Wildfires, medicine, and community resilience: A physician’s role

As devastating wildfires cut across Southern California, burning 16,000 structures and displacing more than 180,000 people last month, physicians and medical staff across Los Angeles faced unique challenges helping those in need while also ensuring their own safety.

In the latest Permanente DocsChat episode, Christopher Subject, MD, assistant regional medical director, and Jeremy Maggin, MD, emergency medicine physician, joined host Alex McDonald, MD, to discuss disaster response and preparedness. All three are Southern California Permanente Medical Group physicians who were personally involved in wildfire response.

Download and listen today to learn how Kaiser Permanente’s integrated structure and innovations supported rapid response, the challenges of delivering care during evacuations, and ways physicians can take a more active role in disaster planning and preparedness.

Guests

• Christopher Subject, MD, assistant regional medical director, Southern California Permanente Medical Group
• Jeremy Maggin, MD, emergency medicine physician, Southern California Permanente Medical Group

Related Resources

• HHS ASPR Technical Resources, Assistance Center, and Information Exchange (TRACIE)
• Los Angeles Medical Reserve Corps Links & Resources
• Office of Medical Reserve Corp (HHS)
• DeLValle Institute (Community emergency management training)

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Welcome everyone to this special edition of the Permanente Docs Chat. I’m your host Alex McDonald. I practice family and sports medicine here as part of the Southern California Permanente Medical Group. I’d like to welcome both my guests today, Dr. Jeremy Maggin and Dr. Chris Subject. Welcome, gentlemen. Thank you for being here.

Christopher Subject, MD: Thanks for having us.

AM: This is a special episode. We really felt in light of the devastating and destructive Southern California wildfires over the past weeks that have destroyed 16,000 structures, displaced over a hundred thousand people, including many of our physician colleagues. We needed to talk about this. These fires are still burning in Southern California, and we felt compelled to really host this special episode to process, recover, and help us all prepare for unfortunately the next natural disaster. I want to note for those of you who are struggling personally or professionally, please see the show notes where we’ll provide links to personal and professional resources where you can obtain further support. With that note, I’d like to welcome both my guests, Dr. Jeremy Maggin and Dr. Chris Subject. I’ll have them introduce themselves. Dr. Maggin, we’ll start with you. Please tell us who you are and what you do.

Jeremy Maggin, MD: Thanks for having us here today. I’m Jeremy Maggin. I’m an emergency physician in KP Southern California at Woodland Hills, and then I’m also the Southern California Regional Physician Director for emergency preparedness.

AM: Great. Thanks for being here. And Dr. Subject.

CS: I’m glad we’re able to talk about this topic. Chris Subject. I’m a hospital medicine physician from the Los Angeles Medical Center here in Southern California. I’m also a service line leader over hospital-based services, which includes emergency preparedness and Dr. Maggin services. Thanks for having us.

Importance of personal and organizational disaster preparedness

AM: Great, and thanks to all of you out there listening and watching right now. I want to just do a check-in and see how you’re both doing. Personally, I don’t live too far from these wildfires. The air quality has been impacted where I live. I’ve actually had family and friends who’ve been forced to evacuate, and some of my colleagues actually lost their homes entirely. I volunteered at the evacuation center in Pasadena and the sort of the impact and the toll is beyond anything that I can really express. I just want to check in. How are you both doing personally and professionally?

CS: I can start here. I’ll be honest. Running a little bit on adrenaline, especially the acute phase, I think that’s just now starting to wear off. You watch it on TV, you see disasters from afar, but realizing this is sort of in your backyard, knowing that your patients, your members, your fellow colleagues are being affected. It adds something to it all. I’ll describe an experience we had, and luckily my family and myself were in South Pasadena, we’re safe. But as this was unfolding, our teams were directly impacted. My administrative partner was evacuated. Our regional emergency medicine chief was evacuated. Dr. Maggin had to be evacuated. So even the teams we rely on are directly impacted and it’s an emergency, you sort of act and you figure it out, but it does add a different dimension when it’s so close, so personal and knowing colleagues and members that were directly impacted either evacuation or losing their homes. I think being busy and being, it helps for me anyway, to distract from a lot of those thoughts, which I think could have been overwhelming. So that action was a needed relief at times. Dr. Maggin hand it over to you.

JM: And I would echo a lot of that. My personal experience was we lost power in our house for about 36 hours towards the tail end of that. The last 12 of those hours we evacuated ourselves, me, my wife, and my two kids and whatever we could throw in the car. Fortunately, the fire that popped up near us was the Kenneth Fire got under control relatively rapidly, but it was terrible timing because it was right when we were trying to start to set up our operations in the main evacuation shelter. I really couldn’t be of much help to Chris and the others. I think I tried to call in on a meeting on the road on the way to the hotel that we were not yet sure where we were going, and he was nice enough to tell me to just refocus my efforts on getting my family somewhere safe, which is hard. It’s hard to try to balance doing that and knowing that you have a responsibility to both your work, but to the community at the same time.

CS: That’s so inspiring because I’m having to tell Dr. Megan, please focus on your family and be safe. Get to a safe place, and he’s wanting to help and we appreciate him so much for that. But that played out over and over again.

AM: When a disaster hits so close to home, I mean, finding that balance of not being overwhelmed when you’re personally impacted and your family’s personally impacted is certainly a unique and challenging situation to say the least. Thanks Dr. Maggin, and I hope you’re both safe and your families are safe and your homes are safe at this point.

AM: Dr. Maggin, I’ll turn to you. Can you give us some of these unique challenges of physicians responding to disasters, not only when it’s in our own backyard, such as the wildfires, but just how do physicians prepare to respond to disasters just in general?

JM: You touch on that every disaster’s kind of unique and there’s factors in each of those situations that kind of play a role in terms of how you can and should respond to disaster. One of them is exactly that. Does it happen in your city? Does it affect you and your family personally? Does it happen at your place of work, whether that’s a clinic or a hospital? You’re going to respond in a very different way than if it was an external event that was maybe still affecting your facility, but not necessarily inside your facility or right outside the doors in the case of wildfires. And then every disaster comes with its own unique set of challenges, whether this is a wildfire or a hurricane somewhere else in the country, or if we ever end up facing that next big earthquake here in Southern California or northern California for that matter.

Again, the way to really prepare ahead of time is to just kind of understand the larger disaster mechanisms. The federal government has through FEMA the National Disaster Management Service that outlines a framework for the scalability of disasters. All disasters occur locally. We manage them locally, certainly for the first three to five days. But tapping into the resources at county, state and federal levels is really important for continuing the response. Kind of understanding how that system works is really important. Understanding the roles of physicians within any kind of disaster is important. And with anything that’s as large scale as this has been, there’s always going to be a role for physicians, nurses, the larger medical community as a whole, and that’s different for every disaster. I’ll kind of go through with this kind of how that played out and why. Every disaster at its heart is really just an imbalance of resources and demands.

The fires kind of drove that in a few different ways. One, it caused staff shortages kind of across the board and locally by impacting homes and communities where our staff lives or disrupting traffic patterns, making it hard for them to get into work on time. Lots of people are late for a lot of factors over these last couple weeks. One, kind of protecting themselves and their family from those disruptions in traffic, whether or not that’s actual closures of main roads because of fire or smoke or just increased traffic on the road because, in those first few days, there were different parts of the city evacuating at different times, going all kinds of different directions. We have later on a huge amount of fire service resources that are coming from elsewhere in the state or even from other states, from other countries. There’s a lot more people here than there normally is and an already congested traffic system.

All of that kind of plays into staff shortages. You’re also kind of facing a decrease in resources and space. We always think about disasters and resources really as fitting into the categories of space staff and stuff. We talked about staff space and stuff are being affected, because our equipment is being affected, because there are medical facilities that are evacuating medical facilities that are burning down. Fortunately, that didn’t include large scale medical centers or hospitals within the county. A lot of it was long-term acute care and skilled nursing and assisted livings. But those are all places where some level of medical care is provided and now that medical care has to be provided somewhere else with decreased resources. And then the third thing is that on top of these resource demands, the fire also increased patient care demands in a unique way as well, because now you have folks that are evacuated, they’re living in shelters or living with family or friends in areas of the city or of the county or of the state they’re not used to.

They’re separated from their kind of comfortable medical community where they know how to seek care. Some of them don’t have their glasses or they left their medications behind. They have to deal with issues of food and shelter and medication and security that they don’t normally have to deal with. And you combine those things together and that’s all going to kind of make chronic conditions much worse, force them into seeking care in unfamiliar settings, which kind of pushes them into easily accessible avenues of care like urgent cares and emergency departments. And then on top of that, this is all happening on the backdrop of a particularly busy respiratory winter respiratory season with the flu at the time. And it just kind of boils over in overcrowding in patient surge and staff shortages and resource shortages. That all is happening within the course of a few days. Very difficult to deal with. That can’t happen in any kind of event where evacuation plays a role. The other thing that the fires make worse is that they’re also throwing a bunch of toxins and smoke into the air that makes any respiratory illness worse. We are trying to manage all of that all at once.

Leveraging organizational resources and structure

AM: That’s a great summation of a very complex environment and challenging environment to work in with lots of different coordination and moving parts. And that actually will dovetail to actually very nicely to my next question for Dr. Subject. Can you talk about from a healthcare systems perspective, what role the healthcare organizations have? And here in California you have these very large medical groups and organizations to provide care. So how do we step up from a systems point of view to care for our communities during a disaster?

CS: It’s a great question because we’re part of an ecosystem. We’re one of many healthcare organizations. We’re a large one. And one of the great things about our organization is the way we’re structured. Just to give you an example. We got a call, “Can you set up a medical response in 12 hours at the shelter?” I think a lot of organizations would’ve difficulty with that. Not that we didn’t. We were able to do that. We were able to get physicians on the ground 12 hours later. We had our pharmacy stood up; we had our nurses there, behavioral health there because of the way we’re integrated, but there’s also other healthcare systems there. We showed up the shelter, Allmed was there, amazing partners in the community, and we all work seamlessly together for the patients over there. And things change over time. The immediate need was really more on what Dr. Maggin was describing, evacuation rates with just being out. At the shelter, we had entire skilled nursing facilities, patients just came there, they were now on cots, no aspiration prevention things there, oxygen, even hospice patients there. The immediate thing there was, doctors with that expertise, we can leverage that in our system. The needs change. Beyond that, in our Hospital at Home program, we had patients that were currently enrolled and in these evacuation centers. Something that we have thought about but never had to implement was how do you transition someone to a new address, continue that care without having to send them in to the hospital. All these things, and then the staff that provides that care was impacted either by the roads or something else, or there’s power outages.

Some of the technology we provided can’t be implemented. I think one of the big things as an organization is just a lot of people want to help. And I think that’s human nature. I was inspired by that, but if it’s help that’s not organized or not integrated, it’s not as helpful. I think we ran across some of that in the beginning was we just can’t have 50 people show up at once. We have to have roles and how they’re going to show up. And every part of our organization had a role in whether it be DME, whether it be pharmacy, behavioral health needs or medical needs, and making sure we had designated people at designated times and that we were connecting with the American Red Cross, the City of Pasadena government relation gets involved with that piece. And then really having things go through a central command center.

And again, in the beginning, things are coming in from all over, but when we’re successful, everything’s going through that one channel or organizing the response and therefore being more effective. But again, just inspiring the way that everyone did lean in to help. And I think our role as an organization was just to make sure that was organized to maximally impact our communities. And then being able to adjust over time. One day it’s the City of Pasadena, the next day the American Red Cross is there. And just establishing those channels of communication from our boots on the ground to our higher ups in the organization to make sure that everything is coordinated. So that’s a lot of work, a lot of people, and then Dr. Maggin’s structure with the command center is the best way to really filter all that and have one response from our organization, one point of contact for all the other healthcare providers in the area, another point of contact for all the government agencies that are coming through. A lot of learnings there.

Addressing social determinants of health during disasters

AM: And you talk about the importance of the communication and the coordination and so many moving parts and so many organizations and so many people involved that it really needs to have sort that systematic overview. And I think to your point also, you talked about a lot of these skilled nursing home patients coming to that evacuation center. When I was there, there were some who were on Hoyer lifts and some who were paraplegics and some who had 24-hour caregivers who actually went with them to the shelter. These are patients that are set up for problems, so to speak, very kind of high-risk patients to begin with. And that kind of dovetails into my next question. Thanks for the setup, really thinking about the social determinants of health and some of these socioeconomic factors which can make a community more or less vulnerable to disasters, particularly patients who don’t have anywhere else to go, who don’t have family nearby, who can’t afford to stay at a hotel. What role do physicians and healthcare systems have in addressing some of these disparities that are exacerbated by wildfires and disasters?

CS: One thing that became very clear early in this response was what you mentioned. The shelter was a perfect example. I think people of means, a lot of them, were able to find shelter somewhere. It wasn’t easy at all during that time, for sure. People had to go all the way to San Diego and some out of state to really find housing during that time. But it was a vulnerable population that was left. The ones who couldn’t find alternative housing, some of them were unhoused before this event and had the same risk that everyone else did with this air. Things in the air not being able to find a safe place to find food, that sort of thing. And so that shelter was really a mix of all those things. And part of it was identifying what those needs were in the shelter.

A lot of it was social, some of it was preexisting, some of it was new. And just trying to wade through all that with everyone from the behavioral health needs to food security to housing to any other needs. There were pet needs. And that was even at the shelter. You may have seen that we had quite a few pets there. They had nowhere to go and pet food lined up. We even gave IVs to animals there, someone knew how to do that, and we did that. But all those things came together there. And just for me, it was a real reminder of these problems existed even before this disaster and the importance of trying to address them because it just becomes all that on steroids during the time of a disaster. And we saw that play out there for our members. It was one thing. And our system for the non-members, it was really navigating all those community resources. But everyone else did show up to have those resources available like L.A. County and others, and just trying to tap in Dr. Maggin I know was part of your analysis as well.

JM: Just in terms of what do we do to respond to those inequities or as a medical community because they’re there, there’s unfortunately not a lot that we can do from our perspective beforehand other than identifying them and trying to mitigate them as much as possible. But during the event itself, it’s really doing what we did, which is what Dr. Subject set up at the convention center. What our mobile health vehicles did all over the city in different avenues was to go to those patients that needed the care at the time. They didn’t necessarily because of those socioeconomic issues, then the food and shelter and medication insecurities, they didn’t have access to medical care. They weren’t able to move as freely as they normally would. Having a medical presence at the shelters, at the distribution centers, at the resource centers that FEMA and the county setup is what we could do as a medical community and really providing that care where the patient was not just in our comfy settings in clinics and hospitals.

And then after addressing some of the issues that came up that maybe didn’t go as well in the shelters and in those other areas, working closely with Red Cross and the county to make sure that we really understand how to set up a shelter in the safest way possible from an infectious disease perspective, from a physical contact perspective. And drilling those things and making sure that five years from now we revisit this for the next time this happens, hopefully we won’t have to deal with another similarly impactful event between that time, but really getting together with our external partners to make sure that we know how to work together the ways that we needed to work together this time around.

AM: I think in anything in medicine, when things go well or go poorly, you always sort of take a step back and do a post hoc analysis in terms of lesson learned and how can we improve the systems? How can we improve our teamwork to make things better? And it sounds like this is no different in this, just a much larger scale.

CS: Now, the American Red Cross has already shown a desire to work with us going forward, and we’ve had a great partnership during this. But then how do we prepare for the next one? We just had a meeting just an hour ago about that and learnings from this one, what role we each play the communication pieces. Dr. Maggin and I both look forward to that.

How physicians can contribute to disaster preparedness

AM: It’s almost like you guys read my next question because my next question was about, okay, what now? How do we prepare for the next one? Obviously there’s a lot of recovery that needs to go on at this point. We’re sort of out of the acute crisis, but now how do physicians better prepare for the impact of unfortunately increasing frequency of these natural climate disasters, be it hurricanes or earthquakes or floods or you name it. How do physicians take steps as individuals within their communities, within their clinics or within big health systems to stay informed and prepare themselves and their patients? I’ll open up to either of you.

CS: I’m going to let Dr. Maggin go first on this one because we do have an emergency preparedness structure in our organization.

JM: I would say you always have to start with personal preparedness, right? Because you can’t really, we touched on this earlier, it’s really hard to balance trying to take care of yourself and your family, and then at the same time trying to go in and one, even just do your normal day-to-day job, let alone also insert yourself into helping with the new stuff going on within the community. After personal preparedness, and there’s really a lot of options for this, right? There are community emergency response teams in nearly every community, every urban community that you can join, you’ll learn personal preparedness, you’ll learn community preparedness. You’ll learn how to help at shelters and other volunteer aid stations. And who are the volunteer organizations that kind of come in and assist after those first few days? There’s also Medical Reserve Corps in every state. It’s a government function as well, but it provides educational training and really experiential training for active and retired medical professionals in emergency management.

You can always go to your local facilities emergency management committee. We have them in all of our service areas and join or participate in drills that happen every year or trainings that happen every year. And even if you don’t want to get specifically involved and go out and interact with other people, there’s tons of online resources through FEMA, and it’s called ASPR TRACIE. They have a ton of emergency management training online. There are also more private organizations. One that I got a lot of training from was the DelValle Institute, which is out of Massachusetts, really focused on community emergency management training. And after you’ve got your personal preparedness taken care of, your more global community training done, it’s really just taking those steps to, as an organization, join together with our both internal partners. We say internal here because we have local emergency management committees, we have regional emergency management committees, we have national emergency management committees within the KP framework. But really getting to know all the resources that we have, anything that you can request, anything that you can deliver to somebody that is requesting it. And then really understanding, again, that NDMS structure where every response, every disaster is scalable. You can take care of small disasters on your own, and then you may need to request resources from local, county, state, national levels. All of that exists as long as you know how to access it. That’s the best thing you can do to kind of be prepared.

AM: I think that access piece is the part because it can so overwhelming and so confusing when things are happening so fast. By the way, shout out to the Medical Reserve Corps. I’m a member of the San Bernardo County Medical Reserve Corps. And then something as simple as, especially in this day and age of cell phones, when I was a kid, we had a designated meeting spot in case there was an emergency with your family and friends. Really basic things like that. Having extra water, having an evacuation or an emergency kit on hand and having a plan with your family I think is so important. Giving you one level of comfort. So that’s my own shout out personally. Dr. Subject, any more thoughts there? Especially from a systems point of view about preparation and resilience?

CS: I think our organization has moved the needle quite a bit on physician wellness and things. But I think as physicians in general, and I’m talking to myself, really great at taking care of others, and maybe we could focus more on ourselves, I think, and I saw this play out during the disaster, I think make sure you’re safe. You can’t take care of others until you and your family are safe. But you spoke to it just now, the personal plans, having those in place and really focusing there and then you could better serve. And then if you want to help others, you’re in a place to do so. So I just think real focus on that first piece of taking care of ourselves.

JM: And I do just want to add real quickly. I think that our organization is uniquely structured to be able to assist rapidly and to a great extent. I obviously have less experience in how other healthcare organizations are structured, but the mere fact that we have staff resources and space and equipment that can be easily repositioned and reallocated within the course of 12 hours is something that I think that we should really, one, be proud of, but two, promote to hopefully help other healthcare organizations put themselves in a similar situation. And when I say these things, I mean specifically our mobile health vehicles that are in daily operation, helping assist with clinic operations during normal non-disaster times and out at community events promoting preventative health and health education. And they’re staffed. They’re staffed with nurses who were more than excited and happy to be able to move those to shelters, distribution centers, distribution events, resource centers, and provide just acute care services to the community.

And on top of that, I know the doctor subjects is very humble about this, but I do want to say that having a leadership structure that promotes the nurses and doctors into these regional and local administrative roles while still maintaining their clinical time to some degree, really also positions us in a place where those leaders can be redirected or repositioned, redistributed back into a clinical setting, particularly in these extra settings that we did. And Dr. Subject and Dr. Nolan Chang, Dr. Tong, Dr. Amy Wolf, they worked a lot of those day and overnight shifts in the shelter to get us through that first week. And I want to also call out Maybelle Liquigan because she is our SVP out in Kern. And just as our structure goes, the SVP is essentially the equivalent of a CEO of a hospital. How many other healthcare organizations do you know that has a CEO of a hospital willing to basically leave her day job for a short period of time to go and run a evacuation shelter for two and a half weeks?

AM: And I think it’s a great example of the importance of community engagement, of reaching beyond the four walls of the hospital, of the clinic, and really practicing what we preach in terms of putting resources into the community, putting physicians, putting nursing, nursing into the community to really make a difference. I’m exceptionally proud to be part of this organization, and I hope both of you are as well. And I’m proud to have leaders like both of you running these programs and these disaster responses.

CS: The word pride comes to mind, and I’ve always been proud, but after this, I’m inspired. Definitely the response everyone had. I’m talking about everyone in the organization. Dr. Davidoff was an entire first day at the shelter. It was that kind of all hands on deck. I’m inspired.

The importance of physician leadership

AM: I think the other piece too here is it’s about physician leadership, right? We’ve had physicians in these leadership roles doing the hard work, preparing, but then we also had physicians who actually stepped up during the moment when we needed them. And that physician leadership is so critical. Obviously health care is a team sport. It requires everyone involved, but really having that physician leadership I think makes a difference. Well, you both touched a little bit more on this, but maybe just in a quick word or two or any specific recommendations on how our listeners can get more involved in disaster planning efforts within KP or external and other local agencies. You want to give a shout out for folks to learn more?

JM: Our regional structure, I report to Dr. Subject as the physician director for emergency preparedness. There’s a core team of about six or seven people that we all meet regularly with representatives from KFH and from Permanente and kind of help drive the direction of the overall regional emergency management plan and our objectives every year. And at the local levels, there’s a physician champion and an emergency management officer, or emergency preparedness planner is what we’ve titled them. Every service area has one. Every team is responsible for carrying out the annual plans of drills and training and our emergency operations plans, reviews, reviewing all of our potential hazards every year, how to mitigate those hazards. There’s a lot of emergency management work going on all the time and getting involved in those local emergency management committees that are led by the local physician champion and emergency management officers. Those are either their own individual committees or they’re part of the larger environment of care committees and identifying who those people are and getting involved is really the way to, one, get a better sense of how the system works within our organization, but two, get a lot of training opportunities and emergency management in general.

AM: Wonderful. Well, thank you, Dr. Subject. Thank you, Dr. Maggin for joining us, sharing your insights, your expertise, and we really appreciate your time.