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 This report could not be published before, since the Communist regime did not allow the spreading of news about devastating events with multiple casualties - not even for scientific reasons.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.

4. Conclusion

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.

1. Alarm

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:

1. Primary emergencies - severe burns with chances of survival (30-35 patients). These were the first to be sent to the operating theatres.

2. Secondary emergencies - severe burns without chances of survival (25-30 patients). These were placed on stretchers and beds and prepared for operation after the primary emergencies. All patients awaiting an operation were given perfusions and oxygen by endonasal catheters.

3. Tertiary emergencies - superficial burns (about 25 patients) as the last turn in the operating rooms. Some of these could be treated directly in the emergency room.

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.
According to the Romanian official regulations at the time, the following were performed:
Local treatment; general anaesthesia. Wound cleansing with a soap solution or a quaternary ammonium compound. Removal of phlyetenae. Painting with alcohol. Application of Sulfamylon. Exposure of cephalic extremity and trunk, and dressing of limbs (in the last few years we have abandoned this type of local treatment: currently the method of choice is an original one - selective coagulation with a 5% silver nitrate solution; this method proves effective both as local treatment and in handling mass accidents). Incision in restrictive burns of limbs.
General treatment. We applied an Evans-type approach, which suggests a lower rate of blood and macromolecular solutions. No strong sedatives or blocking drugs were used, and diuresis was not forced. For 10 days broad-spectrum antibiotics (gentamicin, Pyopen) and Trasylol were given. Aerosol inhalations with antibiotics were used to promote expectoration. The patients included five pregnant women, in whom therapeutic abortions were performed.

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.

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 condition, etc.
During the first days some escharotomies were performed as local treatment. Detersion was initiated by baths and wet dressings, to prevent secretion clogging. Healing of third-degree burns was achieved in 18-21 days, by which time granular tissue was forming in patients with fourth-degree burns. The discharge of patients with mild burns was possible after 10 days; those with spontaneously healed wounds left hospital after 20-25 days. All other survivors needed longterm hospitalization and one- or two-stage skin grafts in the plastic surgery department. In view of their need to readapt to a normal life after this tremendous psychic aggression, recovered patients were transferred for an intermediate healing stage to the Tractorul Hospital, where they were allowed to contact families and kept under medical control. Three patients were transferred to the Neurosis Sanatorium.

The data obtained can be summarized as follows:

1. Respiratory complications were the most frequent. They were particularly enhanced by a background of low resistance to injury-causing factors, due to pre-existing interstitial fibroses. Twenty-eight patients had radiologically documented pneumopathies, mostly presenting as bronchopneumonias. Nineteen of these died: ten within the first eight days, six on the 9th day (with severe cardiac failure) and three between the 15th and the 21st day. Among the nine survivors, three had residual radiological images with no clinical correspondence. All lung complications were further handled after 10 days with co-trimoxazole associated with oxacillin or ampicillin.
2. Cardiac complications
   All victims showed right cardiac load, sometimes with minor right heart block. This may have been due to lung obstacles or to microemboli. All these conditions gradually disappeared in the patients who survived. Many of those who eventually died showed severe dysfunctions such as tachycardia with excessive heart rate, gallop rhythm, paroxysmal fibrillation, ventricular premature beats and different degrees of heart hypoxia. In eight cases the immediate cause of death was related to cardiac problems.
3. Pulmonary embolism was present in two patients, one of whom died.

4. Late digestive tract haemorrhages such as melaena were present in four patients, of whom two survived.

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 burns).
The reported fire disaster can therefore be characterized as follows:

• a mass combustion accident (93 casualties) caused by a fire jet. Moderate gas pressure;
• casualties with a background of low natural lung resistance to injury-causing factors;
• extremely rapid transport of casualties;
• hospital care:
• competent and efficient team
• competent sorting of cases
• good facilities: 14 operating theatres available, attended by complete teams and staff familiar with primary care of burn wounds
• handling of patients in specially created wards
• teamwork of different specialists in specific problems;
• general outcome at the highest prognostic level.

A fire disaster is an alarming situation not only for the people directly involved but also for the medical staff in a hospital.
That sunny early September morning all sorts of vehicles were bringing the injured into the hospital courtyard. The victims were yelling with pain and, agitating their wounds and the remains of their clothing, and everywhere there was an awful smell of smoke and burned flesh, as if in a "danse macabre": a panic-inducing scene (13).
Obviously, any report on mass disasters is welcome in the literature. The rules to be observed in such situations are of the utmost importance - and exhaustive guidelines have already been recommended (11). But let us not forget that there are no true similarities between such accidents, between their various pathologies and management formulas, if we go beyond theoretical models (3, 5, 10).
However, we do consider that some essential points are raised by the severity of an accident, the number of victims and the demands involved in the modern handling of burn wounds. Bearing in mind the fact that these patients need a rapid and competent management from the beginning, their transportation, by any means,available and as soon as possible, to the nearest hospital with qualified staff able to attend them, is the best solution - as our case proved. Therefore, wherever there are places of work with a high fire disaster risk, people need to know exactly where the victims should be taken in the event of an emergency. An emergency situation involves rapid transport by any available means; it is not possible to wait for ambulances, which are usually late and insufficient. Emergency care at the scene of an accident with multiple casualties - however controlled it may be - requires time (and this is a major deteriorating component) (7).
The essential point in hospital care is a control team to ensure the sorting of the casualties (an operation that needs highly qualified staff) and the organization and partial transformation of the hospital within a few hours into a specialized burn care unit.It is essential to establish a single local and general treatment plan according to the previous experience of the surgical and intensive care team. It is also important that this plan should be simple and feasible, given the particular overloaded circumstances (12). Basically, therapy after a mass accident cannot involve sophisticated individual treatment; it has to follow a strategy adapted to particular group care (14). Ideally, all casualties should be handled in the same hospital, which need not be a highly specialized clinic (such clinics are usually remote and have a limited number of beds). It is advisable to make use of the nearest hospitals that normally-attend single burn cases, as they can provide the qualified staff to achieve correct treatment. Specialists from other medical services may also be called in to deal with particular cases.
Fire disasters are rare and unpredictable accidents. Emergency care in such events thus produces situations that cannot be planned beforehand (such as evacuating a building); treatment has to be prepared within minutes, according to each particular situation.

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.

BI[BLIOGRAPHY

1. Aburel V., Visa L, Dragan M.: Ponderea factorilor agravanti in evaluarea riscului vital al arsurilor. Consfatuire Interjudeteana Brasov, 1984. (Romanian)
2. Aburel V., Visa I., Dragan M., Malene G.: An original method of primary local treatment of burns by silver nitrate in a selective coagulating concentration. Eur. J. Plast. Surg., 16: 139-42, 1993.
3. Arturson G.: The Los Alfaques Disaster: a boiling liquid, expanding vapour explosion. Burns, 7: 233-51, 1981.
4. Azolov V.V., Dmitriev G1: Principles of classification and care of patients with bums in mass accidents. Sovetskaia Meditsina, 1: 3-5, 199 1. (Russian)
5. Buerk C.A.: The M.G.M. Grand Hotel Fire. Arch. Surg., 117: 641-4,1982.
6. Dmitrenko O.D.: Burn catastrophes (the problem of organizing the delivery of care to burn patients). Vestnik Khirurgh Imeni 1. 1. Grekova, 146: 143-6, 1991. (Russian)
7. Filopuolos E.: Mass burn casualties and the role of emergency prehospital services. Arm. Medit. Burns Club, 5: 177-9, 1992.
8. lonescu A., Chiotan N., Isac F., Milicescu S.: Bazele teoretice si practice ale ingrijirii arsilor. Ed. Medicala, Bucuresti, 1978. (Romanian)
9. Kossman T., Wittling L, Buehren V., Sutter G., Trentz 0.: Transferred triage to a level I trauma centre in a mass catastrophe of patients, many of them with bums. Acta Chirurgiae Plasticae, 33: 145-50, 1991.
10. Mackie D.P.: Fate of mass bum casualties: implications for disaster planning. Bums, 16: 203-6,1990.
11. Masellis M., Ferrara M.M., Gunn S.W.A.: Immediate assistance and first aid on the spot in fire disasters - education of the public and self-sufficiency training. Ann. Medit. Bums Club, 5: 200-6, 1992.
12. Micheels J., Lamy M., Jacquemin D.: Role of surgical emergency department in the management of a disaster bringing a great number of patients with burns. Acta Chirurgica Belgica, 86: 192-6, 1986.
13. Powers P.S., Maher M., Helm M.D., Cruse C.W., Luria W.: Impact of a disaster on a burn unit. Psychosomatics, 27: 553-7, 1986.
14. Sharpe D.T.: Management of bums in major bums disaster injuries. Injury, 21: 41-4, 1990.