 Okay, so you may be wondering why Cal OES is sitting here in the middle of a football stadium. We're here at Qualcomm, and we're talking to Dr. Jim Dunford. Thank you for being here. My pleasure. I really appreciate it. And the reason we're talking to you today is because you are the incident commander for the medical team here. Is that the right way to put it? Why don't you put it in better words for me? Yeah, I think that's a good way to put it. Okay, and your current role, you are the city's medical director here in San Diego. Yep, since 1997 I've overseen the fire department and paramedic program in the city. Great. So things were a little bit different back then in 2007 during the fire siege. There weren't any evacuees here on the inside part of the stadium. Is that correct? That's correct, yeah. This was absolutely empty. There was nobody here. Everything actually occurred outside, starting in the parking lot, and then coming inside within the enclosed spaces, where we actually even had a small hospital of almost 350 people. Well, let's talk about that. How did that come to be? You know, to a certain extent, we have to go back to 2003 and realize that we'd actually gone through a drill in 2003 with wildfires where Qualcomm actually had become a place of refuge for a lot of people. And in 2007, again, that same thing started to roll with the early evacuation of nursing home patients being directed toward Qualcomm. So by the time I got here in the middle of the afternoon, there were actually several large bus loads of individuals that had arrived and were actually beginning to assemble themselves on the plaza level, where they had actually taken up residence. And, you know, people were putting out cots, people were in wheelchairs, and there was a semblance of actually the beginning of individual rooms that were being dedicated to particular nursing homes that had already arrived. So your main concern then at this particular point was making sure that these elderly folks, these senior citizens who had come from these nursing homes, had their healthcare needs met. Exactly. I mean, this was an assortment of people, some of whom really went so far as to have dementia, didn't really know what their medical problems were. We were certain that among this population, we were having people who were going to be needing evening doses, could have been anti-epileptic medicines, diabetes medicines, hypertensive medicines, but a lot of people didn't know what medications they were even on. And on top of that, we had a group of people that were out on the grounds that had brought themselves here who also had medical needs that were going to need to be attended to. So it was a combination of trying to provide maintenance care for a large group of elderly people and then some of the acute needs of people who might, for example, have asthma and have forgotten their inhalers or some of the other kind of things that would naturally pop up at any large-scale event. So besides the nursing home folks, what were some of the other medical needs that need to be met back then? Well, and again, I think one of the important things is to remember is that we weren't really trying to replicate an emergency department here. Some of the volunteers early on when they got to the stadium thought that that was what we were really intent on building, was sort of a way station because as if the hospitals had already reached their capacity. And that wasn't the case at all. I work at UC San Diego Emergency Department and I have great contacts with my colleagues there and all the other ERs in town and all the ERs were wide open. So the last thing our stadium needed to do was to try to scan up an emergency department. So one of our early priorities is use the 911 system and get people out of here if they really have emergencies. So we created a sort of a stabilization and transport for those handful of people that had an emergency pop up. Now we weren't really trying to keep them here for any length of time. So it became important really to understand that principle and then design the incident command system around more of a process that would stabilize in transport emergencies if they actually arose. Not encourage emergencies to come here by not advertising to the community. We weren't really trying to replace an ER and then really sort of setting about to find out what's the matter with all these older people here and what medications are they going to need as soon as possible. So what was going on out there with regard to the fires and then the subsequent evacuations was the event that was happening out there affecting their mental capacity here? Did you see that? We actually had a couple of psychiatrists available for people who had had acute stress reactions. It wasn't the majority of the patients though. I mean we had a very well behaved group of people that were actually very calm and I think that was part of the attitude was to make sure that people didn't feel that there was a sense of urgency. There was naturally smoke in the air. That was not too good for people who had asthma or emphysema. But for the most part what we were seeing were people who had been displaced who were afraid and upset out of the medicines that they really needed to take. And so among the earliest things we had to do was to kind of create a pharmacy response. Luckily the local pharmacies jumped into the equation. We had a pharmacist here from one of our hospitals who took a lead on that and before you knew it we actually had CVS and some of the other local pharmacies were extremely willing to be able to service directly to Qualcomm Stadium for all of these patients and their needs. We actually got a rapid turnaround when somebody purchased us a printer fax machine so we could actually fax prescriptions. We established a pharmacy that was right on one of the bars upstairs. A bunch of pharmacies came in. Doctors started writing prescriptions. Before you knew it we were writing Parkinson's drugs, heart failure medicines, diabetes and even for people who really had cancer pain. We were writing narcotics. So it was pretty amazing and it was all being delivered to Qualcomm. Some of the pharmacies actually said that they would provide up to seven days with the free medications just to get people through. So there was this fantastic community based response to the medical needs of the people that were actually having to be sheltered here. What did that do for you and your pride in your city, your town, your county? The way that everybody came together like that, was free medications for a week. The whole event actually was pretty inspiring and we were very fortunate that we had good national television coverage and I think we deserved to actually have good national TV because there was a sense of what happened in the stadium that in the face of something really tragic and horrible that San Diego would actually be able to put something together pretty special. We didn't really want to compare ourselves to what happened in Katrina in New Orleans but the fact spoke for themselves because for whatever reason, it worked out really well in San Diego and not too long before that it hadn't been quite so favorable in New Orleans. We had the weather work to our advantage. This is an outside stadium. The wind had to be blown in the right direction. Luckily the smoke was going in a different direction. If we were completely shrouded in soot it would have been a different thing but we were lucky in that respect. It was relatively mild conditions so that people could sleep out. We weren't in 10 degrees zero conditions. Did you have contingency plans that if in fact the wind shifted and brought that smoke this way? Was there a Plan B for these folks who had problems with their breathing anyway? The answer is no. There was a separate facility up in Del Mar at the racetrack so there was another county-wide large-scale event where people were encouraged to go not just the horses but the people themselves went there and in fact the Cal-Mat disaster team was actually deployed to the Del Mar fairgrounds to actually help them because we had plenty of what we needed here from a healthcare point of view. We had pharmacists. We had my team of guys emergency medicine physicians from UCSD that were working 12-hour shifts and we had lots and lots of support staff. In fact you have too many. The problem a lot of times in something like this is you have too many volunteers. Oh okay. Managing them is a challenge when you get to be such a big staff. You should take care of a lot of people with a relatively small number of people. One of the biggest challenges we had and we learned in retrospect was that we actually had somebody who wasn't who they said they were. Really? How does that happen? It came out in the news about a week after one of our best nurses turned out not to be a nurse and she had volunteered here and had done a very able job and it turned out that all of her credentials were fictitious. Wow. Yeah. So vetting people in a disaster is actually something that you actually have to think a lot about. And the way it worked was about the time I got here shortly after the fires were determination was made people were going to be coming here all the doors of the stadium were still open and you have to start from the beginning close all the doors, create one incident command and you would like to know that everybody who comes in and says that I'm a firefighter or I'm a physician or I'm a nurse that you could scan something and you'd be able to prove it on the spot. That doesn't happen in a disaster and I think it's an important thing for anybody who's involved in these large scale incidents is to realize at some point and as rapidly as possible you really do have to create some sort of credentialing process and allow them the people that belong here to stay and the people that don't because we found people that literally went down to Army Navy surplus and bought gear that made them look like people they weren't. Firefighter outfits on individuals that were not firefighters and people who said that there were physicians and nurses who weren't. So these people were just folks who wanted to participate, wanted to help or did they have ulterior motives here? I didn't see anything ultimately malicious but you can actually you have to take into account the possibility that that could happen, right? So God knows why somebody says they are who they are when they're not. I don't know. There's one particular person it turned out to be quite news with for a week or two that she actually did a great job but when the newspaper called me up and said, hey, do you remember so-and-so? I said, yeah, she's wonderful. I said, what would you think if I told you she wasn't a nurse? So that's how you found out? Yeah. Yeah, that's how I found out. Did you pick your job off the floor? They got a little Bluetooth in my headphones so I think maybe my head hit the steering wheel. Oh no. They should have asked you to pull over first before telling you that information, right? Yeah. Oh man. Yeah, but that was one of the lessons that we've learned and I think when you're really going through this kind of thing you rely on your close friends. You know, we operate here every time the charges play. So the nice thing about this is that the fire department integrates every weekend in this stadium one way or another if they have special events. If there are truck pulls or any other kind of thing there's always a presence of fire EMS sitting up there in the incident command of whatever's going on. So for us to kind of turn on the lights if you will and say now we're going to host a disaster here it's not that different. I think that was the important thing is that the fire department knows this stadium backwards. We've run two Super Bowls in this stadium so if you think preparations for an event are key we'll try running a Super Bowl so we know the ins and outs of this place. We know where we put our teams and it really wasn't that much different honestly to be able to say okay we're going to set up a scenario at the stadium and we're going to actually run something there. Where did you guys actually hole up? Did you have a main office in here somewhere? Well on the plaza level there's actually a very nice level over in the plaza section where there are bars where you normally would get your carved meat stations and you'd pick up your custom beers and that was turned into one of the large areas where there were a lot of inside elderly people and as you go down that hallway there are at least two or three more areas all of which have public bathrooms and then where there were areas that were made private so that you could actually take care of the kind of problems that you really encounter which are not so much emergent as nursing home problems but if you wanted to take out a stadium all you have to do is flush a diaper down a toilet and I'm not kidding. I mean one of the most critical infrastructural elements of a stadium during one of these large scale instances is the sewer system and so it was imperative that none of the elderly people would flush something down a toilet that wasn't supposed to go down there. When we got a lot of medical equipment sent in here from the state they sent us equipment that frankly we didn't need. We weren't really preparing ourselves to stand up a freestanding emergency room for a week or two because all the hospitals in San Diego had been taken out. To the contrary all the hospitals were open and running. What we really needed were basic elementary sanitary supplies and the things that you would need if you were going to try to prevent an outbreak. You don't want to have a cruise ship diarrheal incident in the middle of 350 or 10,000 people and it was that type of simple stuff. Lave las monos. We were washing our hands reminding people of the way that they were doing things and to be particularly careful about just routine sanitary things assuring privacy, showering, avoiding falls and a lot of the things that nursing homes normally pay a lot of attention to. In the wake of all that of course we also learned a lot of lessons about having transportable medical records. So we had no medical records on the majority of our patients. The nursing homes in San Diego didn't have electronic records and in substitute of that we've created a lot better systems that if this happens again that the nursing homes will have means by which they can transmit the electronic health records and make sure we know the medicines. We have much more robust availability of other nursing homes in the community that might be able to accept patients so that maybe people wouldn't have to go to a stadium again. It's a big stadium. How did you communicate with all your staff? Well, you know, we ran it very much like ICS the incident command system almost like HICS like the hospital incident command system so we had a medical director we had meetings and appointment times we had individuals who had designated positions and then we basically had runners and so at the top of the stadium is where police and the overall logistics incident commanders operated then the medical team reported for the meetings periodically like we were supposed to and they came down and visited us. It sounds to me planning was key to all this planning but then adapting to the environment. For those of us that had gone on incidents whether you went to Katrina or you went to Hurricane Rita or if you're part of a disaster medical assistance team or an urban search and rescue team and you know something about the architecture of preparedness it's pretty easy to slip in there and then that's really what you need or you need the cards to tell you what to do and you need the vests to tell you what your job responsibility is. So I think with a basic understanding of how an incident command structure works understanding how the FAR department is so essential to kind of establishing those sorts of things what role law enforcement has to play and it falls together fairly easily but that's because I'm an emergency physician and I've spent my life in emergency medicine and I'm an EMS specialist so these large incident should be run by people who have that same kind of background and expertise. It's great to have volunteers who want to come in and help but there are people in every city in the United States that know exactly how to do this. All the big cities in the U.S. they're medical directors they're all friends with me. We all know each other and whenever these incidents happen we're comparing notes. We have a bullet there then I call him up and I want to know how I'm going to handle that and it just this is the way this goes now. I could listen to this all day but the last question I have to ask you I think at this point is if there was any one or two pieces of advice wisdom, some things that you have learned from this 2007 incident what would you pass on to folks who might be in your position in another town, another city, another state? Well I think it's important to know that these large scale facilities can suddenly be turned into facilities that operate for a totally different reason like this and that you have to be familiar with the people that are actually running them. It's a responsibility of EMS physicians to get to another community very well and I'm not telling anything to anybody that's in this business that I am that they probably don't already know but the old adage of you don't want to exchange business cards with key stakeholders during a disaster is really true. So for me, having worked previously with the police department working every day with the fire department understanding the hospital system understanding the emergency response the helicopters and all the things that kind of go into this type of thing it becomes sort of a second nature and I think it's just drilling and then listening to what other people because there were a lot of people who actually knew an awful lot about it I just knew the medicine part. Dr. Jim Dunford, thank you so much for joining us here at the home of the San Diego Chargers Go Chargers!