Medical management after major burns incidents

Transcription

1 Medical management after major burns incidents

2 The printing of this thesis was financially supported by: The Dutch Burn Foundation, Bio Implant Services Foundation, the Ministry of Health, Welfare and Sport. The studies were financially supported by a grant from the Ministry of Health, Welfare and Sport. Medical management after major burns incidents Thesis, University of Amsterdam, the Netherlands Copyright 2006 Lieke Welling, the Netherlands No part of this thesis may be reproduced, stored or transmitted without prior permission of the author. Lay-out: Printed by: Chris Bor, Medical Photography and Illustration, Academic Medical Center, Amsterdam Buijten en Schipperheijn, Amsterdam

3 Medical management after major burns incidents ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. mr. P. F. van der Heijden ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Aula der Universiteit op vrijdag 29 september 2006, te uur door Lalita Welling geboren te Bombay, India

4 Promotiecommissie Promotores: Prof. dr. D. J. Gouma Prof. dr. R. W. Kreis Co-promotores: Dr. C. P. Henny Dr. E. Middelkoop Overige leden: Prof. dr. P. M. M. Bossuyt Dr. H. Boxma Prof. dr. C. M. A. M. van der Horst Prof. dr. J. A. Rauwerda Prof. dr. M. B. Vroom Faculteit der Geneeskunde

5 Alles op deze wereld kan men ongedaan maken, alleen het weten niet. Alberto Moravia ( )

6 Preface Mass casualty management has gained profound attention from both governments and health care systems across the world. This is mainly due to the increasing frequency of mass casualty incidents, and terrorist attacks in particular. In January 2001, a fire in a café in Volendam caused the death of fourteen young people. In total, 182 victims were hospitalised. Soon after the fire, the ministry of Health, Welfare and Sport instituted a committee to investigate the cause of the fire and the response of the local authorities (The Alders Committee). The large number of victims posed substantial stress on the Dutch healthcare system which required non-conventional solutions, such as the transport of unstable patients to burn centers in neighbouring countries. As elsewhere in the world, participating healthcare workers in the Netherlands responded to the need to learn from the medical pre hospital and in hospital response after the fire in order to improve the care for mass casualty victims. The Academic Medical Center, the Free University Medical Center, both in Amsterdam, and the Burn Center of the Red Cross hospital in Beverwijk (as a representative for the three Dutch Burn Centers) instituted a research project titled Medical Evaluation of the café fire Volendam (Dutch acronym: MERV). The results of this study were presented to the ministry of Health, Welfare and Sport in 2003 and The second part of this project, the consensus study, is presented in this thesis. The thesis focuses on medical and medico-organisational aspects of the response to the café fire and is partially based on the data collected for the MERV. The study was performed at the Academic Medical Center in close collaboration with the Free University Medical Center, and the Burn Center of the Red Cross hospital.

7 List of contents Chapter 1 General introduction and outline of the thesis 9 Chapter 2 The café fire on New Year s Eve in Volendam, the Netherlands: description of events Burns 2005; 31(5): Chapter 3 Medical management after indoor fires, a review Burns 2005; 31(6): Chapter 4 Reliability of the primary triage process after the Volendam fire disaster Journal of Emergency Medicine: accepted for publication 51 Chapter 5 Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam café fire European Journal of Emergency Medicine 2005; 12(6): Chapter 6 Interhospital transportation of mass burn casualties Submitted 81 Chapter 7 Clinical status and intramural treatment of the victims of the café fire in Volendam, a descriptional study To be submitted 97 Chapter 8 Impact of modification of burn center referral criteria on primary patient outcome Journal of Burn Care & Rehabilitation: accepted for publication 111 Chapter 9 A consensus process on management of major burns accidents: Lessons learned from the café fire in Volendam, the Netherlands Journal of Health, Organisation and Management 2006; 20(3):

8 Chapter 10 General discussion 139 Chapter 11 Summary of the thesis 149 Appendices Nederlandse samenvatting Contributing authors Publications related to this thesis Dankwoord Curriculum vitae

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11 General introduction and outline of the thesis

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13 General introduction Mass casualties Historically, disasters involving multiple burn casualties are not uncommon 1-8. The most common incidents are associated with commercial or residential fires, traffic accidents, mass gathering events and terrorist actions 9. In the past years, mass casualty incident management has gained increased attention from both public agencies and health care workers across the globe 10. This is mainly due to the increasing frequency of worldwide terrorist actions 8. In recent years, the care for mass burn casualties after incidents such as the World Trade Center and Pentagon attacks, the Oklahoma bombing, the Rhode Island nightclub fire and the terrorist attack on a nightclub in Bali have stretched health care systems far beyond their capacity 8,9. Mass casualty incidents require special strategies and resources and specific elements can be identified in most burn disasters 11. Clear communication is of pivotal importance. Studies describing the response after mass burn incidents show that this remains a substantial problem in disaster management 12,13. Characteristics of mass casualty management A large variety of rescue workers from different disciplines are deployed at the disaster site and the training and preparation of these rescue workers is a matter of concern 14,15. In the Netherlands, it has been a common believe that rescue workers are able to respond adequately to disaster situations, due to their normal professional knowledge and daily experience and they do not routinely receive any specific standardised training in disaster response or disaster management 16,17. The medical response to a mass casualty incident however, involves aspects which are unusual in common circumstances such as triage, field resuscitation, knowledge of the command structure, the logistics of evacuation and cooperation between rescue workers of different disciplines 18,19. A fundamental component of mass casualty management is triage (whether primary or secondary), which means that patients should be sorted according to severity of injury and subsequent urgency of care 10. The concept of triage has been known since the time of Napoleon, but has not been used widely in civilian practice until the 1970 s 20. The sudden presentation of many burn patients simultaneously may overwhelm medical facilities and necessitate the adaptation of selection criteria to determine treatment priorities. These are based on the extent of the burn injury, age, the presence of inhalation injury or other additional injuries, treatment facilities, transportation capacity and the availability of specialised burn center beds. Several strategies are available for distribution of victims of mass burn incidents. Depending on the availability of transport, victims may be quickly removed from the scene and brought to the nearest hospitals for stabilisation ( scoop and run ). Subsequently, secondary distribution or interhospital transportation is often needed, as was the case after the Ramstein disaster, in which all victims were initially brought to the closest hospital and subsequently distributed to Chapter 1 General introduction and outline of the thesis 13

14 different hospitals 21. Another strategy is to stabilise the victims at the scene ( stay and play ) and bring them directly to the appropriate care facility, thereby often preventing the need for secondary distribution 1. No consensus seems to exist with respect to primary treatment, transportation and secondary distribution of a large number of burn victims. 14 Burn care in the Netherlands Burn care can be divided into four phases: initial evaluation of burns and concomitant injuries, resuscitation, initial wound excision and biological closure, and rehabilitation and reconstruction In the Netherlands, patients who have been involved in a burn incident with limited victims involved are generally transported to a hospital near the site of the incident for initial resuscitation and stabilisation. Subsequently, referral criteria, described in the Emergency Management of Severe Burns protocol (EMSB), are used for admission to one of the three Dutch burn centers, located at Beverwijk, Rotterdam and Groningen 23,24. For example, all adult patients with a Total Body Surface Area burned (TBSA) of more than 10 % and children with a TBSA of more than 5 %, should be admitted to a burn center. These secondary referral criteria are widely accepted, both in the Netherlands and countries worldwide 25. The experience in treating severely burned patients in non specialised hospitals is therefore limited. In a mass casualty situation, the number of patients who meet the admission criteria, mentioned above, often outnumber the available beds in burn centers. Thus a substantial number of patients who would have been admitted into a burn center in a single-patient situation may have to be treated at non specialised hospitals instead. The café fire in Volendam, January 2001 Shortly after midnight on the first of January 2001, the café fire in Volendam resulted in the worst mass burns incident in recent Dutch history. A short intense fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in an unusually high number of severely injured burn victims. Four victims died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the site of the accident, Mobile Medical Teams (MMT) ensured transport priority and the necessity of treatment of the injured. There were 245 victims with a median TBSA of 12%. Inhalation injury was present in ninety six patients. A total of 182 victims had to be hospitalised, a 112 of whom were admitted onto an Intensive Care Unit (ICU). Seventy eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, thirty six hospitals in three countries participated in the care of these patients. Ten patients died in the hospital. Response to a mass casualty burn incident Incidents involving mass burn casualties have demonstrated that the specific needs of the burn patient should be incorporated in disaster planning 26. The management of such

15 casualties demands effective triage (and adequate care if needed) at the site of the disaster, primary distribution to nearby hospitals, secondary distribution to burn centers, as well as the infrastructure and coordination to facilitate the entire process. The optimum response in the different stages of a major burns incident is still not established 26. This thesis describes several of the aspects of the medical treatment and specific requirements that were associated with this mass casualty burn incident. Outline of the thesis In chapter 2 an insight is provided into the medical and organisational requirements of a major burns incident through a detailed description of the events following the accident in Volendam. Medical management of the victims at the scene, in the Emergency Departments (ED) and during admission in the hospitals is described. During the extensive evaluation of the medical aspects of this disaster, it became obvious that information on similar incidents is relatively scarce in the literature. Chapter 3 systematically reviews the existing information in the medical literature on indoor fires and provides findings and knowledge used in the evaluation of the medical management after indoor fires and for future mass burn casualty preparedness, mitigation and response. In a major burn incident, correct triage is crucial for emergency treatment and transportation priority. The sudden presentation of many burn patients simultaneously may overwhelm medical facilities and necessitate the adoption of selection criteria to determine treatment priorities. Chapter 4 evaluates the triage process pursued at the site of the accident and in the ED. The reliability of the estimation of burn severity and the presence of an inhalation injury at the site and in the ED and its impact on immediate medical treatment and transportation priority are analysed. Chapter 1 General introduction and outline of the thesis 15 A large variety of rescue workers from different disciplines are active at the disaster site and it is a matter of concern how these rescue workers should be trained and prepared 14,15. Currently, in the Netherlands, rescue workers do not routinely have specific standardised training in disaster response or disaster management. After the café fire in Volendam, around 200 rescue workers were deployed onsite. Chapter 5 investigates the rescue workers experience with regard to their level of preparation for the emergency response by means of a structured interview, focused on education, task perception, triage, registration and cooperation.

16 Two main strategies are available for distribution of victims of mass burn incidents. No consensus seems to exist with respect to primary treatment, transportation and secondary distribution of mass burn victims. Chapter 6 establishes the impact of the interhospital transportation of the severely injured patients on their condition and outcome and determines the influence of the different modes of transport. 16 Burn care can be divided into four phases: initial evaluation of burns and concomitant injuries, resuscitation, initial wound excision and biological closure, and rehabilitation and reconstruction. Chapter 7 describes the intramural treatment given in the first three phases of burn care after the café fire in Volendam in January In the Netherlands, referral criteria exist for admission to a specialised burn center. For example, adult patients with a TBSA of more than 10 % and children with a TBSA more than 5 %, require admission to a burn center. In a mass casualty situation, the number of patients who meet these admission criteria may exceed the available beds in burn centers. This situation occurred after the major burns accident in Volendam. In response to this, the admission criteria were adjusted and a number of patients who would have been admitted to a burn center in a single-patient situation were treated at non specialised hospitals instead. In chapter 8, the results of treatment of these burn patients at non specialised hospitals are compared with a historical control group consisting of similar patients treated at a burn center. The endpoints of this study are mortality, morbidity (complications), length of hospital stay, intensive care stay, and ventilation time. The fire has been subject of several governmental investigations concerned with organisational and medical aspects Based on the findings in these investigations, a multidisciplinary research group started a consensus study comprising three postal rounds (Delphi Method) and a consensus conference (modified Nominal Group Technique), with a multidisciplinary panel consisting of experts, working in influential positions within the sphere of disaster management and healthcare. In chapter 9 the results are presented, which reveal areas of improvement in the care after mass burns incidents. In chapter 10 lessons learned and future perspectives are discussed. Finally, in chapter 11, a summary of this thesis is provided.

17 References 1. Arturson G. The Los Alfaques Disaster: a boiling-liquid, expanding-vapour explosion. Burns 1981; 7: Arturson G. The tragedy of San Juanico--the most severe LPG disaster in history. Burns Incl Therm Inj 1987; 13: Becker WK, Waymack JP, McManus AT, Shaikhutdinov M, Pruitt BA, Jr. Bashkirian train-gas pipeline disaster: the American military response. Burns 1990; 16: Cassuto J, Tarnow P. The discotheque fire in Gothenburg A tragedy among teenagers. Burns 2003; 29: Herndon DN. A survey of the primary aid response to the Bashkir train-gas pipeline disaster. Burns 1990; 16: O Hickey SP, Pickering CA, Jones PE, Evans JD. Manchester air disaster. Br Med J (Clin Res Ed) 1987; 294: Sharpe DT, Roberts AH, Barclay TL, Dickson WA, Settle JA, Crockett DJ, Mossad MG. Treatment of burns casualties after fire at Bradford City football ground. Br Med J (Clin Res Ed) 1985; 291: Sheridan R, Barillo D, Herndon D, Solem L, Mohr W, Kadilack P, Whalen B, Morton S, Nall J, Massman N, Buffalo M, Briggs S. Burn specialty teams. J Burn Care Rehabil 2005; 26: Kennedy PJ, Haertsch PA, Maitz PK. The Bali burn disaster: implications and lessons learned. J Burn Care Rehabil 2005; 26: Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil 2005; 26: Barillo D. Burn Disasters and Mass Casualty Incidents. J Burn Care Rehabil 2005; 26: Harrington DT, Biffl WL, Cioffi WG. The station nightclub fire. J Burn Care Rehabil 2005; 26: Mozingo DW, Barillo DJ, Holcomb JB. The Pope Air Force Base aircraft crash and burn disaster. J Burn Care Rehabil 2005; 26: Gunn SWA. The scientific basis of disaster medicine. In The management of Mass Burn Casualties and fire disasters: Proceedings of the first International Conference on Burns and Fire Disasters. Dordrecht/ Boston/London: Kluwer Academic Publishers; 1992: Wachtel TL, Dimick AR. Burn disaster management. In Herndon DN (ed). Total burn care. London: Saunders; 1996: de Vries GM, Luitse JS. Emergency medicine in the Netherlands. Ann Emerg Med 2001; 38: Welling L, Perez RS, van Harten SM, Patka P, Mackie DP, Kreis RW, Bierens JJ. Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam cafe fire. Eur J Emerg Med 2005; 12: Born CT, DeLong WG, Jr. Organizing the orthopaedic trauma association mass casualty response team. Clin Orthop 2004; Hoey BA, Schwab CW. Level I center triage and mass casualties. Clin Orthop 2004; Hoyt DB, Mikulaschek AW, Winchell RJ. Trauma triage and interhospital transfer. In Mattox KL, Feliciano DV, Moore EE (eds). Trauma. New York: McGraw-Hill; 2000: Martin TE. The Ramstein airshow disaster. J R Army Med Corps 1990; 136: Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev 2006; 19: Chapter 1 General introduction and outline of the thesis 17

18 23. Cartotto RC, Innes M, Musgrave MA, Gomez M, Cooper AB. How well does the Parkland formula estimate actual fluid resuscitation volumes? J Burn Care Rehabil 2002; 23: Sheridan RL. Comprehensive treatment of burns. Curr Probl Surg 2001; 38: Friedrich JB, Sullivan SR, Engrav LH, Round KA, Blayney CB, Carrougher GJ, Heimbach DM, Honari S, Klein MB, Gibran NS. Is supra-baxter resuscitation in burn patients a new phenomenon? Burns 2004; 30: Mackie DP, Koning HM. Fate of mass burn casualties: implications for disaster planning. Burns 1990; 16: Commissie Onderzoek Cafébrand (Commissie Alders). Cafébrand Nieuwjaarsnacht Eindrapport Inspectie voor de Gezondheidszorg. Evaluatie aanbevelingen onderzoek geneeskundige hulpverlening slachtoffers cafébrand Volendam Stuurgroep Medische Evaluatie Ramp Volendam. Medisch Rapport Cafébrand Volendam

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20 Lieke Welling Sabine M van Harten Joost JLM Bierens Maarten Boers Jan SK Luitse David P Mackie Ad Trouwborst Dirk J Gouma Robert W Kreis Burns 2005; 31(5):

21 The café fire on New Year s Eve in Volendam, the Netherlands: description of events

22 Abstract Introduction The café fire in Volendam occurred shortly after midnight on the first of January 2001 and resulted in one of the worst mass burn incidents in recent Dutch history. The aim of this study was to provide an insight into the medical and organisational requirements of a major burns incident. 22 Patients and methods Shortly after the fire, two university hospitals and a burn center in the region of the accident developed an initiative to evaluate the medical care given during and after this major burns incident. A multidisciplinary research group investigated the medical management of the victims at the scene, in the Emergency Departments (ED) and during admission in the hospitals. All 245 casualties were included in this study. Results A short heavy fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in an unusually high number of severely injured burn victims. Four victims died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the scene of the accident, mobile medical teams ensured an order of transport or treatment priority of the injured. There were 245 victims with a median Total Body Surface Area burned (TBSA) of 12%. Inhalation injury was present in ninety six patients. A total of 182 victims had to be admitted, of whom 112 on an Intensive Care Unit. Ten patients died in the hospital. Seventy eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, thirty six hospitals in three countries participated in the care. Conclusions An accident with a high number of burn victims imposes a challenge on the health care system. The difficult circumstances at the site demonstrated the need for robust organisational structures. The primary and secondary distribution of patients required extensive coordination and general hospitals were able to provide initial medical care to major burn casualties.

23 Introduction Events in closed buildings can result in numerous burn casualties in case of a fire. Incidents involving mass burn casualties have demonstrated that the specific needs of the burn patient should be incorporated in disaster planning 1. The management of such casualties demands effective triage (and adequate care if needed) at the site of the disaster, primary distribution to nearby hospitals, secondary distribution to burn centers, as well as the infrastructure and coordination to facilitate the entire process. The optimum response in the different stages of a major burns incident is still not established 1. The café fire at Volendam, which occurred shortly after midnight on the first of January 2001, resulted in the worst mass burns incident in recent Dutch history. The incident has been the subject of several investigations concerning organisational and medical aspects 2-4. The aim of this study was to provide an insight into the medical and organisational requirements of a major burns incident through a detailed description of the events following the accident in Volendam. The results may be of importance for future planning of burn disaster management. Patients and methods Shortly after the fire, two university hospitals and a burn center in the region of the accident developed an initiative to evaluate the medical care given during and after this major burns incident. A multidisciplinary research group investigated the medical management of the victims at the scene, in the Emergency Departments (ED) and during admission in the hospitals. All 245 casualties were included in this study. Parameters from on scene medical records, ambulance registration forms (on scene data), ED records and hospital medical records were evaluated retrospectively. The Total Body Surface Area burned (TBSA) estimated after hospital admission, most often performed by a team of burn specialists (B-team), was considered the final TBSA. For patients not admitted to a hospital, TBSA estimated in the ED was used as the final value. The diagnosis of inhalation injury was retrospectively defined as being present if patients required artificial ventilation for respiratory failure, for at least 72 hours, commencing within three days after the fire. Regarding complications, the medical records were searched for signs of major complications, as sepsis or systemic inflammatory response syndrome (SIRS) when no pathogen was identified, acute respiratory distress syndrome (ARDS), failure of one or more organs, a period of severe hemodynamic instability or disseminated intravascular coagulation (DIC). Chapter 2 The café fire, description of events 23

24 In order to gain knowledge about the medical organisation at the scene of the accident, interviews with health care workers were conducted and reports of other investigations were used 2-4. Results 24 The scene of the disaster On New Year s Eve, about 350 young people were gathered in a crowded café (top floor of a three-story building with other cafés below) on a narrow embankment in Volendam. This is a small village on the shore of the IJsselmeer, a lake in the northern part of the Netherlands 2. The access road to the café is single-lane. The closest town is situated at 10 kilometres distance; Amsterdam, the capital city with two university hospitals is 20 kilometres distant whereas the nearest burn center is located 40 kilometres from the scene of the disaster. To mark the festive season, the café had been adorned with fir-tree branches, slung under the ceiling in fishing nets. The course of the fire Shortly after midnight, around 00:20h, sparklers lit inside the café accidentally set fire to the Christmas decoration on the ceiling 2. The fire spread rapidly and burning debris fell on to the crowd, setting fire to the clothes of the visitors. The lighting failed and there was copious production of thick, acrid smoke which hampered escape and increased the panic. Although the actual blaze lasted approximately one minute, the temperature in the room reached 400 degrees Celsius 2. As the visibility improved, people managed to leave the café, some of them badly burned. After the fire had stopped and the windows were broken, victims were able to leave the café and reach the roof of the café below. The outside temperature was only one degree Celsius and there was a strong wind. Some victims jumped into the icy water of the lake; others were sprayed with cold water by fire fighters who had arrived at the scene. Medical emergency response: on scene triage and treatment The first emergency call reached the Ambulance Dispatch Centre (ADC) at 00:38h 3. The fire department and an ambulance were requested to come to the site of the incident. The ADC sent an ambulance and immediately notified the police and the fire department. At that point there was no indication of the scale of the incident. At 00:53h, after additional calls, the duty officer at the ADC scaled up, according to an established protocol. Within fifteen minutes several disaster duty officers and organisations were contacted and went to the site of the disaster. Subsequently, the ADC alerted hospitals in the region to expect victims. Initial contact involved nine general hospitals and the closest four university hospitals. The three Dutch burn centers were notified as well 3. Soon after the fire, many

25 volunteers went to the embankment to offer their help. Before arrival of the medical and paramedical teams, casualties were sheltered and cooled in neighbouring cafés and houses. The first ambulance arrived at the scene at 00:51h. The crew was unable to carry out their primary task of coordination and communication. An overview of the situation could not be achieved because the injured were sheltered in various buildings which prevented an accurate estimation of the magnitude of the incident. In addition, the crew of the first ambulance was besieged by casualties and relatives, desperate for help 2. The ambulance officers started to help the police and the fire men to evacuate victims from the bar to nearby cafés. As more ambulances arrived, the first victims were selected for treatment when necessary, by ambulance personnel and local doctors who had reached the site. At approximately 01:00h, a Mobile Medical Team (MMT) from the Free University Medical Center in Amsterdam was deployed. This team, which existed of a specially trained doctor and nurse, arrived at the site of the incident at around 01:45h. They were immediately directed to the severely injured patients in the different bars and started triage and treatment. Within the next two hours four additional teams arrived. At 01:10h, the first severely injured victims could be transported to the hospitals. Around 01.40h the estimated number of victims was 120. About twenty ambulances were on their way or already at the site and transported patients from the site (Figure 1). Patients were taken to the nearest hospitals by relatives and bystanders as well. From 01.40h until 02.40h two field tents were erected for mass casualty treatment. Large numbers of casualties, some of them severely wounded, were brought to the tents from the different cafés. At 03:30h all victims had left the cafés and were gathered in the tents where the MMT s continued their triage and treatment. From the tents, they were transported to the hospitals within the region. Transportation of victims from one tent was delayed because this tent was placed on the narrow embankment and blocked the road. All members of the Chapter 2 The café fire, description of events 25 Figure 1 Cumulative number of ambulance transportations

26 26 MMT s finally concentrated their work in this tent, which contained the most critical patients. Many suffered respiratory distress and at least ten patients were intubated and ventilated in the tent. As insight into the final number of victims grew; ambulances were directed not only to the nearest hospitals, but also to hospitals outside of the region. By 03.30h it was stated that there were still 25 victims who had to be transported. A few of them were severely wounded and monitored by a MMT. They were all transported at about 04.40h. At about 04:45h, eighteen patients were transported by bus which headed to the nearest hospital 4. Since this hospital was already over crowded, the bus was commanded to change its destination to a nearby university hospital. Around 05.30h the decision was made to end the disaster procedure. Several helpers attended debriefing meetings held at different places. Four victims died at the scene. After all patients had been transported, they were inspected by a forensic physician. Primary distribution A total of 241 people visited a hospital, 110 victims were transported by ambulance, eighteen came by bus and 113 casualties referred themselves to the nearest hospital (Table 1). Twenty hospitals participated in the primary care. The nearest small general hospital received seventy three patients and became severely overburdened. Two patients were transported straight to the ED of a burn center. As these two patients were moribund, the burn centers decided to invoke plans made previously for the management of mass burn casualties: the ADC was ordered not to transport any victims to the burn centers, in order to preserve space for the secondary distribution of the severely wounded. In total, 233 patients visited an ED at the first of January. The remaining eight patients were admitted directly to an Intensive Care Unit (ICU), or visited the ED after the first of January. Almost all of the ED s had a protocol for disaster planning. At half of the participating ED s, patients were treated according to the ATLS protocol. The attention was mainly focused on the estimation of the TBSA, the subsequent need for fluid resuscitation, the possibility of an inhalation injury and the need for endotracheal intubation and ventilation. Admission and secondary distribution Of the 233 patients who visited the ED, 182 were admitted, most of them at regular, non specialised hospitals. As more patients required admission, it became clear that the demand for artificial ventilation machines could hardly be met by these hospitals. Some patients had to be ventilated with the machines in the operation theatres. An urgent need for a coordinated secondary distribution existed, and in the morning of the first of January, a coordination center was set up at the nearest burn center. Two teams of doctors specialised in burn care; the so called Burn teams (B-teams), visited most of the hospitals to which the victims were admitted. Their main task was to identify those patients who would benefit the most from specialised care. The B-team evaluated the TBSA and the presence of inhalation injury. At the same time, an inventory was made of the available specialised burn beds in the Netherlands,

27 Table 1 Logistics Acute phase Time evacuation (hours) 4h30 Mode of primary transportation Own vehicles 113 Ambulance 110 Bus 18 Hospital admission Visiting a hospital 241 Admission 182 Admission in ICU 112 Secondary distribution Interhospital transportation 78 Patients treated abroad 24 Participating hospitals 36 (9 abroad) ICU: Intensive Care Unit Belgium and Germany. This task was greatly facilitated by the existence of a centralised burn bed coordination system in the latter countries. As the normal criteria for admission into a burn center were met by almost all casualties, the criteria were substantially modified in order to achieve an acceptable level of care for the injured (Table 2). Table 3 shows an example of the distribution of the Volendam patients following regular and adapted criteria. A total of seventy eight patients were transported to other hospitals. The majority of the transports took place within the first 24 hours after the incident. Twenty four patients were transported to burn centers abroad. Table 4 shows the location of patients after the primary distribution on the first of January and after the major part of the second distribution on the fourth of January. Finally, 112 patients were treated in an ICU and seventy patients on a general ward. Chapter 2 The café fire, description of events 27 Patient details A total of 245 patients are known to have been involved in this fire, four people died at the site of the incident, 241 visited a hospital. 162 were male, eighty three were female. Mean age was 17.3 years (SD 2.5, min/max 13-27). 215 patients had burns (Figure 2). The median of the TBSA was 12 % (min/max 0-95) (Table 5). The areas that were affected most frequently were the face and the hands (Table 6). Inhalation injury, conform the previously described criterion of a minimum ventilation time of 72 hours, was present in eighty seven patients. In the first two days after the fire however, nine patients died in the hospital due to extensive burns. They are believed to have suffered inhalation injury as well (Figure 2). Thirty six patients suffered non-burn injuries. Most were less severe, i.e. bruises and small fractures.

28 Table 2 Regular and adapted criteria for admission in a burn center (EMSB) 28 Regular criteria 1. TBSA (partial and full thickness burns) of more than 10 % in adults. 2. TBSA (partial and full thickness burns) of more than 5 % in children. 3. Partial and full thickness burns on the face, hands, feet, genital area or covering main joints. 4. Full thickness burns of more than 5 % in all age groups. 5. Significant burns, due to electricity or chemical agents. 6. Inhalation injury. 7. Circular burns of chest or extremities. 8. Burns in babies or the elderly. 9. Burns in patients with pre-existing co morbidity, which can complicate the healing process. 10. Burns and significant concomitant injury. Adapted criteria 1. TBSA (partial and full thickness burns) of more than 30% and (signs of) inhalation injury. TBSA: Total Body Surface Area burned EMSB: Emergency Management of Severe Burns Table 3 Adaptation of EMSB admission criteria, following the Volendam fire Admission according to regular criteria (N=182): Regular criteria Treated in burn center Treated in regular center Yes (n=171) No (n=11) 1 10 Admission according to adapted criteria (N=182) Adapted criteria Treated in burn center Treated in regular center Yes (n=46) 41 5 No (n=136) EMSB: Emergency Management of Severe Burns Regular center: non specialised (non-burn) center Table 4 Number of patients admitted on the first and the fourth of January 2001 First of January (N=182) Number of patients admitted Fourth of January (N=145) Number of patients admitted Regular hospital 116 Regular hospital 41 University hospital 60 University hospital 48 Burn center inside NL 6 Burn center inside NL 32 Burn center outside NL 0 Burn center outside NL 24 Regular hospital: non specialised (non-burn) hospital NL: the Netherlands

29 Figure 2 TBSA and presence of inhalation injury TBSA: Total Body Surface Area burned However, one patient had no visible burns but leapt from the roof of the café and died on site from severe head and thorax trauma. The median length of in hospital stay of the 112 patients who were admitted into the ICU was thirty days (min/max 1-176) (Table 7). The median TBSA was 22% (min/max 1-95). All ninety six patients with inhalation injury were treated in the ICU. The median time of artificial ventilation was fifteen days (min/max 1-90). Signs of one or more major complications such as SIRS, ARDS, failure of one or more organs, a period of severe hemodynamic instability or DIC occurred in forty eight of the 112 patients (Table 8). The median length of the in hospital stay of the patients who did not need treatment in the ICU was 5.5 days (min/max 1-59) (Table 7). The median TBSA was 6% (min/max 0-21). None of these patients were ventilated and none suffered a major complication. Chapter 2 The café fire, description of events 29 Mortality The mortality in the entire population (N=245) was fourteen (5.7%). Four people died at the scene, no registration could be traced about their injuries and cause of death. Ten of the 182 patients who were admitted died in hospital (in hospital mortality 6%). Of these ten patients, five succumbed on the day of the fire as a direct result of their severe injuries. The median TBSA in these patients was 90% (min/max 86-95). Three patients died within the first month, due to major systemic complications of their burns. One patient died after six months from endocarditis. The median TBSA in this group was 56% (min/max 40-95). One patient without burns died two days after the fire from cerebral injury. All ten admitted patients died in the ICU (ICU mortality 9%).

30 Table 5 Patient characteristics (1) 30 N=245 Male / Female ratio 2:1 Mean age (range) 17.3 (13-27) Injuries Patients with burns 215 (88%) Median TBSA (range) 12% (1-95%) Inhalation injury 87 (36%) Mortality Overall (N=245) 14 (5.7%) In hospital (n=183) 10 (5.5%) Intensive Care (n=112) 10 (8.9%) TBSA: Total Body Surface Area burned Table 6 Affected body regions Affected body region(s) Patients with burns in a region (%) Face 81 Neck 28 Body 46 Arms 53 Hands 87 Legs (including feet) 30 Table 7 Patient characteristics (2) ICU patients N = 112 Ward patients N =70 Total admission days f 30 (1-176) 5.5 (1-59) ICU days f 18.5 (1-166) 0 TBSA (%) f 22 (1-95) 6 (0-21) Inhalation injury 96 0 Ventilation days f 15 (1-90) 0 Complications (%) * ICU: Intensive Care Unit, TBSA: Total Body Surface Area burned, f: (median, min/max), : count * Major complications e.g.: systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), failure of one or more organs, a period of severe hemodynamic instability or disseminated intravascular coagulation (DIC)

31 Table 8 Major complications* of ICU patients N=112 Number of patients SIRS 15 ARDS 5 Kidneyfailure 4 Hemodynamic instability 5 Liverfailure 1 Two complications 11 Three or more complications 6 Reanimation following cardiac arrest (e.c.i.) 1 ICU: Intensive Care Unit * Major complications e.g.: systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), failure of one or more organs, a period of severe hemodynamic instability or disseminated intravascular coagulation (DIC) Discussion The café fire in Volendam took place on New Year s Eve in an overcrowded café, containing approximately 350 young people. The number of emergency exits in the café was limited. This is a common phenomenon observed in other café and disco fires 5,6. In Volendam, the actual blaze lasted only a minute. In most similar accidents, the fire lasted much longer resulting in huge smoke development and panic The short duration of the Volendam fire was unusual, resulting in large numbers of severely burned casualties reaching the hospital alive. In previous incidents, on scene mortality has been higher and the severity of the burn injury of those reaching the hospital was lower 1. The Volendam fire however demonstrates that indoor fires can cause a high number of casualties requiring specialised care. More than one third of all visitors to the café turned out to have an inhalation injury. The high number of patients with inhalation injury is probably related to the fact that the fire occurred in an enclosed area. More than half of the admitted Volendam patients were treated in an ICU. In the first hours after the fire, ICU capacity in burn- and regular centers was realised for more than hundred patients. This was about ten percent of the total ICU capacity of the Netherlands. Mainly due to the high number of living victims and the fact that the victims rapidly spread to neighbouring cafés and houses, the on scene situation became chaotic. The task of the first ambulance workers arriving at a scene of an accident is to gain an overview and start the coordination of disaster management. After the Volendam fire however, they were overwhelmed by the numerous requests for help and therefore unable to get a clear indication of the amount of victims and the severity of the injuries. In the course of time, approximately 200 rescue workers were deployed at the site of the accident. Coordination and efficiency was difficult since most workers had little or no training in the emergency Chapter 2 The café fire, description of events 31

32 care of large numbers of burn victims. More extensive training and preparation of individual rescue workers could prove helpful, as shown in similar situations 11. Hart et al. however, claim that rehearsals of such incidents are of limited value, being expensive and disruptive of normal routine and that a regular discussion of emergency procedures would be more useful 9. A further investigation of this topic is reported elsewhere in this thesis. 32 The evaluation of the Volendam fire showed that on scene triage and treatment and the primary distribution are important topics. In mass casualty situations, health care workers inevitably have to deal with more wounded than can be treated by all medical resources simultaneously, especially when transportation is protracted. In these situations, triage is necessary 12. The main goals of the triage process are to deliver an acceptable level of care and to prevent deaths in severely injured yet salvageable patients 13,14. After most fires, patients are transported from the scene of the accident to a hospital as soon as possible without extensive triage ( scoop and run strategy) 6,15,16. The Volendam café fire was an exception to this, since prompt evacuation of the victims was protracted due to the infrastructure around the café. At the scene of the accident, Mobile Medical Teams ensured an order of transport or treatment priority of the injured. This was primarily done based on observations of vital parameters, TBSA and the suspicion of an inhalation injury 4. Several patients were intubated and received fluids and pain medication ( stay and play strategy). It is reported in the literature that detailed assessment of the injuries of burn casualties is very difficult and only practical in a clinical environment where adequate facilities and specialised personnel are available, but quantitative research is not available 17,18. Further research into the feasibility of on scene diagnostic and therapeutic procedures and to identify the optimal strategy toward the emergency response in a mass burn casualty is therefore warranted. In the Netherlands, burn patients usually receive primary care in regular hospitals before they are transported to a burn center. In contrast to most indoor burn disasters in which few escape, the Volendam fire was characterised by a large number of severely burned escapees 4,8,15. An unusual high number of hospitals participated in the primary care, which required extensive organisation and coordination. Given the relative scarcity of specialised burn facilities, the concept that casualties should be primarily transported from the disaster site to the most appropriate facility is clearly unattainable and secondary spread of the burn victims to burn centers after an overview has been achieved on the entire patient population at stake, is a widely accepted sequence of events 19. However, some feel that each trauma center should include a burn unit 20. The selection of those patients who would benefit most from burn center care, should ideally be performed by burn specialists 21. The B-team functioned well after the primary distribution. They visited most patients and, based on aggregated information, decided afterwards who would benefit most from specialised burn care. However, in the Netherlands, this team had no official status and operated on a voluntary basis. This is in contrast to the United States, where three Burn Specialty Teams are deployed and sponsored by the government 4,22,23.

33 Even a moderately large disaster will fill all available burn beds in a wide area, especially in a small country such as the Netherlands 1. The Volendam disaster is yet another example showing the importance of collaboration between burn centers in different countries 24. Within 24 hours after the incident, about half of the admitted patients were relocated to other hospitals. Controversy still exists about the optimal time of transportation of a burn patient who can be vitally unstable during the first few days following injury 25. Besides transporting patients to burn centers abroad, the choice was made to adapt the criteria for admission in a burn center in order to treat more burn patients in regular hospitals. The results of this procedure and the financial consequences will be reported elsewhere. It still needs to be investigated whether treatment of severely burned patients in regular hospitals influences final outcome and whether this will change the principle of specialised care or not 22. A study on this topic will be reported elsewhere in this thesis. After correction for age, mortality in the entire population was lower than expected in comparison with a group of patients with similar injury severity 26. Both burn centers and regular hospitals were responsible for the care of this young group of burn patients. All patients were given extraordinary attention with frequent inter collegial consultation, both in the Netherlands and abroad. These concomitant efforts probably have lead to this result. Conclusions Due to the mechanism of the Volendam fire a relatively large number of severely injured patients survived, as compared to other indoor disasters. The adaptation of the medical response to this exceptional situation was very challenging. Rapid transportation from the scene was protracted and on scene triage and treatment was performed in suboptimal circumstances. The secondary, interhospital distribution of the patients, coordinated by the burn centers was carried out effectively. The majority of the rescue workers, as well as the medical personnel in regular hospitals were not familiar with the specific demands of the burn patient, but their exceptional dedication, combined with frequent consultation by burn specialists proved effective and many burn patients were successfully treated in both burn centers and regular hospitals. Chapter 2 The café fire, description of events 33

34 References 1. Mackie DP, Koning HM. Fate of mass burn casualties: implications for disaster planning. Burns 1990; 16: Commissie Onderzoek Cafébrand (Commissie Alders). Cafébrand Nieuwjaarsnacht Eindrapport Inspectie voor de Gezondheidszorg. Evaluatie aanbevelingen onderzoek geneeskundige hulpverlening slachtoffers cafébrand Volendam Stuurgroep Medische Evaluatie Ramp Volendam. Medisch Rapport Cafébrand Volendam Cassuto J, Tarnow P. The discotheque fire in Gothenburg A tragedy among teenagers. Burns 2003; 29: Saffle JR. The 1942 fire at Boston s Cocoanut Grove nightclub. Am J Surg 1993; 166: Faxon N.W., Churchill E.D. The Cocoanut Grove disaster in Boston. JAMA 1942; 120: Gill JR, Goldfeder LB, Stajic M. The happy land homicides: 87 deaths due to smoke inhalation. J Forensic Sci 2003; 48: Hart RJ, Lee JO, Boyles DJ et al. The Summerland Disaster. Br Med J 1975; 1: Mackie DP, Koning HM. Fate of mass burn casualties: implications for disaster planning. Burns 1990; 16: Buerk CA, Batdorf JW, Cammack KV et al. The MGM Grand Hotel fire: lessons learned from a major disaster. Arch Surg 1982; 117: Sparkes BG. Treating mass burns in warfare, disaster or terrorist strikes. Burns 1997; 23: Hirshberg A, Holcomb JB, Mattox KL. Hospital trauma care in multiple-casualty incidents: a critical view. Ann Emerg Med 2001; 37: Levi L, Michaelson M, Admi H et al. National strategy for mass casualty situations and its effects on the hospital. Prehospital Disaster Med 2002; 17: O Hickey SP, Pickering CA, Jones PE et al. Manchester air disaster. Br Med J (Clin Res Ed) 1987; 294: Martin TE. The Ramstein airshow disaster. J R Army Med Corps 1990; 136: Allison K. The UK pre-hospital management of burn patients: current practice and the need for a standard approach. Burns 2002; 28: Ashworth HL, Cubison TC, Gilbert PM et al. Treatment before transfer: the patient with burns. Emerg Med J 2001; 18: Marichy J, Chahir N, Peres-Tassart C et al. [Prehospital management of burns]. Pathol Biol (Paris) 2002; 50: Brough MD. The King s Cross fire. Part 1: The physical injuries. Burns 1991; 17: Griffiths RW. Management of multiple casualties with burns. Br Med J (Clin Res Ed) 1985; 291: Boxma H, Dokter J, Welvaart WN. [Use of trauma triage teams at the cafe fire in Volendam]. Ned Tijdschr Geneeskd 2001; 145: Sheridan RL. Burn care: results of technical and organizational progress. JAMA 2003; 290: Arturson G. The Los Alfaques Disaster: a boiling-liquid, expanding-vapour explosion. Burns 1981; 7: