Burns and Fire Disasters - vol. XII - n° 2 - June 1999
FIRE DISASTER AND BURN DISASTER:
PLANNING AND MANAGEMENT
Masellis M., Ferrara M.M., Gunn
Divisione di Chirurgia Plastica e
Terapia delle Ustioni, Ospedale Civico, Palermo Mediterranean Club for Burns and Fire
Disasters - WHO Collaborating Centre
planning and response require ever more scientific elaboration. All phases of the rescue
processneed an efficient managerial system, from prediction and prevention to
preparedness, immediate medical response, assistance, and rehabilitation. Definitions are
given of the various types of disaster. A thermal agent disaster is "a disaster
causing severe losses in liuman lives and material goods as a result of massive heat
production." Burn disaster can be defined as "the overall effect of the massive
action of a known thermal agent on living beings. It is characterized by a high number of
fatalities and of seriously burned patients with a high potential rate of mortality and
disability." Any health management plan in the event of a burn disaster must include:
a) rapid evaluation of the extent of the disaster; b) specific and rapid health assistance
response on site; c) assessment of the capacity of local specialized structures to receive
burn victims; d) selective evacuation of the injured away from the disaster zone. Disaster
plans, like those for any other types of rescue operation, will be no more than empty
words unless they are tested in training programmes, made intelligible to the general
public, supported by adequate resources, and updated as necessary. The acquisition of
emergency capability by ordinary people is a sign of civil and cultural progress, but the
most important factor of all is disaster preparedness.
All disasters, whether flood, earthquake,
cyclone, drought or extensive fire, inevitably cause upheavals not only in the physical
but also in the social and economic context where they occur.
If a disaster is of major proportions, as may be the case in an earthquakes or flood, an
entire region or extensive national territory may be involved.
The study and analysis of factors that cause a disaster, the characteristics that shape
its evolution, the effects on the population and the natural environment, the instruments
that can mitigate their effects, and the various ways of reestablishing the optimal living
conditions of the persons and communities involved have led to the creation of the new
science of Disastrology, which studies disasters from all points of view and establishes
guidelines for their management.
"Disaster medicine" considers the health aspects of disasters, in particular the
study and collaborative application of the various health disciplines involved, i.e., from
paediatrics, epidemiology, communicable disease, nutrition, public health, emergency
surgery, social medicine, community care, humanitarian relief, and international health,
to the prevention, immediate response, and rehabilitation of the health problems arising
from disaster, in co-operation with other disciplines involved in comprehensive disaster
These approaches have led to the scientific elaboration of disaster planning and response.
This has been gradually transformed from a combination of ad hoe and humane actions for
the stricken persons into an efficient managerial system throughout all the phases and
aspects of the disaster, from prediction and prevention to preparedness, immediate medical
response, assistance, and rehabilitation. 2,4
a fire disaster need not necessarily reach catastrophic proportions, it will present some
of the characteristic aspects of a disaster because of the highly destructive action of
fire and of the considerable number of victims. The surviving casualties will have mainly
serious and extensive burns requiring immediate rescue procedures that cannot always be
provided by local resources.
A fire of vast proportions can moreover cause damage to the surrounding environment by the
massive production of heat and the emanation of burn gases and fumes. 5
Smoke and gas, because of their suffocating action and their direct action on the airways,
represent other specific danger elements. The danger of smoke and gas is generally
underestimated by the population.
One factor that makes all fire disasters dramatic is panic. Anybody close to a sudden fire
is affected by panic. This is due to the realization that the fire can kill within a few
moments, cause injuries and permanent disfigurement, and inexorably destroy everything in
the vicinity. When a violent fire breaks out, there is an initial moment of psychological
paralysis, generally followed by total incapacity for logical thought, and this leads to
instinctive behavioural reactions whose one aim is to save oneself and all that is most
dear, and reach safety. 6
This sequence of actions not infrequently serves only to worsen the extent of damage
caused and to create an even more dramatic and tragic situation. In animals this may
indeed be the only reaction possible, which is purely instinctive, but in man there is
another option which at first sight may seem almost paradoxical: to keep calm and take
rational decisions. This can be achieved only in one way: through information about the
risks involved, through understanding of the dangers, and through instruction about how to
behave in case of fire.5,6
A fire disaster has very special characteristics if one considers the particularities of
the causative agent and the type of damage it produces in living beings. When fire comes
into contact with objects and materials it burns or destroys them in a relatively short
The action of fire on a living organism can be lethal within a few seconds. In man, if not
immediately lethal, fire determines a pathological condition, the burn, which is
considered to be the most complex trauma that can strike the human body. 5,6
For the above reasons, burn disaster management must, besides prevention, be mainly
directed towards planning and application of measures necessary to mitigate the damage
caused to man, to prevent its aggravation, and to promote healing.5,6
It is therefore useful to bear in mind some specific aspects of a fire disaster, briefly
summarized as follows: 5
Thermal agent disaster, burn disaster
- the number of persons involved is
- the burns tend to be extensive,
and the general condition of the victims precarious;
- the burn is often associated with
other serious pathologies, such as wounds, fractures, electrocution, and blast or
- hypovolaernic shock, a
characteristic feature in the first phase of the burn illness, as early as within three
hours of the trauma, induces a state of tissue hypoxia, with irreversible damage to the
various organs and systems; the time interval between the burn accident and initiation of
resuscitatory therapy must be less than two hours;
- the inhalation of combustion
gases, fumes, and hot air causes damage to the airways and this alone can jeopardize
- the place where the disaster
occurs is not always easily accessible, and speedy care and assistance may be inadequate;
- triage in loco of the
victims must be carried out by specialists, as only experts are able to evaluate the
immediate gravity of the burn and the measures to take;
- besides the number of dead, the
overall assessment of the severity and damage must be made on the basis of the number of
persons in a condition of potential mortality and severe risk of disability;
- the rapid assessment and care of
the viable and potentially curable victims is paramount.
light of the above considerations, and in order to have at our disposal precise points of
reference as regards the management of rescue operations, in 1990 we proposed to
differentiate precisely the two concepts of "thermal agent disaster" and
"burn disaster". Although these two concepts are linked by the common
denominator of heat, they refer to events which, in view of the different darnage caused,
require operational rescue phases with differing commitments. We propose the following
The plan for disasters
Gunn Multilingual Disaster Dictionary defines in global and concrete vision the
term Disaster management as follows: "all phases of prevention, planning,
preparedness, training response, relief, rehabilitation and reconstruction of a major
emergency or disaster situation".1,5
Thermal agent disaster: a disaster causing severe losses in human lives and
material goods as a result of massive heat production. This definition expresses the
relationship between a generic cause of the event (massive heat production) and the
consequences for human beings and material goods. It is an exclusively mathematical
expression of the damage caused, i.e. of the number of the dead and injured, and the
extent of damage to material goods.5,6
Burn disaster can be defined as the overall effect of the massive action of a known
thermal agent on living beings. It is characterized by a high number of fatalities and of
seriously burned patients with a high potential rate of mortality and disability. Its
extent may be aggravated if appropriate rescue operations are delayed. Some decisive
factors involved here are the type of causal agent, the type of pathology caused, the
overall characteristics of the harmful action of the thermal agent, the immediate
evaluation of its gravity in relation to emergency care, and the modalities of rescue
In burn disaster, two concepts are therefore involved: the pathological condition, i.e.
extensive burns, as well as the high number of persons injured. Its extent depends on the
potentially high number of fatalities, which is related to the considerable number of
persons involved, the seriousness of their condition and, above all, the early initiation
of emergency therapy. 2,5
The formulation of two different definitions of "burn disaster" and
"thermal agent disaster" proves useful at both the didactic and the operational
levels. The formulation in fact allows a clearer understanding of the two events in the
vast chapter of disasters; it offers more specific indications for drafting of
preparedness plans and alerting and management of the problems connected with the
emergency; and lastly it suggests a more effective programme for the mitigation of human
The planning of health management of a disaster must take into account the results of
studies on the risks that can cause them and on the predictable damage in the environment
and human population.7,14
Planning must therefore indicate what instruments are necessary to prevent, avoid, or
reduce the immediate effects on the population and on society (physical suffering,
disability, life-endangering trauma, hospital conditions). All this must be related as far
as possible to every kind of expected pathology: there must be adequate programming for
every kind of disaster, i.e. specific responses in health, communication networks,
transport of casualties, use of medical and nursing personnel, management of resources. 2,5,6 Everything must be planned with a view to effective
preparedness for the event. Plans must also take into account measures necessary for the
most rapid return to normal conditions for the affected population.
In this way planning will have a more scientific approach, because it will not be mainly
dependent on the actual disaster but rather on the results of predictive studies of the
causes and risks of disasters, on studies regarding the prevention of potential damage to
the population, on emergency responses to the damage that has occurred, and on action to
restore conditions of normality. 2,6,7,8,9,10,11,15,16
The plan for burn disaster
drafting of an operational rescue plan for a burn disaster cannot fail to take into
account two points:
- the victim's pathological picture,
i.e. the presence of extensive burns, inhalation lesions, and polytrauma;
- the type of intervention required.
Plans must be
developed along three lines: immediate care; medical rescue within three hours; use of
specific equipment and means for the rescue of the burned patient.
The timeliness and the effective impact of relief work depend on both general and local
factors. In the particular case of "burn disaster", as defined earlier, the
particular circumstances - such as the moment when the disaster occurs (e.g. night,
daytime, public holiday, weather conditions), the place of the disaster (residential area,
skyscraper, night club, isolated locality), the degree of accessibility, the distance from
operational rescue forces - all acquire importance because any delay will prevent relief
work from being immediately available. 5,6
A decisive role is therefore played also by local
intervention factors that chiefly depend on the behaviour of the people present at the
scene of the disaster and on the speed and action of the operative teams that arrive on
the scene. 5,6
The peculiar nature of the
burn disaster therefore dictates well-defined chronological and qualitative operative
phases. A person with burns of the airways and associated trauma needs immediate care of a
different type from that given to the victim of an earthquake, flood, or cyclone. It is
also of fundamental importance, for prognostic reasons, that pending the arrival of
organized relief some medical and/or surgical first aid be given within a very short time,
according to the type of lesion present.2,4,6,17,18,26
For the above reasons the
basic points of any health management plan in the event of a burn disaster must include:
- rapid evaluation of the extent of
- specific and rapid health
assistance response on site
- assessment of the capacity
of local specialized structures to receive burn victims
- selective evacuation of casualties
from the disaster area.
evaluation of the extent of the disaster
rapid evaluation of the extent of a burn disaster is essential for calculating the size of
the rescue forces that need to be involved (teams operating on the spot, teams brought up
to the operative area, local first-aid units, regional/interregional/intemationaI units,
etc.) for health assistance to the injured.19
The death of 25-30 persons indicates a burn disaster of very severe proportions,
especially considering the high number of additional burn patients that can be expected.
A burn disaster certainly requires specific management as local rescue forces are most
often unable to cope with the initial health impact and conditions are unequal: consider
that in the event of a disaster in an urban area the resources available may be greater
than those available in a rural or isolated area; but it should not be forgotten that
faced with a high number of burn victims even the most sophisticated Burns Centre may
When a burn disaster causes hundreds of burn casualties it may be necessary to call on not
only regional and interregional health forces but also national and international
organizations. Link-ups with international organizations, with their specific experience
in this type of rescue work, must be included in disaster management planning. 2,20,21
The number of dead and injured, the
types of pathology involved, the availability on the spot of material and personnel
capable of providing assistance, local environmental conditions as regards access to the
disaster area - all these factors are essential information for the assessment of the
initial gravity of a disaster.
The persons on the spot, who provide immediate aid, must be able to provide rapid
information on local conditions and the extent of the disaster for the use of local
authorities in charge, i.e. fire brigades, police, etc. These will in turn send the alert
to local hospitals, specialized centres, ambulance services, helicopter rescue, etc.19
All these persons must be able to assess, even if only approximately, the time necessary
for the arrival of fullscale first-aid support.
A more accurate assessment will be possible later when the first experts arrive on the
scene, e.g. the fire brigade. The real extent of the disaster can then be notified to the
operation control centres.
Specific and rapid health assistance response on site
distinct phases can be defined in rescue operations: immediate care, medical first aid,
and organized relief. 5,6
1. Immediate care. This is provided by persons present at the scene
of the disaster: relatives, friends, passers-by, uninjured survivors - all persons who
witness the disaster or who arrive immediately on the scene. Generally speaking, their
help is an automatic reaction derived from affection, friendship, and a spirit of human
In the event of burn disasters, in particular, it is important that the first people to
provide assistance should be fully aware of what they have to do.2
The behaviour of the rescuers in immediate care can be summarized as follows: 2,4
- Reduction of the fire
- Extraction and transfer of victims
to the open air
- Appropriate action when clothing is on tire
- Removal of burning clothing
- Emergency treatment of burned areas
- Knowledgeable action pending more complete relief
- Dealing with chemical burns
- Dealing with electrical burns
To acquire the
necessary experience and know-how, rescue teams must have attended specific training
courses, taken part in civil defence and disaster simulation exercises, and attended
emergency health courses for persons of all backgrounds and ages, starting from school
2. Medical first aid. This refers to the action of trained persons
present in the immediate vicinity who have already received experience in rescue
operations and who organize and go into action very rapidly, within 2-3 hours. They may be
physicians, nurses, EMS paramedics, members of voluntary organizations, etc. They are
supported by public and private organizations in the area - hospitals, casualty
departments, clinics, fire brigade, police, etc. - co-ordinated by the local authorities. 5,6,22
The occasional rescue workers must be able to perform, even if only in summary fashion, an
initial assessment of the damage that has occurred and activate the first triage
In a disaster with great numbers of burn patients and other casualties occurring in a
rural or isolated area, with predictable delays in the arrival of the first rescue
workers, the persons present on the spot should mark out a safe place as an area for
assembly of the injured. This area should be accessible to vehicles already in the
vicinity or on their way (ambulances, helicopters, private cars, etc.). This will
facilitate the task of the first rescue workers who arrive as they will be able to proceed
immediately to their task and perform initial triage and initial resuscitatory treatment.5,6
The authorities provide guidelines on specific stockpiles
in convenient locations, the management of ambulance services, traffic control, the use of
local and regional mass media, general means of transport, and other relevant services.5
The kind of trained assistance provided by these first rescuers is of primary importance
for the prognosis of the casualties. They must carry out the first triage of urgent cases
and the many polytraumatized patients. Given the particular evolution of burn disease,
particularly worsening hypovolaemic shock, they must also initiate all medical and
surgical procedures necessary for preliminary resuscitatory therapy and the initial local
treatment of burns.
6,15,17,23,40,41 These first-aid groups could be supported by other teams of
physicians, nurses, and specialized technicians with appropriate equipment for the
specific care of burn patients. These teams, sent in by air, would represent an outpost
for organized relief when it arrived. 6,14,25
It must be stressed that it is of fundamental importance
that the particular procedures regarding both medical assistance and general behaviour,
which rescue workers have to carry out, must be based on specially prepared protocols
publicized through information media, education campaigns, refresher courses, and training
sessions aimed at citizens of every social group, starting at school age. 6
The following are ten points that these medical firstaid teams must follow: 6
- Immediate triage of all victims
- Inspection of the upper airways
- Qualitative assessment of the
- Quantitative assessment of the
- Intravenous resuscitatory therapy
- Analgesic therapy
- Bladder catheterization
- Pressure-relieving incisions
- Examination of the patient with
particular attention to respiratory capacity
- Hospital transfer
relief. This refers to the mobilization of all civil defence, military and volunteer
forces that are ready to intervene in the event of a large disaster. These forces arrive
on the site as rapidly as possible, but mostly not within the first three hours, equipped
with the necessary means and structures able to perform rescue action within the first
48-72 hours after the disaster, until all the wounded have been evacuated. These units
will be involved in triage of the victims, i.e. stabilization of the condition of serious
victims, separating the less injured, preparing a preliminary evacuation plan, contacting
dispatching stations, selecting means of transport, organizing first-aid posts, and
clearing the dead. 5,19,25,41
Such forces are used less now due to increased rapid air
Air transport is also the rule in maxi-emergencies or when the disaster occurs at some
distance from urban areas, with large numbers of casualties necessitating extensive triage
and complex evacuation problems. 26
Specialized triage can save human lives, facilitate a more functional evacuation of the
injured, and make more rational use of specialized bed availability. Triage must bear in
mind prognosis. Absolute priority is given to injured persons who will die unless treated.
Those injured persons who will survive even without therapy, and those who will die even
if treated, are given second priority.
In other words, the priority of casualty selection in a disaster is radically different
from the priority followed in normal rescue conditions, where the most seriously injured
are given priority, whatever the prognosis. 14,19,21,22,26,28,38
Burn casualty triage is conditioned by the number of
patients, the gravity of the burns, the age of the patients, the presence of respiratory
complications, and the availability of beds.
In burn disasters, it is useful to distinguish action for patients according to gravity
- Minor burns/noncritical sites
(<10% TBSA for children; <20% TBSA for adults): dress wound; tetanus prophylaxis;
- Minor burns/critical sites (hands,
face, perineum): admit, early operation, special wound care, short hospital stay.
- 20-60% TBSA: burns unit, trained
personnel; requires intravenous fluids/careful monitoring.
- Extensive burns (>60% TBSA);
- Minor burns/inhalation
injury/associated injuries; administer oxygen, measure carboxyhaemoglobin and/or intubate,
ventilate, care of injuries.
suggest simplifying triage by the use of certain flexible formulas. For example, the
gravity of burns can The expressed in terms of extent and age: where the sum of the age
and extent of burns is greater than 90, there is an empirical 50% chance of survival. By
extending this number up or down, depending on the overall situation, one can increase or
narrow the number of burn casualties who ought to be transported first.19
Triage must be looked upon as a continuous and dynamic process.
It begins on the spot and continues wherever the patients are transferred. A second level
of triage may be performed in a decentralized, safer area, where casualties have been
assembled, for example outside a hospital. A third level may be necessary in the hospital
itself before sending on patients to the specialist treatment units. 12,19,27
Once the patients have been selected on the basis of the
gravity of their condition, they should be labelled with cards or other clearly
recognizable means of identification in relation to the priority of health care.
Burn victims should never be marked on the skin with visible signs or by the application
of adhesives to the forehead.
A widely adopted method is to attach tags of various colours, in relation to priority of
health care and critical condition. There is no standard system but the following is quite
- red tag = immediate treatment for
very serious lifeendangering lesions
- green tag = secondary priority
with urgent but stable trauma
- yellow tag = less urgent lesions
- black tag = deceased or fatal lesions
some disagreement as to the use of coloured tags. Some use a higher number of categories
in order to avoid problems in the second and third phases. Others believe that this system
can work satisfactorily only in urban rescue conditions, and that its use is debatable in
disasters in rural areas. 27,28
Language and cultural differences also complicate their use on the international level.
The Pan American Health Organization of WHO uses a colour system: 27,30
- Red tag = First priority for evacuation: burns complicated
by injury to the air passages.
- Green tag = Second priority for evacuation: seconddegree
burns covering >30% T13SA; third-degree 10% T13SA; burns complicated by major lesions
to soft tissue or minor fractures; third-degree burns involving such critical areas as
hands, feet or face but with no breathing problem present;
- Yellow tag = third priority for evacuation: minor burns,
second-degree covering less than 15% TBSA; third-degree <2% TBSA, first-degree <20%
TBS/ excluding hands, feet and face;
- Black tag = dead.
C) Assessment of the capacity
of specialized and nonspecialized structures for the treatment of burn victims
planning of burn disaster management must include the following:
- mapping of hospital
facilities, private clinics, and reanimation and emergency centres in the entire region; 31
- list of the larger hospitals in the region having burn
centres, including bed capacity;
- list of smaller regional hospitals with burn unit,
including bed capacity;
- indications for the use of
regional data banks used by the provincial and regional emergency health services. Inter
alia, these give information on the availability of beds by sectors and by type of
emergency, updated periodically. In some countries this aspect is already operational,
e.g. INFOBRUL in France; NDMS in the U.S.; Argo in Italy; 32,33
- guidelines for the use of specialized and nonspecialized
hospital structures (interregional, national, and international) for the organization of
transport and transfer of casualties in disaster emergencies;
- guidelines for the internal organization of hospital
facilities in the event of disaster, including fire disaster.
hospital must be ready to set up an Emergency Co-ordination Operational Centre responsible
- making available
specialized and non-specialized beds and organizing patient transfers and discharges on
the basis of predictions of mass arrivals of injured and burned patients; 8,9,17,34-37
- organizing emergency rota systems for medical and nursing
- organizing a central collection point for new victims
arriving in order to organize a second triage;
- organizing availability of operating rooms and beds
(especially for respiratory reanimation), out-patient rooms, and areas for less serious
patients requiring local burn treatment and therefore internal means of transport;
- alerting laboratory and analysis services, radiology, blood
- alerting pharmacy services and laundry for supplies of
medical and surgical material;
- arranging consultancy services with other departments
(neurosurgical, ophthalmic, orthopaedic, pneumological, paediatric, etc.);
- organizing an office for contacts with patients' relatives
- organizing an office for
contacts with foreigners, if any are involved, to help them with language problems and
bureaucratic matters related to the repatriation of the dead and injured; 20
- organizing an office for press relations in order to supply
up-to-date reliable information on the evolution of the disaster and the conditions of
patients, issuing medical bulletins at intervals;
- organizing a liaison office with civil defence operative
centres, fire service, police, provincial and regional emergency health services,
helicopter rescue service, and other hospital facilities;
- collaborating with the
Chief of the Burns Centre or Burns Unit in order to integrate nursing personnel on the
spot, with a view to optimal distribution of burn patients in the various departments and
to the despatch, if necessary, of more personnel to the scene of the disaster.
Selective evacuation of casualties from the disaster area
certainly the most complex phase on both organizational and operational grounds.
Selective evacuation depends on three factors:
- quality of triage already done (and continuing) on the spot;
- the means of communication with the disaster area;
- availability of transport for the injured.
As specialized burn care centres are few and far between and their
beds are nearly always all occupied, the first phase of triage is of vital importance for
orderly evacuation of the injured and rational use of beds. Triage, particularly after a
burns disaster, must be as specialized as possible, dynamic, and give priority for
transfer of patients who need stabilizing, resuscitatory therapy and attention to
conditions quoad vitam. This clearly concerns the majority of the patients. Such
procedures will facilitate the task of the physicians in the reception centres.
Triage is not static; the need for further careful triage can be related to the high
number of burn patients, the evolution of the victims' condition, or the lack of
experience or specialized personnel on the spot. This will lead to risky and less accurate
evacuation of casualties.
The "load and go" evacuation system must never be used, especially in burn
disasters. It causes great hold-ups in transport, a chaotic use of specialized beds, and
considerable risks for patients who receive resuscitatory treatment only after long
The efficiency of the communication system is of great importance
here. If the fire and police services are not immediately alerted following the disaster,
the entire rescue operation risks being delayed and jeopardized.
Disaster planning must give precise indications as to how to organize immediate and
uninterrupted links between the disaster zone, especially if this is not in an urban area,
and the operating centres of the fire brigade, police force, emergency health services,
hospitals, and civil defence. 19,33
Efficient communications are imperative in order to follow the initial phases of a
disaster, which require co-ordinated and rapid responses in every aspect.
Apart from normal communication services (telephone, fax), there must be radio links with
the EMS, local and national police, fire brigade, voluntary organizations, regional
emergency services, the army, and helicopter rescue.
Efficient communications between the disaster area and specialized local structures will
also make it possible to activate, pending the arrival of specialist teams, a system of
medical radioconsulting to initiate emergency resuscitatory treatment. Experience from
previous disasters and civil defence drills has highlighted the serious difficulties that
occur in road connections between the disaster area and immediate response operating
centres and hospitals. This can be avoided by isolating the affected area and creating a
direct approach route for the arrival and departure of ambulances and rescue teams.
Particular care must be taken to control the influx of family members and bystanders.
Traffic jams and other hold-ups will occur if the main access routes are not kept clear.
The rational evacuation of burn disaster victims is closely related
to the condition of the injured, to their numbers, to the type and number of transport
available, to the distance to be covered, and to the availability of facilities at
destination.37 Land transport is to be preferred if the
patients' condition is stabilized and requires only maintenance treatment, the roads are
free, and properly equipped ambulances are available. 39
Planning must include a census of all ambulances, the public and private emergency health
services in the territory, and the type of assistance they can provide in transit.
Patients with minor burns and light trauma who are able to walk can use buses, private
cars, and covered trucks and lorries (these have to be requisitioned).
If greater distances have to be covered in a limited time, air transport will have to be
used. The most practical means is the helicopter, although its use depends on appropriate
weather and visibility conditions and on the presence of landing strips in the area. 26,38
A census of fixed-wing aircraft and helicopters available in the region makes it possible
to have updo-date information on the number of air facilities and the time necessary for
their arrival on site.
Such aircraft should offer resuscitation systems on board and be equipped for the
transport of stretchers, patients, and medical and normal passengers.
Aircraft with resuscitation systems are used for the transfer of burn patients with
life-threatening conditions, in a grave toxic state, and requiring a transport time of
less than 60 minutes.
Aircraft should also be used for patients with stabilized conditions requiring
resuscitatory therapy in flight and who have to cover greater distances to reach
specialized centres. In maritime areas rapid boat ambulances are helpful.
Other means can be used for the evacuation of less seriously injured persons and to
transfer specialist teams and first-aid material to and from the disaster area.
We have several times mentioned prediction and prevention of
disasters, planning, management, the need for an effective response to disaster, and the
appropriate measures for restoring normal living conditions. We have stressed the need for
specific training in health management, particularly in burn disasters and public
education as regards immediate aid. We have also referred to the responsibilities of the
community in guaranteeing effective and efficient technical health services for immediate
rescue operations and for the restoration of basic living conditions after the disaster.1,2,21
All this, translated into operative terms, means "preparedness", which is
defined as: "The aggregate of measures to be taken in view of disasters, consisting
of plans and action programmes designed to minimize loss of life and damage, to organize
and facilitate effective rescue and relief, and to rehabilitate after disaster.
Preparedness requires the necessary legislation and means to cope with disaster or similar
emergency situations. It is also concerned with forecasting and warning, the education and
training of the public, organization, and management, including plans, training of
personnel, the stockpiling of supplies, and ensuring the needed funds and other resources.
In order to be effective, disaster management must therefore be based on serious
The more appropriate and realistic this is, the more valid will be the combination of
actions to prevent, to diminish the risk, and to reduce the harmful effects of disasters.
The technical and managerial progress achieved in recent years is undeniable.
Sophisticated methods, instruments, experience, and research have made possible the
science of Disastrology, which is already proving useful in natural and man-made
disasters. It is now more possible to reduce and mitigate their effects, and even to
prevent some of them.
One of the ways to reach this goal is training: training of the population at large and
training of specialists.
In the past, the traditional response to disasters has been more of chance and goodwill
than of knowledge. While an expression of personal, national, or international solidarity
has often brought comfort to stricken populations, the effective results have usually been
hampered by a lack of trained personnel at all levels.
The citizen has to be trained to know what to do and when and how to do it.
The procedures initiated to assist the victims of a burn disaster, either by the first
rescuer present on the spot or by the better-organized relief forces arriving soon after
on the scene, are of paramount importance.
In fire disasters, all assistance to exposed persons or who have extensive burns must be
specific, precise, considered, and timely.6
At the same time rescuers must protect themselves against the risks of fire and be fully
aware of the difficulties they face when saving fire victims.
Health education and training programmes thus acquire particular importance. These have to
tackle three aspects of disaster:
the operational aspect,
concerned with coordinated and effective relief, ranging from self-relief to immediate
assistance and specific first-aid measures. 5,6
- the technical aspect, aimed at the nature and extent of the damage caused by the fire
and of the immediate behaviour of the people directly involved
- the clinical aspect, assessing the extent of the trauma to the person, the deterioration
in the various phases of the burn, and the specific type of therapy these call for
The implementation of these plans must follow welldefined programmes of
teaching at school, starting from primary school level, through educational civil defence
courses, periodic refresher courses for physicians, nurses, volunteers, Red Cross, Red
Crescent, fire brigade, police, etc.1 as well as periodic exercises with simulated fire
disasters, with the involvement of the general population and the local rescue services. 2,4-6,22,30,34,39
Particular attention must be paid to the teaching methods. These must be effective and
suitable for separate age and social groups. In addition to illustrated brochures,
stickers, colouring alburns, posters, and notices, etc., various audiovisual means, in
particular videotapes, have been successful. These re-create and simulate situations, and
propose actions for the assistance of the victims.5,6
A simple user-friendly interactive computerized medium using the most advanced techniques
has been developed with regard to prevention of, and action in, fire disasters.42
The clear advantages of this instrument over traditional training methods (conventional
audiovisual courses and those based on the use of printed texts or photographic material)
derive from the dynamic interaction between the user and the learning instrument and from
the multimedia presentation of the learning material. Recent research on leaming capacity
has in fact shown the importance of interaction in the training instrument. Most people
are able to learn 50% of what they hear and see at the same time, while they can learn 90%
if they can themselves, at will, re-see and re-hear the material. 2
Multimedia presentation with audio, video, written text, and graphics of a subject
provides ingenious ways of gaining the user's attention and achieving greater learning
effectiveness than the usual mono-medium message. Clearly such systems, which are
essential not only for prevention but also for teaching, may become fundamental in
refresher courses. Thus, several universities and educational institutes in various
countries have set up efficient training courses for disasters. At the European Centre for
Disaster Medicine in San Marino courses are conducted on disaster health, on management at
the Asian Disaster Preparedness Centre in Addis Ababa, at the Pan American Health
Organization in Washington, and elsewhere. 42
The Mediterranean Club for Burns and Fire Disasters - the WHO Collaborating Centre for
Prevention and Treatment of Burns and Fire Disasters - organizes annually specialized
training courses on burns and fire disasters in each country of the Mediterranean area. 42
Scientific investigation generates its own language and literature. Serious periodicals
are now published, such as the quarterly Prehospital and Disaster Medicine by the
World Association for Disaster and Emergency Medicine, the Natural Hazards Observer by
the University of Colorado, and the Annals of Burns and Fire Disasters by the
Mediterranean Club for Burns and Fire Disasters.
Books have been written on general or particular aspects of preparedness and co-ordination
by Erik Aufder Heide; Industrial Emergency Preparedness by Robert Kelly; Guide
to Emergency Planning by the Society of Industrial Emergency Services Officers; and The
Management of Mass Burns Casualties and Management ofBurns and Fire Disasters -
Perspectives 2000 by Masellis and Gunn. 2
Many international societies on burns, such as ISBI and EBA, and national societies should
be interested in such programmes for training.
The Disaster Committees of various international organizations should establish links
among themselves in order to create continual contacts for the management of international
courses on disasters. This would help eliminate language, conceptual and operational
barriers and harmonize the international response, especially in maxiemergencies.
To conclude, it will be sufficient to repeat some basic concepts:
planification pour les désastres et l'organisation de la réponse nécessitent une
élaboration de plus en plus scientifique. Toutes les phases des secours ont besoin d'une
gestion efficace depuis la prévision et la prévention jusqu'à la préparation, la
réponse médicale immédiate, l'assistance et la rééducation. Les Auteurs fournissent
des définitions des divers types de désastre. Le désastre d'agent thermique est
"un désastre qui cause de sévères pertes en termes de vies humaines et de biens
matériels comme résultat de la production massive de chaleur", tandis que le
désastre de feu peut être défini comme 'l'effet total de l'action d'un agent thermique
connu sur les personnes. Il est caractérisé par le nombre élevé des personnes
décédées et des personnes gravement lésées avec un taux potentiel de mortalité,
d'invalidité très élevé". Tous les plans pour la gestion sanitaire en cas de
désastre de feu doivent inclure: a) une évaluation rapide de l'ampleur du désastre; b)
les secours sanitaires spécifiques et rapides sur-le-champ; C) l'évaluation de la
capacité des services spécialisés locaux pour recevoir les patients brûlés; d)
l'évacuation sélective, loin de la zone du désastre, des personnes lésées. Les plans
pour les désastres, comme les plans pour tous les types des opérations de secours,
n'auront aucune valeur s'ils ne sont pas testés dans les programmes de formation, rendus
intelligibles pour toute la population, soutenus par des resources adéquates, et mis à
jour selon les nécessités. L'acquisition par la population de la capacité d'affronter
les désastres est un signe de progrès civil et culturel, pourtant, le facteur le plus
important est la préparation.
Gunn S.W.A.: Multilingual
Dictionary of Disaster Medicine and International Relief. Kluwer Academic Publishers,
Gunn S.W.A., Masellis M.:
The scientific basis of disaster medicine. Ann. Medit. Burns Club, 5: 51-4, 1992.
Gunn S.W.A.: La m6dicine
des catastrophes - Une nouvelle discipline. Helv. Chit. Acta, 52: 11-13, 1985
Konigova R.: Ethical
problems in mass disaster. Ann. Medit. Burns Club, 6: 190-2, 1993.
Masellis M.: Thermal agent
disaster and fire disaster: Definition, damage, assessment and relief operations. Ann.
Medit. Burns Club, 4: 215-8, 1991.
Masellis M., Ferrara M.M.,
Gunn S.W.A.: Immediate assistance and first aid on the spot in fire disaster - education
of the public and self-sufficiency training. Arm. Medit. Burns Club, 5: 200-6, 1992
Masellis M., laia A.,
Sferrazza Papa G., Pirillo E., D'Arpa N., Cucchiara R, Sucameli M., Napoli B., Alessandro
G., Giami S.: Fire disaster in a motorway tunnel. Arm. Burns and Fire Disasters, 10:
Arturson G.: The Los
Alfaques disaster: a Boiling Liquid Expanding Vapour Explosion. Burns, 13: 87-102, 1987.
Arturson G.: The tragedy of
San Juanico - The most severe LPG disaster in history. Burns, 13: 87-102, 1987.
Ciambelli R, Bucciero A.,
Maremonti M., SaIzano E., Masellis M.: The risk of transportation of dangerous goods:
BLEVE in a tunnel. Arm. Burns and Fire Disasters, 10: 241-5, 1997.
Viala B.: Risque chimique
en milieu souterrain. Ann. Burns and Fire Disasters, 10: 50-3, 1997.
Dioguardi D., Brienza E.,
Portineasa A., Di Lonardo A., Matarrese V.: A proposal for the strategic planning of
medical services in the case of major fire disasters in the city of Bari. Ann. Medit.
Burns Club, 2: 147-50, 1989.
Cannata E., Masellis M.:
Study of an emergency plan in the event of a violent fire in a high-rise building. Ann.
Medit. Burns Club, 2: 151-4, 1989.
Barclay T.L.: Planning for
mass burns casualties. In: Wood C. (ed.), Accident and Emergency Burns: Lesson from the
Bradford Disaster, Proceedings of extended panel discussion held in Bradford 1985. Royal
Society of Medicine Services, 81-8, 1986.
Arturson G.: Analysis of
severe fire disasters. In: Masellis M., Gunn S.W.A. (eds): The Management of Mass Burn
Casualties and Fire Disasters, Kluwer Academic Publishers, Dordrecht/Boston/ London,
Iliopoulou E., Lochaitis
A., Komninakis E., Poulikakos L., Asfour S., Chalkitis S., Tzortzis C.: Mass disasters in
Greece. Ann. Medit. Burns Club, 7: 36-9, 1994.
Masellis M.: Management of
burn casualties in disasters. Ann. Medit. Burns Club, 1: 155-9, 1988.
Vitale R., D'Arpa N., Conte
F., Cucchiara P., Guzzetta C., Masellis M.: Clinical file and protocol for general doctors
and for nonspecialized hospital doctors to assist burn patients. In: Masellis M., Gunn
S.W.A. (eds): The Management of Mass Burn Casualties and Fire Disasters, Kluwer Academic
Publishers, Dordrecht/ Boston/London, 198-221, 1992.
Magliacani G.: Mass burn
rescue operations: Organization and medicosurgical therapy. Ann. Medit. Burns Club, 2:
Fonrouge J.M.: Les
problèmes posés par le franchissement des frontières par des patients anonymes lors des
catastrophes de grande ampleur. Ann. Burns and Fire Disasters, 6: 267-2, 1993.
Gunn S.W.A.: Emergencies:
Regional approaches to global problems. Ann. Medit. Burns Club, 2: 143-6,1989.
Flaujat A., Maille P.:
Organisation des secours d'urgence. Ann. Medit. Burns Club, 6: 116-9, 1993.
Mazzoleni F.: Therapeutic
priorities in fire disasters. Ann. Medit. Burns Club, 1: 152-4, 1988.
Caruso E., Crabai P, Donati
L., Klinger M., Garbin S., Zaza R.: Ready-to-use emergency kit for treatment of severe
burns: Definition and specifications. In: Masellis M., Gunn S.W.A. (eds), The Management
of Mass Burn Casualties and Fire Disasters, Kluwer Academic Publishers, Dordrecht/Boston/
London, 239-42, 1992.
Buccetti R.: First-aid
organization in burn accidents within the Military Region of Sicily. Ann. Medit. Burns
Club, 1: 160-4,1988.
Santos FX, Sanchez Gabriel
J., Mayoral E., Hamman C., Fernandez Delgado J.: Management protocol of burn patients
during air evacuation. Ann. Burns and Fire Disasters, 8: 236-9, 1995.
Zeballos J.L.: Triage in
disasters. In: Further aspects of disaster medicine, Heresu Publishing Co. Inc., Tokyo,
Champion H.R.: Assessment
and triage. In: Medicine for Disaster, Baskett P. (ed.), 1990.
Kossmann T., Wittling L.,
Buhren V., Sutter G., Trantz 0.: Transferred triage to a level of Trauma Center in a mass
catastrophe of patients, many of them burned. Acta Chirurgiae Plasticae, 33: 145-50, 1991.
Pan American Health
Organization: Health Service Organization in the Event of Disaster. Scientific Publication
N. 443, Washington, D.C., 24-25, 1983.
Dioguardi D., Brienza E.,
Altacera M.: The role of information sciences in the management of disaster. Ann. Medit.
Burns Club, 1: 165-7, 1988.
Costagliola M., Laguerre
J., Rouge D.: Infobrul - The value of a telematic databank for burns and burns centres in
the event of a disaster. In: Masellis M., Gunn S.W.A. (eds), The Management of Mass Burn
Casualties and Fire Disasters, Kluwer Academic Publishers, Dordrecht/Boston/London, 190-4,
Martinelli G.: The ARGO
satellite system: A network for severe burns and disasters. In: Masellis M., Gunn S.W.A.
(eds), The Management of Mass Burn Casualties and Fire Disasters, Kluwer Academic
Publishers, Dordrecht/Boston/ LondoD, 7-12, 1992.
Masellis M., Di Stefano F.,
Colletti P., Pirillo, E.: Mass burns in Sicily? Logistic welfare organization in relation
to the regional burn centres and to the operating of military sanitary structures. Riv.
Ital. Chit. Plast., 13: 174-80, 1974.
Servais J.M.: Fire
emergency in a hospital. In: Masellis M., Gunn S.W.A. (eds), The Management of Mass Burn
Casualties and Fire Disasters, Kluwer Academic Publishers, Dordrecht/Boston/ London,
Aburel V., Visa I.,
Grigorescu D.: The 1979 fire disaster (93 casualties) in Brosov, Romania: the importance
of rapid transport and unitary treatment in a hospital. Ann. Medit. 13 ums Club, 8: 30-5,
Hadjiiski 0., Dimitrov D.:
Organization and transport in mass burn disasters. Ann. Burns and Fire Disasters, .11:
Santos Heredero FX:
Physiopathology of burn disease during air evacuation. In: Masellis M., Gunn S.W.A. (eds),
The Management of Mass Burn Casualties and Fire Disasters, Kluwer Academic Publishers,
Dordrecht/Boston/ London, 243-5, 1992.
Konigova R.: System of
postgraduate training in burn emergencies in Prague. In: Masellis M., Gunn S.W.A. (eds),
The Management of Mass Burn Casualties and Fire Disasters, Kluwer Academic Publishers,
Dordrecht/Boston/, 140-4, 1992.
Di Salvo L., Vitale R.,
Masellis M.: Therapeutic kit and procedures for fluid resuscitation in disasters. In:
Masellis M., Gunn SW.A * (eds), The Management of Mass Burn Casualties and Fire Disasters,
Kluwer Academic Publishers, Dordrecht/Boston/ London, 231-8, 1992.
Brienza E., Madami L.M.,
Catalano F., Del Zotti M.: Organizational criteria for setting up a field hospital after a
fire disaster. In: Masellis M., Gunn S.W.A. (eds), The Management of Mass Burn Casualties
and Fire Disasters, Kluwer Academic Publishers, Dordrecht/ Boston/London, 195-7, 1992.
Gunn S.W.A., Masellis M.:
The World Organization Centre for Prevention and Treatment of Burn and Fire Disasters: The
Mediterranean Club for Burns and Fire Disasters. Ann. Burns and Fire Disasters, 11: 3-6,
|This article was received
on 18 June 1998.
Address correspondence to Prof. Michele Masellis,
Divisione di Chirurgia Plastica e Terapia delle Ustioni,
Ospedale Civico, Via C. Lazzaro, 90127 Palermo, Italy.
Tel.: +39 091666 36 61 - 666 36 34; Fax: +39 09159 64 04;