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Mass burn casualties: a rational approach to planning
Burns 28 (2002) 403–404
Editorial
Mass burn casualties: a rational approach to planning
This issue of Burns contains two related articles concerning the management of major burn incidents. Papers on this subject in the burns literature are scarce and these contributions are warmly welcomed. The first paper describes the generation of a number of key statements, which have been formed by a process of consensus-building among selected experts in burn care, disaster planning and disaster management. The second paper attempts to translate these statements into practical guidelines. In this way, a number of interesting and relevant recommendations have been produced. However, the presentations seem to preclude critical appraisal of the outcome; indeed, the Delphi technique itself deliberately avoids debate and discussion. As a result, the recommendations appear somewhat arbitrary and dogmatic. This impression is unfortunate as the optimal approach to fire disaster planning is by no means certain. Furthermore, since specific measures for fire incidents will inevitably have to integrate with broader contingency planning, some degree of flexibility and pragmatism is essential. An alternative approach to the technique described above consists of a rational analysis of the particular problems posed by mass burn casualties, to provide a logical background upon which various planning scenarios can be constructed. As the authors stress, the scarcity of specialised burn beds is the single most restricting factor in planning for major fire incidents. A process of expert triage to identify those casualties who require specialised burn care, is therefore central to any planning for fire incidents. Previous analysis of fire disasters has shown that the majority of those involved either escape rapidly, sustaining relatively minor injuries, or they become engulfed in the conflagration, sustaining lethal injuries. In certain incidents, appreciable numbers of fatally injured casualties may survive long enough to reach hospital. The proportion of patients sustaining injuries between these extremes is relatively small [1]. It is this group which has the first priority for specialised care. Accordingly, expert triage must take place before any patient is transferred to a burn unit. Expertise and experience are essential for this assessment process, because factors such as burn depth, patient age, cultural expectations and a knowledge of regional burn bed availability may be decisive, especially at the triage margins. To this end, the formation of a burn assessment team (BAT), as suggested by the papers in this issue, is most
desirable. The BAT should not be deployed to the disaster site for two reasons: firstly, the assembly of such a specialised team will take hours, rather than minutes; secondly, it is arguable that accurate burn triage under field conditions is impracticable. Instead, the BAT can most usefully deploy to the primary admitting hospital(s) where, under optimal conditions of warmth, lighting and nursing support, patients may be examined in a relatively calm environment. Surgeons and casualty officers in general hospitals therefore require training in basic life support for burn patients, and hospitals should have contingency plans to deal with large numbers of burn casualties. Burn specialists have a responsibility to disseminate their unique knowledge throughout the hospital services in order to meet this need. The number of casualties which hospital services should be expected to cope with in peacetime is arbitrary, but several factors help to influence decision-making. The majority of the incidents that have been reported in the medical literature resulted in less than a hundred hospital casualties. However, the aeroplane crash at Ramstein resulted in 340 hospitalised casualties and, following the recent New Year café fire in The Netherlands, more than 200 victims were admitted to hospital. (More than 80 of these required artificial ventilation for inhalation injury, a daunting logistic challenge in itself). Both of these incidents occurred in recent years in developed countries. Much greater incidents have occurred in the past, requiring the intervention of outside agencies, typically the military forces. While these very large events fall outside the scope of this discussion, it does seem realistic to advocate contingency planning to cope with incidents resulting in up to 500 casualties with significant burns. For planning purposes, it is reasonable to predict that perhaps 300 will require admission to hospital and of these, less than one in four will have burns of more than 25% TBSA. The actual numbers of patients reaching any particular hospital will depend on factors such as geography, casualty dispersal policies, and the level of pre-hospital medical intervention. At the European Burns Association meeting in Lyon last year, a debate was held, but not resolved, on the merits of “scoop and run” versus “stay and play” in the field of pre-hospital care. In favour of scoop and run, it was argued that burn victims are initially stable and therefore rapid evacuation to hospitals, where facilities for assessment and appropriate treatment are available, is the policy of choice.
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 2 ) 0 0 0 8 1 - 5
404
Editorial / Burns 28 (2002) 403–404
The argument for “stay and play” was the contention that the unregulated transport of patients to hospitals will merely displace the scene of chaos to the hospital environment. Elementary on-site stabilisation by trained trauma teams will gain time for an orderly evacuation of victims to hospitals, which will have had some opportunity to prepare for an influx of casualties. There are merits to both approaches, but past experience has shown that in the absence of effective disaster management, large numbers of victims may reach nearby hospitals by any form of transport that is available, including buses, private vehicles, and on foot. In planning for mass burn casualties it should be appreciated that burn patients are often alert, mobile and frightened. From the above analysis, it is possible to generate reasoned arguments for specific plans to cope with large numbers of burn victims. The most appropriate approach for any particular area will vary according to such factors as geography, population density and the availability of health resources. The proposals contained in the two papers in this issue provide an excellent reference point for developing and refining such plans. There is an important role for national and regional burn associations in this context, firstly
to co-ordinate the debate within the burns community itself, leading to the formation of proposals which have the broad backing of burn specialists; and secondly to ensure that these proposals are submitted to the appropriate authorities for integration into existing disaster contingency plans. In addition to the proposals contained in the two papers, I would therefore like to add one more: all national burn associations should establish disaster committees to ensure that practical measures to deal with mass burn casualties are incorporated and maintained within existing disaster contingency plans. Optimal care of burn patients in large incidents is only possible if burn specialists become actively involved in disaster planning. Reference [1] Mackie DP, Koning Fate of mass burn casualties: implications for disaster planning. Burns 1990;16:203–6.
David P. Mackie Red Cross Hospital, Beverwijk, The Netherlands
Editorial
Mass burn casualties: a rational approach to planning
This issue of Burns contains two related articles concerning the management of major burn incidents. Papers on this subject in the burns literature are scarce and these contributions are warmly welcomed. The first paper describes the generation of a number of key statements, which have been formed by a process of consensus-building among selected experts in burn care, disaster planning and disaster management. The second paper attempts to translate these statements into practical guidelines. In this way, a number of interesting and relevant recommendations have been produced. However, the presentations seem to preclude critical appraisal of the outcome; indeed, the Delphi technique itself deliberately avoids debate and discussion. As a result, the recommendations appear somewhat arbitrary and dogmatic. This impression is unfortunate as the optimal approach to fire disaster planning is by no means certain. Furthermore, since specific measures for fire incidents will inevitably have to integrate with broader contingency planning, some degree of flexibility and pragmatism is essential. An alternative approach to the technique described above consists of a rational analysis of the particular problems posed by mass burn casualties, to provide a logical background upon which various planning scenarios can be constructed. As the authors stress, the scarcity of specialised burn beds is the single most restricting factor in planning for major fire incidents. A process of expert triage to identify those casualties who require specialised burn care, is therefore central to any planning for fire incidents. Previous analysis of fire disasters has shown that the majority of those involved either escape rapidly, sustaining relatively minor injuries, or they become engulfed in the conflagration, sustaining lethal injuries. In certain incidents, appreciable numbers of fatally injured casualties may survive long enough to reach hospital. The proportion of patients sustaining injuries between these extremes is relatively small [1]. It is this group which has the first priority for specialised care. Accordingly, expert triage must take place before any patient is transferred to a burn unit. Expertise and experience are essential for this assessment process, because factors such as burn depth, patient age, cultural expectations and a knowledge of regional burn bed availability may be decisive, especially at the triage margins. To this end, the formation of a burn assessment team (BAT), as suggested by the papers in this issue, is most
desirable. The BAT should not be deployed to the disaster site for two reasons: firstly, the assembly of such a specialised team will take hours, rather than minutes; secondly, it is arguable that accurate burn triage under field conditions is impracticable. Instead, the BAT can most usefully deploy to the primary admitting hospital(s) where, under optimal conditions of warmth, lighting and nursing support, patients may be examined in a relatively calm environment. Surgeons and casualty officers in general hospitals therefore require training in basic life support for burn patients, and hospitals should have contingency plans to deal with large numbers of burn casualties. Burn specialists have a responsibility to disseminate their unique knowledge throughout the hospital services in order to meet this need. The number of casualties which hospital services should be expected to cope with in peacetime is arbitrary, but several factors help to influence decision-making. The majority of the incidents that have been reported in the medical literature resulted in less than a hundred hospital casualties. However, the aeroplane crash at Ramstein resulted in 340 hospitalised casualties and, following the recent New Year café fire in The Netherlands, more than 200 victims were admitted to hospital. (More than 80 of these required artificial ventilation for inhalation injury, a daunting logistic challenge in itself). Both of these incidents occurred in recent years in developed countries. Much greater incidents have occurred in the past, requiring the intervention of outside agencies, typically the military forces. While these very large events fall outside the scope of this discussion, it does seem realistic to advocate contingency planning to cope with incidents resulting in up to 500 casualties with significant burns. For planning purposes, it is reasonable to predict that perhaps 300 will require admission to hospital and of these, less than one in four will have burns of more than 25% TBSA. The actual numbers of patients reaching any particular hospital will depend on factors such as geography, casualty dispersal policies, and the level of pre-hospital medical intervention. At the European Burns Association meeting in Lyon last year, a debate was held, but not resolved, on the merits of “scoop and run” versus “stay and play” in the field of pre-hospital care. In favour of scoop and run, it was argued that burn victims are initially stable and therefore rapid evacuation to hospitals, where facilities for assessment and appropriate treatment are available, is the policy of choice.
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 2 ) 0 0 0 8 1 - 5
404
Editorial / Burns 28 (2002) 403–404
The argument for “stay and play” was the contention that the unregulated transport of patients to hospitals will merely displace the scene of chaos to the hospital environment. Elementary on-site stabilisation by trained trauma teams will gain time for an orderly evacuation of victims to hospitals, which will have had some opportunity to prepare for an influx of casualties. There are merits to both approaches, but past experience has shown that in the absence of effective disaster management, large numbers of victims may reach nearby hospitals by any form of transport that is available, including buses, private vehicles, and on foot. In planning for mass burn casualties it should be appreciated that burn patients are often alert, mobile and frightened. From the above analysis, it is possible to generate reasoned arguments for specific plans to cope with large numbers of burn victims. The most appropriate approach for any particular area will vary according to such factors as geography, population density and the availability of health resources. The proposals contained in the two papers in this issue provide an excellent reference point for developing and refining such plans. There is an important role for national and regional burn associations in this context, firstly
to co-ordinate the debate within the burns community itself, leading to the formation of proposals which have the broad backing of burn specialists; and secondly to ensure that these proposals are submitted to the appropriate authorities for integration into existing disaster contingency plans. In addition to the proposals contained in the two papers, I would therefore like to add one more: all national burn associations should establish disaster committees to ensure that practical measures to deal with mass burn casualties are incorporated and maintained within existing disaster contingency plans. Optimal care of burn patients in large incidents is only possible if burn specialists become actively involved in disaster planning. Reference [1] Mackie DP, Koning Fate of mass burn casualties: implications for disaster planning. Burns 1990;16:203–6.
David P. Mackie Red Cross Hospital, Beverwijk, The Netherlands