Executive Summary

The 1992 Los Angeles Civil Disturbance was the most devastating and largest such event in the United States this century. It began almost immediately following the announcement of the Rodney King trial verdict at 3:00 PM on Wednesday, April 29. The acquittal of four police officers charged with using unreasonable force in arresting Rodney King was the immediate cause of the disturbance. The resulting civil disturbance lasted for four days. Overall, the local and state agencies and private organizations charged with meeting the medical needs of the victims responded rapidly and well. Prehospital providers were able to care for and transport a significant number of the injured. Hospitals were able to triage and care for all of the injured brought to them in a timely manner. On November 19, at the request of Emergency Medical Services Authority's Director, the Governor officially recognized Emergency Medical Technicians, public service agencies, private ambulance companies, and hospitals for heroic action taken by them and their employees to save lives and care for the injured. This report presents preliminary data on the injuries and their causes, and examines the emergency medical (EMS) response to this medical disaster from Wednesday, April 29, through Saturday, May 21, 1992. The report uses data and reports available as of November 24, 1992, with some follow up material drawn from later dates. Interviews were conducted with fire service and private ambulance company administrators and staff directly involved in the incident. An effort was made to gather the opinions of all field responders with a survey. 'Hospital administrator and emergency department staff were also interviewed. Injuries and Deaths Initial hospital emergency department data indicates that 2,383 persons were injured between April 29 through May 3. Of these, 227 were admitted. Based on preliminary findings from a Centers for Disease Control study, hospital estimates of the number of injured directly related to the disturbance may be overstated by as much as 761 (32%). If this correction is appropriate, then hospitals treated between 1,620 and 2,383 patients whose injuries were directly caused by the civil disturbance. The Emergency Medical Services Authority estimates that prehospital care providers treated an estimated 179 to 238 injured persons in the field. Fire Service and EMS responders sustained three or four serious injuries depending on the source of information. The Los Angeles Police Department, California National Guard, and other law enforcement agencies reported 66 injuries. The total count of injured above includes these injuries. After careful examination of the causes of death, the Los Angeles County Medical Examiner determined that as of August 11, 51 deaths occurred during the Los Angeles Civil Disturbance. EMS Emergency Telephone Calls On a typical Wednesday, the Los Angeles Police Department's Public Service Answering Point receives 12,049 emergency calls and answers about 79% of them. The remainder go unanswered because the caller hangs up (abandons the call). This call volume is in sharp contrast to that of Wednesday, April 29, the first day of the civil disturbance. On that day 35,558 calls came in. This represented a 195% increase in call volume over a typical day. Answered calls increased by 157% percent, but there was also a 341 % increase in unanswered calls. The greatest emergency call volume came in on Thursday; a 364% increase. Abandoned calls increased by 449% on that day. The abandoned call volume rate returned to normal by Friday. By Saturday, emergency call volume be an to approach a more normal level resulting in more answered calls. EMS Field Response On a typical day the city receives from 700-1,000 EMS calls in a twenty-four hour period. Wednesday saw a substantial drop in patient transports even though the number of EMS calls did not exceed that for a typical day. Approximately 745 transports were made by public and private ambulances originating in the area of the civil disturbance from Wednesday through Friday. The emergency medical field response was integrated with Los Angels City and County Fire Service operations at the community level. Rescue units and private ambulances were dispatched into the civil disturbance area with little, if any, law enforcement protection on Wednesday, the most violent day of the riot. Food, sleeping arrangements, and other staff support services were primitive at best. All of the responding agencies implemented their general disaster response plan. Casualties were transported to the hospital by a number of methods. According to a CDC study, ambulances accounted for 33.9% of the transports, police cars 11.3%, and walk-ins for 12.9%. The percent of the injured who took themselves to the hospital or were transported by friends varies by source of data; 30.6% according to preliminary Centers for Disease Control data, compared to 60% to 70% reported by hospital emergency departments. A field morgue for dead bodies was not established. Hospital Response Twenty-eight hospitals cared for about 85% of the casualties. Some hospitals that are next to each other varied markedly in the number of casualties they received. Hospitals outside the immediate disaster area received significant numbers of casualties. It was difficult for the Los Angeles Emergency Medical Services Agency to control the distribution of casualties due to the large number of self-transports. Hospitals implemented their general external disaster plans. The Emergency Medical Services Authority interviewed administrators at three of the hospitals that received a large number of casualties. All three experienced minor problems with obtaining medical supplies, food, and staff. None of these problems affected the ability to deliver care. The Emergency Medical Services Authority, and the Los Angeles Emergency Medical Services Agency successfully established a system to provide additional staff, and to deliver blood products to the hospitals. Hospital security was provided by hospital security employees for the most part. The California National Guard protected one hospital on Friday. Factors Contributing to the Success of the Emergency Medical Response The emergency medical response was successful because: Various city and the county fire services quickly established a highly localized and effective system of staging areas and managed the prehospital emergency medical response at the neighborhood level with logistical support from city and county fire service. Citizens living in the disaster area transported a significant portion of the injured to the hospital. Many of the patients who crowd the emergency department on a day to day basis did not come in for care. Hospitals were able to triage the injured, establish special minor wound care clinics, leaving the ER available for the more seriously injured, and had sufficient numbers of staff immediately available to staff this expanded service. Their efforts were supported by the Los Angeles County Emergency Medical Services Agency. Prehospital responders and hospitals did not run out of critical medical supplies. While neither prehospital nor hospital emergency medical care providers had specific plans for responding to a civil disturbance, they did have generic disaster plans which they had practiced. Two additional factors, unrelated to the EMS system, also contributed to this success: The civil disturbance did n6t continue at a high level of violence for a long period of time; the first two days of the civil disturbance produced the most casualties, dropping significantly on Friday; and Hospitals were not directly attacked by large numbers of rioters, armed individuals or gangs making it impossible for the hospital to deliver services. Key Recommendations for Improving the Response Our key findings and recommendations are grouped together and listed in Chapter IX. The most important findings and recommendations for improving the ability of the emergency medical services system to rapidly and effectively respond to a civil disturbance are identified below. From our perspective, this system begins with a 9-1-1 call, and ends with care provided in a hospital emergency department. When a disaster occurs it expands beyond a particular county to include its neighbors and State agencies. During this period of severe budgetary cuts and constraints, it may be very difficult to quickly implement all of the recommendations. Also, there may be easier and quicker ways to implement the report's findings than those recommended here. The Emergency Call Answering System The number of caller abandoned 9-1-1 calls due to answering system overload, probably increased the number of public transports of the injured to the hospital. Efforts to expand the capabilities of the 9-1-1 answering service when a disaster occurs should receive high priority. The Spanish speaking emergency call line's abandoned call rate was even higher than that for 9-1-1 during the civil disturbance. This could indicate that this population is at greater risk of not having access to emergency medical resources when they are urgently needed than the rest of the LA basin's population. A management analysis study should be initiated by the appropriate agency to determine if staffing is appropriate, and that there are sufficient telephone lines. Telephone answering protocols should be reviewed to make certain that they are ethnically appropriate. Prehospital Response Law enforcement protection must be immediately available so that EMS field responders can quickly gather, enter the disaster area, provide medical care in the field, and transport the injured. This should extend to protecting large clinics, and private ambulance dispatch and communications facilities. Law enforcement intelligence about the progress of the civil disturbance (direction, expected intensity, etc.) should be forwarded immediately to the Los Angeles Emergency Medical Services Agency so that they can coordinate transport of the injured with hospital bed availability. Field responders need to be rotated after about thirty dispatches, provided with nutritious food, and a quiet place to rest. This should reduce stress and improve the response. At least 60% of the injured, many with gun shot and other serious wounds, where transported by the public to hospitals. Basic public service announcements need to be prepared that are keyed to the telephone book first aid instructions, showing how to control bleeding and deal with shock. A second set of public announcements should show which hospitals the public should transport the most injured to. Large community clinics should be integrated into the response. They would be able to provide care to victims who do not have life threatening injuries. All prehospital public and private agencies should prepare a civil disturbance response annex for their disaster plans. Hospital Response Law enforcement protection should be provided to hospitals as soon after a civil disturbance begins as possible. Hospitals need to be able to anticipate medical supply and personnel short falls so that the Los Angeles Emergency Medical Services Agency has time to meet their needs. This includes understanding and using the established system for obtaining this aid. A civil disturbance annex should be added to each hospital's external disaster plan. Los Angeles Emergency Medical Services Agency A Civil Disturbance Annex should be added to their disaster response plan. Civil disturbances are very infrequent. The lessons learned from this one should be preserved. The Los Angeles Emergency Medical Services Agency needs to continue its work with the appropriate professional groups to further clarify how medical supplies, and surgical and other specialty care providers will be obtained and delivered to hospitals when a disaster occurs. Reimbursement for Prehospital and Hospital Care A mechanism for reimbursing disaster related operating costs and uncompensated care provided by private hospitals and ambulance companies needs to be developed by the Los Angeles Emergency Medical Services Agency, with the assistance of the Emergency Medical Services Authority, and the Office of Emergency Services, and put into place before the next State declared medical emergency occurs.

Medical Care for the Injured

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