Ann. Medit. Burns Club - vol. VII - n. 1 - March 1994

MASS DISASTERS IN GREECE

lliopoulou E, Lochaitis A, Komninakis E, Poulikakos L, Asfour S, Chalkitis S, Tzortzis C.

Department of Plastic and Reconstructive Surgery and Burn Unit, General District Hospital, K.A.T. Kifisia, Greece

SUMMARY. In our perpetually developing modem society, mass disasters tend to occur with increasing frequency, making the necessity of a great range of preventive measures, as well as coordination between State Authorities and volunteers, more and more imperative. What really aggravates the situation in a catastrophe is not only the number of casualties but also the disproportion between needs and means available (the latter being inadequate to meet demands). It is therefore of paramount importance to employ all available means and resources to attain full efficiency. The main goal of this article is to study to what degree these principles of action were applied in a mass accident that occurred in Eleusis (Greece) on 1 September 1992 and how these affected the final outcome of the patients, if indeed they did.

Recent incidents involving mass burn casualties have demonstrated that the specific needs of severely burned patients cannot be ignored in disaster planning. Despite the evidence available from past disasters, adequate provision for the management of bum casualties is still lacking in most disaster plans (3). A typical feature in most mass disasters is the time and place coincidence as well as the similarity of the injuries caused to the victims. "Misfortune" or negligence are the primary causes (5), but this is not always the case (in war or terrorist actions the plarming of events is obvious).

Mass casualties can be due to:

• an industrial accident
• a traffic accident
• natural calamity
• terrorist action
• war activities
• nuclear accidents.

The extent of the disaster will of course be determined by the cause and by the congregation of people at the site of the accident (6). The time the accident takes place is directly related to the number of victims. The accident at the King's Cross Underground Station in the rush hour (7.15 p.m.) would have caused fewer victims if it had happened a few hours later (2).
Further factors to be taken into consideration when we analyse the response to a mass disaster should be:

• the community affected
• the territory or environment (typically, "outdoor" or "open space" accidents are considerably more catastrophic as far as the number of casualties is concerned than "indoor" or "closed space" accidents). However, the number of fatalities caused by the latter type is far higher than that caused by the former (3).
• the coordination and efficiency of first-aid measures, organization of rescue work, quality of health system, etc.

A large percentage of mass disasters are caused at work. This is attributable to the expansion of industrial activities which involve - despite all security measures - certain oeccupational hazards, e.g. LPG (liquid petroleum gas) or BLEVE (boiling liquid expanding vapour explosion) disasters. The main determining factors of the gravity of a disaster are more or less the same; however, specific groups of the population are affected. There is an overt greater involvement of men than of women, of poorly educated than of more highly educated workers, and of younger persons than of older persons (victims universally belong to the "productive" age groups) (7).
The study of.the circumstances in which a mass disaster has occurred is of paramount importance (analysis of the data usually requires a whole team of specialists) in order to avoid similar incidents in the future, to improve protective measures and to upgrade the services of the existing health system (6).
For a correct evaluation of the consequences of a mass disaster, one should take into consideration not only the reactions of the victims involved but also the attitude and reactions of the groups of people who in any way provide the victims with care (1). These observations should be carefully assessed and borne in mind on the occasion of another disaster. Around the site of disaster we can distinguish (with reference to rescue work) three main zones;
Zone A is in the vicinity of the accident, and is only rudimentarily equipped (with medical facilities that are relatively insufficient to meet demands). The zone should not expand beyond a radius of 500 metres, in order to give rapid access to zone B, where appropriate and swift action will be the strongest determining factor in the success of our endeavours. A whole army of medical and nursing personnel should arrive in this zone as soon as possible, supported by army units and means of transport, and, needless to say, an abundance of medical equipment. Victims should be labelled according'to their gravity, and life-saving procedures and even operations must be performed immediately. Mobile army hospitals are required, and these should arrive as soon as possible; since their equipment may be insufficient, they have to be resupplied continuously.
Zone B should extend for not more than a radius of 2 km.
Zone C is the evacuation zone (by car, ship or plane to other centres or even abroad).
Let us proceed now to the main goal of this article, which is to study to what degree these principles of action were applied in a specific mass accident, and how they affected (if indeed they did) the final outcome of the patients.The accident happened at Eleusis (about 55 km southwest of Athens) in one of the largest oil refinery units in Greece, on I September 1992. The time of the accident was 7.15 a.m., Athens time. The cause of the accident (which was an LPG disaster) was the leakage of flammables, mainly gases, from two different points of the pipes, in a partial distillation unit. The correct functioning of the pipes had been checked two days before the event and it was found to be sufficiently safe. This followed a six-month interruption in the operation of the unit for maintenance work. Both the company and the trade-union leaders had agreed that the maintenance work had been carried out satisfactorily. The whole refinery is characterized by comparatively low productivity but high storage capacity (hence the relatively small number of personnel - about 380 persons). Each storage tank is well insulated, and this averted any further expansion of the explosions, which might have caused in-numerable casualties in the nearby community and further damage to the environment. The small medical station on the site is not well equipped and is totally insufficient to meet first-aid needs in a major disaster. There were two explosion sites. The explosions themselves originated from overheated gas in contact with air from the leakage points. The high pressure wave that was caused resulted in the shattering or collapse of every window pane in the vicinity; screaming and high flames caused the immediate automatic activation of the alarm system. Within 10 minutes the local police and fire service, together with first-aid ambulances from the neighbouring refineries (Greek Distillery, Aspropirgou and Motor Oil) and the Municipality of Eleusis, had already arrived.

Within 30 minutes, the first victims had arrived at the nearest large hospital at Nikeas (at a distance of about 30 km. from the site of the accident), from where the casualties were transferred to Burn Units within another half-hour (which must be a record, if we consider that the ambulances covered a distance of some 20 km or more through the very crowded centre of Athens in the rush hour). By 9.15 (two hours after the accident) the last patient had reached a Burn Unit, having already received basic first aid. The total number of casulaties was 35, of whom 32 were men. The three women belonged to the administrative staff. they rushed to a window in their office to see what had happened, and one sustained severe burns from flames that burst in. Of the 35 patients, 13 were discharged im-mediately. One person was found carbonized at the site of the accident (Table 1). As has been universally observed, the vast majority of the casualties belonged to the productive age group (fourteen were aged between 30 and 50 years). With the exception of the three women who were members of the administrative staff and a man who was a chemical engineer, the majority were work-ers or technicians. Thirteen patients received burns of over 60% TI3SA, predominantly full- or deep partial-thickness, with only clusters of superficial burns or intact skin. Concomitant injuries regarded one case with a tibial fracture and ten cases of inhalation injury. Sixteen patients were admitted to the two major Burns Units in Athens and one directly to an ICU. In the first hours or days post-burn ten of these patients were transferred to the ICU when signs of severe re-spiratory damage became manifest.
To our great disappointment, ten of the hospitalized patients were transported abroad (four to the UK, one to the USA and five to Lyons, France). This was despite our instructions and advice to family members, and clearly indicates that many Greeks are still nowadays credulous and reluctant to trust our welfare system. All these measures did not in fact affect the outcome of the patients: of the 21 hospitalized patients 13 (all with burns of over 60% TI1SA) died after a hospital stay varying between one day and two and a half months (mean hospitalization period: 10 days).

During hospitalization most of the patients required intubation, while three of them were operated on abroad, with the use of cadaver skin grafts - still legally forbidden in Greece.
With reference to the site of the accident, the fire was totally extinguished within 4 hours, which is a satisfactory time. This was achieved by means of extensive mobilization of the fire service and police forces. This was of paramount importance, since apart from the storage tanks a railway line and more gas-, kerosene- and naphthatanks are located in the vicinity. The event naturally caused not only an outburst of public opinion but also further investigations, which led to the following conclusions:

1. The leakage was due to corrosion of the pipe, which had not been changed since 1973.
2. There was no automatic gas-control system, which currently exists in every refinery in our country. This system, when it works, causes the immediate interruption of function if the leaking of certain gases is detected.
3. The partial distillation unit was very old and had already presented problems before, but nevertheless it had not been meticulously checked. After an interruption of six months it was put into operation the night before the accident.
4. Arson had been initally postulated, but this was ruled out when the first victim was found stuck to the pipe at the exact spot the leakage occurred.
5. The unit pressure when the accident occurred was half the pressure attained in maximum function conditions.

Compared with other major industrial accidents, the number of victims was small (Table 2). This was due to the following factors:

1. The accident occurred between shifts, when many workers had already left and others had not yet arrived at their posts.
2. The unit is old and has a comparatively small number of workers.
3. On the basis of a specific arrangement between the refinery in question and two other major refineries in the vicinity, the fire-extinguishing services of the latter arrived within 8 minutes, before even the police arrived, and started extinguishing the fire, freeing many workers who were trapped.
4. The State services, although somewhat delayed, functioned in perfect coordination (EKAM special firemen unit). Owing to the limited distance of the accident site from major health centres, zone B did not exist. From the medical point of view:

1. The survival rate was very low (13 out of 21 hospitalized patients died), owing to the severity and extent of the injuries sustained. Under the circumstances, primary operations on so many patients simultaneously would have been risky and practically unfeasible.
2. The medical and nursing personnel demonstrated stamina, devotion, skill and coordination beyond all expectation.
3. The infrastructure of the Greek health system in the event of a major disaster was proved insufficient.

Absolute priority should be given by every nation to identify zones, situations and types of potential risk, so that rescue resources can immediately be made available and proper preparedness assured in order to control a disaster, particularly when the danger zones are close to inhabited areas. Industries should undergo meticulous controls conforming to the Seveso directives (821501, 1988). Last but not least, both medical and nursing personnel should receive special training in the manner of action and ethics in the event of mass casualties.

RESUME. Dans notre société moderne, toujours en développement, les catastrophes d'incendie se produisent avec une fréquence croissante, et par conséquent il faut absolument garantir toute une série de mesures préventives et une -bonne coordination entre les autorités de l'Etat et les organisations bénévoles. La gravité d'une catastrophe dépend non seulement du nombre des victimes mais aussi de la disproportion entre les besoins et les moyens disponibles (ceux-ci sont normalement insuffisants pour les nécessités). Il est donc de la plus haute importance que l'on emploie tous les moyens disponibles pour atteindre une efficacité maximum. Cet article vise sur tout à étudier jusqu'à quel degré ces principes d'action ont été appliqués dans la catastrophe qui s'est produite à Eleusis (Grèce) le premièr septembre 1992 et comment ils ont influé sur l'évolution des patients, si en effet ils ont exercé une influence.

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