Hospital and Emergency Department Response

The Emergency Medical Services Field Response

Finding 30:
The existing hospital emergency department and trauma system were able to absorb the injuries and casualties that came to the hospital for care during the civil disturbance.
Recommendation 30:
A follow up epidemiology study and evaluation of medical records is needed to determine if there was excessive morbidity and mortality among patients who could not leave their homes due to the disturbance, their lack of mobility, or closure of a community service or program (visiting nurses or in-home care for example). Department of Health Services, Office of Emergency Preparedness and Injury Control, and Los Angeles County Department of Health Services should conduct such a study with EMSA as co-researcher.
Finding 31:
While hospitals were able to successfully organize themselves to respond to the civil disturbance, it appears that an element for responding to civil disturbances was not part of their external disaster plans.
Recommendation 31:
The Hospital Council of Southern California should consider a project similar to the one that produced the "Hospital Earthquake Preparedness Guidelines" to recommend guidelines for planning for civil disturbances (HCSC, 1991). A similar effort could be started by the EMS Authority or the State Department of Health Services for community clinics. The model plan developed by Salud Para La Gente could be updated with this material (Salud, 1991). Suggestions made by the New York State Department of Health in 1969 (NYDH, 1969) and information from other sources should be consulted (Hospitals, 1968b). The EMS Authority should also consider updating, "Hospital Emergency Incident Command System," to include a reference to planning for civil disturbances.
1. Communications
Finding 32:
The number of unexpected emergency department self transports, combined with suspension of the requirement to communicate with the receiving hospital probably increased confusion.
Recommendation 32:
Paramedic to receiving hospital communications should not be completely suspended during a civil disturbance. One option might be to require ambulances to give some sort of an identifier, the status of the patient, and estimated time of arrival. Another could be to have the ambulance communicate this information to Medical Alert Centor which in turn assigns their destination and notifies the hospital. In any case, they should continue to be allowed to use standing orders.
Finding 33:
Emergency department staff cannot Provide patient care and report statistical data to the county. This results in an unavoidable conflict that must be resolved in favor of treating patients.
Recommendation 33:
This is a difficult problem that may have to be resolved at each hospital. One solution might be to assign a competent staff person such as a ward clerk from another section of the hospital to the emergency department, who is trained to manage the ReddiNet and report the required data, A second option is to move the radio to the Incident Commanders operations room. Auxiliary antenna connections and emergency power would have to be made available. This would make radio communications available to those who need them, and separate data coil action and transmission from the ER.
Finding 34:
For some hospitals, telephone communications between hospital administrators and the LAEMSA EOC were partially functional depending on how well the telephone system worked.
Recommendation 34:
LAEMSA should consider encouraging these hospitals to participate in the HEAR or ReddiNet systems.
2. Staff
Finding 35:
Hospitals had to provide food, a place to sleep, and personal hygiene facilities to some portion of their staff who had to stay at the hospital.
Recommendation 35:
Hospital disaster plans should include a component for sheltering and feeding a significant portion of their staff and perhaps, their family.
Finding 36:
Hospitals may be perceived by community residents as a source Of food and shelter.
Recommendation 36:
Consideration should be given to feeding treated ambulatory patients and special Populations (elderly, pregnant women, etc.) close to the hospital. During a civil disturbance consideration should be given to identifying an area suitable for sheltering ambulatory patients that is away from the emergency department and special clinics.
3. Supplies
Finding 37:
Hospitals experienced problems obtaining supplies during the civil disturbance.
Recommendation 37:
Contracts with vendors should include a paragraph stating that they will make deliveries during a civil disturbance. The hospital should arrange with their own security or with LAEMSA for police protection of supply transports. Consideration should also be given to the Southern California Hospital Council's recommendation that: "Hospitals need to look beyond their traditional resources, including DHS, to plan for disasters. the [Multi Hospital Task Force] will look at offering a vendor organization such as Purchase Connection as a contingent resource (HCSC, 1992)." The role of LAEMSA should be clarified: are they an arbiter, helper or provider of supplies of last resort?
4. Hospital Based Emergency Care
Finding 38:
While general surgeons, physicians, nurses, and other hospital staff were readily available and did respond, specialists, such as vascular and neurosurgeons, did not appear to be available. For example, in two reported cases a vascular surgeon could not be located.
Recommendation 38:
A review of hospital records for civil disturbance related patients with trauma injuries should be made to determine if they received appropriate surgical care. If the problem cases reported to us are verified, then consideration should be given to requiring surgical and other critical medical specialists, as a requirement for obtaining privileges at any hospital, to be readily available to provide emergency care in their specialty when a local disaster affecting a hospital that they have privileges at is declared. If they have privileges at more than one hospital, then the one expecting to receive or receiving the most seriously injured casualties should have first call on their skills.
Alternatively, a critical specialist physician assignment plan could be developed by the Los Angeles County Medical Association, and other specialty associations. The plan could identify specialists who are available to go to hospitals to provide care.
Until this problem is resolved, LAEMSA should be immediately informed when surgical and other critical specialists are not available.
Finding 39:
Hospital staff established suturing, ambulatory care, and other specialty care clinics. Patients were triaged to these clinics according to their injury. This is consistent with standard hospital disaster plan protocols.
Recommendation 39:
Hospital disaster planners should continue to pre-plan for the creation of emergency care clinic(s) consistent with the injury profile of an expected disaster. They should distinguish between minor injuries to be treated at a clinic and major injuries to be cared for in the ER.
This concept should be extended to preplanning for other likely disasters. For example 1, when a medical hazardous materials incident occurs, minor injuries caused by inhalation, eye and skin exposures could be treated at special clinics. This would leave the emergency department available for more serious exposures and trauma care.
Finding 40:
LAEMSA used County ambulances and other vehicles to transport blood and medical care providers through the disaster area to hospitals.
Recommendation 40:
LAEMSA should consider formalizing the use of County Department of Health Services vehicles for disaster response including, for example, transporting medical supplies and personnel in the disaster area. During a civil disturbance a law enforcement officer could be placed on board or a patrol car assigned to convoy the transport.
Finding 41:
In many cases treated patients were reluctant to leave the hospital to return home during the civil disturbance. They were afraid of being, injured again. In some cases taxi cabs were willing to transport them.
Recommendation 41:
LAEMSA should consider entering into an agreement with local ethnic minority and other taxi cab companies to provide emergency transport for treated patients from hospitals to their homes if they elect to return and conditions are sufficiently safe. Reimbursement should be set at level consistent with the risk.
Alternatively, Red Cross could be asked to set up a temporary shelter at or close to the hospital.
Finding 42:
This study did not examine the condition of the community's primary health care system or look at other community services such as in-home care, dialysis, community clinics or the availability of private physicians during and following the civil disturbance. However, it appears that this system collapsed and was not available to provide primary care or to treat minor injuries during, the event or immediately following it. The lack of these services may have increased the pressure on hospital emergency departments.
Recommendation 42:
LA DHS should consider conducting a study of the problems faced by primary care providers and other community based systems during the South Central Los Angeles civil disturbance.
5. Security
Finding 43:
Hospitals depended on their own and for the most part unarmed security force to protect them. Armed police officers were not assigned to protect the facilities. California National Guard protected one hospital, reducing staff anxiety.
Recommendation 43:
Consideration should be given to establishing a law enforcement rapid response team with local police or even with a contract security agency. Alternatively, a CNG rapid response force staffed by military police could be immediately deployed to protect hospitals when a civil disturbance occurs. Hospitals would be required to provide food, sleeping, and toilet facilities to these added security personnel. It should be noted that special training may be necessary including an orientation to the hospital and how to calm agitated people so that violent incidents can be avoided.
Finding 44:
Safe routes to and from hospitals for hospital staff and delivery trucks were not identified by law enforcement.
Recommendation 44:
The County EOC Law Enforcement Branch, should identify and establish safe and secure routes to and from hospitals within the disaster area and make this information known to LAEMSA who, in turn, should forward the information to the hospitals. (This may not always be feasible, particularly when field conditions are rapidly changing.)
6. Community Relations
Finding 45:
Good community relations help to improve the security of a hospital during, the civil disturbance.
Recommendation 45:
Hospitals should participate in new County and City efforts to train community residents. Hospital Council Of Southern California (HCSC) should coordinate these efforts with hospitals close to or in Central Los Angeles to establish health care manpower development programs funded by new Federal monies.
7. Payment for Caring for Civil Disturbance Related injured
Finding 46:
Hospitals have not been allowed to request reimbursement from OES and FEMA for the cost of caring for the injured.
Recommendation 46:
Hospitals should be allowed to recover costs of caring for the injured who have no insurance or other means Of Payment other than county funds. Efforts by LAEMSA, HCSC, EMSA, and FEMA should be continued to resolve this problem.

Medical Care for the Injured

Continue to Los Angeles County Emergency Medical Services Agency's Response

Return to the Table of Contents