Annals of Burns and Fire Disasters - vol. XII - n° 4 - December 1999

MASS DISASTERS. BULGARIAN COMPLEX PROGRAMME FOR MEDICAL CARE FOR PATIENTS WITH BURNS AFTER FIRE DISASTERS

Hadjiiski 0.

Burns and Plastic Surgery Centre, Pirogov Emergency Medical Institute, Sofia, Bulgaria

SUMMARY. A medical programme for action in the event of mass burns is described. It is the result of the observation of 20 mass accidents, with 155 victims, that occurred in Bulgaria in the period 1990-97. The programme is in line with the recommendations of similar programmes such as that of the Mediterranean Club for Burns and Fire Disasters and with national demands for such programmes. The programme is in two parts. It includes pre-hospital management at the place of the accident - non-medical medical aid, first medical aid, and pre-hospital transport - and hospital treatment in hospitals not specialized in burns, inter-hospital transport, and treatment in specialized burns centres.

General considerations

Accidents are the result ofa conflict between nature and man with serious consequences. The severity of the accident depends on the number of victims and the extent of the material damage. In a burns centre it is immediately possible to observe the disparity between the casualties need for help and the possibility of actually providing it. One of the most frequent injuries in such accidents is thermal trauma. Mass burns can be defined as the massive effect on people caused by a thermal agent and, in rare cases, by an electrical or chemical agent. Their main characteristic is the large number of fatalities and the presence of survivors who usually present extensive burns that create a treatment problem. For example, in the year 1984, in a fire in San Dusuanko (Mexico) after a gas explosion, 7000 people were injured, over 2000 were hospitalized, and over 500 died. When the explosion of a gas main caused a mass fire in Bashkiria (USSR) in 1989, some 11,200 persons were injured, over 800 were hospitalized, and more than 500 died. In Bulgaria, in the period 1960-97, 687 persons were injured in 42 mass burn accidents. Medical assistance in such situations depends on the speed with which the medical teams can handle the victims, take the correct decisions, and apply their skills. Trained teams can investigate the situation for one or two hours and initiate appropriate first aid. The triage of the burn victims must be performed by a specialist. The existence of a burns centre makes it possible to improve specialized medical aid for burn patients.
Natural and terrorist-provoked disasters are a prime cause of premature death and the worsening of the quality of life. Such disasters constitute a serious conflict between nature and man, creating problems for a number of organizations medical, public, national, and sometimes international and imposing the application of specific medical acts.
A disaster is any case of an ecological disturbance that worsens health and makes health care difficult. After a disaster the number of victims in the immediate short term is high, requiring the solution of numerous problems that are rare and not routine. Boutrous Ghali, the former United Nations Secretary, has expressed the opinion that up-todate action at disaster sites presupposes an analysis of the situation and collaboration between different health teams for prophylaxis, immediate response, and the restoration of health to persons affected by the disaster.
Accidents are caused by the sudden technological breakdown of machinery and equipment followed by stoppage of, or serious damage to, the technological process, with explosions, fire, environmental pollution, material damage, fatalities, and danger for the life and health of the population. An incident is a sudden event causing injuries and material damage that can be handled with local resources. A mass incident is an incident with a great number of victims and considerable damage that can however be managed by local or regional resources. Risk is the possibility of an incident's happening and its possible consequences.
An accident is a sudden event with serious consequences, victims, injuries, and material damage, necessitating immediate rescue and reconstructive intervention at the place of the event. According to the American Heritage Dictionary of the English Language, an accident is an event that leads to very widespread damage and misfortune. WHO defines an accident as a situation with unpredictable and serious sudden threats for human health. Management of the accident depends first on local resources and then on the support of other teams, link-ups, and co-ordination.
According to WHO accidents can be divided into:

1. natural - climatic, topological, tectonic;
2. large industrial accidents - chemicals, radiation, etc;
3. transport - mass crashes, railway, ships, planes;
4. military conflict;
5. war situations - with or without the use of conventional and mass damage weapons;

6. other disasters - acute diseases, epidemics, mass poisoning, ecological disasters.

From a medical point of view, mass disasters are:

1. small - up to 25 persons injured, of whom at least ten need hospitalization;
2. medium - at least 100 persons injured, of whom more than 50 need hospitalization;

3. large - with at least than 1000 persons injured.

Popzacharieva classifies accidents as "local" (up to ten persons injured), "regional" (up to 50 injured), "territorial" (up to 500 injured), federal (over 500 injured), and "transborder" (when more than one country is affected). An accident can cause a limited number of casualties and limited damage, but a critical situation cannot be managed with local resources - help will be needed. A mass disaster is defined as an accident in which the number of injured exceeds by 10% the number of the beds in the admitting hospital. The extent of a mass disaster depends on the material damage and most of all on the number of injured. In the definition of the type of mass disaster, the number of injured is important but not the only condition. Also of importance are the difficulties of health care and other problems, which are observed together with the deterioration of people's health.
The definitions given by different authors of the terms "disaster", "accident", and "mass incident" are clearly not identical. All authors however agree that these are all sudden events with a certain disparity as regards the need of help and the possibility of providing it. This necessitates the introduction of critical situation medicine, which the WHO Expert Committee of Emergency Relief Operations defines as a "learning and applying different medical knowledge for prophylaxis, immediate answer and restoration for a health problem due to mass disasters or accidents together with other disciplines". Burns are common to all mass disasters - earthquakes, volcanic eruptions, military conflicts, nuclear accidents, terrorist acts, industrial accidents. Burns are considered to be among the most serious traumas that can strike living creatures. Their action can lead to death in a matter of
seconds. Thermal accidents are the result of the excessive production of heat. There are usually many fatalities and patients with severe and problematic burns. Fires can cause damage also because of the huge production of smoke and toxic gases. They are normally associated with other kinds of trauma - fractures, multiple lesions, and electric shock.
The publication Guidelines from the National Swedish Board of Health and Welfare informs us that in the period 1971-95 approximately 150 mass accidents occurred every year, with a total of 1.5 million dead. Seventy per cent of these accidents are defined as extensive fires and explosions. The most severe of these accidents are known as LPG (liquid petroleum gas) disasters. The annual number of such accidents has increased in the last 15 years from 100 to 2200, and the number of dead from 60 to 900.
Tremendous accidents like those at Bipal and Chemobyl are only the tip of the iceberg. There have been many smaller unreported accidents in which many people have suffered. The development of industry and arms has led to an increase in the number of injured persons. In the Second World War the rate of burn injuries in the British Forces was 1.5%, in Vietnam it was 4.6%, in the IsraelEgypt conflict (1973) 10%, in the Falkland Islands conflict (1982) 14%, and in the Persian Gulf 6%. 18,23 In military conflicts combination with other traumas is common - mechanical, chemical, radiation. 24 In the Gulf War burns 23 were most often combined with mechanical traumas, while in industrial accidents the commonest combination is with smoke inhalation.

Advanced planning of medical acts

Disaster situations are unpredictable and every accident is unique, because it is sudden and affects areas with different social, economic, and health care states among the injured. There are some similarities, such as the limited medical facilities at.the moment of the disaster and the problems of providing help. The similarities are used in advanced planning in order to overcome a number of organizational problems, to prepare adequate medical aid, both at hospital and pre-hospital level, and to achieve a significant decrease in losses. Planning varies from hospital to hospital, in relation to the location of equipment and to training. Knowledge of disaster epidemiology helps in prophylaxis and planning, and information about causes of death is useful in the training of rescue teams. A programmed response and preparedness in disaster situations includes the existence of certain contingency plans, some of which we hope will never be used. Nevertheless, preparedness must exist. The United Nations proclaimed the years 1990-99 as the International Decade for Natural Disaster Reduction. Advanced training in "acts in critical situations" is beneficial. The lack of well-organized systematic action in two big disasters in Japan in 1995 (the Kobe earthquake and the terrorist act in an underground railway tunnel) resulted in only four hospitals, out of a total of 58 in the region, sending teams to the sites in the first two hours after the incidents. Contrasting with these accidents is the fire in a blanket factory in the Urim kibbutz in Israel, which was totally destroyed. Sixty-two persons were injured, of whom 45 suffered smoke inhalation, but without burns. The reason for this was the systematic training the workers had received about how to act in a fire emergency." On 16 April 1991, in a fire in a train in a railway tunnel near Zurich, rescue operations for the 140 injured passengers were initiated within 27 minutes. There were no fatalities because 18 months before the accident a training rescue study had been carried out in the same tunnel.
Every country must have its own plan for action in disasters The Trauma Care System is integrated with plans for training people for action in mass disasters. In Germany hospitals have five different action plans: for mass hospitalization after crashes, burns, and mass disasters; for poisoning incidents; for radiation incidents; for epidemics; and for internal hospital accidents.Member countries of the Mediterranean Club for Burns and Fire Disasters offer a standard protocol for all those who have to work with the consequences of disasters caused by thermal agents - surgeons, general practitioners, policemen, firemen. This protocol consists of 13 points and assesses the pre-disaster "normal" situation, the disaster itself, and ways of dealing with it. In Australia
such a plan is put into 10 victims.
On the basis of such plans for large hospitals, Moralejo describes similar plans for the smaller hospitals where victims are first taken. These plans regard preparation and work on the disaster site and methods for the resumption of normal work after an accident.
Today in the world there are over a hundred large and many more small organizations that deal with the problems of disaster prevention. In Switzerland an action plan published by the National Board of Health and Welfare includes the preparation and training of personnel. Basic to this plan is the preparedness of local resources, plus local and regional co-ordination. In bigger disasters the national ministry administration is involved.
The overcoming of disasters is a multinational problem. Fire disasters cannot simply be passively waited for. Scientific knowledge and technological know-how have to be mobilized, at international level, to prevent disaster situations from occurring. In the Bashkiria disaster an American team helped to treat 150 casualties in the hospital at Ufa. The 32nd Congress of Surgeons, held in Palermo in 1988, saw the first gathering of European specialists on the problems of preventing fire disasters. In 1994 a computerized teaching system for the treatment of burns was published and the Mediterranean Club for Burns and Fire Disasters (MBQ was founded with a view to cooperation in critical situations. Our country, Bulgaria, is an Associate Member and has connections with WHO.
Research shows the need for preliminary preparation and planning of action for the rescue of disaster victims. The existence of such programmes makes it possible to unify first aid and treatment aimed at rescuing the greatest possible number of casualties. Mass disasters and accidents usually occur without forewarning and require the rapid solution of numerous medical and other problems. Our operation when there are more than observations in over 20 mass accidents in Bulgaria in the period 1990-97 with 155 victims show the great will to help everyone and at the same time the lack of co-ordination of acts on different levels up to the stage of specialized medical help. For example:

* At the place of the accident

• Lack of knowledge about simple manipulations and life-saving action in non-medies instructed for this kind of intervention
• Lack of prioritization and consequent action by medical first-aid teams
• Hasty action by both medics and non-medies for the transport of victims, without assessment of the moment in time, the state and kind of transport, and the hospital where the victims are to be transported

* At the accepting hospitals

• Lack of organization in the hospitalization of victims
• Lack of readiness in most hospitals and inadequate attempts to hospitalize and initiate treatment of this kind of victim
• Inaccurate infusion treatment
• Local treatment, when initiated, often not correct
• Documentation of victims either incomplete or missing
• Tendency of medical teams, especially in smaller hospitals, to await arrival of specialist teams and administrators before organizing the next stage of work to be done

The Bulgarian programme

Only preliminary preparations and precise lines of action can lead to correct action and minimize losses. We have prepared a programme that takes into account the demands of our country and the proposals of European organizations, especially those of the Mediterranean Club for Burns and Fire Disasters. The main aim was the unification of the action of all medical teams providing help at the place of the accident until termination of treatment. Our proposed guideline-programme is divided into a system on the basis of the stages of treatment and evacuation. It is structured as follows:

Pre-hospital management and treatment - First medical aid by non-medics at the place of the accident
This is provided by non-medics and teams from the Bulgarian Red Cross or Civil Defence. The aims are to stop the action of the thermal agent, to perform lifesupporting acts, and to evacuate the accident site. First medical aid on site is provided by medics and ancillary teams and is aimed at life-supporting manipulations, initiation of treatment, triage of the victims, and the various stages of transport. Pre-hospital transport is a stage of treatment. The kind of transport is previously defined, as also the direction and the end point of transportation.

Hospital treatment - Treatment at hospitals near the scene of the accident
The stay in hospitals that are not specialized in burn patient treatment includes initial treatment, diagnosis of primary injuries, initiation of stabilization of the patient's general state, and preparation for transport.

Inter-hospital transport is another stage in treatment. It must be effected as soon as possible after the trauma without depressing the patient's general conditions. We prefer land transport, unless the journey is more than 250 km, in which case we use air transport.

Treatment in specialized burn hospitals is carried out using modem methods administered in the context of the treatment of other patients in the centre.

The proposed 125-page programme or guideline has been approved by the Bulgarian Ministry of Health and published as "Method Instruction N° 6-7/1998". The programme can thus be disseminated as a methodical form of instruction all over the country and will make it possible to unify behaviour at the outset of the trauma and at all stages of the victims' treatment. Unified action will help to prevent wrong decisions and lack of co-ordination at the accident site, mistakes that are often transferred to the hospital, thus impeding efficient treatment.

RESUME. L'Auteur présente un programme médical pour la réponse aux désastres de feu. Le programme est le résultat des observations effectuées dans 20 désastres en Bulgarie qui ont causé 155 victimes pendant la période 1990-97. Le programme est conforme aux recommendations à des programmes semblables comme celui du Club Méditerranéen des Brûlures et des Désastres de Feu et aux demandes nationales pour ces programmes. Le programme, divisé en deux parties, comprend la gestion préhospitalière sur le lieu de l'accident (soins nonmédicaux, premiers soins médicaux, transport préhospitalier) et le traitement hospitalier dans les hôpitaux non spécialisés pour les brûlures, le transport interhospitalier, et le traitement dans les centres des brûlures spécialisés.

1. Leonard R.B., Teitelman U.: Man-made disasters. Crit. Care Clin., 7: 293-320, 1991.
2. Gunn S.W.A., Masellis M.: Evaluation of disaster medical response - a proposal for a research template. Ann. Medit. Burns Club, 9: 240-2, 1996.
3. Kadry M.: Co-operation in the Mediterranean area in fire disasters. Ann. Medit. Burns Club, 10: 67-71, 1997.
4. Ghali B.B. In: Schramm D.: Management, university, business and government linkages; global continuing education for disaster. Proceedings of Sixth World Conference on Continuing Engineering Education: 477-83, 1995.
5. Hersche B., Wenker 0.: The casualty handling system CHS. Internet J. Disaster Medicine, 1: no. 1, 1997.
6. Gunn S.W.A.: "Multilingual Dictionary of Disaster Medicine and International Relief'. Kluwer Academic Publishers, Boston, Dordrecht, London, 1990.
7. American HeritageO Dictionary of the English Language, III ed., 1995.
8. Eldad E.: Mass casualty. State of the art lecture. Abstracts book, p. 1, Tenth ISBI Meeting, 1998.
9. Burkle F.M., McGrady K.A.W. et al.: Complex, humanitarian emergencies: Measures of effectiveness. Prehospital and Disaster Medicine, 10: 48-56, 1995.
10. Preliminary Report of World Conference on Natural Disaster Reduction. Yokohama, Japan, 1994.
11. Popzacharieva V.: "Disaster medicine". St Zagora, 386, 1995.
12. Hersche B., Wenker 0.: First-aid station FAS. Internet J. Disaster Medicine, 1: no. 1, 1997.
13. Norberg K.A.: Disaster medicine and disaster planning - the Swedish perspective. Internet J. Disaster Medicine, 1: no. 2, 1998.
14. Gunn S.W.A.: Principles of the scientific basis of disaster management. Disaster Prevention and Management, 1: 16-21, 1993.
15. Masellis M., Costagliola M., Torres V.G., loannovich J., Magliacam G.: A multimedia computerized teaching system in the field of burns. Ann. Medit. Burns Club, 7: 121-7, 1994.
16. WHO Guidelines: "World Health Statistics Annual, 1989", World Health Organization, Geneva, pp. vi-xxvi, 1989.
17. Badran I.: The other side of the coin - a discussion on burns and fires: Prevention and protection. Ann. Burns and Fire Disasters, 10: 180-3, 1997.
18. Sparkes B.G.: Treating mass burns in warfare, disaster or terrorist strikes. Burns, 23: 238-47, 1997.
19. Masellis M.: Thermal agent disaster and fire disaster: Definition, assessment and relief operations. In: "The Management of Mass Burn Casualties and Fire Disasters", Kluwer Academic Publishers, Boston, Dordrecht, London, 7-12, 1992.
20. Masellis M., Gunn S.W.A.: "The Management of Mass Burn Casualties and Fire Disasters", Kluwer Academic Publishers, Boston, Dordrecht, London, 332, 1992.
21. Kumar P., Jagetia G.C.: A review of triage and management of burns victims following a nuclear disaster. Burns, 20: 397-402, 1994.
22. Arturson G.: Civil burns disasters. International Congress on the Management of Mass Burns Casualties, Antwerp, 1991.
23. Dillingham T.R., Spellman N.T., Braverman S.E., Zeigler D.N., Belandres P.V., Bryant P.R., Salcedo V.L., Schneider R.L.: Analysis of casualties referred to Army physical medicine services during the Persian Gulf conflict. Am. J. Phys. Med. Rebabil., 72: 214-8, 1993.
24. Carsin H., Dutertre G., Le Bever H., Ainaud P., Le Reveille R., Rives J.M.: Multiple trauma and burns. Cah. Anesth6siol., 43: 20914, 1995.
25. Dougherty W., Waxman K.: The complexities of managing severe burns with associated trauma. Surg. Clin. North Am., 76: 923-58, 1996.
26. Noji EX.: Disaster epidemiology: Challenges for public health action. J. Public Health Policy, 13: 332-40, 1992.
27. Rowlands B.J.: Are we ready for the next disaster? Injury, 21: 61 2, 1990.
28. Micheels J.: The general practitioner and collective disaster plans. Rev. Med. Li~ge, 49: 481-91, 1994.
29. Liu S., Quenemoen L.E., Malilay J., Noji E., Sinks T.: Assessment of a severe-weather warning system and disaster preparedness, Calhoun County, Alabama, 1994. Am. J. Public Health, 86: 87-9, 1996.
30. Ricci E., Pretto E.: Assessment of pre-hospital and hospital response in disaster. Crit. Care Clinics, 7: 471-84, 1991.
31. Lechat M.F.: Accident and disaster epidemiology. Public Health Rev., 21: 243-53, 1993-94.
32. Koopman C., Classen C., Spiegel D.: Dissociative responses in the immediate aftermath of the Oakland/Berkeley firestorm. J. Trauma Stress, 9: 521-40, 1996.
33. Levitin H.W., Siegelson H.J.: Hazardous materials. Disaster medical planning and response. Emerg. Med. Clin. North Am., 14: 327-48, 1996.
34. Noji E.K.: Disaster epidemiology. Emerg. Med. Clin, North Am., 14: 289-300, 1996.
35. Poncelet J.L., de Ville de Goyet C.: Disaster preparedness: Institutional capacity building in the Americas. World Health Stat., 49: 195-9, 1996.
36. Global Disasters Report, vol. 2, no. 1, 1996.
37. Benmeir P., Sagi A., Rosenberg L.: An example of burn prevention: The Urim factory fire. Burns, 15: 252-3, 1989.
38. Wenker 0., Wenker E.: Train fire in Zurich, Switzerland. Internet J. Disaster Medicine, 1: no. 1, 1997.
39. Micheels J.: The general practitioner and collective disaster plans. Rev. Med. Liege, 49: 481-91, 1994
40. Trunkey D.D.: Trauma care systems. Emerg. Med. Clin. North Am., 2: 913-22, 1984.
41. Kossman T., Vitling I.: Triage and first aid during mass accidents (with burns) and transportation to trauma centers. Acta Chir. Plast., 33: 100-5, 1991.
42. Weyer F., Hoffer W.: Management of a major incident involving burned casualties. Internet J. Disaster Medicine, 1: no. 1, 1997.
43. Moralejo D.G., Russell M.L., Porat B.L.: Outbreaks can be disasters: A guide to developing your plan. J. Nuts. Adm., 27: 5660, 1997.
44. Norberg K.A: Disaster Medicine and Disaster Planning - the Swedish perspective. Intemet J. Disaster Medicine, 1: No. 2, 1998.
45. Kulyapin A.V., Sakhautdinov V.G., Temerbulatov V.M., BeckerW.K., Waymack J.P.: The Bashkiria Lrain-gas pipeline disaster: A history of the joint USSR/USA collaboration. Burns, 16: 339-342, 1990.
46. Masellis M., Ferrara M., Gunn S.W.A: Fire disaster and burns disaster: Planning and management. Ann. Burns and Fire Disasters, 12: 67-77, 1999.
47. Gunn S.W.A., Masellis M.: The WHO Centre for prevention and treatment of burns and fire disasters: The Mediterranean Club for Burns and Fire Disasters. Ann. Medit. Burns Club, 10: 3-6, 1998.
48. Saini K.: Methodology of recording the causes of fire disasters. Ann. Medit. Burns Club, It: 233-5, 1998.
49. Hadjiiski 0.: "Guidelines for burns management during mass burns disasters". V. 6-7, 125, Sofia, 1998.