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Disaster Medicine

Where There’s Smoke, There’s Fire





Susan M. Fitzgerald, MD, FACEP



I got the alert on my cell phone at 0151.  “Please come to the ED if you are available to help with the surge from fire victims and evacuees.”

My first thoughts: “What fire?  What evacuees?  Which ED is this?”

I was sound asleep and it took a while to figure out.  I’d transferred from Kaiser Permanente Walnut Creek to Kaiser Permanente Santa Rosa two years prior, and still got the occasional alert from Walnut Creek.

I’ll be honest, it took me a while just to figure out how to figure it out.

I finally woke up enough to realize I could log onto the ED track board.  KP Santa Rosa didn’t look unusually busy.  I called my friend/colleague Josh Weil, who was on the overnight shift.

“Josh, I got the page, was that you guys?  Do you need help?”

His voice was uncharacteristically strained.

“I think my house is gone.  Claire and Sophie just evacuated; they literally ran through a wall of flames to get out.”  Claire is his wife and Sophie is his 15-year old daughter. 

 “What do you need?” I asked.  It was hard to take in, our entire ED had just had an end-of-summer BBQ at their house a few weeks before.

“I don’t know what I need.”

“I’m coming in.”  I hung up the phone.  This was real.

My partner Fred came in through the back door.  I hadn’t even noticed he was gone.  He’d been driving around our small neighborhood to see if he could locate a fire.

“I can’t see any fire, but the smoke is bad.”  I stepped outside.  The wind was brisk, and the smell of smoke was pervasive. 

“I have to go into work.  Josh’s house is on fire.  Claire and Sophie barely got out.”  Fred’s face fell. 

He turned on the tv.  I threw on some scrubs. 

“There’s fires everywhere.” 

Realizing I might be gone for a while and Fred might need to evacuate here, I gathered some things for him to take just in case; papers, pictures, and cherished family items.  My hands were shaking as I packed.

I’m an ED doc, and I also spend half of my work time in disaster planning and training for Kaiser Permanente Northern California.  I’ve worked both domestically and internationally in disaster response, including NY after Superstorm Sandy and Haiti after the earthquake.

I’d like to say all I had to do was grab my prepacked evacuation bag and I was out the door in five minutes, but I wasn’t.   Although we have a home disaster kit with supplies and food/water for our family, and an evacuation bag for our dog, I hadn’t compiled the important documents and family items I now found myself stuffing into boxes and bags.

After what seemed to be an eternity, I found myself hurtling east down Guerneville Road toward the hospital.  There was a large orange glow on the horizon, the smell of smoke was getting stronger, and I couldn’t help but notice the steady stream of cars driving west, away from the fire.

There weren’t many cars going in my direction, toward the fire.

My normal route was blocked.  To this day, I can’t tell you exactly how I got there, but I found myself at the Bicentennial Way exit of northbound 101.  The exit was also blocked, there was a police car stationed there with lights flashing. 

I showed my ID, and the officer let me through.  I thought back to all the times I’d taught staff to keep their ID’s with them. I always promise it will get folks through a roadblock and it did.  I later learned many of our hospital administrators were not so lucky, didn’t matter what they showed or said, they were turned away at other entry points because they were in active fire zones.

I kept driving.  A sea of flashing lights and emergency vehicles appeared before me, only a half block from the hospital.  I turned left into the parking lot, wound my way around the buildings, and parked in the garage.  

The smoke was incredibly thick when I got out of the car, and a security guard was controlling access to the ED. 

That’s when things get fuzzy.  My brain didn’t register the people carrying their belongings walking the other way, or the embers flying through the air.  Although I walked right past the Journey’s End Mobile Home Park on my left, only yards away from our property line, and at that point almost completely engulfed in flames, my brain didn’t register anything unusual there either. 

Here’s what I do remember, the smoke in the ED and hospital hallways, the calm focused intensity in the Hospital Command Center, and the decision to evacuate the hospital when the fire department told us they were making “a last stand.”  I remember the cadre of police officers who showed up when weneeded to step up the evacuation even further, and how we went floor to floor in teams to clear out the bedbound patients.   My brain finally registered the fire as I passed a fourth-floor window and saw the flames at our property’s edge.  We staged patients by the freight elevators and took them down one by one.  Once downstairs, we lined them up in the hallway to await transport.  We assigned one staff member, from MD’s to RN’s to EVS workers-- to every patient, and documented each patient as they went through the lobby doors onto the ambulances and city buses waiting to take them to safety.   The patients and staff were amazing; there was no panic, and very little noise.  

And here’s what I remember most—watching the last bus pull away from the Kaiser Permanente Santa Rosa Medical Center at 0600, and realizing we safely evacuated 122 patients in 2-1/2 hours.  Not a bad night’s work. 

Our work didn’t end there of course. It would be more than three weeks until the hospital and clinics were fully back up and running.  Even now, things are not back to normal, given that over 200 of our staff and physicians lost homes, and entire neighborhoods in our community are gone—they never will be.  Instead, we have a new normal—one that is wiser, stronger, more realistic, and most of all—kinder and more cooperative. 

Lessons Learned

  • Not all disasters happen at 10 am on a Monday.   A disaster that occurs at 3 am on a Sunday night presents increased challenges in terms of personnel availability and functionality.
  • Planning to be prepared at home or at your medical center without actually doing the work is not helpful when the time comes.  We know whatto do to prepare, but need to follow through and do it before we need it, to be our most effective during a real event.
  • Keep your medical ID with you at all times.
  • Some of your key responders may not be able to get to the hospital in a disaster event.
  • Evacuation is a parallel process. The resources needed to evacuate the adult ICU and NICU patients are different from those needed to evacuate the patients on the floor.  For those who can walk, buses and private cars are your new best friends if the situation is urgent.  If you even think you might have to evacuate, start preparation immediately, including making plans for how you will track your patients, and what supplies, patient care information, and medical personnel you will send along with them.  Much of this can be determined and practiced in advance.
  • When evacuating patients or when handling a patient surge, assign one staff member to each patient to monitor, track, and help transport.  Having direct eyes on every patient, medically-trained or not is invaluable during chaotic disaster events.
  • Practice makes perfect when it comes to disaster response and infrequently used plans such as evacuation plans.  Talk through and drill your plans as often as you can.  Muscle memory will be extremely helpful when the time comes.
  • The concept of the “disaster brain” is real, though the extent to which it dictates behavior in a disaster varies.  We may not even realize our brains are not 100% until much later.  It’s like they used to teach us for codes, take your own pulse first.  Call a huddle, do a quick time out.  Make sure everyone’s on the same page.  If the situation gets worse or more chaotic, repeat this sequence, just like you would repeat the ABC’s in a difficult or extended code.  Drill under time pressure.  Training under pressure makes us more resilient in real events.


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