One thing that was clear following the Jan. 13 missile scare in Hawaii is that the state does not have enough hospital capacity to handle a nuclear attack, which could involve mass casualties.

There are 2,600 licensed hospital beds across the islands for the estimated 168,000 people projected to be injured on Oahu if a 150-kiloton nuclear missile were to explode over downtown Honolulu.

“There’s no way we could respond to 10-, 20-, 100,000 casualties. It’s not possible,” said state Sen. Josh Green (D, Kona-Kau), a Big Island emergency doctor. “A missile attack couldn’t be dealt with if there were 100,000 casualties. We’d be hard-pressed to handle 300 serious casualties all at the same time. Thousands would go untreated until we have rescue support.”

The false missile alert issued by the Hawaii Emergency Management Agency led to 38 minutes of panic in the islands before a correction was sent to cellphones, and has raised questions about how well the state is prepared for a real attack.

The state has a contingency plan to significantly expand hospital capacity using field hospitals, lower- level medical centers, neighbor island facilities and, in the worst-case scenario, transporting patients to mainland hospitals 2,500 miles away, said Chris Crabtree, director of Hawaii Healthcare Emergency Management, a 162-member coalition of medical facilities including hospitals, nursing homes and urgent-care centers.

“We know it’s going to generate a huge number of casualties. We’re anticipating tens of thousands of people being injured,” Crabtree said. “The reality of it is the number of casualties that would be generated would be so much that we would have to start pushing them to the mainland. We would stabilize them here and have medical crews utilizing military crews to fly them to the federal coordination center (through the National Disaster Medical System). We’d help provide teams to bring those patients over to the mainland hospitals once we hit overwhelming capacity. There’s the initial part; then there’s fallout and radiation over time.”

There isn’t an exact number for hospital capacity since medical providers would deploy all resources to make space, Crabtree said.

The coalition would also leverage physicians, nurses and medical personnel from other facilities to help with the surge in trauma patients, while hospitals would follow an emergency operations plan to free up capacity by discharging patients, moving noncritical ones into long-term care and rehab centers, as well as neighbor island facilities, he said.

The group also would set up field hospitals to increase capacity. It would take about seven days for medical teams from the mainland to bring aid to the islands in an emergency, he said.

Alex Wellerstein, an assistant professor at Stevens Institute of Technology in New Jersey who studies nuclear weapons, predicts 142,000 fatalities and 167,700 injuries from a 150-kiloton airburst over downtown Honolulu.

“If you’re talking about a ballistic missile … if it hits right in the heart of Waikiki versus somewhere remote, the numbers are going to be different, so you have a percentage that are critical … then you have the delayed walking wounded that flow through. That is, they just come and get treated appropriately and then are released. They don’t all need beds,” Crabtree said. “But we set up such a strong integrated network that we can leverage everything we have within the health care system to aid and try to handle any mass casualty event. People should have some peace of mind that we exist.”

Hawaii received a failing grade for disaster preparedness in the 2014 report card by the American College of Emergency Physicians, the most recent available, largely due to inadequate hospital capacity, which could “lead to dire outcomes,” according to the report.

“A severe gap in hospital capacity impedes the state’s ability to respond to both everyday emergency care needs and potential disasters or mass casualty events,” the report said.

The state would need to repurpose public facilities, including schools, to care for the most seriously injured who could be saved, Green said.

“You couldn’t have a comprehensive medical response. You could only triage the most seriously injured,” he said.

It would take at least 48 to 72 hours before the state could get significant medical support from the mainland, and 12 to 24 hours just to erect emergency facilities, Green said.

“Queen’s (Medical Center) is usually full. Hawaii Pacific Health is near full every day,” he said. “That would tax all of our trauma services very seriously. When you have a situation like that, you get creative. That’s when you activate other spaces.”

Hawaii Pacific Health includes Straub, Kapiolani and Pali Momi medical centers.

Emergency officials have said the state must be self-sufficient since resources can’t be moved interstate like they can on the mainland. Hawaii last year scored below average in a report measuring public health preparedness — the ability to respond to natural disasters, disease outbreaks and other public health crises, according to the 2017 National Health Security Preparedness Index. The state received 6.4 on a 10-point scale, compared with 6.8 for the United States as a whole, according to the Robert Wood Johnson Foundation.

Oahu hospitals are consistently over capacity, particularly during flu season, which has hit the islands particularly hard this year.

“Add an external disaster or surge of patients on top of this and we’re in trouble,” said Dr. James Ireland, assistant clinical professor of medicine at the University of Hawaii John A. Burns School of Medicine. “In disaster situations it’s all hands on deck, and places like hospital conference rooms, waiting rooms and any other available space can be turned into patient treatment areas.”

Dr. Rick Bruno, The Queen’s Medical Center’s vice president of patient care, said the state’s only trauma center is preparing for any type of incident that could happen in the community. That includes canceling all elective operations and clearing out operating rooms, placing less acute patients in lower-level settings and providing expanded care in clinics.

“Our preparation and planning has contingencies for a large number of patients who would influx. We understand Queen’s is going to play a central and important role in any mass casualty incident on Oahu,” Bruno said. “Any time there’s a change in the risk of a disaster or an emergency, we look at our plan and we adjust it, and this incident is no different. We take this very seriously.”

Green said so far he hasn’t seen a comprehensive disaster preparedness plan in light of a potential missile threat.

“We’ve prepared for large infectious disease outbreaks … but preparing for mass casualties from trauma requires a lot of added professional support. I don’t think we’re adequately prepared for that yet,” he said. “I’ve never seen a blueprint on my desk that shows how many surgeons, nurses, burn units we’d try to bring to our state. I’ve never seen that kind of plan regarding a missile attack. That’s the kind of master planning that I hope the administration is considering in this new era.”