Mackie D.P., * Hoekstra MJ. **

SUMMARY. On 4th October 1992, a Boeing 747 cargo plane crashed into a block of flats in the BijImermeer, on the outskirts of Amsterdam. Approximately 50 people died at the site of the disaster. 37 patients were treated in local hospitals, of whom 16 were admitted. 3 patients suffered severe burn injury. Although the numbers injured were limited, a full-scale disaster response was evoked, providing an opportunity to study the effectiveness of existing plans. lle rapid response of the ambulance service and the hospitals involved indicates that rehearsed disaster planning is effective. The dispersal of the injured to several nearby hospitals prevented the overloading of casualty departments. Secondary transfer of severely burned patients to the burn centre was well ordered and followed existing guidelines. In retrospect, communication between the various services might be subject to minor criticism, but no problems were encountered which seriously threatened a well-executed rescue operation. No patient who survived the immediate impact subsequently died.

On Sunday 4th October 1992 a Boeing 747 cargo plane crashed into a 10-storey block of flats in the Bijlmermeer, a suburb of Amsterdam, shortly after taking off from Schiphol airport. 27 apartments were destroyed on impact. Approximately 47 people are thought to have died at the site of the disaster. Hospitals in Amsterdam treated a total of 37 casualties, of whom 16 were admitted. In this paper the response of the medical services is described, with particular emphasis, on the management of casualties with burn injury. As no detailed information of ffie medical response has yet been published, the accuracy of some of the data presented by the authors, one of whom was actively involved in the rescue effort, cannot be guaranteed. However, the general description of events following the crash may give some impression of the effectiveness of existing disaster plans in the Netherlands.

Holland is a densely populated country with a comprehensive infrastructure. Plans for dealing for disasters of lin*ed scale are therefore based on the assumption that rapid access to substantial hospital facilities will normally be available.

The ambulance service is responsible for the initial assessment of casualties and their transport to hospital. In the event of a disaster, deployment of vehicles and personnel is coordinated through a network of regional control centres. Disaster scenarios are well-rehearsed, and ambulances throughout the country may be mobilized and directed as required. The first ambulance crew to arrive at a disaster should report to the regional control centre with an initial assessment of the incident. Thereafter, first priorities include the establishment of one or more triage posts, where casualties can be assessed and transport organized. The assistance of trauma teams (see below) may be requested. The evacuation of casualties to hospital is coordinated by the ambulance control centre. As several hospitals are likely to be situated within easy reach of any location within Holland, a strategy of casualty dispersal is employed in order to prevent individual hospitals from becoming overloaded. The ambulance control centre is required to alert the hospitals to prepare for multiple casualties.

All major hospitals in the Netherlands are required to maintain contingency plans to cope with mass casualty incidents. Such plans typically include a cascade call-out system for medical, nursing and ancillary personnel, and logistic arrangements for the rapid "processing" of multiple casualties.

The ambulance service may also call on the assistance of hospital trauma teams. These teams, provided by selected regional hospitals, include medical and nursing personnel to assist in triage and patient treatment at the scene of the incident.

Although the centralization of burn facilities in the Netherlands has led to obvious improvements in general burn care, the capacity of the three national burn centres to admit large numbers of burn victims is limited. Planning for the management for mass burn casualties is based on the premise that in large disasters the majority of victims sustain wounds which are either too trivial or too extensive to require the specialized facilities of a burn centre (Mackie and Koning, 1990). Detailed triage is therefore essential. The plan stresses the importance of early evacuation of victims to nearby hospitals by ambulances as described above. Adequate early management in hospital is essential, and a treatment flow-chart is available to guide fluid therapy. With appropriate fluid therapy the clinical condition of uncomplicated burn patients remains stable for several hours. Time is thus available for the process of triage. A team of burn specialists, comprising a surgeon, an anaesthetist and a nurse, is provided by one of the burn centres for early deployment to the receiving hospitals, to advise on further treatment and to aid the selction of patients for specialized burn care. In the present plan, the burns team is deployed at the discretion of the ambulance service.

18.35 hrs At the moment of impact, the Boeing 747 cargo plane was fully laden with fuel. The pilot was attempting to return to Schiphol Airport following the loss of both starboard motors. Just prior to impact, the aircraft began to spin, crashing into the building at a steep angle with the fuel-filled wings at right angles to the apartment block. Much of the fuel therefore exploded on the grass in front of and behind the block; the apartments adjacent to those directly destroyed were remarkably free from damage. The intense but confined conflagration may also explain the relatively limited number of injured survivors found at the site.
18.45 With the arrival of the first ambulances the nature of the incident became apparent. A triage post was established and the rescue of casualties commenced.
18.50 Ambulance and fire-fighting vehicles were now arriving in strength. First aid for casualties was provided by fire-fighting and ambulance personnel. Nearby hospitals were alerted, and the evacuation of patients was begun. The disaster plans of several large Amsterdam hospitals were put into operation, including the Academic Medical Centre (AMC), The Free University Hospital (VU) and the Onze Lieve Vrouwe Gasthuis Hospital (OLVG). Police acted to cordon off the area and to keep essential roads open to rescue vehicles.
19.10 Casualties were now arriving at the Amsterdam hospitals, mostly by ambulance, some by private transport or taxis. 'Me nearest burn centre, at the Red Cross Hospital, Beverwijk, was alerted by the ambulance service. The hospital disaster plan was put into operation, and communications established with the burn centres at Rotterdam and Groningen. The hospital disaster plan of the Zuider Ziekenhuis, which houses the Rotterdam Burn Centre, was also evoked. The trauma team from the Free University Hospital was dispatched to the disaster site.
19.30 Within an hour of the crash, the rescue services were fully mobilized. Some 75 ambulances, assisted by the trauma team, were gathered in the Bijlmermeer to evacuate further victims. Several hundred doctors, nurses and other personnel were standing by in the Amsterdam hospitals and in the burn centres of Beverwijk and Rotterdam. It transpired later that by now almost all casualties had already arrived in hospital.
20.00 1he AMC requested transfer of a patient (EC.) with extensive burns and inhalation injury, to the burns centre in Beverwijk.
21.00 In response to a report that numerous casualties remained trapped in traffic, a burns team departed from Beverwijk to the AMC. This rumour turned out to be unfounded, as the last casualties had reached hospital more than an hour previously.
22.30 'Me ambulance service announced that no further casualties were expected. The state of readiness of the hospitals involved was downgraded.
23.00 Two patients with severe burns (1.K. and W.R.) were transferred from Amsterdam hospitals to the burn centre in Beverwift.
The following morning, the mother of lK, who had been admitted to Slotervaart Hospital with minor burns, was transferred to Beverwift on social grounds.

Approximately 37 patients were treated in hospital casualty departments within 90 n-iinutes of the disaster. The majority of patients had minor lacerations or burn injuries, and were allowed home. 16 patients sustained injuries which required admission to hospital. Summary details of the injuries are given in Table 1.
The three patients with extensive burn injuries were stabilized and treated appropriately with intravenous fluids before transfer to the burn centre in Beverwift. Two of the three patients, all of whom had deep facial burns, were intubated and ventilated prior to transport.
Details of the patients treated in the burn centre are provided in Table 2.
Primary treatment of patients was prompt, orderly and appropriate. No victim found alive following the Biffirnermeer disaster subsequently died.

Given the nature of this incident, the number of people killed and injured in the Biffirnermeer disaster is less than might have been expected. Nevertheless, the alarm was such that a full-scale disaster response was put into operation. Sufficient casualties were dealt with to provide some insight into the efficiency of the rescu operation. The rapid response of the ambulance service and the hospitals involved suggests that rehearsed disaster planning is effective. Within an hour of the crash the mobilization of resources was such that the capacity to transport and treat casualties far exceeded the actual requirements. The ability of hospitals to absorb multiple patients was further enhanced by the strategy of casualty dispersal. The management of victims with severe burn injuries also followed the pre-existing guidelines: patients were assessed in the primary hospitals, resuscitated, and transferred in a controlled sequence to the burn centre after consultation with burn specialists. Although the ambulance service and the hospitals both responded admirably to the disaster, the efforts of these two services might have been more closely coordinated. The trauma team from the Free University Hospital was not deployed for almost one hour after the crash, and the burns team was not called out at all by the ambulance service. In retrospect it seems more logical to transfer responsibility for the deployment of the burns team to the receiving hospitals, as indeed occurred on the evening of the disaster. During the hours in which the hospitals remained on full alert, little information was received on the course of events at the disaster site. The provision of regular bulletins from the ambulance control might have helped to prevent uncertainty and rumours. Although the number of casualties resulting from the Biffirnermeer incident was lin-dted, disasters such as that at Ramstein in 1988 have demonstrated that very large numbers of burns victims are possible following aeroplane crashes. Such a disaster would completely overwhelm the specialized burn resources of a small country such as the Netherlands. Optimal care could then only be achieved if distant burn centres were involved. Organizations such as the European Burns Association may have an important role to play by compiling regional data on the location and capacity of specialized facilities, and by urging governments to rehearse the logistic procedures involved. Finally, while this account of the management of the victims resulting from the Biffirnermeer disaster has concentrated on the performance of the ambulances and hospitals, the rescue of casualties was greatly facilitated by the contribution of other services and individuals, such as the police, fire brigade, and telephone operators (who acted to divert non-essential telecommunications away from the Amsterdam area). The Amsterdam Local Authority, which had overall responsibility for the disaster response, succeeded in virtually all respects in maintaining the commendable standard of competence and compassion which characterized the management of this appalling accident.

RESUME. Le 4 octobre 1992 un avion cargo Boeing 747 est allé se fracasser sur un immeuble à Bijlmermer, dans les faubourgs d'Amsterdam. Une cinquantaine de personnes sont mortes sur les lieux du désastre. 37 patients ont été traités chez les hôpitaux voisins, dont 16 ont été hospitalisés. Trois patients ont subi des brûlures graves. Malgré le numéro réduit des patients, le désastre a provoqué une réponse de grande envergure, ce qui a permis d'étudier l'efficacité des plans d'urgence existants. La réponse rapide du service d'ambulance et des hôpitaux intéressés a démontré l'importance de la préparation soigneuse des désastres. La répartition des patients chez les divers hôpitaux voisins a évité la surcharge des services des urgences. Le transport secondaire des patients graves vers le centre des brûlés a été ordonné en accord avec les lignes directrices existantes. Rétrospectivement on pourrait critiquer un peu les divers services, mais il faut aussi dire que l'opération de sauvetage a été effectuée sans aucun problème important. Aucun patient qui a survécu au moment immédiat du désastre n'est mort par la suite.

1. Mackie D.P., Koning H.M.: Fate of mass burn casualties: implications for disaster planning. Burns, 16: 203-206, 1990.