MASS BURN CASUALTIES AND THE ROLE OF EMERGENCY PREHOSPITAL SERVICES

Filopoulos E.

Coordinator, Education Committee of the Hellenic Centre for Immediate Care (EKAB), Athens, Greece

SUMMARY. The importance of preparedness for mass burn casualties is underlined. Training programmes are required, as well as specific plans for the medical management of such disasters. Emergency prehospital services also play a vital role. A number of guidelines are given, as well as recommendations for eflicient triage.

Although the incidence of mass accidents (M.A.) is quite high, our societies frequently appear unable to manage them. This may be due either to the lack of equipment and properly trained personnel or to the fact that health systems are orientated in many areas exclusively 'to the management of the individual case and ignore M.A. and their consequences, as if they did not concern them or because they may never happen.
The medical management of a M.A. includes a series of actions commencing at the moment of its occurrence and ending when the last victim has been transferred and is receiving appropriate care in a specialized centre. Table I shows the required actions in chronological order.

Table 1 Medical Management of Mass Accidents

1. Notification and mobilization of organized medical reaction
2. Triage and first aid on scene
3. Transport with medical care to the hospitals
4. Triage and treatment in hospitals
5. Transportation and hospitalization in specialized centres

The successful outcome of all the above actions requires correct planning, disciplined and coordinated behaviour by all personnel engaged, mobilization ability and availability of all medical resources necessary, and finally a full and correct communication network.

Mass Accidents and Emergency Prehospital Services
Recent progress in the successful management of M.A. is mainly due to the contribution of emergency medical systems and especially of services providing emergency prehospital care (1,2).
These services, when fully developed, provide:

1. all necessary equipment and the proper organization for the immediate transport of medical aid on scene;
2. well-trained personnel in the management of emergency cases;
3. permanent readiness for action in emergency cases;
4. well-developed and effective communication systems.

Emergency prehospital services (E. P. S.), independently of the way they are equipped with medical staff, either participate in everyday activities or are specially called in by the hospitals, and irrespective of their function and form they are the only services capable of under-taking the main weight of the coordination and medical management of a M.A.

Emergency prehospital services
Although the basic elements of the way health systems and E.P.S. react are standardized and valid for every M.A., there may be some differentiations in estimating the particularities of each area, especially with respect to ways of approaching it and to local medical resources, as also to problems arising from the cause of the M.A.
In many cases there are no special plans for the management of mass burn casualties. This may be due to the fact that fire disasters do not usually cause great numbers of victims and that mass burn casualties are relatively rare (3).
In planning the medical reaction to fire M.A. and their consequences there are certain particular problems:

1. The number of victims and the kind of wounds to be expected depend on what causes the M.A., and when and where it occurs. The number of victims can _ be large after a boiling liquid and expanding vapour explosion in inhabited areas or in closed crowded places if the fire breaks out at a time when the individuals are not able to react to the accident immediately and calmly(1,4). The classification into outdoor and indoor accidents can be helpful since the former are followed by a greater number of patients requiring hospitalization and the latter are characterized by a larger number of victims suffering from respiratory problems(3).
2. The fact that the Fire Brigade has general command of the situation facilitates order and the prevention of confusion. Medical groups on the scene should bear in mind that the first triage station is usually relatively far away from the scene of the M.A.
3. Since many bum casualties feel well and are able to walk, they often get to the nearest hospitals by themselves. This uncontrolled arrival of patients in the hospital causes particular problems which could be avoided by the creation of more than one triage stations working simultaneously on the scene.
4. Many scientists consider it necessary that a plastic surgeon should be present on the scene, because he is best qualified to estimate injury severity and the number of critically injured (5,6). If a plastic surgeon is immediately available, as is the case in Athens, owing to the closeness of the Burn Centre to the Immediate Care Centre (EKAB), his presence on the scene is particularly useful. However, if there are difficulties in finding a plastic surgeon immediately, or if many first triage stations are functioning simultaneously, we think that it would be more useful to employ a plastic surgeon in the E.P.S. Despatching Centre, which has the role of a centralized Communications Centre, from where he could help the medical groups on the scene as well as the doctors in the base hospitals.
5. The triage must distinguish five important burn groups, as in Table 2 (5).

 

Table 2 Triage of victims in Mass Burn Disasters

1. Minor burns (c~ 20% BSA in adults and <I 0% BSA in children)
2. Minor burns in critical sites
3. Burn in 20%-60% BSA
4. Extensive bums (>60% BSA)
5. Inhalation injury

Triage can be undertaken by specially trained E.P.S. personnel, although it has been observed that non-specialists often overestimate burn extent. Continuous training in Bum Centres will improve the ability of personnel to carry out accurate triage.

6. For the transfer of the injured to hospital, the following points must be remembered:
   • Most.burn casualties will reach the hospitals in the area independently;
   • All burn victims, except those with minor burns, must receive immediate fluid replacement (5);
   • All ambulances must have oxygen equipment, especially if it is an indoor accident;
   • Special labelling is necessary for unidentified victims in order to avoid problems later.
   • Apart from the transportation immediately after mass burn casualties, there will be an increased demand for interhospital transfer burn victims in the next few days.

7. The hospitals which receive mass burn casualties must:
• Mobilize surgeons, especially if there is an indoor accident where the need for treatment of respiratory diseases is urgent;
• Contact immediately the plastic surgeon in the Communications Centre;
• Be ready to manage unidentified victims (4);
• Prepare all nece~ssary interhospital transfers.

8. Special Burn Centres must coordinate their efforts in the hospitalization of as many casualties as possible. This is very difficult and that is why there is a great need of international aid and coordination.

Conclusion
The successful management of Mass Accidents is a question of correct organization and coordination. The capabilities of the emergency prehospital services afford the most effective and immediate medical response. However, it is always necessary, in cases of mass bum disasters, to prepare properly organized and well-functioning plans specifically for this purpose.
It is also important to establish international cooperation which, in addition to the exchange of experience, will lead to common action among a great number of Burn Centres.
May the Mediterranean Countries become the model for such cooperation!

RESUME L'auteur souligne Fimportance de la préparation pour les catastrophes d'incendie, comme aussi des plans spécifiques pour la gestion de ces catastrophes. Les services d'urgence pré-hospédaliers jouent un réle tr&s important. L'auteur présente enfin des indications et des recommandations pour un triage efficace.

BIBLIOGRAPHY

1. Buerk C.A.: The MGM Grand Hotel Fire. Arch. Surg., 117: 641-644, 1982.
2. Jacobs L.M.: The role of a Trauma Center in Disaster Medicine. J. Trauma, 23: 697-701, 1988.
3. Mackie D.P.: Fate of mass burn casualties: implications for disaster planning. Burns, 16: 203-206, 1990.
4. Arturson G.: The Los Alfaques Disaster: a boiling liquid, expanding vapour explosion. Burns, 7: 233-251, 1981.
5. Griffiths R.: Management of multiple casualties with bums. B.M.J., 291: 917-918, 1955.
6. Sharpe D.T.: Management of bums in major disasters. Injury, 21: 41-44, 1990.