Annals of Burns and Fire Disasters - vol. XII - n° 2 - June 1999

REVIEW ARTICLE

FIRE DISASTER AND BURN DISASTER: PLANNING AND MANAGEMENT

Masellis M., Ferrara M.M., Gunn S.W.A.

Divisione di Chirurgia Plastica e Terapia delle Ustioni, Ospedale Civico, Palermo Mediterranean Club for Burns and Fire Disasters - WHO Collaborating Centre

SUMMARY. Disaster 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.

Introduction

Although 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 time.5,6
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

• the number of persons involved is usually high;
• 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 inhalation lesions;
• 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 survival;
• 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.

Thermal agent disaster, burn disaster

In the 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 definitions. 5,6
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 operations.5
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 suffering. 5,6

The plan for disasters

The 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
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

The drafting of an operational rescue plan for a burn disaster cannot fail to take into account two points:

1. the victim's pathological picture, i.e. the presence of extensive burns, inhalation lesions, and polytrauma;
2. 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:

1. rapid evaluation of the extent of the disaster
2. specific and rapid health assistance response on site
3. assessment of the capacity of local specialized structures to receive burn victims
4. selective evacuation of casualties from the disaster area.

A 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 prove inadequate.14
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.

Three 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 solidarity.2,4
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

1. Self-control
2. Self-protection
3. Reduction of the fire
4. Extraction and transfer of victims to the open air
5. Appropriate action when clothing is on tire
6. Removal of burning clothing
7. Emergency treatment of burned areas
8. Knowledgeable action pending more complete relief
9. Dealing with chemical burns
10. 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 age. 5,6
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 procedures.
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

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 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

1. Immediate triage of all victims
2. Inspection of the upper airways
3. Qualitative assessment of the burns
4. Quantitative assessment of the burns
5. Intravenous resuscitatory therapy
6. Analgesic therapy
7. Bladder catheterization
8. Pressure-relieving incisions
9. Examination of the patient with particular attention to respiratory capacity
10. Hospital transfer

3. Organized 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 transport.
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 categories: 19,29

• Minor burns/noncritical sites (<10% TBSA for children; <20% TBSA for adults): dress wound; tetanus prophylaxis; out-patient care.
• 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); mortality high
• Minor burns/inhalation injury/associated injuries; administer oxygen, measure carboxyhaemoglobin and/or intubate, ventilate, care of injuries.

Some Centres 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 practical: 12,27

• 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

There is 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

The planning of burn disaster management must include the following:

1. mapping of hospital facilities, private clinics, and reanimation and emergency centres in the entire region; 31
2. list of the larger hospitals in the region having burn centres, including bed capacity;
3. list of smaller regional hospitals with burn unit, including bed capacity;
4. 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
5. 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;
6. guidelines for the internal organization of hospital facilities in the event of disaster, including fire disaster.

Every hospital must be ready to set up an Emergency Co-ordination Operational Centre responsible for:31,11

• 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 staff,
• 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 bank;
• 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 and friends;
• 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.

D) Selective evacuation of casualties from the disaster area

This is certainly the most complex phase on both organizational and operational grounds.
Selective evacuation depends on three factors:

1. 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. 14,16
   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 delays.

2. 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.

3. 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.
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. 1,2,21
In order to be effective, disaster management must therefore be based on serious preparedness.
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. 5,7,17
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 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 operational aspect, concerned with coordinated and effective relief, ranging from self-relief to immediate assistance and specific first-aid measures. 5,6

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.

RESUME. La 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.

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