Both were playing in the car and were unbelted when the collapse occurred. The two adults in the front
seat perished immediately, and the nine-year girl was critically injured when she was thrown forward to the
back of the front seat, suffering severe facial injuries. She was intubated at the scene and transported from
the site fairly soon after the arrival of the initial emergency medical personnel. This had occurred some 20
minutes prior to my arrival at the scene. The six-year old boy had slid forward with both of his legs
trapped under the driver’s and passenger’s seats respectively. His right leg was crushed and pinned by the
entire weight of the upper deck just below the level of his knee and his left leg was pinned under the seat to
the level of his mid-thigh. He was semi-conscious and hypotensive. Two peripheral IV’s were started and
Lactated Ringer’s was rapidly infused. The fire rescue team was working desperately to free his left leg
from the seat. His right leg could not be freed. In addition, the body of an adult woman was sitting in the
passenger seat and crushed from the waist down, with severe upper body and head injuries as well. She
was lying lifeless angled into the backseat compartment. The time was now approximately 1930 hours. As
the rescue team feverishly worked to free his left leg, the area was being illuminated by arc halogen fire
scene lights. The temperature rapidly rose, and with the dust and smoke at that locale, large exhaust fire
fans were intermittently turned on to evacuate the dust and smoke. This would drop the temperature in that
location from what was estimated to be the high 80’s to low 90’s, down to the 60 degree range.
It was obvious that his right leg would have to be amputated, but it was essential that his left leg
be freed. In addition, the body of the deceased adult female in the right front seat, who was assumed to be
the boy’s mother, was preventing access to his right leg. Attempts at removing the body by cutting away
her clothes with the use of a surgical scalpel was futile. In consultation with the Incident Commander, who
was an Oakland Fire Captain, a choice was made to use an extrication chain saw to divide her body. The
surgeons performed that maneuver. At the time this was a clinical decision made to remove a portion of
the body of the deceased woman. Looking back on that day some 14 years later, doesn’t soften the impact
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of that decision. However, its necessity was considered a valid clinical and functional choice at that time,
as well as now. With the division of the upper half of her body and torso with the chain saw, the child’s
right leg was exposed. The heavy rescue team was able to raise the left seat and free his left leg, and an
amputation of the right lower leg was performed. Fortunately, the leg had been crushed to just below the
knee, so the approach was through the knee joint. A tourniquet was applied to the right lower thigh, and
despite receiving liters of lactated Ringer’s, the child was still semi-comatose, and hypotensive. He was
ventilating adequately with a non-rebreathing O2 mask. Local anesthesia was injected circumfrentially
through the skin around the knee joint. Additional local anesthetic was infiltrated into the knee joint itself.
Lying on an extrication board with the hot halogen arc lighting located behind my head, and with very
impeded vision of his knee joint, an incision was made through the joint dividing all the supporting
ligaments, vessels and nerves. I grasped the popliteal artery and vein between my left index finger and
thumb, and applied, almost blindly, hemostats to the vessels. His body was then evacuated from the
vehicle. Several more hemostats were placed on the bleeding geniculate vessels and he was placed on a
backboard and brought down from the structure. Upon arrival at our trauma center resuscitation bay, his
blood pressure was 50/20 and his hemoglobin was measured at 3, with a hematocrit of 11. He required
numerous surgical procedures, including extensive thigh and lower leg facsiotomies on his left extremity
and a revision of his right amputation to an above-the-knee location. He was hospitalized 63 days. His
sister required major facial reconstructive surgery. Today they are both healthy and grateful for this multidisciplinary team approach, which resulted in their successful rescue and care.
The aftermath of this event for me is long lasting. With private and public ridicule for my use of
the chain saw, and the unique circumstances requiring the need to divide the deceased adult’s upper body,
and the field amputation, members of the medical staff, and even my own partners questioned my decision
for such extraordinary measures. However, that event only provides a glimpse of what the next
catastrophic earthquake will bring to this region. Austere medical care implies that all services and the
ability to care for victims of such a future event will be exhausted. In 1989, we were able to provide the
highest level of support, both at the scene and at the hospital, to save a victim’s life. In the scenario of
overwhelming numbers of critically injured individuals, those who will be saved, will be the much-less
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significantly injured patients who require medical attention. In addition the institution itself, could be
damaged so severely that it would not be functional. At this point, the patients who have minor injuries
would ultimately require minimal support, and those moderately injured would receive the majority of
available medical attention. The patients most critically injured, and usually place as “highest acuity,”
would be given the lowest priority, and allowed to succumb. Using an ever dwindling amount of resources,
to futilely attempt to save a gravely injured patient’s life, and denying support for those less injured, but
more likely to survive, would be impractical. Hopefully we will never have to face a disaster that would
require the implementation of such an austere process of medical care. However, for those living so close
to the potential of wide-spread disaster, the reality of that thought lingers heavily.
The West Coast and Pacific Rim are not the only areas at risk. There are major geological faults
through Utah, and the Mississippi River region, western Tennessee, and as far east as New York, New
England and Canada. They also present a potential for a natural disaster unwitnessed in this country. The
recent terrorist events of September 11th in New York City, Washington D.C., and Pennsylvania, bring a
sobering clarity to the potential for overwhelming casualties for even the most advanced trauma systems
and hospitals. For that, we must continue to be prepared to take extraordinary measures to deliver trauma
care. There exists a real and sobering potential for multi-casualty, catastrophic events in the United States.
We must recognize these potential needs and possible limitations of resources for such an occurrence. A
continued dialogue between the multidisciplinary agencies and services involved must be ongoing. Only
then, might we be prepared.