The 1965 Watts Riots and Hospitals and Discussion

Existing hospital emergency departments and the trauma system in and surrounding South Central Los Angeles were able to absorb the patients caused by the civil disturbance. Available information indicates that the seriously injured did not have to wait an unreasonable length of time for care. However, there appears to be at least one case where a death could have been prevented had a vascular surgeon been available. Controlling the distribution of patients among hospitals was a difficult problem. A major uncontrollable factor was that 40% to 60% of the injured self transported. LAEMSA's suspension the requirement to communicate with an EMT's base station may have compounded the problem as the hospital had no means of predicting or planning for the number of injured that it might receive. One approach for addressing this problem would be good intelligence about the geographic direction that the disturbance is taking. Direct communications with EMS personnel on site or dispatching to the area to team about casualties might be helpful (Roeschlaub, 1968) Such information might serve as an indicator for predicting where significant numbers of self transports might go. An effort to steer them using Emergency Broadcast System messages, maps on television of all of the closest hospitals etc., might also help. Also, as done by LAEMSA, EMT civil disturbance protocols that limit the amount of communications with base stations and allow a broader scope of practice to care for victims might improve coordination without jeopardizing care. Looking at the entire geographic area of the event and the way the disturbance unfolded, it becomes apparent that each hospital was situated in its own micro-civil disturbance environment. Various external and internal factors affected who would get injured and when they would present for treatment, how the hospital's staff experienced the event, and what problems each hospital had in developing and maintaining its response. This also suggests that each hospital could "fail" in a different way; for example, one from staff burn out and another from lack of food. The County an State will face significantly different response and supply problems from hospital to hospital. Good voice and data communications, and the staff to maintain them, are critical to managing such an event in a way that tracks such variables before they become Critical (Koehler, 1991). In our opinion, after four to five days the hospitals would have begun to experience significant problems in different areas that could have affected the delivery of services. For some this might have come from the depletion of medical and other supplies, for others exhaustion of a significant number of their staff could have precipitated a crisis. This suggests that the EMS Authority's policy of trying to anticipate problems and to begin to put systems in place to respond to them is well founded. This is particularly true as it appears that hospitals will wait until they have exhausted nearly all other avenues available to them for additional personnel and supplies before they request help from the County. It may be too late at that time to avoid some affect on their capability to continue providing services at the existing level. All of the hospitals were able to successfully manage their internal disaster response. However, adopting the Hospital Emergency Incident Command System would improve the response for two reasons. First, the system integrates all the hospital's functions into a single emergency management structure. The emergency department would be closely linked to administrators who are making decisions for the entire hospital. Second, with each hospital having a common emergency management system it would be easier for LAEMSA to determine whom to talk to. They could easily learn about the hospital's status, and coordinate resupply and other efforts. Currently these systems vary from hospital to hospital, increasing confusion. Tracking the health care delivery status of a group of hospitals is not an easy task. Some of it can be done by collecting data on critical variables such as the number of injured and damage to the facility. However, in our opinion, particularly given the unique problems that each hospital must face, it is necessary to achieve and maintain voice communications between LAEMSA and the few hospitals directly involved in the response. Anticipation of problems and better information exchange about the current state of the disturbance and the response might be possible. A comparison of the Watts Riots of 1965 with the recent civil disturbance is helpful to identify recurring hospital emergency medical response problems. In 1965 Governor Brown appointed a commission to look into the causes and consequences of the violence. The McCone commission's report examined the general provision of health care but did not discuss or assess the transport or treatment provided to the injured. However, it did describe the hospitals that were available to the residents. "The hospitals readily accessible to the citizens in southeastern Los Angeles are... grossly inadequate in quality and in numbers of beds. Of the eight proprietary hospitals, which have a total capacity of 454 beds, only two meet minimum standards of professional quality. The two large public hospitals, County General and Harbor General, are both distant and difficult to reach." p. 74 Some of the hospitals located on the maps that accompanied the report are no longer identifiable. Our brief overview of the status of health care in South Central Los Angeles shows that difficulties continue with access to and availability of hospital care. On the other hand, an emergency medical system or trauma care system did not exist in 1965. The medical centers that provided care during the 1992 civil disturbance are vastly superior in their capability and capacity to care for the injured including their ability to expand day-today capacity to meet increased demand. A 1970 literature search for information about the emergency medical response to the 1965 riot found nothing that described the response in other than anecdotal terms (Boskin and Pilson, 1970). Neither a special health care study conducted by Milton Romer, UCLA School of Public Health, or the report @@ f the Police, Fire, and Civil Defense Committee mentioned the issue. Boskin and Pilson note: Other studies of the confrontations in the sixties can be criticized for their failure to take serious note of the medical treatment of the injured. The prestigious Report of the National Advisory Commission on Civil Disorders..., while interested in the sanitary conditions of ghetto life, nevertheless neglected this aspect of the revolt. The important Los Angeles Riot Study... conducted by a team of interdisciplinary experts, also contributed nothing to the subject (Boskin and Pilson, p. 354). A computer search conducted for this study found a few journal articles about civil disturbance related hospital based emergency care in other parts of the nation but only two articles about the 1965 Los Angeles riot (Beam, 1965; and Boskin and Pilson, 1970). Boskin and Pilson's study of hospital emergency department records is the only relatively detailed one available. Some startling parallels with the. current event emerge. In both cases: The injured were dispersed among numerous treatment centers scattered around and in the area of the civil disturbance. "Private automobile was the way by which most injured were conveyed to the nearest emergency hospital" (Boskin and Pilson, p.355) Police cars and ambulances were also used. No consistent procedure was used to determine which hospital should receive the injured. No hospital buildings were seriously damaged. Incidents involving angry groups of people did occur just outside the hospitals. "During one period, the hospital appeared to be under attack by a milling, irate crowd. Although some windows were smashed and medical personnel were prevented from entering the building, many of the alleged demonstrators were simply inquiring about the injured" (p.360). It was difficult for staff to get to the hospital. Some had problems crossing police lines, others found that public transportation was not available. Boskin and Pilson note that: "In order to maintain full patient coverage, a number of employees remained at their position throughout the disturbance (p.358). " Some hospitals had more trouble than others with maintaining an adequate level of staffing. The normal emergency department load dropped by about 50% but there was still a significant number coming in for illness unrelated to the civil disturbance. One hospital prepared a special ward to treat victims. Cab drivers were available for transport to and from the hospitals during the event. In at least one case, telephone service was disrupted at a hospital. Hospitals were pressured by media for casualty statistics. One important difference is that unlike the 1965 riots, LA County hospitals did play an important role King/Drew Medical Center, LA USC Medical Center, and Harbor all received patients. The top three hospitals where most patients went included two privates and one public indicating that the two sectors were both involved in delivering care. One difference did emerge. According to an anecdotal report by Beam, their was an increase in births both from women living in the area and women outside the area who experienced emotional stress (Beam, 1965). The above list of similarities between the two events could almost serve as a summary of findings for this report. The only critical issue missing is the hospital supply problems experienced during the more recent disturbance. A general overview of the experience of hospitals in midwest and Eastern cities where riots occurred in 1968 further supports these findings (Kentucky, 1968; Roeschlaub, 1968; Hospital topics, 1968; NYSDHS, 1969). They too had problems with telephone systems failing, staff getting to the hospital, and distribution of casualties. The most impacted hospitals were closest to the event but other hospitals farther away received casualties. Only a few hospitals received any damage. Also, hospitals in the disaster area did not necessarily receive an overwhelming number of casualties like others did. Finally, arrangements had to be made for staff to stay at the hospital. Roeschlaub's study and the Hospital Topics article identifies various innovative solutions to these problems. During riots occurring in the 1960s on the East coast, security was improved by locking down the hospital, closing the emergency room to patients after five PM, and not allowing relatives or friends in. Television and radio carried announcements for staff about shifts and when to come into the hospital. Hospital vehicles or ambulances transported staff. Ambulances with radios took up positions at critical institutions, serving as an emergency communications net. Elective surgery was stopped. The hospitals set up special emergency care clinics. Hot line telephone lines tied together law enforcement, fire, and hospitals so that each was kept aware of the needs of others. Hospital casualty data was written down on placards and displayed in the emergency department for media. Amateur radio provided additional inter-hospital communications to compensate for lost telephone coverage. There is very little information about surgical and other care provided during a civil disturbance. An article by Wait, Wilson, Rosenberg, Arbulu, Grijka, Kobold, and Lucas about the experiences that their hospital, Detroit General Hospital, experienced during the 1967 Detroit riots does include some significant comments on this subject. Their hospital treated 1,475 patients during a six day period. During [the busiest] 36 hours 456 patients were treated.... Of these, the 87 that sustained gunshot wounds presented the more serious problems. This number was not unusual for an emergency room which treated 138,000 patients last year [1986] (an approximate average of 380 per day) but differed in the disproportionate number requiring immediate surgical care and the fact that it was provided with complete elimination of delay. Fifty-two major operations were performed between July 23 and July 28. Of these, 43 resulted from injuries sustained in the riots.... The remainder were emergency procedures for urgent surgical conditions unrelated to the riots (p.9293). [Later in the article the authors made the following points.] Preoccupation with plans for surgical emergencies should not distract attention from the need to provide treatment of normal, non-riot-connected emergencies. An adequate number of beds should be kept for gynecological and medical admissions, as a number of these patients will require urgent treatment. Whereas virtually no cases of the more common surgical emergencies such as appendicitis, cholecystitis, and gastroduodenal perforation were seen during the six days described in this report, a significant number of medical patients required admission. In particular, a rapid and fairly sudden influx of patients with diabetic acidosis and epilepsy were noted after the first 48 hours, presumably attributable to the inaccessibility of various drugs and person neglect in a time of disturbed routine. No new lessons were learned about the surgical handling of casualties. Certain essential were reemphasized. The great value of readily available consultation from many different specialties in the management of multiple injuries was obvious from the start. (Wait, 1967, p.94-95). These studies suggest that civil disturbances have enough in common to successfully plan for them. In fact after the 1967 riots, hospitals in New Jersey did review their plans which improved their response to civil disturbances in 1968 (Roeschlaub, 1968). Several people interviewed for this study indicated that general disaster response training had helped them prepare to respond. Many of the following recommendations were also made in these earlier reports.

Medical Care for the Injured

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