SUMMARY. The concept of burns in groups of people lies between that of burns in a single person and that of mass fire disasters. We give a definition of the term with regard to the number of persons injured by the thermal agent. The places where such burns most commonly occur are reported, and it is observed that some working sites are especially dangerous, such as metallurgical industry plants, coal mines, business enterprises, and factories. Neglect of technological processes leads to very severe consequences. Professional incompetence, technical failures, and lack of maintenance are the main reasons for such burns. Carelessness in handling various household appliances leads to the same outcome, causing burns in houses, schools, and kindergartens. We present statistical data indicating the incidence of burns in groups of people in recent years in Albania. The most important conclusion to be drawn is that these burns are not as fatal as burn catastrophes and mass burns. Medical teams must take advantage of this fact and save human lives through better management of the situation and by being technically prepared in advance, on the basis of a detailed strategy.
This article is the continuation of “Burns in groups of people during the last twenty years in Albania”, published in Annals of Burns and Fire Disasters in 1997, and it is conceived as a scientific meditation on a new notion in the treatment of severe burns. It is not just the second part of a long and voluminous paper but rather the scientific synthesis of a careful statistical analysis.
The goal of this paper is to define a new term, that of “burns in groups of people”. Between burns in a single individual and mass fire disasters there is a difference that must be considered in the evaluation of both organization and management.
This paper will review cases where burns in groups of people have occurred and the main causes of such burns. Prevention includes the strengthening of professional discipline, the avoidance of technical defects, and the maximization of care in paediatric patients.
The statistics deal with the incidence of burns in groups of people, overall mortality, mortality in different sectors of industry, and different social activity environments. Some data that have been previously reported now assume new value when compared with the first article, as more time has been available for study from new viewpoints and the data are thus more meaningful and cast more light upon the very important issues of prevention and management.
In this context the management of burns in groups of people assumes primary importance. In this part of the article, stress will be laid on the role played by the resuscitation teams that are first to reach the burn patients and on the responsibility of hospitals in the treatment of burns in groups of people injured by the thermal agent.
We find the term “gap” appropriate to indicate the empty or indefinite space between burns in a single individual and burns in mass fire disasters. As we were well aware of the existence of burns in groups and conscious of their importance, we decided to fill this vacuum with the aim of improving the classification of severe burns.
In numerical order, after the single individual come two or three persons, then a few persons (i.e., 4-7), and then a group of persons. The best known dictionaries define the word “group” as a community of two or more similar things or persons.1-3
Not wishing to remain prisoners of a strict mathematical or numerical definition, we developed the concept in two senses. Thus, in the practical clinical sense, burns of two or three persons are very frequent, and the definition “burns in groups of people” should include cases when four persons are burned. The expression “two or more persons”, on the other hand, is not a clear definition of the maximum number of persons that can be regarded as a group. We are of the opinion that four to seven persons correspond to the definition “small group”, while a large group means a community of 7-15 persons (Table I). <% immagine "Table I","60_fig_01.gif","The gap between the burn of an individual and mass fire catastrophes", 350 %>
How did we come to the conclusion that the maximum number of persons in a large group could vary from 7 to 15? We had in mind the numerical unit called a “team”. This is equivalent to the term “group of workers”, and a “squad of soldiers” or a “team of sportsmen” means the same thing: a group of people. As a team generally consists of 6-7 up to 10-15 individuals, we took the last number as the maximum number of persons that can be regarded as a group. Nothing is however absolute, and other suggestions are possible.
In conclusion, unifying the small and large groups of burned individuals, we reached a final definition: the term “burns in a group of people” means burns affecting a group of 4-15 persons.
Seventeen cases of burns in groups of people have occurred in the last 25 years in Albania. The sites of the accidents were as follows: metallurgical plants, 4 cases; coal mines, 3 cases; factories and enterprises, 5 cases; social activity environments (dwelling houses, schools, kindergartens), 5 cases (Table II). <% createTable "Table II","Where in groups of people have occured in the last 25 years in Albania",";#Metallurgical plants;4 cases @;#Coal mines;3 cases @;#Factories, enterprises, handicraft businesses;5 cases@;#Dwelling houses, schools, kindergartens ;5 cases@;#Total;17 cases","",2,300, false %>
The causative agents depended on the sites of the accidents. Thus, in the metallurgical plants the causative agent of the burns was hot metal, in coal mines it was explosions due to the ignition of methane gas, and in the other cases (factories, enterprises, dwelling houses, kindergartens, etc.) the burns were due to flame.
In all members of the groups the body surface (BSA) burned was always over 20% and usually deep II-III degree. This is a criterion we established in order to exclude cases of slight or medium burns and also to determine whether the injured persons constituted a group or not. As for the location of the burns, these were distributed all over the body, in most cases involving the head and upper limbs.
What were the reasons for these particular burns?
In industry, they were generally due to professional incompetence, disregard of technological processes, sudden technical faults, or simply human error. In social environments, burns in groups of people were due to deficient technical control, to misuse of various appliances (for heating, cooking, etc.), and to inadequate care of children (and also to children’s natural impulsiveness, especially in the first four years of life) (Table III). <% createTable "Table III","Why the burns occured","§4§#Industry;• Professional incompetence@;• Neglect of technological processes@;• Technical failures@;• Human error@§4§#Social environments;• Insufficient technical control@; Misuse of appliances@;• Inadequate care of children@;• Young people’s impulsiveness","",2,300, false %>
Plotting the years taken into consideration against the number of events of burns in groups of people shows that the incidence or probability of occurrence of such an event is 1.5 times per year. In other words, our hospital comes up against such a situation at least once or twice a year. This figure relating to our own experience might be applicable to other clinics or other countries. This probability depends not only on the overall number of events of burns in groups of people but also on the number of burns centres in a country, the population, and the medical organization for mass casualties.
Altogether 118 patients were treated, corresponding to an average of seven persons per group. Of the 118 patients, 89 (75.4%) were adults and the remaining 29 children (24.6%). The data show that 43 patients died and 75 survived. Overall mortality was 36.4%, with mortality among adults being rather higher (42.7%) and significantly lower among children (17%) Only five children died.
We studied mortality also in relation to the site of the accident. Burns in metallurgical plants were very severe, with nearly all patients suffering burns in more than 50% BSA. Consequently mortality in industrial burns was the highest (85%), all the victims having poor chances of survival. In burns in coal mines and social life environments, mortality fell drastically to 22% (Table IV). <% createTable "Table IV","Mortality related to the site of accident in burns in groups of people",";Site of accident;Mortality@;Metallurgical industry;85%@;Coal mine;22%@;Home, schools;22%@;Factory;5%","",2,300, true %>
We are of the opinion that burns of over 20% BSA, and in a group consisting of 4-15 people, are the two main criteria for declaring the occurrence of burns in a group of people. Smaller burned BSA areas and fewer or more persons than the above limits constitute a different situation.
The management of burns in groups of people can be divided into two stages. The first stage begins the moment first aid is given and ends with the transfer of patients to a hospital that is specialized in burns treatment. The first urgent aid cannot be given better than by a resuscitation team. In this respect, it is necessary to have organized preliminary training under conditions that mimic as far as possible the real conditions that can be expected to have to be dealt with by the medical staff.
Resuscitation teams should always be absolutely ready to intervene immediately in industrial or intensely inhabited residential areas. Their tasks are:
The second stage of management starts with the arrival of patients in the hospital and ends when they come out of the critical phase of the disease. This period involves all aspects of the medical management that the patients have to pass through, and is therefore long and entails many problems in the practical and organizational sense.
The main tasks of the clinical staff are as follows:
Clearly, both stages of management are synchronized in relation to a single consideration: saving the life of the persons who have survived the original event. Resuscitation teams must do their utmost to maintain the patients’ vital functions, regardless of BSA burned, until they are taken to a burns centre. At the same time, the medical staff must take all their chances, be they material or conceptual.
The organization and scientific management of the hospital has a primary role in co-ordinating and achieving the aforesaid goals. Realistic information has to be made available to the relevant organs and institutions, with clear reports of the real possibilities of treatment. If selfishness is left aside, if bureaucratic management methods are fought, and if links are set up with similar hospitals in neighbouring countries, it will be possible to create the premises for the transfer of the most severe patients to specialized burns centres.
The most important conclusions on the question of burns in groups of people and their management are the following:
RESUME. Le concept des brûlures dans des groupes de personnes est à mi-chemin entre celui des brûlures dans une seule personne et celui des désastres en masse. Les Auteurs offrent une définition du terme pour ce qui concerne le numéro des personnes lésées par l’agent thermique. Ils indiquent les lieux où ces brûlures se vérifient le plus fréquemment et ils notent que certains environnements professionnels présentent des risques particuliers, comme par example les installations de l’industrie métallurgique, les mines de charbon, les entreprises commerciales et les fabriques. La négligence envers les processus technologiques peut avoir des conséquences très sévères. L’incompétence professionnelle, les incidents techniques et le manque de maintenance sont les causes principales de ce type de brûlure. L’insouciance dans l’emploi des appareils électriques domestiques porte aux même résultats, et provoque des brûlures dans la maison, à l’école et dans le jardin d’enfants. Les Auteurs présentent des données statistiques qui indiquent l’incidence des brûlures dans les groupes des personnes dans les années récentes en Albanie. La conclusion la plus importante que l’on peut tirer est que les brûlures de groupe ne sont pas tellement fatales comme les désastres d’incendie et les brûlures en masse. Les équipes médicales doivent profiter de ce fait et sauver les vies humaines à travers une gestion meilleure de la situation, grâce à une préparation technique supérieure qui si base sur une stratégie détaillée