Burn Management in Disasters and Humanitarian Crises

New York City—September 11, 2001

In New York, two hijacked airliners were flown directly into the Twin Towers of the World Trade Center. Although many were injured or killed, few survivors had severe burns. The victims were sent mainly to two burn centers, although more centers were easily reachable. Nineteen were seen at New York Presbyterian Hospital; there, the victims' average age was 44 years, and the burn size averaged 52.7%. In total, 39 burns were reported by nine hospitals; 27 patients were admitted. Although enough burn beds within 1 hour's transport were available, only 26% of burned patients were triaged first to burn centers. Two thirds of burn injuries were ultimately treated in a burn center. The usual portion of burn victims triaged to burn centers in New York City in a year is 75.2%. BST-1 from Boston, Massachusetts, responded to this event within hours ( Fig. 5.1 ).

Kuta, Bali, Indonesia—October 12, 2002

A suicide bomber detonated a backpack bomb in a nightclub. People fled to the outside, where a car bomb exploded. There were 202 deaths and an additional 209 injured. The Australian Defence Force (ADF) initiated Operation Bali Assist, the largest Australian aeromedical evacuation since the Vietnam War. An aeromedical staging facility (ASF) was prepared in a Bali airport hangar, whence 5 C-130 planes flew 61 Australian patients to Royal Darwin Hospital (RDH). Of the 61 patients, 28 had major injuries (Injury Severity Score >16). At RDH, 55 escharotomies were performed, along with 43 other surgical procedures. Three patients had been intubated in Bali; 12 more were intubated at RDH. Within 36 hours after first admission to RDH and 62 hours after the bombing, 48 patients were evacuated to burn centers. There were no “walking wounded.” BATs were used for initial care at RDH.

Eleven patients were transferred to Concord Repatriation General Hospital. Burn injuries ranged from 15% to 85% total body surface area (TBSA), mostly full-thickness burns. All patients showed injuries from both the first and second blasts. There were complications from infections with Acinetobacter baumannii and Pseudomonas aeruginosa and from fragment injuries. Many ophthalmic injuries occurred, some being detected only later.

Royal Darwin Hospital received its first information about the incident from a patient who had been treated in Bali and then fled to Australia. The hospital learned nothing of the number of patients or the severity of injuries before the first wave of patients arrived. Palmer et al describe a need for improvement mainly in military–civilian communication. Communication in the hospital also was problematic: Mobile phones had no reception, there was no time to read electronic texts, and land lines were not mobile. ADF provided satellite phones to the medical staff for communication between the hospital in Bali and ADF.

Madrid, Spain—March 11, 2004

Bomb attacks on four commuter trains killed 191 and injured 2051 of 6000 persons present. Thirteen bomb bags each contained 10 kg of dynamite plus fragments. Three bombs failed to explode. Of the 191 dead, 175 died instantly, and 16 died later. It was not known that unexploded bombs remained on the trains while ambulance staff worked. Ambulance staff worked without coordination and were oblivious to overall medical priorities. Patients with only minor injuries were transported. Ambulances ran out of all medical supplies. No joint field medical command post was set up.

Patients were taken to 15 hospitals in Madrid and two field hospitals, ranging from 5 to 312 patients each. Communication problems in hospitals and among organizations arose. Only 33% of patients were transported in ambulances under medical control; 67% found their way to hospitals without triage and medical or organizational control. Most went to the nearest hospital, which received patients with both serious and minor injuries. Of 312 patients taken to Gregorio Marañón University General Hospital, 45 had burns. The most common injuries were tympanic perforation (in 41%), chest injury (40%), fragment injury (36%), extremity fracture (18%), eye injury (16%), head injury (12%), abdominal injury (5%), and amputation (5%).

London, England—July 7, 2005

Four bombs in the transit system killed 56 (53 at the scene) and wounded 775. Train bombs exploded in three locations; the fourth bomb exploded on a double-decker bus. The number of explosion sites was initially unclear because passengers left the subway at various exits. Triage was performed; 55 patients were classified as severely wounded (P1 and P2). Communication was difficult: All but one mobile-telephone network failed; radio communication between the scenes and ambulance control was very difficult. The fire brigade established an inner cordon and ascertained that there were no signs of chemical substances threatening the rescuers, but the presence or absence of more bombs was not confirmed before rescue work began. Patients mainly in triage groups 1 and 2 were transported to six university hospitals after minimal triage and treatment.

Gothenburg, Sweden—October 30, 1998

Fire in an overcrowded discothèque during a Halloween party killed 61 teenagers at the scene; 2 died later; 235 were wounded ( Fig. 5.2 ). Initial information was poor, resulting in incorrect alerts. There was no triage officer at the scene. Hospital disaster plans in some cases were unknown or not implemented. Preexisting disaster plans had the same personnel simultaneously performing conflicting roles. Within 2 hours, 150 patients were admitted to four Swedish hospitals. Thirty-one patients presented with significant burn injuries; 11 patients were transferred secondarily to other burn centers in and outside Sweden.

Despite the initial chaos at the scene, there were timely escharotomies and triage in the hospitals before transfer to burn centers. Inhalation injuries were diagnosed in 158; 54 of them were treated simply with suction and expectorants. In 51 of 61 deaths, carbon monoxide (CO) was the cause. Eleven patients were transferred secondarily to burn centers in four other cities, one in Norway. All 11 had second- or third-degree burns of more than 20% of the TBSA.

Volendam, the Netherlands—January 1, 2001

A fire at a New Year's Eve party killed 8 and injured 203 of 350 present. An early error in directing emergency traffic caused transportation chaos. Emergency-services tents were insufficiently staffed, and tent placement was problematic. In all, 241 patients went to hospitals: 110 by ambulance, 18 by bus, and 113 by self-referral to the nearest hospital. Of 182 admitted, 112 went to intensive care units (ICUs). Nineteen hospitals provided initial care. The closest hospital, receiving 73 patients, was overwhelmed.

After primary treatment in the hospitals, burn specialists did tertiary triage, distributing patients to hospitals and burn centers in and outside the Netherlands. Burn center criteria were adapted on the basis of both burn extent and inhalation injury: The indications for burn center treatment were greater than 30% TBSA burn with inhalation injury.

Warwick, Rhode Island—February 20, 2003

Fire at The Station, a nightclub, killed 100 and injured 215 of 439 present. The building totally collapsed within 30 minutes. Rhode Island Hospital (RIH) first became aware of this incident from breaking news on television; shortly after, RIH got official notification that 200–300 burn victims were expected. A triage site was established. Sixteen area hospitals evaluated 215 patients. Patients admitted to RIH numbered 47. TBSA averaged 18.8%. There were 33 burns of less than 20% TBSA, 12 with TBSA of 21–40%, and 2 of greater than 40% TBSA. Of 32 patients presenting with inhalation injuries, 28 required intubation; 12 needed escharotomies; and in just 6 weeks, 184 bronchoscopies were necessary. Retrospective analysis called for improvement in communication with the disaster scene and in specific instructions for patient transport.

Buenos Aires, Argentina—December 30, 2004

Fire at the overcrowded República Cromañón nightclub killed 194 and injured 714 of 3000 present. CO and hydrogen cyanide poisoning were the main causes of death. At the scene, 46 ambulances and 8 fire crews sent the victims to the 8 closest hospitals, which were overwhelmed by critically ill patients within 2 hours. In Buenos Aires city, 38 hospitals were engaged and another 5 elsewhere in Buenos Aires province.

Ramos et al describes the experience of Argerich Hospital, to which 74 patients were taken. All had inhalation injuries. There were no severe burn injuries. Eighteen patients (24%) were pronounced dead on arrival. Twenty-five showed respiratory insufficiency and reduced level of consciousness and were intubated. Initially, 22 patients were sent to the ICU; the 14 sent to the operating room for mechanical ventilation were transferred to other hospitals in Buenos Aires Province within 48 hours.

Kiss Nightclub Fire, Santa Maria, Rio Grande do Sul, Brazil—January 27, 2013

In this fire, 242 people were killed, and more than 630 others were wounded because of the use of fireworks. Firefighters had to create a hole in the outer wall to help people to escape. From the estimated 1200–1300 people present in the disco, 169 were hospitalized because of inhalation injuries and burns. The extent of the disaster was not communicated to the response workers. Triage was hindered by crowded bystanders and victims. The military police had to hinder relatives from entering the disaster site that was filled with smoke and toxic gases. Many of them were in critical conditions, emergency departments (EDs) of 5 hospitals, and ICUs of 6 hospitals, and all of the emergency units were crowded. Fifty-four patients had to be transported by helicopters and ground transport to hospitals in Porto Alegre and Caxias do Sul and Cachoera do Sul and Canoas. Transport was supervised and coordinated by a Brazilian Air Force officer and the Brazilian government corporation responsible for operating the main commercial airports. The main issues were with command and control at the incident scene and the absence of a disaster plan.

Colectiv Nightclub Fire, Bucharest, Romania—October 30, 2015

Fire in the nightclub caused by fireworks during a show killed 26 on the spot, 38 died in hospitals, and 184 were injured. About 200–400 people present in the club were engulfed in a stampede when they realized there was fire. The fire started at 22:30, first and emergency call was sent over 112. The first ambulances arrived 12 minutes later. A field hospital was set up. Resuscitation of the unconscious was tried; the effect was not described. At 23:30, the police isolated a perimeter of several streets around the night club. Seventy-five special vehicles of the Inspectorate for Emergency Situations and 57 SMURD trucks and ambulances were in place. A total of 500 emergency service personal were mobilized. Victims accessed hospitals driven by bystanders, taxis, and ambulances. Twelve hospitals received between 57 and 15 victims each, and some had to be redistributed to other hospitals because of overburdening. Ventilation devices had to be moved from other hospitals to the places they were needed. After 1 week, victims were distributed to burn centers in Israel, The Netherlands, Belgium, Austria, the United Kingdom, Norway, Germany, and France. Patients died during or immediately after the transport because of the severity of their injuries. In Bucharest, enzymatic debridement was used to reduce the logistic challenge. There were problems in identifying 29 of 146 hospitalized victims because of the severity of their burns. On March 14, 2016, the last victim treated in a Romanian hospital died.

Alcanar, Spain—July 11, 1978

A tanker truck carrying liquefied flammable gas exploded beside the Los Alfaques campground, killing 102 at the scene and injuring 288; eventually, the dead totaled 215 ( Fig. 5.3 ). The burning tanker divided the scene into two parts. The 58 patients transported north to Barcelona received adequate care before transfer. The 82 patients taken south to Valencia received minimal treatment before and during transport. Both Valencia and Barcelona had state-of-the-art burn centers. There was no significant difference in age or the extent and depth of burns between these two groups. After the first 4 days, Barcelona's survival rate was 93%, and Valencia's was 45%. Ultimately, the mortality rate did not differ.

Lyce Diyarbakir, Turkey—July 21, 2014

A driver of a liquid petroleum gas tanker lost control over the vehicle and caused an over roll followed by a boiling liquid expanding vapor explosion after 15 minutes. Sixty-nine patients were admitted mainly to Dicle University Faculty of Medicine and Diyarbakir Training and Research Hospital, including 62 male and 7 female patients. The average TBSA was 51 ± 32%, including 4 patients with minor burns (<2%), 9 with moderate burns (2–10%), and 56 with severe burns (>10%). In 75%, fasciotomies had to be performed. Twenty-seven (48%) required endotracheal intubation, and 13 (23%) needed tracheostomy. A total of 76% of the patients with severe burns had to be transferred to a burn ICU. Forty-seven (68%) of the patients were distributed to 14 different locations. The overall mortality rate was 49%. The length of hospital stay was 19.4 ± 19.8 days for the survivors and 6.4 ± 4.2 days for those who died.

Ramstein, West Germany—August 28, 1988

Aircraft collisions and crashes during an air show killed 70 and injured more than 1000 of 300,000 present ( Fig. 5.4 ). Three pilots and 67 spectators died; 346 others had serious injuries. Cooperation was hindered by medical systems that were not adapted to each other. On day 1, 12 hospitals were treating the injured; on day 2, 28; and on day 3, 74.

Outpatients numbered 213; 146 were admitted as inpatients; 84 others were transferred to ICUs. There were 112 with mechanical injuries only; 263 had isolated burn injuries; 68 had both mechanical and thermal injuries. Patients with burns of less than 20% TBSA numbered 209 (79.5% of 263). Patients with TBSA of 20–49% numbered 37; 3 of them died. Six of 9 patients with TBSA of 50–70% died. Another 8 patients, with TBSA greater than 70%, died. Of the 68 patients with combined injuries, 55 had TBSA less than 20%. Three of the 9 with TBSA of 20–40% died. No patient with combined injuries and TBSA burns greater than 40% survived.

The burn center at Ludwigshafen received 28 victims. The existing emergency plan was activated; overstaffing occurred on the first day. Initial care in the burn unit was provided in the normal way, not according to emergency plans. Experienced burn teams evaluated the patients. The disaster plan worked, but incomplete initial documentation greatly increased the next days' workload. During treatment, there were no problems with the expanded nursing staff. Qualified medics who worked double shifts for weeks were exhausted. Heavy use of burn beds caused cross-infection problems. The senior surgeon on duty on day 1 concluded that patients should have been transferred to other burn units, where free beds were available.

Kerosene caused difficulties in respiration and in function of patients' kidneys, livers, and central nervous systems. Evaluating cyclic carbohydrates in the blood soon after the incident may be important for prognosis.

Pope Air Force Base, North Carolina—March 23, 1994

Two planes collided in the air, attempting to land on the same runway. The C-130E was able to land; the F-16D, whose crew ejected, slid into a parked, fully fueled C-141 cargo plane with a crew aboard (see Fig. 5.2 ). Five hundred paratroopers, waiting 50–70 feet from the plane, were sprayed with a fireball of burning aviation fuel, with flying debris, and with the F-16's 20-mm ammunition, which began cooking off from the heat. Fifteen to 30 minutes after the incident, casualties arrived at Womack Army Medical Center (WAMC), a 155-bed hospital 5 minutes away. Fifty-one patients were treated and released; of 55 admitted, 25 went to ICUs. Six patients needing urgent surgery were sent to nearby hospitals. Seven patients were sent to the closest civilian burn center, Jaycee Burn Center at the University of North Carolina at Chapel Hill.

One U.S. Army Burn Flight Team arrived 4 hours after the accident and another after 9 hours. Escharotomies were reevaluated; some had to be repeated. Resuscitation was guided by urine output, but fluid amounts initially were not documented. Use of the Parkland formula (4 mL/kg/TBSA), rather than the modified Brooke formula (2 mL/kg/TBSA), along with untrained personnel's overestimation of TBSA, contributed to overresuscitation. Forty-one patients were transferred to the U.S. Army Institute of Surgical Research (USAISR) Burn Center for treatment, of whom 13 required mechanical ventilation. Patients assessed as having nonsurvivable injuries stayed at WAMC.

Points from Mozingo et al's review include the following:

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  Initially, patients with the largest burn sizes were transferred to a nearby civilian burn center. Most of them later died. This sapped resources in the burn center with little impact on outcome.

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  Use of different resuscitation formulas caused difficulties.

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  Patients with obviously lethal injuries were not transported. This did not meet expectations of the referring hospital (WAMC).

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  Several burn victims remained at WAMC without burn specialists because all the burn specialists were needed at the USAISR.

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  There was a lack of burn experience and training at WAMC. Knowledge deficits were noted in techniques (e.g., escharotomy).

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  Training of nonsurgical staff in Advanced Trauma Life Support (ATLS) and Advanced Burn Life Support (ABLS) was needed because the surgical staff was busy doing emergency procedures.