The Hospital Response
After an Earthquake
Carl H. Schultz, MD
Professor of Emergency Medicine
Director, Disaster Medical Services
UC Irvine School of Medicine
Introduction
• Current research suggests earthquakes
of magnitude 7.0 or larger occur on the
Jordan Valley segment of the Dead Sea
Fault about every 1000 years
• The last major earthquake occurred in
1033
• Jerusalem located less than 40 km from
the fault
Introduction
• Estimate of worst-case event:
– Moment magnitude 7.5 earthquake on
the Jordan Valley segment
– 30 billion dollars U.S. in
economic losses
Introduction
• Hospitals are vulnerable
• 1971 San Fernando earthquake (Los
Angeles, California, USA )
– 50 of 64 deaths due to hospital
collapse
– 4 hospitals with structural failure
were closed
Introduction
• 1994 Northridge earthquake
(Los Angeles, California, USA)
– 8 hospitals evacuated patients
• 6 completely
– 4 of these closed and demolished
• 1995 Hanshin-Awaji earthquake
(Kobe, Japan)
– 13 hospitals partially or totally destroyed
Introduction
• Delayed hospital closures can occur days to weeks
after event
– 2 hospitals closed 3 and 14 days after quake
• Inspections not perfect
– Red, yellow, and green tags
– Based on objective and subjective criteria
• ATC 20-1
– Political and financial considerations are involved
Introduction
• Office of Statewide Health Planning and Development,
State of California, 2001
– 48% of California’s hospital buildings are at high risk
for collapse or loss of function from structural failure
after a Northridge magnitude event
– 91% of nonstructural components essential to safety
and patient care will fail or sustain serious damage
• Rand Corporation 2007
– 305 acute care hospitals have buildings vulnerable to
collapse. ½ will be condemned by the 2013 deadline
due to failure to retrofit
– Cost of seismic improvements: $110 billion U.S.
Overview of Hospital Response
• Initial assessment
– Hospital
– Regional
• Hospital is functional
– Convergence behavior
– Personnel (staff)
– Equipment (stuff)
– Facilities (structure)
– Standard of care
• Hospital is non-functional
– Triage
– Internal patient
evacuation
– Off-site patient
evacuation
• Communication
• Staff behavior
• Government assistance
Initial Hospital Assessment
• Immediate status of environment
– Performed by Charge Nurse
– Manual ventilation of patients
• Threats to patient safety
– Evacuate to safer area of unit
• Contact House Supervisor and report
status
Initial Hospital Assessment
• House supervisor - makes initial assessment
(hospital intact, partial damage, evacuation
needed)
– Assessment from patient care staff
– Assessment from maintenance staff
• Activates disaster plan
– Implements hospital incident management
system
• Communicate with hospital director (if possible)
Initial Hospital Assessment
• Need basic tool for rapid assessment of
structural safety
– Building inspectors may take 6-12 hours to
arrive
– ATC-20-1
http://www.atcouncil.org/Merchant2/merchant.
mv?Screen=CTGY&Category_Code=a201
• Assess not-structural components (plumbing,
heating/air conditioning, generators, water
supply)
Initial Regional Assessment
• Ideal metric – available quickly, identifies all
areas of damage, easily disseminated
• Traditional approach
– Identification of epicenter
– Measurement of moment magnitude
• Richter scale
– Reconnaissance
– Systematic verbal reports from responders,
government workers
• Modified Mercalli Scale
Initial Regional Assessment
• Epicenter
– Point on the earth’s surface overlying the where
the fault rupture begins (hypocenter)
– Not the area of greatest shaking
• Advantages
– Available quickly
– Gives general location of the earthquake
• Disadvantages
– Not provide specific information on areas of
significant shaking and damage
Initial Regional Assessment
• Moment magnitude
– Measures overall energy
release
• Advantages
– Gives a general measure of damage potential
• Disadvantages
– Poor predictor of shaking and damage at any
one location
– Energy not radiate out symmetrically
Initial Regional Assessment
• Reconnaissance
– Helicopters, spontaneous reports
• Advantages
– Available quickly
• Disadvantages
– Large sampling error
– ? reliability
– Many areas with significant damage are not
readily apparent from the air
Initial Regional Assessment
• Systematic reports
– Government employees, typically postal workers,
provide assessment of degree of shaking and
observed damage
– Use the Modified Mercalli Scale
• Advantages
– Gives fairly accurate assessment of damage
distribution
• Disadvantage
– Slow
– Difficult to distribute the information
Modified Mercalli Scale
Initial Regional Assessment
• Any of these measure qualify?
– NO.
• What does?
– Instrumental intensities
• Peak ground velocity and peak ground acceleration
are plotted as Shakemaps
– Available within minutes of an earthquake
– Can be downloaded by anyone from the internet
– Easily interpreted by non-seismologists
Instrumental Intensity
Initial Regional Assessment
• Shakemaps can depict the degree of ground shaking
– Can this actually work and can it also assess risk for
injuries and death?
– YES
• Data?
• Epidemiologic
– Ramirez, Peek-Asa: Epidemiology of Traumatic
Injuries from Earthquakes. Epidemiol Rev 2005
– Peak ground acceleration was highly predictive
– Distance from the epicenter in the Northridge quake
was a poor predictor of injury and death
Initial Regional Assessment
• Disaster Medicine
– Schultz, Koenig, Lewis: Decisionmaking in Hospital Earthquake
Evacuation: Does Distance from the
Epicenter Matter?
Ann Emerg Med 2007 (in press)
– No significant difference in distance from the
epicenter for evacuated and non-evacuated hospitals
– Statistically significant difference in peak ground
acceleration measurements between both groups of
hospitals
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
5 miles
N
Initial Regional Assessment
• Median distance from the epicenter for
evacuated hospitals = 8.1 miles (13.5 km)
• Median distance from the epicenter for
control hospitals = 14.1 miles (23.5 km)
• Difference in medians = 6 miles
95% CI: -4.8 to 11.9 miles
Not statistically significant
Initial Regional Assessment
• Median peak ground acceleration for
evacuated hospitals = 0.77 g, where 1.0 g
equals the force of gravity
• Mean peak ground acceleration for control
hospitals = 0.36 g
• Difference in medians = 0.41 g
95% CI: 0.14 to 0.55
Statistically significant (p=0.009)
Initial Regional Assessment
• Take home message:
– Shakemaps are useful way to assess the risk of
damage across the entire region of an
earthquake
– Are predictive of increased risk for building
damage, injury, and death
– Shakemap assessment by hospital personnel and
emergency managers in the immediate aftermath
of an earthquake needs to be included in the
disaster plans of all vulnerable regions where
such information is available
Hospital Is Functional
• Prepare for patient convergence
– Closest hospitals will receive most of the patients
– Israel has real experience
• Versailles nightclub
collapse
• Terrorist bombings
– Earthquakes on larger
scale
– Credentialing of medical volunteers
Hospital Is Functional
• Alternate sites of care
– Parking lots
– Temporary structures (tents)
– Areas not used for patient care
• Classrooms
• Auditoriums
• Early discharge of patients – problematic
• Delivery of supplies/equipment
– Agreement with vendors, Home Front Command
Hospital Is Functional
• Change in standard of care?
– Triage based on who receives care and who
doesn’t
– Delayed closure of lacerations
– Use of ventilators
– Admission to Intensive Care
Units (ICUs)
Hospital Is Not Functional
• Triage
Order of patient movement
off unit: Sickest patients first
– No immediate threat to
safety (immediate building collapse unlikely)
– Efficiency of movement not critical
– Individuals use great deal of resources
– Order of floor evacuation not matter
Hospital Is Not Functional
• Triage
– Order of patient movement off unit
• Healthiest patients first
– Immediate risk to safety (building collapse
possible)
– Efficiency of evacuation important
– Can move more patients with less
resources (some can evacuate themselves)
– May need to leave trapped patients behind
– Evacuation lower floors first
Hospital Is Not Functional
• Internal patient evacuation
– Movement of patients
• Used gurneys, backboards, sheets,
wheelchairs
• Did not use specialized devices and would not
use them if available
• FLASHLIGHTS CRITICAL
• Elevators will not work
• Evacuation routes must only use stairs
• Take patients charts and medications
Hospital Is Not Functional
Off-site patient evacuation
• Control of hospital evacuations
– Traditional model
• Emergency Operations Center (EOC) controls all
aspects of patient transfer
• Transportation assets
Ambulances, helicopters
• Destination decisions
– How many patients go to which hospitals
– Northridge model
• EOC provides vehicles to hospitals per their request
• EOC and hospitals share destination decisions
Hospital Is Not Functional
• Northridge model (Schultz et al: New England
Journal of Medicine, 2003)
– 1066 patients evacuated totally, 818 in first day
– How many people answering phones would it
take for the EOC to coordinate the transfer of 800
patients in the midst of chaos?
– Efficient use of time?
– Other demands during first critical 24 hours
– Use of shakemaps?
Hospital Is Not Functional
• Outcome
– EOC able to mobilize transportation assets
• Used ambulances, buses, county vehicles
• Very effective at this task
– EOC can coordinate movement of some patients but
not all
– Hospitals can and will move patients on their own
– Hospitals belonging to systems will be most effective
– Recognition of hospital role should be part of disaster
plan
Communication
• Most forms of communication fail
during a disaster
– Telephones (damaged or over-utilized)
– Cellphones (towers damaged, battery back-up
fails, over-utilized)
– Satellite phones (batteries not charged)
– Microwave radios (repeaters down, power
out)
Communication
• Forms of communication that function
during a disaster
– Pay phones
– Fax lines
– Certain types of internet lines
– Ham radios
– Police, fire, and ambulance radios (not
compatible in the U.S.)
Staff Behavior
• Concerns regarding commitment of staff.
Will they remain on duty and will
replacements arrive?
YES.
– Studies by Quarantelli demonstrate basic
volunteer nature of society
– Article in JAMA after the Northridge
Earthquake documenting staff dedication
Staff Behavior
• Hospitals reported staffing
shortages after the Northridge
Earthquake, some more than 50%
– Not due to individuals refusing to remain on
duty
– Not due to unwillingness of staff to come to
work. Unscheduled staff reported to hospitals
– Due to inability to get to work or could not
leave families
Staff Behavior
• Solutions to the staffing problem
– Establish daycare, supervision for pets
• Surge capacity
– Use staff from other hospitals (Kazzi et al:
Prehospital and Disaster Medicine, 2000)
• Raises issues of credentialing
• National vs local database
• Resolved within 7 days
Government Assistance
• Government assistance critical for overall
response but may not be acute care asset
• May arrive too late to impact initial
outcomes in a significant way
• Biggest impact in supporting ongoing
health maintenance
• Attack after earthquake
• Transportation an issue
United States Teams
• Urban Search and Rescue teams
– Riverside County team 2 hours away by car
– Earthquake occurs at 04:30
– Team not begin activities at site of Northridge
Meadows Apartment collapse until 23:30
– Live victims already extricated
United States Teams
• Oklahoma City Bombing 1995
– Multiple USAR teams dispatched
– Last survivor recovered from building 18
hours after explosion
– Number of survivors recovered by out-of-state
USAR teams:
– ZERO
United States Teams
• Disaster Medical Assistance Teams
– No teams arrived in the first 24 hour (Leonard
et al: Prehosp & Disaster Med 1995)
– 4 team arrived in the next 24 hours, 3 from
California
– Each team can see up to 200 ED type
patients or 400 clinic patients per day
– Demand for emergent care back to baseline
by 7 days
Israeli Home Front Command
Urban Search and Rescue Team
• January 2006: Nairobi, Kenya building
collapse
• 117 victims found in collapsed building
• Israeli Home Front Command forces
arrived 23 hours after event
• Rescued 2 individuals, one a
volunteer who became trapped
after the event
Government Assistance
• Local solutions
– Granada Hill hospital
• Staff shortages
• Used staff (MDs and RNs) from UCI
Medical Center to support Emergency
Department Care
• Surge capacity: National database?
TODA RABAH
Carl H. Schultz, MD
1-714-456-3713
schultzc@uci.edu