Annals of Burns and Fire Disasters - vol. XVII - n. 3 - September 2004

A FIRE DISASTER AT A WEDDING IN A VILLAGE IN THE EASTERN PROVINCE, SAUDI ARABIA

Al-Hoqail R.

Division of Plastic Surgery, King Fahd Hospital of the University, Saudi Arabia

SUMMARY. This is a cross-sectional study of a fire disaster that occurred during a wedding in a village in the Eastern Province of Saudi Arabia on 28 July 1999. The number of persons involved was 169 - all women and children. By February 2000, 74 of the victims had died. The patients were initially distributed in 17 various provincial and national hospitals. The total number remaining hospitalized was 25 in October 1999 and 6 in February 2000. Fourteen patients were sent to the UK and the USA. Our recommendations include performing nationwide studies of fire incidents and the socioeconomic losses they inflict; documenting the historical evolution of fire prevention, control, and management laws; training more physicians, nurses, and first-aid personnel; effecting disaster site control over a larger zone; renovating available burn units to up-to-date standards; having advanced burn centres that satisfy calculated needs; establishing computerized communication between various burn units; achieving interhospital transfer of cases within 24 h; organizing public education for behaviour in the event of disasters, especially fire-related disasters; and developing a body of collaboration of regional Gulf countries as regards fire disasters.

Introduction

The World Health Organization defines a disaster as “a situation in which there are unforeseen, serious and immediate threats to public health”.

Fire disasters usually result in many burn victims, and are catastrophic. Such cases usually have a unique pathophysiology that necessitates speedy evaluation and medical therapy. Many technicalities are involved. Magliacani and Masellis2 stated that these disasters frequently occur in inaccessible areas where medical assistance is inadequate, with victims mostly suffering from extensive burns in many cases associated with other traumas. For these reasons, and contrary to what happens in other types of disasters, an accident causing 25 or more deaths and/or involving 50 or more persons with burns must be considered a disaster, especially when it is provoked by man and limited to a well-defined geographical area. The incident we describe easily fulfils these criteria.

The unique pathology of fire disasters necessitates that unique facilities and specialized services should be provided with the capacity to communicate adequately and to transfer patients to various regional specialized burn units or centres. In some Mediterranean countries, because of the limited number of specialized bed-places, this type of solution cannot be sufficient and international collaboration will be necessary.

The aim of this paper is to study the morbidity and mortality outcomes of a fire disaster that took place in a Saudi village, and to recommend some measures for avoiding recurrence of such disasters in the future.

Methods

This is a cross-sectional overview and analysis of the fire disaster, the management of the victims, and the final outcome of an accident that occurred on 28 July 1999 in a village in the Eastern Province of Saudi Arabia, a study carried out in co-operation with the office of the Fire Disaster Management Co-ordination and Civil Defence in the Eastern Province. All the cases were evaluated until 16 August 1999 initially, then on 19 October 1999, and finally in February 2000. The data were extracted from official reports and tables of cases, outcome statements from the fire disaster co-ordination office, the Civil Defence report, and verbal communication with the Modar charity association.

A review by the Psychological and Social Care Office, which was part of the fire disaster co-ordination office, and its supporting role are also included. This office was established with the aim of rehabilitating the victims’ families. It is staffed by specialists, social workers, psychologists, sociologists, and specialists on health education. They established 3-4 teams for home visits and evaluation. A lady offered her services as a guide and a bus was used to transfer the teams. Local health centres in the village were utilized to obtain the background of the original problems faced by the families, and a unit was established in one of them. A pro forma to study the role of the teams and the unit and to provide information was specially designed and used. Counselling with schools to consider the special circumstances was performed, and a daily report was prepared for the Director of Health Affairs in the Eastern Province.

Results

The event was a wedding, the time was 9.30 p.m., and many people were attending. However, in accordance with social traditions in Saudi Arabia, the women were having a separate wedding party from the men. The party was being held in a tent, outdoors. Suddenly a fire started in the tent, due to an electrical contact accident and to fireworks being played with by children inside the tent. At first, everyone inside the tent panicked, until the arrival of volunteers and the spontaneous reaction of bystanders, who immediately started transporting people to the nearest health centre or hospital, Al-Qatif Central Hospital (QCH), using their own cars. The Civil Defence was notified at 10.40 p.m. (i.e. 70 minutes later) and the disaster plan for the region was activated. The patients filled the QCH within 15 minutes. No resuscitation or triaging was performed on site. The evacuation of all patients was completed by 11.00 p.m. from the site of the terrible incident. The various hospitals in the region were then contacted and patients were transferred, after initial resuscitation, within 2 h. The transfer of patients within the region was completed by 1.00 a.m., while patients transferred to other hospitals outside the Eastern Province reached their destination within 24-36 h.

The patients were distributed throughout provincial hospitals, following activation of the government’s disaster plan. The total number of cases was 169. The male-to- female ratio was 1:16.9. Ten out of the total number were males (5.9%), their ages ranging from 9 months to 9 yr, of whom six died. Evacuation was completed by 11.00 p.m. of all the dead and living; 24 h later, the bodies of three burned children were found away from the site of the incident.

Table I presents the various Saudi hospitals to which the patients were transferred as of 16 August 1999, as also the total body surface area (TBSA) burned, age range, and number of cases. The total number of patients still in admission on this date was 84. Their ages ranged from 7 months to 60 yr. The range of TBSA involvement was 5-85% (Table I). The rest were not indicated for admission. By 19 October 1999, 25 patients were still in admission - eight patients in the Eastern Province, ten in other hospitals in the Kingdom, and ten patients were abroad (i.e. outside the Kingdom of Saudi Arabia).

The total number of patients transferred to King Fahd Hospital of the University (KFHU) on the night of the disaster was nine. They were triaged, some were intubated, and all were initially resuscitated in the first-level hospital (QCH), after which they were transferred one by one.

The ages ranged from 6-46 yr, with TBSA ranging from 50 to 85%. The burns were all full thickness and the patients suffered inhalation injuries. Our hospital’s disaster plan is activated only if the number of victims is 20 or more. Since only nine patients were admitted after this particular disaster, the plan was not activated.

Owing to their need of ventilation, six patients were admitted to the General ICU. They were all ventilated and resuscitated, and escharotomies were performed when indicated. Central venous lines were established, as needed. The ICU and plastic surgery unit teams co-ordinated two consultants’ rounds every 24 h, morning and night around the clock. Residents did the afternoon rounds, as required. In co-ordination with the hospital administration, the patients in the ICU had to be transferred to other burn centre facilities, and special plans were started for that purpose. A partition was set up between the patients and the rest of the ICU with strict antiseptic precautions during rounds, and patient care with limited visiting - in order to mimic as far as possible the conditions in the burn unit - was initiated.

These nine patients had the following outcome: five died within 22 days of admission, three were transferred to other facilities, and one remained hospitalized until January 2000. Hospital stay ranged from 1 to 156 days (28.3 ± 48.5 days, mean ± SD), SEM = 16.18. The patient who remained in-house was subjected to three operations of excision and split-skin grafting in the posterior neck, back, and both arms (Table II).

The overall outcome of the fire disaster included the death of 37 persons within the first hour, with deaths reported from three hospitals. The total number of deaths was 74 by February 2000. Ten of the patients were initially transferred abroad, and subsequently the total number of patients abroad was 14. Of those in the UK, one died (50% TBSA, adult) and another remained under treatment; the rest were transferred to the USA. The total number in the USA thus became 12. Information regarding exact age and percentages of TBSA involved was inaccessible (verbal communication with the Modar charity association) for the first ten patients who were sent (Table III). In February 2000, the total number still in hospitals within the Kingdom of Saudi Arabia was six, with an age range of 3-45 yr: three in Tabouk Military Forces Hospital, two in King Fahd National Guard Hospital in Riyadh, and one in King Fahd Military Complex in Dhahran. The total number of patients discharged from hospital and still in follow-up was 50, with an age range of 2-50 yr.

Personnel from the Psychological and Social Care Office visited 111 houses. Multiple visits were needed for 33 of these, and 165 patients were interviewed. The patients referred to the health centres were 50 females, 12 males, and one child. Five women and three men were referred to the hospital.

Further activities included:

• Open days for the victims among students at school. One day, in two different elementary schools, a breakfast meal was provided and gifts were given to girls participating in activities.
• Entertainment activities were organized for the children of victims with a trip for preparatory and secondary school students to visit a local farm. A full programme of activities was also organized for elementary school students to visit an entertainment centre. Students were allowed to use the whole morning to play video games and have rides; then lunch was served and in the afternoon they were taken to a local farm that had a mini-zoo.
• Group therapy for adult victims, children and mothers of victims.
• A lecture by a lady dermatologist and a lady plastic surgeon (the author of this paper) regarding the long-term effects of burns and the management of the various deformities, attended by women victims and relatives of victims in the Modar charity association.

Discussion

Fire disasters are incidents that impose both social and economic challenges on the modern world.

Such disasters must be approached at three levels, with regard to the phases they are going through:

• Phase 1 - Pre-hospital response at the site of the disaster
• Phase II - First-level hospital response
• Phase III - Second-level hospital response and final stage of medical treatment

The literature is rich in instructional scientific articles containing guidelines on approaches at various levels. First-aid organization in mass burns disasters, on the basis of the recommendations of a number of specialists, should be as follows:

• Immediate care: provided at the site of the accident, usually by persons on the spot who are not affected by burns.
• First aid: provided by people with both experience and medical knowledge (teams of physicians and nurses, Red Crescent and civil defence volunteers). These are assisted by firemen, police, transport authorities, etc. Within 2-3 hours, these teams perform a triage of the affected persons and determine necessary indications (respiratory tract condition, state of circulation, burn area site, need of intravenous infusion, analgesics, or immobilization).
• Organized relief: provided by military and civil forces, which organize their work at the site of accident

In Saudi Arabia, in conformity with health emergency disaster plans, when the officials concerned receive notification of an incident, the Civil Defence authorities organize the disaster site and co-ordinate the evacuation process, which includes the evacuation of victims and control of the incident (fire, etc.), facilitated during field movements by the medical teams of the Ministry of Health (the Saudi Red Crescent), who organize the medical evacuation of patients to the designated centres on the basis of the initial triaging results. Site security is controlled by the armed forces.

In Bulgaria, the emergency medical services provide well-organized transport of patients by ambulance cars and ambulance aircraft. Transport to the nearest specialized centre is expected to take less than 30 minutes. Injured persons are transferred urgently, without infusion therapy. In the cases described, the patients transported from the site of accident to a burns centre without i.v. infusion did not suffer any complications during transport or during the following days. If TBSA exceeds 25%, if children are involved, and if transport is expected to be a lengthy process, i.v. therapy is initiated at the site of the accident, even in mass disasters. Interhospital transfer is expected to take place within 24 h.

In the USA, there are annually approximately two million thermal injuries, with 10,000-12,000 persons dying as a direct result of their injuries. The young (< 2 yr), the elderly (> 65 yr), bystanders to the fire (21%), and the careless constitute high-risk groups for severe burns.

Dias4 emphasized the role of the air force in fire disaster management. In Portugal, the air force has to undertake tasks of a civil nature and their role is decisive for the solution of disasters. Dias also noted that the manner of participation may vary from country to country according to the authorities’ plans in the different countries.

Shoigu5 in Russia classified fire disasters among the most important factors that destabilize economic and social development, with reference to forest fires, industrial fires, and nuclear fire disasters in that country. The Chernobyl reactor fire was a special catastrophic case. He reported that the Russian System of Disaster Management was being developed.

Atiyeh and Saba6 at the American University in the Beirut Medical Centre attempted to evaluate the cost/benefit values of a burn unit at their university hospital. They found that it may be economically much wiser in small countries like Lebanon to establish a central burn unit and small multiple day-care centres for minor cases with the assistance of the government authorities, instead of creating highly expensive small units. They found that they were dealing more with less critical burns than with life-threatening lesions. The decision therefore varies according to individual country needs.

In 1997, Deng et al.7 analysed severe fire disasters in China between 1989 and 1993). They found that the principal causes of these disasters were administrative faults and operations not in conformity with regulations, and suggested that an active law of fire control and a programme of constructive administration should be implemented.

In 1999 a study was published by Wu and Wang,8 presenting an epidemiological analysis of fires occurring in China between 1950 and 1994. They noted that the annual economical loss had risen greatly, reaching a maximum of 1.3 billion Yuan (RMB) in 1994. Data collected from 17 departments and different provinces showed that fire frequency was highest in residential quarters in cities and in the country.

The experience in Cyprus over the last decade as reported by Mantas9 showed that most fire disasters in that country were farmland fires, with a limited number of forest and industrial fires, and that the number of industrial, civil, and vehicle fire incidents remained stable. Mantas also appreciated the significant role of the air force in the management of fire disasters.

The victims of the disaster described in the present paper were distributed around the Kingdom of Saudi Arabia in order to decrease the impact imposed upon each individual centre and to achieve maximum utilization of the available resources in all private or government hospitals. The main reason why some of our patients were transferred abroad was the lack of local resources for epidermal cell culturing or dermal reconstitution; others were transferred owing to social reasons after relatives’ requests and appeals that they should be treated abroad, with various indications for their transfer. This kind of' technical service is usually needed when the patient has a limited extent of skin left, and treatment is available only in very expensive, highly specialized centres. Some of the Saudi centres were able to obtain artificial skin and skin substitutes to aid in the management of such cases. Cost effectiveness is an important issue under evaluation, and this needs to be assessed in relation to the number of survivors, the effect on health care costs, and the rehabilitation required in cases where such treatment is not utilized.

An advanced burn centre includes the full resources of an acute care hospital (emergency services, respiratory and cardiac facilities, wound care rehabilitation, transitional care) with the highly specialized resources needed for burn care such as a skin bank with high-tech skin grafting equipment, skin culture, and transplantation technology. Surgical wards for microvascular surgery and reconstructive surgery with a multidisciplinary team of doctors is extremely important. Hydrotherapy, hyperbaric oxygen, and a debridement room are also needed, as also state-of-the-art infection control policies, minor burn care facilities, and rehabilitation and burn support groups. These last two aspects were efficiently covered by the Psychological and Social Care Office, which coped successfully with the disaster on a local basis.

Vidal-Trecan et al.10 reported in 2000 from France on the differences between burns in rural and urban areas. Burns were more frequent in rural than in urban areas, also with regard to occupational burns. The characteristics of patients did not differ between the areas. Outdoors, burns occurred more often in rural than in urban areas, frequently owing to flames, explosions, barbecues, or open fires. Rural burns were more severe than urban burns. The cases we report, considering the number of deaths and the severe conditions of the patients transferred to KFHU, support their results.

The two factors of electrical contact and the use of fireworks inside a tent compounded the injuries suffered by the victims. Rojas et al.11 found in their study of children burned by fireworks in Chile that the male sex predominated, that the age group affected in both sexes was that between 6 and 10 yr, and that 70% of the children were from low-level socio-economic districts in Santiago. Rojas strongly recommended that the domestic use of fireworks of any kind should be prohibited and that their use in public firework displays should be strictly regulated.

In 2003 Chen et al.12 found that burns caused by explosions in fireworks factories were quite different from thermal burns resulting from the incorrect use of fireworks. In the first case, the burns were sustained in a closed area, while in the second case they were sustained in an open area. In enclosed workshops the injuries were due to high temperature/high speed airflow and to gunpowder’s alkalinity; many of the victims suffered severe burns with inhalation injury and associated injuries, leading to a high mortality rate. The same finding was observed in the severity of burns combined with inhalation injury in our nine patients at KFHU. The finding of the bodies of three burned children 24 h later at some distance from the site of the incident was also significant - probably pain and fear made them run away unnoticed in the middle of the disaster.

As Badran13 wrote in 1997, “reliance on preventive measures, under all circumstances, continues to be the most effective approach to the containment of fire hazards. Industrial safety codes, building regulations, and fire-relevant measures for prevention, extinction, and escape are now highly developed and are reflected in contemporary architecture and life styles.” He reflected on the magnitude of this experience in Egypt, where the cost of fire damage in 1994 was more than 400 million dollars. He classified the types of fire observed as: 1) moderate and multiple small fires; 2) serious fires threatening to assume disastrous dimensions; 3) unpredictable disasters; 4) fires due to natural disasters.

During mass disasters an important aspect is the ethical problems encountered. Triaging is based on patient evaluation at the site. Königová14 asked the question, “Who should receive higher and who should receive lower priority in triage?” It is difficult to answer this, owing to the many factors involved - economic, social, humanitarian, relatives’ opinions, etc. Königová recalled that Howard Champion in 1988 stressed the low priority of patients who will live without treatment and of those who will die despite treatment.

Fire safety essentials were emphasized by Schroll15 in 2001, while the three Rs of fire safety, emergency action, and fire prevention plan - “rules, responsibilities, and resources” - as preventive measures in general and at the work site were defined by Thomson in 2003.

An epidemiological study from Denmark on the effect of a prevention programme through an intensive information campaign in the media showed that the rate of burn injuries due to scalds and corrosive materials in children had significantly reduced over a 17-yr period. The annual incidence showed a steady downward trend of 3% per year.

Training people in fire safety can be performed both by instructors and by using a computer-based instruction programme, with no significant difference in pre- and post-programme tests between the two groups.18 Virtual environment fire emergency simulations have also proved to be effective and suitable training tools.19 Technology is important and supportive in the planning and preparing of staff development and readiness in the handling of fire emergencies.

Donati and Ponzielli20 in 1988 suggested that the solution to the problem in the event of a disaster is to try to consider it from a general point of view, for a more intelligent use of all available resources. We totally agree with this approach.

Kadry21 in 1997 wrote, “efficient planning can always reduce the impact of a disaster”, praising the great co-operative efforts between the various countries in the Mediterranean area regarding plans for fire disaster management.

In 198922 Gunn suggested that “the international community must have mechanisms for planning, mobilization, and co-ordination in order to achieve maximum results. It has however been found that the actions of various international organizations is more efficient when organized and applied on a regional basis.”

Measures of prevention should not overlook civil defence and its preparation. We must consider firefighters and select them on the basis of criteria utilizing the body mass index, which was recently found to be useful as a preventive screening tool for general health and duty fitness status among firefighters.23 Some studies found that persons who frequently participated in fire-extinguishing operations and faced toxic factors demonstrated a higher level of disability.24 Toxic encephalopathy is another medical illness from which firefighters can suffer.25 The occupational hazards they experience can increase their risk of testicular cancer,26 while the masks they wear can affect their monocular and binocular peripheral vision - the effect on their ability to perform essential functions still needs to be evaluated.27

Two other questions come to mind in this respect: which personality should lead the burn team?28 and what is a fire risk analysis in a given building or space?29 Both these questions are however are beyond the scope of this paper.

The overall management of the disaster we describe was rated as very satisfactory and showed the beauty of the collaborative efforts of the various regions in our Kingdom to cope successfully with the situation.

Recommendations

The following recommendations are made.

• Performing nationwide epidemiological burn studies in order to evaluate annually the extent of fire incidents and human and financial losses, creating a national burn registry for Saudi Arabia.
• Documenting the history of evolution of fire prevention, control, and management in our nation (learning from the experiences of other countries in order to minimize the time needed to reach the latest up-to-date level target).
• Ensuring that the site of incident control includes a system to evaluate a larger surrounding zone, especially when the fire disaster involves children.
• Completing interhospital transfers within 24 h.
• Developing a national fire management body made up of the various departments involved (this already exists).
• Training more burn care physicians, nurses, occupational therapists, physiotherapist, and first-aid personnel.
• Renovating regional burn units and centres with the latest equipment needed for burn patient care, e.g. trolleys, hydrotherapy, patient lifters, debridement rooms, and operating rooms in the burn units.
• Expanding the capacity of regional burn units to accommodate patients with inhalation injuries up to their total bed-number capacity, in order to function at maximum capacity during a disaster.
• Having advanced burn centres, the number of which depends on the expected caseload per year.
• Connecting all burn units activated during a disaster by computer technology, in order to have appropriate medical control even in remote areas.
• Educating the public, utilizing the mass media, with regard to methods of fire prevention, precautionary measures, and behaviour during mass disasters, especially fire disasters (e.g. first aid, cardiopulmonary resuscitation, etc.).
• Developing a regional body of collaboration among Gulf countries for fire disasters.

RESUME. L’Auteur a effectué une étude en coupe transversale d’un désastre par feu qui s’est vérifié le 28 juillet 1999 pendant un mariage dans un village de la Province Orientale de l’Arabie Saoudite. Le numéro des personnes touchées était 169 - toutes femmes et enfants. Au mois de février 2000, 74 des victimes étaient mortes. Les patients ont été distribués au début dans 17 divers hôpitaux provinciaux et nationaux. Le numéro total des patients encore hospitalisés était 25 en octobre 1999 et 6 en février 2000. Quatorze patients ont été transférés au Royaume-Uni et aux Etats-Unis. L’Auteur présente une série de recommandations: effectuer des études sur échelle nationale des incidents par feu et des pertes socioéconomiques qu’ils provoquent; documenter l’évolution historique de la prévention et du contrôle des incendies et les lois sur leur gestion; garantir la formation d’un numéro toujours majeur de médecins, d’infirmiers et de personnel qui effectuent les premiers soins; contrôler les sites des désastres dans des zones plus vastes; renouveler les unités des brûlures existantes pour atteindre les niveaux les plus modernes; créer des centres des brûlures de pointe qui répondent aux exigences calculées; établir des communications informatisées entre les diverses unités des brûlures; effectuer le transfert interhospitalier des patients en moins de 24 h; promouvoir l’éducation de la population pour le comportement en cas de désastres et, en particulier, les désastres par feu; et développer une organisation de collaboration dans les pays régionaux du Golfe pour ce qui concerne les désastres par feu.

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