|Ann. Medit. Burns Club - vol. VII - n. 1 - March 1994
THE 1979 FIRE DISASTER (93 CASUALTIES) IN BRASOV (ROMANIA) -THE IMPORTANCE OF RAPID TRANSPORT AND UNITARY TREATMENT IN A HOSPITAL
Aburel V., Visa L, Grigorescu D.
Brasov County Hospital, Romania
SUMMARY. We report and discuss the case of a fire disaster (93 casualties) produced by a blast in 1979. The importance is stressed of rapid transport by all means available to a single hospital, where a team of specialists should be formed (surgeons + intensive care specialists + medical organization experts) to ensure the proper sorting of patients (a major problem), primary care and the transformation of part of the hospital into a Bum Unit. The therapy should be unitary, as simple as possible and adequate for the high number of casualties; other specialists' assistance should be available on request. In view of the wide range of factors involved in such collective accidents, no particular model can be defined: this has to be generated by each specific situation.
The accident reported below is the greatest fire disaster that has ever occurred in Romania. This report could not be published before, since the Communist regime did not allow the spreading of news about devastating events with multiple casualties - not even for scientific reasons.
1. Medical care in Brasov - 1979
Though Brasov is the town with the highest industrial density in Romania, the emergency care in work places is usually limited to simple medical procedures, with equipment scarcely fit to face great emergencies. In such situations casualties are immediately sent to the County Hospital, i.e. up to 4-6 km away. Few ambulances are attended by medical staff. The County Hospital (750 beds) has all the major medical and surgical specialties. One of these is the Department of Plastic and Reconstructive Surgery, with 60 beds (of which approximately 15 are usually for burn cases). The Department is attended by two doctors. Burn patients are usually hospitalized after being seen in the surgery emergency room, where they are treated by the surgeons and the intensive care medical staff. The team involved in the emergency care of these patients is a professional and well-trained group. There are 14 operating theatres for all the surgical specialties. Activity starts daily at 9.00 a.m.
2. Circumstances of the accident. Persons involved
The circumstances were evaluated on the basis of the investigation file. The accident happened in the workshop for the preparation of casts for the foundry in the Tractorul factory (Fig. 1). There were considerable amounts of carbon dust - some in suspension and even more precipitated. There were 121 workers of active age present at work, 70% of them women. Owing to the specific environment, with its carbon smoke and dust in suspension, the workers already had a background of different degrees of interstitial lung fibrosis (only two workers had previously been registered with silicosis, but following the accident ten more retired with the same diagnosis). Most of the workers therefore had low natural lung resistance to injury-causing factors. Many women were biologically worn out (after childbirth and excessive strain at the place of work and in the family).
3. The accident
Near the wall at the right extremity of the foundry there was a small furnace with a 38-litre gas-heated crucible. This contained about 20 litres of sodium nitrate(NaN03) in the smelting state (sodium nitrate melts at 300 'C; in order to lower the smelting point to 250 'C, calcium carbonate is added). Sodium nitrate in the smelting state is used to solder the melting pots. NaN03 is known as a strong oxidizer, and in combination with coal it is the main component of gunpowder, of the "good old days". The walls of the furnace containing the melting pot were permeated with coal dust. Suddenly an unusual situation occurred, with fluid leaking from the crucible, together with white smoke and sparks. The fire was immediately turned off. A few minutes later (time, 7.35 - 7.45 a.m.) there was a violent outburst of flame and smoke, the boom and blast affecting about 60% of the foundry. The crucible was blown up, and then crashed down, its contents spreading all over the place. The main element in the accident was not gas pressure (only a few windows were broken), as the foundry building was quite large (about 40,000 cu. in.), but rather the temperature of the gases expelled through the aperture of the furnace, at an angle of about 40-50' (Fig. 2). The time lapse was enough to allow eye and nose closing reflexes to occur. This explains the low incidence of massive eye and upper respiratory tract lesions.
The burn lesions were produced by a strong jet of high-temperature gas and smoke. The direction of the gases caused fatal burns in the persons nearest to the furnace. The greater the distance, the higher up were the areas of burn lesions on the body. The workers farthest away had lesions only on their faces. Although the accident cannot be defined as an "explosion", all the victims inhaled burning gases and smoke.
5. The 93 casualties
All the injured workers were immediately taken to the County Hospital (4 km away from the site of accident), without any initial sorting or treatment, using all available means, i.e. cars, vans, etc. Ambulances arrived only during the last stages of the transportation.
Emergency treatment in the County Hospital
At 7.30 in the morning the medical staff were present in the hospital and the operating theatres were prepared for routine work. At about 7.45 - 7.50 the staff were informed of a massive fire disaster. On such an occasion the Chief of the Plastic and Reconstructive Surgery Department takes control of a special team formed for this purpose; this comprises the Chief of the Intensive Care Department and the Chief Inspector in charge of surgery at the Brasov Local Health Department. Arrangements are made to have all operating theatres free and functional. Teams of surgeons and anaesthesiologists are formed. An emergency alert is extended to the hospital pharmacy and the supply and catering deparment. The medical staff from all the other deparments and wards in the hospital are alerted and partially directed to the emergency rooms. The other specialist in plastic surgery is in charge of planning and controlling all surgical procedures. At 8 o'clock the first victims already began to arrive. This stage lasted about 25-30 minutes. Ninety-one out of the 93 casualties were brought to our hospital: 82 of them were hospitalised, two patients died soon after admittance, and the few others did not need hospital care.
2. Selecting the patients
This stage was under the control of the senior doctor of the Plastic Surgery department and the Chief of the Intensive Care Department. Three or four teams of one surgeon and several nurses were also formed for the initial assessment of the patients The medical staff were informed of the circumstances in which the accident had occurred. Each patient was first registered and then injected with pethidine. The specialist team assessed the severity of each case according to the prognostic index and any aggravating factors. (The Romanian school of plastic surgery makes use of a classification of burn wounds in four degrees of depth, where the 3rd and 4th degrees correspond to degrees 2a and 2b in the three-degree classification. The prognostic index we use is the product of depth x % BSA, which estimates burns between 100 and 150 as the highest vital risk. Survival rate above this limit is rare (8). Our department also takes into consideration the following aggravating factors: age - risks are 2-4 times higher in patients over 55 and under 5 years of age; circumstances of the accident - explosion, immersion; transportation; time since initiation of treatment; secondary lesions; organic failure, pregnancy, other concomitant diseases; electric or thermal burns; localization (face, hand, foot, perineum) (1).
The two senior doctors decided upon the grouping of the patients in one of the following categories:
3. Primary treatment
This was achieved for all patients within
about 21/2 hours, and was constantly supervised by the two Chiefs of Department, after
sorting of the cases. Both local treatment and intensive care followed unitary criteria.
This was a simple task, since all the doctors were familiar with, and had regularly
performed, such primary treatments as a routine.
4. Problems concerning organization
Accommodation of the patients. In the first stage wards from other departments of the hospital were made available. On the second day a special, completely isolated division was set up, with patients grouped according to the severity of their condition and the prognosis. To ensure the required blood supplies, we appealed to donors from all the major industrial enterprises in the county and to blood centres in neighbouring counties. Drug and equipment supplies were provided from the stocks of the Ministry of Health. Specialists from other hospitals in the town volunteered to help, or put themselves on call to help, with their specific expertise (E.N.T., ophthalmology, gynaecology, psychiatry, hygiene). Visitors were not allowed into the wards.
Subsequent stages of treatment
All patients were seen by doctors
three times a day. Every morning complex investigations were performed by the various
specialists, each directed at different areas of pathology. Patients were frequently
transferred from one ward to another on account of their recovery/deterioration, septic
Mortality rate survey
Evolution and complications
The data obtained can be summarized as follows:
Thirty-three out of the 58 women (60%) and
I I out of the 24 men (46%) died (Fig. 4). All five pregnant women died, despite their
therapeutic abortions., The above table shows that even within the range of the 100-200
prognostic index survival was possible for some patients with severe burns; these cases
raised the most complex therapeutic problems. The death rate (Fig. 5) shows
that nine patients died within three days, after which the average declined to five deaths
per day (for a total of 30 deaths) between day 4 and day 9. The death rate curve then
declined rapidly. The high mortality rate in the first nine days is attributable to the
poor conditions of the practically incurable patients, in whom intensive care delayed the
fatal outcome. The last death was recorded on day 56 (a 48-year-old woman with 50% BSA
Discussions and conclusions
A fire disaster is an alarming
situation not only for the people directly involved but also for the medical staff in a
RESUME. Les auteurs présentent un récit et un commentaire sur un désastre d'incendie collectif produit en 1979 par jet de flamme (93 victimes). Ils insistent sur l'importance d'un transport rapide vers un seul hôpital. Ici il faut constituer un "commandement" et une équipe (chirurgie, thérapie intensive, organisation sanitaire) qui assure le triage et la thérapie primaire. En même temps il faut transformer une partie'de l'hopital en hôpital des brûlés. Le traitement sera "unitaire" et facile à appliquer, et approprié au grand nombre de patients. Comme chaque accident collectif est caractérisé par une différente combinaison de facteurs agressifs, de conditions de transport et de traitement, on ne peut pas établir un modèle de conduite: il faut le créer sur le champ.