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'Show up and share': How one UCLA ICU helps patients and staff live with dying

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'Show up and share': How one UCLA ICU helps patients and staff live with dying

Extraordinary things happen in the cardiothoracic intensive care unit at Ronald Reagan UCLA Medical Center.

The sick rise from bed with new hearts and lungs. Machines valiantly take over for faltering kidneys, heart valves, bronchial tubes. All patients enter with grave health concerns, and the vast majority leave recovered, or at least on the road to healing.

The unit has 150 nurses, at least two dozen of whom are on the floor at any time. They are there for all of it: every intubation and needle stick, every setback, every odds-defying rebound. They bond with their patients and advocate hard for their best interests.

“Our business is living, surviving and getting whatever the patient needs to get there,” said Mojca Nemanic, a critical care registered nurse in the unit.

But sometimes, despite everyone’s best efforts, the most common thing in the world happens here, too. Heartbeats slow and then stop forever. Diaphragms release a final breath and do not contract again. People die.

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And when there’s nothing left to fix, CCRN Lindsay Brant said, honoring a patient’s death can be life-affirming.

That’s the ethos behind Community, an initiative Brant proposed two years ago to support patients, their families and unit staff during the dying process.

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2 Brant caresses the hands of a patient.

3 Two nurses light candles in the ICU.

1. Lindsay Brant rings a bell while meeting with fellow nurses before they tend to patients. 2. Brant caresses the hands of a patient. 3. Brant, left, and unit director Katrine Murray prepare candles. (Al Seib / For The Times )

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Led by a 12-member committee of nurses, the initiative gives nurses the tools to care for a patient until, and even after, the moment of death. Community allows these caregivers to advocate as hard for the patient’s preferences at the end of life as they do during their treatment, and to process their own grief after a loss.

“Having somebody survive and recover is such a beautiful story,” said Brant, a 12-year veteran of the unit. “Why shouldn’t death and the transition also be just as momentous?”

The idea for Community began with Marbel, one of Brant’s first patients in her early years in the ICU.

The unit’s nurses speak of patients in broad outlines to preserve their privacy, but even the bare contours of Marbel’s story are haunting: a wound so grievous it nearly severed her body in two; grueling daily treatments that caused as much suffering as they relieved.

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Marbel had had enough. Her surgeons wanted to press ahead. In frustration, Brant planted herself in front of the door to her hospital room, barring entry until doctors acknowledged what the patient wanted, which was palliative care and a peaceful death.

The experience sparked a realization, Brant said: A system set up with the noble goal of saving people could at times inadvertently overlook their humanity.

Brant took a course on care for the dying at Upaya Zen Center in Santa Fe, N.M. She became a certified death doula, a person who helps others prepare for life’s end and supports them during the process.

By 2023, she decided to approach her boss, unit director and CCRN Katrine Murray, with an idea for an initiative that would come to be called Community.

Molly Mayville, Allison Kirkegaard, and Tony Estrada of the Threshold Choir prepare to enter a patient's room to sing

Molly Mayville, Allison Kirkegaard and Tony Estrada, from left, of the Threshold Choir prepare to enter a patient’s room to sing at their bedside in the cardiothoracic ICU at Ronald Reagan UCLA Medical Center.

(Juliana Yamada / Los Angeles Times)

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Murray was immediately interested. The ICU was still reeling from the trauma of the COVID-19 crisis, in which staff cared for a seemingly endless wave of the pandemic’s sickest patients.

Studies have found critical care nurses to be at significant risk for anxiety, depression, post-traumatic stress disorder and burnout since the pandemic, thanks to the toxic combination of unrelenting work and the moral distress of watching patients suffer, and often die, without their loved ones present.

“People dying alone — that was one of the things we’ll never get over,” Murray said.

Even before the pandemic, intensive care nurses reported dissatisfaction and frustration with hospital procedures that failed to honor patients’ preferences at the end of life.

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A 2018 study of intensive care nurses found no physical procedure or patient diagnosis that correlated with nurse distress. Witnessing a patient’s death, respondents said, was not in itself upsetting.

A group of nurses sit at a table.

Brant, left, and Murray, right, discuss which patients the Threshold Choir will visit.

(Juliana Yamada / Los Angeles Times)

But they were three times as likely to report severe emotional distress if they felt that their patient died what they perceived as a “bad” death: afraid, unheard, their wishes and dignity overridden by those around them.

“The dying process is part of humanity, and therefore the process itself needs to be respected, just like the patients themselves need to be respected,” Brant said.

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Starting in June 2023, Brant started surveying colleagues about their comfort and experiences with caring for dying patients. She started small group trainings and circulated “cheat sheets” of advice for supporting patients and their families.

Community officially launched in summer 2024. It encompasses a swath of programs intended to comfort patients and make meaning from death.

In the Goals of Care component, nurses talk with patients about their hopes for treatment and comfort with extreme measures, conversations that are documented and used to communicate patients’ wishes to their medical team.

The unit became an early adopter of UCLA Health’s 3 Wishes program, which helps caregivers carry out final requests for patients and their families: a hospital room wedding, a plaster mold of the entwined hands of a patient and their spouse, a last trip outdoors (no small feat, considering the armada of medical equipment that has to come along).

Nurse Lindsay Brant attends to a patient

Brant cares for a patient in the unit.

(Al Seib / For The Times)

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Brant connected with the Threshold Choir, a national network of volunteers who sing at the bedsides of the ill and dying. Members of the choir’s Westside chapter visit the unit every Thursday to sing soothing harmonies to patients in need of comfort, regardless of their prognosis.

There is the Moment of Silence, a ritual after a patient’s death in which nurses and doctors join the patient’s loved ones in the hospital room to honor their passing.

And for the staff, there is Show Up and Share, a quarterly session on Zoom and in person to debrief about challenging experiences on the unit. Some people vent. Some people cry. Some participants don’t say anything, but write in the chat how much it means to hear colleagues voice a similar emotion.

The hospital previously made social workers and counselors available to unit nurses, but uptake for their services was low, Murray said. In contrast, Show Up and Share “just works, because we’re doing it for each other as opposed to someone else,” she said.

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In late 2024, CCRN Quentin Wetherholt was caring for a patient with a long-term illness when he sensed a subtle change in her demeanor. He initiated a Goals of Care conversation with the patient, her family and doctors that reviewed possible options for treatment, nearly all of which she had already tried. After hearing her choices, the patient spoke up: She no longer wanted life-prolonging measures.

From that point on, the patient’s attitude “was just nothing but joy, ironically. It caught me off guard. Normally, when people realize that they’re facing death, it’s a very sad environment to be in. But with her, it was freeing,” Wetherholt said.

“It was a very difficult road that she was on: lots of pain, lots of surgery. And so for her to have that just instantly be gone, and she could enjoy her time the way she wanted to enjoy it — it brought her back her sense of self.”

Nurse Lindsay Brant attends to a patient in UCLA's cardiothoracic intensive care unit.

“The dying process is part of humanity, and therefore the process itself needs to be respected, just like the patients themselves need to be respected,” Brant said.

(Al Seib / For The Times )

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The patient asked relatives to fly in from overseas. She asked for a milkshake. She died peacefully about a week later, with family around her bed.

After the patient’s death, the unit held a Show Up and Share session to grieve for her and for others who had recently passed in the unit.

“Before, it was almost like a point of pride — you know, ‘Death doesn’t affect me, this is what I do for a living,’” Wetherholt said. “But now it’s become such a nice thing to go through with your co-workers, to be able to have this forum to really heal and to not have to bottle it up.”

Early data are promising: In a survey of nursing staff five months after the Moment of Silence began, 92% felt more connected to their patients and families, and 80% felt closer to their teammates. Brant has applied for a grant to share the Community program with the hospital’s six other intensive care units.

“We are a family here, and we treat patients like they’re an extension of our family,” Brant said. “Nursing is the best excuse in the world to love on strangers, to treat all humanity as if it was your closest friend and loved one. And it’s such a gift to be able to do that.”

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His computer simulations help communities survive disasters. Can they design a Palisades that never burns?

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His computer simulations help communities survive disasters. Can they design a Palisades that never burns?

In what used to be a dry cleaner’s on Sunset Boulevard, Robert Lempert listened, hands clasped behind his back, as his neighbors finally took a moment to step away from recovery’s endless stream of paperwork, permits, bills and bureaucracy to, instead, envision a fire-resilient Pacific Palisades in 2035.

As a researcher at RAND, Lempert has spent decades studying how communities, corporations and governments can use computer simulations to understand complex problems with huge uncertainties — from how an Alaska town can better warn its residents about landslides to how climate change is worsening disasters and what strategies the United Nations can support to address them.

In January, one such complex problem ran straight through his neighborhood and burned down his house.

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As Lempert and his wife process their own trauma forged by flames, Lempert has become fixated on capturing the flickers of insights from fellow survivors and, hopefully, eventually, transforming them into computer programs that could help the community rebuild the Palisades into a global leader in wildfire resilience.

“Otherwise, we won’t end up with a functional community that anybody wants to — or can — live in,” he said. “You can spin out all sorts of disaster scenarios” for the Pacific Palisades of 2035. If the community fails to confront them in rebuilding, “you make them a hell of a lot more likely.”

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Lempert doesn’t see a mass exodus from high-fire-hazard areas as a viable solution. Out of the more than 12 million buildings the climate risk modeling company First Street studies in California, 4 in 10 have at least a 5% chance of facing a wildfire in the next 30 years. (Out of the nearly 10,000 buildings First Street studies in the Palisades, 82% carry that level of risk.) And the areas without significant fire risk have their own environmental challenges: flooding, earthquakes, landslides, hurricanes, tornadoes, droughts. Learning to live with these risks, consequently, is part of the practice of living in California — and really, in most of the places humans have settled on Earth.

After The Fires

After two of the most destructive fires in the state’s history, The Times takes a critical look at the past year and the steps taken — or not taken — to prevent this from happening again in all future fires.

So, Lempert has taken to the modus operandi he helped develop at RAND:

Identify the problem. In this case, living in Pacific Palisades carries a nonzero risk you lose your house or life to fire.

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Define the goals. Perhaps it is that, in the next fire, the Palisades doesn’t lose any homes or lives (and, ideally, accomplishes this without spending billions).

Then, the real work: Code up a bunch of proposed solutions from all of the groups with wildly disparate views on how the system (i.e., Southern California wildfires) works.

Stress-test those solutions against a wide range of environmental conditions in the computer. Extreme winds, downed communication systems, closed evacuation routes — the list goes on.

Finally, sit back, and see what insights the computer spits out.

It’s easy enough to agree on the problem, goals and environmental factors. For the proposed solutions, Lempert set out to collect data.

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Poster paper with residents’ handwritten ideas now fills the walls of the former dry cleaner’s, now the headquarters of the grassroots organization Palisades Recovery Coalition. It’s through these “visioning charrettes” that Lempert hopes his community can develop a magic solution capable of beating the computer’s trials.

Robert Lempert holds a photo of his home before it was destroyed by the Palisades fire.

Lempert holds a photo of his home as it looked before it was destroyed by the Palisades fire.

The streets could be lined with next-generation homes of concrete and steel where even the tiniest gaps are meticulously sealed up to keep embers from breaching the exterior. Each home could be equipped with rain-capture cisterns, hooked up to a neighborhood-wide system of sensors and autonomous fire hoses that intelligently target blazes in real time. One or two shiny new fire stations — maybe even serving as full-blown fire shelters for residents, equipped with food and oxygen to combat the smoke — might sit atop one of the neighborhood’s main thoroughfares, Palisades Drive. The street, formerly a bottleneck during evacuations, might now have a dedicated emergency lane.

Every year, the community could practice a Palisades-wide evacuation drill so the procedures are fresh in the mind. Community brigades might even train with the local fire departments so, during emergencies, they can effectively put out spot fires and ensure their elderly neighbors get out safely.

Lempert, who now lives in a Santa Monica apartment with his wife, doesn’t entertain speculation about whether the Palisades will ever reach this optimistic vision — even though his own decision to move back someday, in part, hinges on the answer.

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Right now, all that matters is that change is possible.

He pointed to an anecdote he heard once from the fire historian Stephen Pyne: American cities used to burn down — from within — all the time in the 19th century. Portland, Maine, burned in 1866 thanks to a Fourth of July firecracker. Chicago in 1871, after a blaze somehow broke out in a barn. Boston the following year, this time starting in a warehouse basement. Eventually, we got fed up with our cities burning down, so we created professional fire departments, stopped building downtowns out of wood and bolstered public water systems with larger water mains and standardized fire hydrants. Then, it stopped happening.

Now we face a new fire threat — this time, from the outside. Maybe we’re fed up enough to do something about it.

“Cities shouldn’t burn down,” Lempert said with a chuckle, amused by the simplicity of his own words. “So let’s just design them so they don’t.”

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China’s Clean Energy Push is Powering Flying Taxis, Food Delivery Drones and Bullet Trains

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China’s Clean Energy Push is Powering Flying Taxis, Food Delivery Drones and Bullet Trains

As an American reporter living in Beijing, I’ve watched both China and the rest of the world flirt with cutting-edge technologies involving robots, drones and self-driving vehicles.

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But China has now raced far beyond the flirtation stage. It’s rolling out fleets of autonomous delivery trucks, experimenting with flying cars and installing parking lot robots that can swap out your E.V.’s dying battery in just minutes. There are drones that deliver lunch by lowering it from the sky on a cable.

If all that sounds futuristic and perhaps bizarre, it also shows China’s ambition to dominate clean energy technologies of all kinds, not just solar panels or battery-powered cars, then sell them to the rest of the world. China has incurred huge debts to put trillions of dollars into efforts like these, along with the full force of its state-planned economy.

These ideas, while ambitious, don’t always work smoothly, as I learned after taking a bullet train to Hefei, a city the size of Chicago, to see what it’s like to live in this vision of tomorrow. Hefei is one of many cities where technologies like these are getting prototyped in real time.

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I checked them all out. The battery-swapping robots, the self-driving delivery trucks, the lunches from the sky. Starting with flying taxis, no pilot on board.

Battery-swapping robots for cars

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Of course, far more people get around by car. And navigating Hefei’s city streets shows how China has radically transformed the driving experience.

Electric vehicles (including models with a tiny gasoline engine for extra range) have accounted for more than half of new-car sales in China every month since March. A subcompact can cost as little as $9,000.

They are quite advanced. New models can charge in as little as five minutes. China has installed 18.6 million public charging stations, making them abundant even in rural areas and all but eliminating the range anxiety holding back E.V. sales in the United States.

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Essentially, China has turned cars into sophisticated rolling smartphones. Some have built-in karaoke apps so you can entertain yourself while your car does the driving.

You still need to charge, though.

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Lunch from the sky

China’s goal with ideas like these is to power more of its economy on clean electricity, instead of costly imported fossil fuels. Beijing has spent vast sums of money, much of it borrowed, on efforts to combine its prowess in manufacturing, artificial intelligence and clean energy to develop entirely new products to sell to the rest of the world.

Drone delivery has a serious side. Hospitals in Hefei now use drones to move emergency supplies, including blood, swiftly around the city. Retailers have visions of fewer packages stuck in traffic.

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But does the world need drone-delivered fast food? And how fast would it really be? As afternoon approached, we decided to put flying lunches to the test.

We decided to eat in a city park where a billboard advertised drone delivery of pork cutlets, duck wings and milk tea from local restaurants, or hamburgers from Burger King. Someone had scrawled in Chinese characters on the sign, “Don’t order, it won’t deliver.” A park worker offered us free advice: Get someone to deliver it on a scooter.

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Undeterred, we used a drone-delivery app to order a fried pork cutlet and a small omelet on fried rice. Then, rather than wait in the park, we went to the restaurant to see how the system worked.

Very rapid transit

China’s bullet trains are famous for a reason. Many can go nearly 220 miles per hour — so fast that when you blast past a highway in one of these trains, cars look like they’re barely moving.

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In less than two decades China has built a high-speed rail network some 30,000 miles long, two-thirds the length of the U.S. Interstate highway system. As many as 100 trains a day connect China’s biggest cities.

Building anything this enormous creates pollution in its initial construction, of course, using lots of concrete and steel. Construction was expensive and the system has racked up nearly $900 billion in debt, partly because it’s politically hard to raise ticket prices.

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But the trains themselves are far less polluting than cars, trucks or planes. And they make day trips fast and easy. So we decided to hop over to Wuhan, more than 200 miles away.

Taxis that drive themselves

We rolled into Wuhan looking forward to catching a robot taxi. While a few U.S. cities have experimented with driverless cars, China leads in the number on the road and where they can operate.

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Wuhan is one of a dozen or more Chinese cities with driverless taxis. Hundreds now roam most of the city, serving the airport and other major sites.

But train stations are a special problem. In big cities, some stations are so popular that the streets nearby are gridlocked for blocks in every direction.

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That was the case in Wuhan. Autonomous cars have not been approved in the chronically gridlocked streets next to the train stations, which meant that, to meet our robot taxi at its pickup spot, we either needed to walk 20 minutes or hop on a subway. (We walked.)

Of course if you want your own personal self-driving car, dozens of automakers in China sell models with some autonomous features. However, you are required to keep your hands on the wheel and eyes on the road. Just this month, regulators told automakers to do more testing before offering hands-free driving on mass production cars.

We wanted the full robot chauffeur experience.

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Robot trucks don’t need windows

After a meal at one of Wuhan’s famous crawfish restaurants, we headed back to Hefei.

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We had enjoyed Hefei’s airborne lunches, but there’s a lot more autonomous delivery in that city than just food. China still has many intercity truck drivers, but is starting to replace them with robot trucks for the last mile to stores and homes.

The trucks look strangely faceless. With no driver compartment in front, they resemble steel boxes on wheels.

The smaller ones in Hefei carry 300 to 500 packages. The trucks go to neighborhood street corners where packages are distributed to apartments by delivery people on electric scooters or a committee of local residents. Larger trucks serve stores.

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Robot delivery trucks now operate even in rural areas. I recently spotted one deep in the countryside as it waited for 13 water buffalo to cross a road.

Subways get a makeover

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Cities across the country are rapidly building subways. So many, in fact, that China has become the world’s main manufacturer of automated tunnel-boring machines.

It has also pioneered the manufacture of prefab subway stations. They’re lowered in sections into holes in the ground. Building a new station can take as little as two months.

Nearly 50 cities in China have subway networks, compared with about a dozen in the U.S., and they tend to be popular and heavily used.

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As in many Chinese cities, people in Hefei live in clusters of high-rises, and many live or work close to stations. The trains cut down on traffic jams and air pollution.

And like so many things, new ones are usually driverless.

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The changes are spreading across the country.

Many Chinese cities have not only replaced diesel buses with electric ones but are also experimenting with hydrogen-powered buses. And driverless buses. And driverless garbage trucks. And driverless vending machines.

One such vending machine was operating in the Hefei park where we ordered our drone lunches. According to a nearby hot dog vendor, the brightly lit four-wheeler drove into the park every morning, though always accompanied by a person on a bike who made sure nothing went wrong.

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A robotic snack machine that needs a chaperone — how practical is that? But the fact that they are rolling around the streets of Hefei at all says something about China’s willingness to test the boundaries of transportation technologies.

Some ideas may not work out, and others might suit China but not travel well. For example, Beijing can essentially order arrow-straight rail lines to be built almost to the heart of urban areas with little concern for what’s in the way. Other countries can’t replicate that. Chinese-built bullet trains in Nigeria and Indonesia, which travel from one city’s suburbs to the next, haven’t proven nearly as popular.

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Still, China shows a willingness to take risks that other countries may not. In San Francisco the death of a bodega cat, killed by a self-driving taxi, has hurt the industry’s image. But in China, fleets of similar cars are operating widely and censors delete reports of accidents. The cars are improving their software and gaining experience.

As for me, after several days putting Hefei’s idea of the future to the test, it was time to head for my next reporting assignment, in Nanjing. By bullet train, of course.

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After the L.A. fires, heart attacks and strange blood test results spiked

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After the L.A. fires, heart attacks and strange blood test results spiked

In the first 90 days after the Palisades and Eaton fires erupted in January, the caseload at Cedars-Sinai Medical Center’s emergency room looked different from the norm.

There were 46% more visits for heart attacks than typically occured during the same time period over the previous seven years. Visits for respiratory illnesses increased 24%. And unusual blood test results increased 118%.

These findings were reported in a new study published Wednesday in the Journal of the American College of Cardiology. The study, part of a research project documenting the fires’ long-term health effects, joins several recent papers documenting the disasters’ physical toll.

While other U.S. wildfires have consumed more acres or cost more lives, the Palisades and Eaton fires were uniquely dangerous to human health because they burned an unusual mix of materials: the trees, brush and organic material of a typical wildfire, along with a toxic stew of cars, batteries, plastics, electronics and other man-made materials.

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There’s no precedent for a situation that exposed this many people to this kind of smoke, the paper’s authors said.

“Los Angeles has seen wildfires before, it will see wildfires again, but the Eaton fire and the Palisades fire were unique, both in their size, their scale and the sheer volume of material that burned,” said Dr. Joseph Ebinger, a Cedars-Sinai cardiologist and the paper’s first author.

The team did not find a significant increase in the overall number of visits to the medical center’s emergency room between Jan. 7, the day the fires began, and April 7. The department recorded fewer in-person visits for mental health emergencies and chronic conditions during that time compared to the same time period in earlier years, said Dr. Susan Cheng, director of public health research at Cedars-Sinai and the study’s senior author.

The increase in visits for acute cardiovascular problems and other serious sudden illnesses made up the difference.

The study team also looked at results from blood tests drawn from patients visiting the ER for serious physical symptoms without immediate explanation — dizziness without dehydration, for example, or chest pains not caused by heart attacks.

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Their blood tests returned unusual results at a rate more than double that seen in previous years. These atypical numbers cut across the spectrum of the blood panel, Cheng said. “It could be electrolyte disorder, change in protein levels, change in markers of kidney or liver function.”

The rate of unusual test results held steady through the three-month period, leading the team to conclude that exposure to the fires’ smoke “has led to some kind of biochemical metabolic stress in the body that likely affected not just one but many organ systems,” Cheng said. “That’s what led to a range of different types of symptoms affecting different people.”

Joan Casey, an environmental epidemiologist at the University of Washington who was not part of the Cedars-Sinai team, noted that the study found health effects lasting over a longer period than similar studies have.

Three months “is a substantial length of time to observe elevated visits, as most studies focused on acute care utilization following wildfire smoke exposure find increased visit counts over about a weeklong period,” Casey said. Her own research found a 27% increase in outpatient respiratory visits among Kaiser Permanente Southern California members living within 12.4 miles of the burn zones in the week following the fires.

“The L.A. fires were such a severe event, including not only smoke, but also evacuation and substantial stress in the population, that effects may have lingered longer,” Casey said.

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Thirty-one people are known to have died as a direct result of injuries sustained in the fires. But researchers believe that when taking into account deaths from health conditions worsened by the smoke, the true toll is significantly higher.

A research letter published earlier this year in the Journal of the American Medical Assn. calculated that there were 440 excess deaths in L.A. County between Jan. 5 and Feb. 1. That paper looked at deaths caused by a variety of factors, from exposure to air pollution to disrupted healthcare as a result of closures and evacuations.

On Tuesday, a team from Stanford University published itsprojection that exposure to the fires’ smoke, specifically, led to 14 deaths otherwise unaccounted for.

Wildfire is a major source of fine particulate pollution, bits measuring 2.5 microns or less in diameter that are small enough to cross the barriers that separate blood from the brain and the lungs’ outer branches.

Compared with other sources, wildfire smoke contains a higher proportion of ultrafine particles miniscule enough to penetrate the brain after inhalation, Casey told The Times earlier this year. The smoke has been linked to a range of health problems, including dementia, cancer and cardiovascular failure.

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In the last decade, increasing numbers of wildfires in Western states have released enough fine particulate pollution to reverse years’ worth of improvements under the Clean Air Act and other antipollution measures.

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