Annals of the MBC - vol. 4 - n' 4 - December 1991

SUMMARY. A distinction is made between thermal agent disasters and bum disasters, and their respective consequences. The management of each kind of disaster is described. Operative proposals are made, and the phases of immediate care, first aid and organized relief are considered. It is stressed that it is important to organize specific training programmes for persons of all levels and for physicians and paramedical staff. It is also important to prepare mobilization plans for specific means and structures.

Introduction

The attention of experts is today more directed at analysis of disaster management than at disaster prevention.
It is in fact widely believed that the results of studies of disasters, although they have helped to reduce their number, will not be able to eliminate the percentage risk of their occurrence , in view of the imponderability of human and technical errors.
S.W.A. Gunn's Multilingual Disaster Dictionary defines disaster management as follows: "Disaster Management is concerned with all phases of planning, preparedness, training, response, relief, rehabilitation and reconstruction of a major emergency or disaster situation".
Two considerations are suggested by a careful examination of this definition:

• The first is that disaster management cannot leave out of consideration an overall assessment of the consequences of the disaster: this assessment must be as accurate as possible, whether it refers to a presumed or actual event.
• The second is that the planning of measures aimed at mitigating the effects on persons, in terms of suffering, disability and risk to life, must be related to a more specific evaluation of the damage, i.e. to the types of pathology that have been caused,

Fire disaster and living beings

The action of fire on living organisms is lethal within a few seconds. In man, if fire is not immediately lethal, it determines a pathological condition, the burn, that is considered to be the most complex trauma that can strike the human organism. A fire of vast proportions can cause damage to the surrounding environment by the massive production of heat and the emanation of burned gases and fumes. For the above reasons, fire disaster management must be mainly directed at the planning of measures necessary to mitigate the damage caused to man and to prevent its aggravation. It is therefore necessary to bear in mind some specific aspects that manifest themselves during a fire disaster. These can be briefly summarized as follows:

• the number of persons involved is always high
• the burns are mainly very extensive, and the general condition of the victims is precarious
• the burn is often associated with other serious pathologies, such as vast wounds, fractures, electrocution, blast lesions, etc.
• hypovolaernic shock, a characteristic feature in the first phase of the burn Illness, as early as 3 hours after the trauma, induces a state of tissue hypoxia, with irreversible damage to the various organs and systems
• the time interval between the accident and initiation of resuscitatory therapy must be less than two hours
• the inhalation of combustion gases, fumes and A fire disaster has very special characteristics, ifhot air causes damages to the airways and this alone one considers the particularities of the causative agent can jeopardize survival and the type of damage it produces in living beings.
• The place where the disaster occurs is not When fire comes into contact with -objects andalways easily accessible, and care and assistance may materials it burns or destroys them in a relatively be inadequate short time.
• the triage in loco of the victims must be effected only by specialists, as only specialists are able to evaluate the immediate gravity of the bum
• the overall assessment of the damage to persons must be made not only on the basis of the number of dead but also on the number of persons in a condition of potential mortality and with severe risk of disability.

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, we think it may be useful to define precisely the two concepts of "thermal agent disasterand" burn disaster.
Although these two concepts are linked by the common denominator of fire, they refer to events which, in view of a different evaluation of the damage caused, require operational rescue phases with varying commitments.

We make the following definitions:

"Thermal agent disaster": a disaster causing severe loss of 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.
"Burn disaster" can be defined as "the overall effects on living persons caused by the massive action from a known thermal agent. It is characterized by a high number of fatalities and of seriously burned patients with a high rate of potential mortality and of disability: its extent may be aggravated if appropriate rescue operations are delayed".
Some decisive factors involved here are: the type of pathology caused, the overall characteristics of the harmful action of the thermal agent, the terms of the evaluation of its gravity, in relation also to precise modalities of managing rescue operations.
In the burn disaster, the concept of the cause of the event is therefore to be referred to a well-defined pathological condition, i.e., "extensive burns", already existing in a high number of persons. Its extent depends on the potentially high number of fatalities, which is related to the considerable number of persons involved, the seriousness of their conditions and above all the early initiation of emergency therapy.
The formulation of two different definitions of "Burn Disaster" and "Thermal Agent Disaster" proves useful on both the didactic and the operational levels.
The formulation in fact allows a more precise location of the two events in the vast chapter of disasters, it offers more specific indications for the drafting of plans for preparedness, alerting and management of the problems connected with their occurrence, and, lastly, it suggests a more effective programme for the mitigation of human suffiering.

Operative proposals

The drafting of an operational rescue plan, in the event of a burn disaster, cannot fall to take into account the following two points:

• the victims' pathological picture, i.e. presence of extensive burns together with inhalation lesions and polytrauma
• typology of required intervention.

This must develop along three lines: immediate care, medical rescue within three hours, use of specific equipment and means for the rescue of the burned patient.
Such an approach will make it possible to achieve maximum efficiency also in relation to the numerous factors that normally condition the evolution of a disaster:

• the unpredictability of when the disaster occurs
• the moment of the disaster (day, night, festivity, etc.)
• the characteristics of the disaster (with explosion, collapse of buildings, production of toxic gases and fumes, if a forest fire, etc.)
• the area where the disaster occurs (city, non urban area, accessibility, presence of material suitable for relief operations, etc.)
• the type of building involved (dwelling, hotel, oftice, hospital, etc.)
• the number of persons injured and the type of trauma
• the population's degree of preparedness to manage the disaster situation.

Immediate care, first aid, organized relief

We can define three distinct phases in the rescue operations: immediate care, first aid and organized relief.

This is provided by persons present on the scene of the disaster: relatives, friends, passers-by, i.e. all those persons who witnessed the disaster or who arrived immediately on the scene. Generally speaking their help is an automatic reaction derived from affection, friendship and a spirit of human solidarity.
This is confirmed by data we have observed in earthquakes. For example, on the occasion of the earthquake in Italy in 1986, 95% of the victims had been extracted from the ruins by citizens using their bare hands before the arrival of organized relief.
In the event of burn disasters it is however important that the first people to provide assistance should be fully aware of what they have to do.
They must for example know how to approach a fire, how to enter burning buildings that may be full of smoke and/or toxic fumes, how to.rescue a person whose clothes are on fire, how to treat burn wounds and associated lesions immediately, and how to provide medical relief.

This refers to the action of persons present or in the immediate vicinity who have already received training in rescue operations and who get organized and go into action within a very short period of time, not more than 2-3 hours. These persons are physicians, nurses, and members of voluntary organizations. They are supported by public and private organizations in the area - hospitals, casualty departments, clinics, Fire Brigade, Police, etc., coordinated by the local authorities.
The authorities act on the basis of guidelines that provide for the stockpiling of specific mobilization materials in the most convenient locations, the management of ambulance services, traffic control, the use of local and regional mass media and general means of transport, etc.
The kind of 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, taking into consideration the high number of polytraumatized patients. Given the particular evolution of the burn pathology (worsening hypovolaemic shock), they must also initiate all medical and surgical procedures necessary for preliminary resuscitatory therapy and the initial local treatment of burns.
These 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 arrives.
It must be stressed that it is of fundamental importance that the particular procedure - as regards both medical assistance and general behaviour - that the rescue-workers have to carry out must be the object of specially prepared protocols that are publicized through information campaigns, refresher courses and training sessions aimed at citizens of every community, starting at school age.

This refers to the mobilization of all the military and Civil Defence forces that are ready to intervene in the event of a disaster. These forces arrive in loco as rapidly as possible, but certainly not within the first three hours, equipped with the necessary means and structures to enable them to perform their rescue early, within the first 48/72 hours after the disaster, until all the wounded have been evacuated.
It must however be pointed out that these forces are generally trained to manage general disasters rather than burn disasters.
Hence the necessity that they should incorporate special units for the management of burn disasters composed of personnel trained in the emergency care of severely burned patients and equipped with specific means and materials.
These units will be in charge of the preliminary triage, i.e. assessing the general condition of the victims, initiating and monitoring resuscitatory therapy and, pending the arrival of burns specialists, preparing a preliminary evacuation plan, contacting despatching stations, selecting means of transport, organizing first aid posts and clearing the area of the dead.

Conclusion

The planning of the management of a fire disaster, in terms of medical and surgical assistance to the victims, has particular characteristics not to be found in other kinds of disasters.
The definition of "burn disaster", which stresses the particular nature of the pathology produced in man and the relationship between the high risk of mortality and delay in initiating therapy beyond strictly defined time limits, indicates the guidelines for the drafting of suitable and appropriate plans for the management of relief.
In the event of a burn disaster, besides the classic concept of "organized relief', meaning the combined organization of personnel, materials and transport standing by to intervene in the event of a disaster, we must also consider the concept of "immediate care", which refers to rescue operations carried out in a competent and well-defined manner by persons who happen to be present in loco, and "first aid" which is provided by operative forces in the area which have received specific training.
The high number of burn victims, the gravity of the trauma, the need for specific and early therapeutic intervention and the necessity of the involvement of operative forces in the area require specific training programmes for persons of all levels and for physicians and paramedicals, together with the preparation of mobilization plans for specific means and structures.

RÉSUMÉ. Les auteurs, après avoir fait une distinction entre les désastres par agent thermique et les désastres par brûlure, et leurs conséquences respectives, décrivent la gestion des deux types de désastre, tout en faisant des propositions opérationnelles. On considère en outre les'phases des soins immédiats, des premiers secours et de l'aide organisée. On souligne l'importance d'organiser des programmes spécifiques de formation pour les personnes de tous les niveaux sociaux et pour les médecins et les infirmiers. Il est aussi important que l'on prépare des projets de mobilisation pour des moyens et des structures spécifiques.

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