Discussion of the Planning and Management of the Los Angeles Emergency Medical Services Disaster Response

As discussed in an earlier section of this report, the overall emergency medical response involved multiple public, and private agencies, each with its own jurisdiction and piece of the EMS system. Other activities were carried out that had a direct impact on how long the incident lasted and the number of resulting injuries. For example, twenty cities established a curfew enforced by its own police or by the Sheriff. The Los Angeles City Fire Department, Lynwood Fire Department, Inglewood Fire Department, and the Los Angeles County Fire Department were the agencies primarily responsible for coordination and management of the field response in the South Central Los Angeles. Private ambulance companies organized and managed their own response too. They self dispatched to fire service staging areas in the disaster area. Field responses were then coordinated directly with the appropriate contracting agency such as Los Angeles County Fire Department. Private ambulance companies set their own priorities which included curtailing non-emergency service to nursing homes close to the disturbance. As noted earlier, Goodhew Ambulance company had difficulties obtaining needed protection for their facilities, and dispatched personnel. Apparently, besides immediate coordination in the field, they were not fully integrated into the disaster policy setting and management processes of any of the public agencies. Unlike hospitals, they were not included in County efforts to obtain reimbursements for services provided to persons injured during the riot. LAEMSA implemented its existing procedures to allow EMTs to use communication failure protocols and attempted to manage the distribution of patients to hospitals. The agency also improved access to hospital emergency departments by dropping catchment area limitations. The section of the paper on the hospital's response clearly shows that each hospital activated itself first (LAEMSA also alerted them), set its own priorities, and ran its own response. They independently attempted to obtain supplies and personnel. Only when these efforts began to fail did they go to LAEMSA for assistance. From an EMS systems perspective, these multiple agencies independently established the disaster response medical system at each level -- field and hospital -- but did not have an effective means for establishing policies and priorities, and an agreed method to implement them, across these two levels. For example, LAEMSA could not directly manage the distribution of field response resources; the fire service retained this responsibility. It must be emphasized that this is consistent with the existing county plan. EMSA "Emergency Medical Services Systems Standards and Guidelines" recommends that the disaster plan "should ensure that disaster medical services are appropriately coordinated and managed in a disaster situation" (EMSA, 1984). The "State Emergency Plan" states that the local disaster medical coordinator will "develop and maintain the ability to identify medical mutual aid resources, transportation, and communications services within the jurisdiction.... (OES, 1990). " The State plan also recommends that "Where two operational areas are in potential competition for the same medical resources, and where one operational area lies entirely within the other (e.g. a large city within a county), then agreements should be reached, prior to a disaster, between the operational areas to coordinate their overall medical and health response (OES, 1990)." Many of the elements necessary for such response and supply coordination seemed weak. There was no single unified command structure with agency representatives in one location tracking the performance of the system from 9-1-1 to transport of treated patients to their homes. There was no single point for establishing priorities or developing a mutually agreed upon strategy for all the parties. There was no single logistics section to obtain medical personnel or supplies. Each public agency and private entity developed its own response within its own jurisdiction and then shared what they were doing through liaisons, and telephone conversations. Each system depended, for the most part, upon existing mutual aid agreements to obtain supplies and personnel. From an overall systems perspective, this was a self organizing response (Koehler, 1990). Many of these problems reflect weaknesses in the assumptions and operational elements of the "Medical Annex" of the county emergency plan. While not directly stating it, the plan allows each agency to remain in control of its own resources and to direct its own response. As noted earlier, LADHS' Medical Director is not in control of the entire medical response but only of those parts under his direct jurisdiction. From the perspective of providers in the field and of good disaster planning, much of this makes sense. It does not disrupt day-to-day operations and relationships. Those who know the most about delivering EMS services in the field and at hospitals are still in control of their portion of the response. However, there is no overall plan in place that shows how the entire system fits together or how priorities are set and scarce resources allocated. Fortunately, this event did not seriously overwhelm anyone's resources or capabilities. However, if a major earthquake occurs and creates many casualties, it will probably overwhelm the existing plan. All available historical evidence, and this report, show that an EMS Agency must work very closely with law enforcement and the fire service to determine the likely direction and magnitude of the event. Secure information about the course it is taking, and forward looking estimates of violence must be shared with medical response planners in each responding organization so that they can prepare their part of the EMS system. For example, tracking the development of a civil disturbance is a critical problem. Real time information about the direction that it is taking, expected level of violence, etc., could be used to warn hospitals, manage victim distribution, and provide appropriate public service messages to the public. These points are more fully developed in the hospital response section. Existing technology may already provide a means for gathering this information (see Appendix C for brief discussion of how this tracking might be accomplished). There has been considerable controversy about how much effort should be put into developing a detailed plan for responding to civil disturbances (Webster, 1992). Current Federal and State planing concepts follow the Integrated Emergency Management System (IEMS). Under the IEMS process, it is understood that commonalities exist in the approach to emergency management for all hazards and that this understanding should be reflected in [Emergency Operations Plans.] Experience has shown that plans developed for one type of emergency are extremely useful for other emergency situations, and a significant level of emergency operational capability can be established by addressing broadly applicable functions such as direction and control, warning, communications, evacuation, and provision of shelter. [Emergency Operation Plans] are multi-hazard, functional plans that treat emergency management activities generically. They provide for as much generally applicable capability as possible without reference to any particular hazard; and they address the unique aspects of the individual disaster agents, thoroughly but compactly, in hazard specific appendixes to the generic document (FEMA, 1985). LAEMSAs' current "Medical Annex" is a multi-hazard functional plan. In addition, guidelines and operational systems for responding to an earthquake have been developed. This includes support for hospitals to use HCSC's "Hospital Earthquake Preparedness Guidelines," (HCSC and SCEPP, 1991), and "The Hospital Emergency Incident Command System" developed by the Orange County Emergency Medical Services Agency (Russell, 1991). LAEMSA and EMSA have either independently or jointly offered hospital disaster workshops for responding to a major earthquake. However, an Annex for responding to a civil disturbance is needed. Historically, major civil disturbances happen less frequently than major wildland fires, earthquakes, and hazardous materials events in California. At least one major (Silmar) and three medium size earthquakes have occurred since the Watts Riot in 1965. Wildland fires are a yearly event. There have been several serious hazardous materials events that required the evacuation of many people, including the Cantara train derailment near Dunsmuir, in the 1990s (Koehler and Van Ness, 1993). The state legislature mandates planning for hazardous materials and nuclear reactor incidents. EMS disaster response planning books seldom mention or provide guidelines for responding to a civil disturbance (Quarantelli, 1983; and Auf der Heide, 1989). Taken together, it appears that planning for a civil disturbance is a neglected area, probably because they happen less frequently than other natural and man made disasters. The current state and local government fiscal situation makes it very difficult to plan for all the disasters that are likely to occur. This creates a planning, training and exercise quandary. The EMS community may engage in these efforts immediately following such an event, but everyday activities and the occurrence of other disasters quickly pushes these efforts out of the limelight. Probably the best approach is to include an annex, as recommended by FEMA and OES, in existing disaster plans that can be quickly referenced when a major civil disturbance occurs (see NYSDH, 1969, for guidance). Civil unrest is endemic in Los Angeles for the foreseeable future. Looting and rioting are now quite possible following a catastrophic earthquake. Also, since many hospital earthquake related problems came up during the Los Angeles civil disturbance, it would not seem unreasonable to practice for such responses periodically using civil disturbance as an exercise scenario. Finally, as noted above, training for and exercising plans to respond to any disaster is beneficial and probably contributed to the success of the EMS response. Opportunities to test communications systems, implementation of ICS and other command systems, and triage is provided. LAEMSA has conducted a large number of training and response exercises over the past few years. They have also responded to several disasters. This work has prepared them to implement the necessary agency response consistent with their plans. The weakness, as noted lies in integrating all of these efforts into an EMS system disaster response. "It could happen again" says the Webster report (LA times, 1992). "Denney trial stirs anger in riot area," reads a Sacramento Bee headline (Sacramento Bee, November 22, 1992). In the same Bee article, community members close to where one of the defendants live, complain about police harassment. Serious economic problems that existed in South Central Los Angeles continue, even as efforts to alleviate them are getting underway. Even these efforts seem to be generating considerable controversy and bad feelings (Los Angeles Times, January 11, 1993).

Medical Care for the Injured

Continue to The Emergency Medical Services Authority

Return to the Table of Contents