The discotheque fire in Gothenburg 1998

Burns 29 (2003) 405–416

The discotheque fire in Gothenburg 1998 A tragedy among teenagers Jean Cassuto a,b,∗ , Peter Tarnow b,c b

a Department of Intensive Care, Sahlgrenska University Hospital, MöIndal, Sweden Institution of Surgical Specialities, Sahlgrenska University Hospital, Gothenburg, Sweden c Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden

Accepted 25 February 2003

Abstract The fire disaster in Gothenburg, Sweden, 1998 killing 63 and wounding 213 teenagers was caused by arson committed by a youth from the same community. The fire was started in the basement of an overcrowded discotheque and made, due to unfortunate circumstances, devastating progress. The ensuing rescue work performed by other youth, fire fighters, police and medical staff was prompt and must be seen in the light of a very difficult situation. As a result of these orchestrated efforts and the fact that this disaster occurred in a major city with substantial resources, all the injured were able to be hospitalized within 2 h. The load on four local hospitals was initially severe due to the large number of injured and the limited number of staff on night duty. The situation was contained by relocating patients from the intensive care units to ordinary wards and by transporting several of the most severe burn injuries by helicopter to burn units in other parts of Sweden and to Norway. Hundreds of relatives and friends gathered at the local hospitals. This was a new experience for the hospitals and staff, involving many positive aspects as well as some negative aspects such as violence, threats and rumors. As a result of the large number of injuries vast psychosocial rehabilitation program was initiated by health care staff, religious communions, schools and the community, has continued over the past years. Such a disaster emphasises a requirement for extensive preparation not only in the rescue and medical services, but also in the ways and areas to rehabilitate patients in society. © 2003 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Fire disaster; Arson fire; Gothenburg; Sweden; Discotheque

1. Introduction Indoor fire disasters have taken place in circus tents, theatres, cinemas, hotels, restaurants, department stores and nightclubs around the world [1–5]. The largest number of deaths reported in an indoor fire occurred in 1845 in Canton, China, when a theatre burned down killing 1670 people. Previous indoor fire disasters in Sweden occurred at the City Hotel of Borås in 1978, where 20 young people were killed and 66 were injured [6] and on the Scandinavian Star ferry in 1990, killing 158 and injuring 30 people [7]. An important incident preceding the present fire disaster was the Estonia ferry disaster, where a passenger ship sunk leaving 796 dead [8]. It became apparent after this accident that a vast psychosocial effort would be reached in the aftermath of similar disasters in the future, and that society had to pre∗ Corresponding author. Present address: Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, SE-43180 Mölndal, Sweden. Tel.: +46-31-3431882(O); fax: +46-31-3431882. E-mail address: [email protected] (J. Cassuto).

0305-4179/$30.00 © 2003 Elsevier Science Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(03)00074-3

pare for it. Thanks to extensive reorganization of the rescue plan of the city of Gothenburg following the Estonia disaster, the difficult situation encountered following the discotheque fire was efficiently dealt with, although new experiences emerged triggering re-evaluation of the plan and further improvements. This was further actualized by a most recent incident on 17 May 2002, when a significant fire started on board the passenger ferry “Princess of Scandinavia” carrying 758 passengers off the coast of Britain. Fire fighters on board managed to extinguish the fire and no injuries were reported. Fire disasters have plagued human societies throughout their history and will continue to do so in the future. By preparing society for the eventuality of a fire disaster, we can improve the outcome. Sharing information with the international community on such events is therefore of uttermost importance. The recent tragic disaster in Volendam, the Netherlands, on 1 January 2001 [9], showed many similarities with the current discotheque fire, with mass injuries among teenagers. Victims from the Gothenburg disaster have therefore visited and exchanged experiences

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with Volendam victims, and have been able to help them in their rehabilitation into society.

2. The disaster and the ensuing rescue actions 2.1. The discotheque The fire started in a two-storey concrete and brick building housing the Macedonian association, a theatre and a few

shops (Fig. 1). The building is located in an industrial area in the central part of Gothenburg, the second largest city of Sweden, with approximately 500,000 inhabitants. The Macedonian club was housed on the second floor of the building and covered a total area of 225 m2 (9 m × 32 m) (Fig. 2). Two doors (0.9 m wide) led into the club, one serving as the main entrance and a second, located in the opposite end of the room, served as emergency exit (Fig. 1). Both doors were reached through separate staircases. The main entrance door led into a narrow hallway, flanked by two

Fig. 1. This illustration of the building, which housed the discotheque (9 m × 32 m) gives an insight on the narrow hallway preceding the main exit door and partly explains the “bottle-neck” situation encountered by the victims. Windows elevated 2.20 m above floor level, some blocked by metal grating and some located 6 m above ground level, further aggravated the situation (courtesy of Roland Thorbjörnsson, GP).

Fig. 2. A schematic overview of the facilities showing the distribution of the deceased inside the discotheque. It is clear from the illustration that a majority of the deceased (illustrated by crosses) were found in the narrow and partly blocked hallway preceding the main entrance door and in the cloakroom facing the hallway. Places where smoke divers and fire fighters entered the building in a life-saving operation are indicated by arrows.

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Fig. 3. Inside of the burned discotheque. The emergency exit door, where the fire was first detected, is seen on the far right side. Behind the representatives of the investigation group, the stage can be discerned. Notice the elevated windows (above head level) along both sidewalls and the metal barred windows (right wall) (courtesy of Kamerareportage).

offices and a cloakroom, before opening into the main hall of the club which was dominated by a large dancing floor (148 m2 ) (Fig. 2). The club had also access to lavatories and a poolroom half a storey below which could only be reached through the staircase leading from the main entrance of the club. The dancing floor was lined on both sides by a number of high level windows (lower frame 2.2 m above floor), some of which were covered by metal bars (Figs. 1 and 3). Linoleum flooring covered the floor, wooden paneling lined the lower part of the concrete inner wall, and the ceiling was built on steel beams carrying fire proof mineral insulation (Fig. 3). 2.2. The party Four young people had rented the club with a declared intention of arranging a birthday party with some 40 invited guests. Instead, they printed and distributed leaflets inviting to a major Halloween party and sold tickets to some 400 people, despite a legal maximum of 150 people inside the club on one single occasion. The party took place on 30 October 1998.

2.3. The fire An estimated 375 people were in the club when, at about 23.30, some of the youths sensed a strong and unpleasant smell. Shortly after, they saw smoke entering the discotheque through the emergency exit door (Figs. 1 and 3). One of the organizers opened the door, and closed it again after detecting hot black smoke in the staircase. One of the two disc jockeys standing on the stage next to the emergency exit (Figs. 1 and 3) tried to attract the attention of the participants by using the loudspeakers and inform partygoers that a fire had broken out, that everyone should leave the premises and that there was no reason for panic. Confusion ensued. Some of the participants responded to the warnings and started to leave the discotheque while others hesitated and some restarted the dancing. Interviews with 309 survivors revealed that despite the fact that most of the survivors were aware of several of the signs preceding the fire, such as others leaving the club, warnings issued by the disc jockey, comments made about a fire, a sharp smell, burning eye sensation, and smoke (none reported having seen flames), only about 50% of the participants decided to leave the discotheque. The other half

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doubted the credibility of these warnings and decided to stay behind [10]. Some of the survivors later described that they felt a strong urge to investigate the credibility of the rumors and decided to open the emergency door, probably on several occasions. Finally, the door was left open by one of the survivors who reportedly was unable to shut it again as the handle had become too hot. Shortly after this, lamps located close to the emergency exit began to explode and thick black smoke entered the dancing floor. People began running towards the main entrance door, which was partly blocked by a table placed in the narrow entrance hall set in place by the person charging entrance fees. A majority of survivors managed however to leave the fire through the main entrance door. When the pressure on the main exit increased, several people fell to the floor inside the entrance door and others, pushed from behind, fell on top of them soon creating blocking cluster of people. Out of the total number of survivors, some 74% exited the club through the main entrance. A majority of these (53%) were able to leave the discotheque without assistance and before the entrance was clogged [10]. The other accessible escape route for the youth trapped inside the discotheque was through the windows, all of which were difficult to reach from the inside (Figs. 1 and 3) with some located 6 m above ground level (Fig. 1). Despite these difficulties, a significant number of the youths were able to climb out of the windows using shelves, furniture or other people as ramps. This route was used by 12% of survivors as a mean of escape. Interestingly, 76% of those who exited through the windows were male (statistically significant) [10] implying that this escape route in most cases required great physical strength. This is in line with previous reports showing that male sex and good physical training coincides with survival [11]. In 14% of cases, the survivors were unable to account for the route of exit from the discotheque, probably due to disorientation or loss of consciousness. 2.4. Experimental reconstruction of the fire scene In order to better understand the course of events at the fire scene, an experimental replica (scale 1:4) of the discotheque was built [12]. Temperatures measured inside the model were considered to be similar to temperatures arising during the real event, while the spread of fire was believed to have been twice as fast. The experiments confirmed that the single most important reason for the explosive spread of the fire was the fact that someone had left the emergency exit door open allowing oxygen to reach the fire. Results also showed that it only took about 2 min for the toxic fumes to reach the entrance door, and that after 2.5 min the level of toxic gases had reached 1.5 m above floor level, beginning to adversely affect the sense of orientation of the victims. After 3 min, the level of toxic fumes reached head-level (1.6 m) and a critical concentration. After 5 min, concentrations were above the levels associated with loss of consciousness. The temperature at the main entrance door

peaked at 150 ◦ C while the temperatures recorded in the far end of the dancing floor, i.e. close to the emergency exit where the fire had started (Fig. 1), reached 900 ◦ C. This is in line with previous reports [13]. Paradoxically, these extreme temperatures may have saved the lives of many by blowing out the windows and forcing out the toxic gases before they reached lethal levels and subsequently allowing fresh air to enter the discotheque through the main entrance door [14]. A computer simulation of the fire scene [15] yielded similar results and conclusions. It further showed that under similar conditions but without the blocking cluster of people formed inside the entrance door, the time to evacuate 380 persons would have ranged between 6 min and 7 min, enough to safely evacuate the building. 2.5. The alert The first emergency call was sent from inside the discotheque at 23.42 and came from a cellular phone belonging to one of the disc jockeys who died in the fire. This was soon followed by several other calls from mobile phones. The Central Alarm facility had great initial difficulties identifying the site of fire due to the screaming and shouting in the background. Fifteen calls from mobile phones arrived within the first 3 min (a total of 110 emergency calls to 112 were registered by the SOS central), which was able to identify the site of fire at 23.45 and issue a general alert. The first ambulance and police arrived at 23.47 and the first fire engine arrived to the fire scene at 23.49 [16]. 2.6. Rescue work by the fire fighters Before the arrival of the fire fighters, several survivors who had managed to exit the discotheque and were now standing in the stairway, had started to pull out some of the youth clogged inside the main entrance door. This rescue effort was slowed down significantly by the fact that each victim had to be carried down to ground level due to the limited space in the staircase. The first team of fire fighters arriving at the fire scene were met by a chaotic situation. It was dark and cold (8 ◦ C). The grounds of the building were crowded with terrified young people. Many were lying on the ground; some were running about, some carrying or attending wounded, while others were just standing around and apathetic (Fig. 4). To their dismay, the first fire fighters also witnessed how people were jumping or were pushed out of windows on the second floor of the burning building. They were falling some 6 m to the ground below (Fig. 1), where other youths lay screaming in pain and agony. Following this dramatic encounter with the fire scene, the fire fighters reported back and demanded immediate reinforcements and took the decision to divert all efforts to life-saving operations instead of fire extinction. Thus, no fire extinction took place during the first 40 min after the arrival of the first team to the premises. Smoke divers and fire fighters now faced the difficult task of saving some 120 people trapped inside the

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Fig. 4. This prize-winning photo illustrates the situation encountered by the rescue teams on arrival to the scene of the fire. The agonized expression in the face of one of the survivors as a friend or relative is taken care of by ambulance orderlies and fire fighters, while the fire was raging in the background. The OLA ambulance formed the first platform for the assembly of the injured on the fire grounds before it was replaced by a nearby building which was later opened up by the police (courtesy of Niklas Maupoix/Kamerareportage).

fire stricken building. Smoke divers were assigned to focus on the only usable escape routes, i.e. the main entrance door and the windows on one side of the building, the others being blocked by the flames or by metal grids (Fig. 3). Inside the entrance, a large number of youth were wedged (Fig. 2). In order to facilitate the rescue operation and improve conditions for the victims, powerful fans were placed outside the entrance. Smoke divers, assisted by some survivors, began to pull people out but as soon as a spot was cleared it was filled with a new body of someone pushed out from the inside. Simultaneously, turntables and extension ladders were raised against the external wall to the level of the windows on the second floor. After clearing the entrance, smoke divers were able to enter inside the burning discotheque and locate a number of survivors in the cloakroom (Fig. 5), where a large number of the victims were later to be found (Fig. 2). The survivors were lifted from the outside up to the level of the window and rescued by the aid of fire fighters standing on external ladders. These coordinated rescue efforts saved

the lives of some 60 youth (20 via windows and 40 through entrance door). The youths who initially set out to remove people trapped inside the main entrance were now assisting the fire fighters and smoke divers, thus playing an important role in the outcome of the rescue operations. At about 00.30, i.e. approximately 40 min after the first alert, the rescue team ruled out the possibility of finding any more survivors inside the burning building and interrupted the rescue operations. Extinguishing the fire was initiated and reached completion at 02.02. Altogether 50 fire fighters from seven fire stations in and around the city participated in the operations [16]. 2.7. Medical staff on the scene of fire The first ambulance arrived on the scene of the fire at 23.53, i.e. within minutes of the first alert by the SOS Alarm Central [16]. When the first team approached the scene of the fire, they saw a column of smoke but had no information on the nature of the accident. They were therefore

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Fig. 5. Desperation when realizing that the escape route through the main entrance door was blocked by a large number of people forming a human plug, forced many of the youth to seek refuge in this narrow cloakroom. A few managed to escape through the high level window using each other or the hat rack as a platform. Some hesitated too long in jumping out of the window when realizing that ground level was 6 m below, thereby obstructing this important route of escape. A few were saved through this window by the aid of fire fighters/smoke divers on external ladders before heat and accumulation of toxic gases disrupted further rescue efforts. A total of 23 of the fatalities were found inside the cloakroom (courtesy of Kamerareportage).

taken aback by the extension of the catastrophe with no time to mentally prepare for the situation. On arrival, the ambulance teams were met by despair and tumult with people running about and youths carrying wounded victims towards them. They started off by establishing contact with the First Commander of Rescue Services on the grounds, and quickly estimated the number of injured as 30 people. This was immediately reported to the Alarm Central along with a preliminary report on the nature of injuries and a request for more ambulances to the fire grounds. The emergency ambulance (OLA; significantly bigger than a normal ambulance) was now established as a preliminary assembly place for the wounded (Fig. 4). The first doctor (general practitioner) arrived shortly before midnight, i.e. soon after the first emergency ambulance. Enquiring about the presence of other doctors on the grounds of the discotheque, she was bluntly informed that she was the only one present along with 30 injured [17]. During the night, all available ambulances (a total of 16 vehicles and 30 ambulance orderlies), were involved. Despite the increasing supply of ambulances, the pressure on the medical rescue teams con-

tinuously increased. These priorities were the result of the strategy adopted by the fire fighter teams who, focusing on life-saving operations, were able to open up the obstructed entrance to the discotheque and save an increasing number of youth from the fire. The medical rescue teams decided to follow the routines of major accidents, i.e. strict priorities for treatment and transportation, although priority cards came only to be used on a few occasions. This was of utmost importance in view of the increasing number of wounded. An increasing problem for the medical rescue teams was the fact that friends and relatives of the wounded were continuously pulling, tugging and trying to draw attention to their dear ones, the situation sometimes becoming hostile when rescue teams had to interrupt resuscitation of a victim. Approximately 40 min after arrival of the first doctor to the fire grounds, another doctor reached the scene of fire from one of the nearby hospitals were he was on guard. On arrival to the scene of fire he was shocked by the nature and extent of the disaster and confirmed that he was unable to obtain adequate information prior to arriving there in person. He was utterly astonished over the extent of disaster, the tremendous

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noise of people and engines and the chaotic situation he encountered [17] (Fig. 4). Two additional medical teams (doctors and nurses) were sent from nearby hospitals, but were delayed due to the increasing numbers of injured now arriving from the scene of fire to their hospitals. A substantial part of the medical rescue teams’ work on the grounds of the discotheque was to ensure, as far as possible, an order of priority of the injured. This was based primarily on observations of respiration and circulation (skin color and pulse), extent and character of burn injuries, level of consciousness, and degree of pain. Blood pressure measurements were not performed. Fluids and drugs were administered by way of intravenous catheters inserted by nurses arriving on ambulances. Pain relief was achieved by intra-muscular or intravenous injections of small doses of ketamine hydrochloride. Oxygen was primarily administered by mask. In cases of severe respiratory deficiency, patients were intubated to secure a free airway. Due to the acute shortage of oxygen, lightly injured were seated in small groups sharing a common source of oxygen, a strategy also used inside the ambulances. Resuscitation was interrupted when doctors decided that a patient was beyond rescue. Death was established based on lack of respiration, pulse and cardiac activity (portable ECG). When a portable ECG was not available, lack of pupil reflex was used as the third criteria [17]. In order to relieve the pressure on the rescue teams, police opened up a garage located on the fire grounds and belonging to a car rental company. The building offered a lit and warm working place and a possibility to gather all the wounded and the equipment in one place in order to better organize the work. At this stage, a rescue cart arrived carrying rescue equipment (blankets, oxygen, fluid and medicine) for about 40 people. Moreover, police were positioned outside only allowing authorized staff to enter the building. A section of the garage was reserved for the deceased. 2.8. Transportation of the injured The dramatic situation at the fire site with increasing accumulated numbers of injured and limited resources for the rescue teams necessitated that patients be transported as fast as possible to nearby hospitals. The fastest and most efficient mean of transportation was by ambulance. In order to satisfy the demand, each ambulance was ordered to carry at least three wounded on each occasion. On one occasion, seven injured were transported in the same vehicle. In most cases however the stretcher was used for the severely injured while the lightly injured were seated on benches along the sides of the ambulance. This was made possible by the fact that one of two ambulance orderlies stayed behind to participate in the life-saving operations. Altogether, ambulances transported 85 injured to nearby hospitals. Despite the efforts made by the ambulances, the increasing number of injured demanded that additional means of transportation be used. This prompted the Commander of Rescue Services, to request three buses at the site of the disaster. Buses were

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assigned for transportation of the lightly injured and their relatives and friends. Additional transportation of lightly injured was achieved by taxis and private cars arriving on the grounds as the news spread. The joint action of these vehicles delivered the remainder of the 180 injured youths to the nearby hospitals. Within 2 h from the alert (at 01.54), all the injured were reported to have been transported from the scene of the fire [16]. Later the same night, the 60 deceased youths were transported to the mortuary at one of the city’s hospitals. 2.9. Police effort The Alarm Central alerted the police at 23.45 with the first police unit arriving to the fire grounds a few minutes later. They reported immediately back on the extent of the fire to the Communication Central of the Police. Four additional police units were subsequently ordered to the place. The police officer assigned to lead the police force took contact with the Head of Rescue Services on the grounds in order to coordinate rescue efforts. The police created cordons in an attempt to seal off the area and keep out all the bystanders. Moreover, they cut open a fence surrounding the perimeter in order to allow ambulances a shortcut to the fire site. During the first hours of the fire disaster, a total of 42 police officers were working at the site. Their assignment was initially to facilitate the life-saving actions of the rescue teams. During the course of the night, police managed to establish an indoor assembly place in a nearby building and secure the surrounding area. This effectively sealed off the emergency assembly area. Another important police task was to identify the deceased, the injured and their relatives. This work, which started at the fire site, continued inside the hospitals and allowed early identification and registration of the wounded and of missing people. Police also lifted some of the pressure from hospital staff involved in the attendance of the injured by taking care of the large influx of relatives and friends. At the peak time, some 170 police officers were working with identification procedures. On the third day after the fire, all the deceased had been identified and their relatives informed, with one exception. One of the victims was discovered inside the building 5 days after the disaster. 2.10. Panorama of injuries The survivors exhibited three main types of injuries: smoke inhalation injuries, burn injuries and other injuries (fractures, contusions, cut wounds). Smoke inhalation injuries being light in character and requiring no treatment were diagnosed in 26% of patients. In 34% of these patients, simple measures had to be taken (e.g. suction, expectorants), in 25% intensive care treatment during 3 days or more was required but injuries were not life threatening, while in 11% of patients injuries were life threatening with substantial risk of serious sequelae. In 4% of cases no data was

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available. Burn injuries suffered by 2% of survivors, were epidermal or superficial partial-thickness burns, 13% of survivors suffered deep partial-thickness and/or full-thickness burns, while 81% had no burns. In 4% of cases data are missing. No particular part of the body was exempt from burn injury. Thus, all the injured admitted to the hospitals had suffered some degree of inhalation injury, but only a limited number of them had suffered severe burn injuries. In 25 cases, severe burns were combined with severe inhalation injuries requiring ventilator care. Other types of injuries were predominantly encountered in survivors who escaped the fire through the windows. In only 5% of survivors did these injuries require intensive care or treatment by other specialists. A majority of survivors (91%) suffered only minor or no such injuries. 2.11. Hospital care At the time of the fire, there was an emergency and disaster plan including four of the hospitals in and around the city of Gothenburg. A unit had been created in order to design a plan and coordinate the educational and training programs, but had no operational responsibilities. Operational activities in a disaster situation were to be handled by an emergency group in each of the individual hospitals. During the current fire disaster, this emergency organization proved to have several shortcomings, which will be discussed below. The initial information on the extent and nature of the disaster to the staff at the four hospitals involved was insufficient, and clearly this was due to deficient communication between the SOS Alarm Central, the Rescue Services on the grounds and the hospitals. As a result, the hospitals did not have sufficient time to prepare for the ensuing flood of patients and relatives. Moreover, the course of events was so rapid that a formal disaster plan only could be initiated at two of the hospitals. The fast influx of patients to the emergency wards of the hospitals soon created a “bottleneck” situation, with rapid exhaustion of resources. A contributing factor was the fact that the fire disaster took place during the night hours, when the number of staff on duty is at its lowest. At this stage it was of uttermost importance to clear the way for the most critically injured patients into the ICUs of the hospitals. A fast relocation of patients within the hospital was initiated, so that critically injured patients from the discotheque fire were allowed access to ventilators and intensive care treatment. This was achieved by ordering extra off-duty personnel to the hospitals and by relocating patients from the ICUs to other wards. A chief physician and a member of the emergency and disaster group at one of the hospitals both estimated that the whole process of transferring all the fire disaster patients from the emergency ward to other units was finalized within 2.5 h of the first alert [17]. Aside from using the present beds at the ICU, new temporary ICU beds were created in other wards. This process was paralleled by overarching instructions by the chief physician with regard to evaluation and documentation of injuries, fluid ad-

ministration, analgesia, ventilation and blood sampling [17]. A plastic surgeon assisted in the grading of burn injuries as well as in the execution of escharotomies, which in several cases had to be performed on the spot. A list of priorities was established and decisions were taken with regard to which patients to send to burn units outside Gothenburg. Smoke inhalation injuries were generally treated by inhalation of steroids and administration of ␤-agonists. In severe cases of inhalation injuries, patients were put under ventilation. At this point, the disaster committee of the hospitals gathered. Their main task was to spread information internally and externally, to collect patient data, to arrange transportation to burn units in other parts of Sweden, to gather information about available medical resources and to establish contact with authorities and media. In summary, a total of 213 wounded were admitted to the four hospitals in Gothenburg, (132 men and 81 women) with a median age of 16 (13–30) years. Out of these, 31 patients had suffered significant burn injuries and 158 inhalation injuries requiring active treatment. Several among them (47 patients) had suffered other injuries like fractures, open wounds or blunt violence injuries. A total of 74 patients required intensive care treatment. In 13 cases with partial/full-thickness burns in excess of 20% TBSA, patients were transported by Vertol helicopters/Hercules plane to burn units in other parts of Sweden and one unit in Norway. This process was started at 07.30 on the first morning of the fire and continued throughout the first 24 h. These patients were sent back for continued treatment in Gothenburg within 2 months from the time of the fire. Seventy-six victims remained in hospital on the third day of the fire, a number reduced to 26 after 2 weeks. The last patient was discharged on 13 April 1999. 2.12. Deceased A total of 63 people died, 61 at the scene of fire and 2 during hospital care. All the deceased were transported to the same mortuary in order to facilitate the identification process and the forensic examinations [18]. A number of analyses were performed post-mortem to document certain facts, such as use of alcohol, narcotics, and drugs [10]. Moreover, blood levels of carboxyhemoglobin (COHb) and cyanide were determined. Sampling and analysis was not executed until 4 days post-mortem, which could have had incremental influence on the results in some cases. Alcohol was found in the blood of four cases and only in relatively low concentrations. Similarly, tetrahydrocannabinol (THC) was found in only three cases. Levels of cyanide exceeded 25 micrograms per gram blood in 46 out of 61 cases but, since these agents undergo degradation after death, the true levels were assumed to be significantly higher. In contrast, CO levels remain unchanged after death and better reflect the degree of intoxication by the victims. Results revealed that 97% of the victims had levels in excess of 30% COHb, far in excess of what is required to induce unconsciousness and 89% had lethal doses of carbon monoxide (>40% COHb).

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The handling of the dead required that consideration be taken to the fact that they represented different ethnic and religious backgrounds, in several cases involving traditions that were only vaguely familiar to hospital staff. A delicate balance had to be maintained between the identification process and the legal need for forensic examinations on one hand, and some relatives’ wishes for fast answers and early burial, on the other. The dialogue established between the staff and local religious leaders proved here to be of great importance and help. 2.13. Violence and threats The chaotic situation at the fire scene with a large number of injured and insufficient medical resources led to frustration with many of the relatives and friends present. This ended up with several episodes of verbal threats and physical violence in the form of punches and kicks, ending up with one member of the medical staff suffering a rib fracture. On another occasion, a doctor was forced to continue resuscitation on a deceased patient, thereby losing valuable time in the effort of saving other patients. A leading staff member communicating by radio from one of the vehicles was accused of hiding and evading responsibility and several policemen were accused of mocking relatives of the injured. These experiences have produced significant stress reactions among the rescue workers [19–21]. In an overwhelming number of cases however, relatives and friends were very helpful and their contributions were of great value during the rescue operations. Despite the fact that this type of aggressive behavior has been described in connection with accidents before [11], they came as a surprise to the people involved in the rescue operations of the present fire disaster. To the London Ambulance Services, this type of aggressive behavior in connection with accidents is a well established and a familiar feature, which they have been forced to deal with for a long time. They have therefore initiated training programs for their orderlies in connection with civil disturbances [10]. The fact that all the injured had been transported from the scene of fire to nearby hospitals did not solve the problem of aggressive behavior from bystanders toward the medical staff. Concomitant with the influx of patients to the hospitals, there was a large influx of relatives and friends. The hospital personnel, being initially under severe pressure having to focus on the injured, were unable to cope with all the questions and requests made by the relatives. This contributed to mounting tensions and hostility on several occasions. In one of the hospitals, relatives broke into locked compartments and went over the intensive care unit in a desperate search for missing family members. This behavior reached a peak when relatives, on one occasion, tried to force their way into the mortuary. Certain wards had significant difficulties managing the large numbers of visitors, forcing the hospitals to recruit guards in order to allow their staff decent working conditions. In addition, rumors of racists having initiated the fire (many of the injured being of immigrant background)

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incited certain individuals to wish for revenge actions, which added to their aggressive behavior. An important part of the efforts undertaken by the psychosocial workers when dealing with the injured and their relatives had to focus on these issues. 2.14. Media One journalist arrived at the site of the discotheque shortly after the first alert and made important photographic documentation of the agony among survivors and the difficult working conditions of the rescue teams. After some time, he was joined by a number of journalists who added to the photographic documentation of the fire scene and also made interviews with the victims and their relatives. The journalists on the grounds received first hand information on the situation from the Head of the Rescue Services. He also ordered the creation of Information Centers at the hospitals to supply the media, the relatives and the hospital staff with accurate information. The Rescue Services also gave the initial information to the local radio stations and Swedish Television. Responsibility for public information was later transferred to the Information Officer of the city of Gothenburg who called the first press conference (04.30) in the presence of representatives of the city, the Rescue Services, the Police and the Medical Units. Parallel to these actions, the Administrative Units of the various districts of the city began establishing Crisis Centers in their respective areas. These centers sent important telephone numbers and addresses to the Police, Urban District Councils, the Swedish Telephone Company, Swedish Radio, TT and to the switchboards of various alert services. The information was sent by fax and updated repeatedly. Foreign media were directed to the main Information Center of the city where briefings were held in English. In order to ease the pressure on the informants and allow foreign media better access to detailed information about the fire disaster, the city also used its Homepage. This process of press conferences continued throughout the week following the disaster. Moreover, the present authors held lectures attended by youth injured in the fire, their friends, relatives and teachers, on the mechanisms of burn injuries in order to improve their understanding of these conditions and reduce the anxiety of the unknown. 2.15. Psychosocial work Apart from the 63 deceased, there were 385 registered survivors between the age of 12 years and 30 years. A majority (262 people) were Swedish citizens, while the rest were nationals from no less than 23 different countries. In the group holding Swedish citizenship, a majority had immigrant background. The fact that so many of the victims represented such a wide variety of ethnic groups required an approach, which was very different from what had previously been experienced in connection with disasters in Sweden. The psychosocial committees of Gothenburg gathered

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during the night of the disaster and decided to recruit a large number of staff from psychiatric clinics, social welfare offices and hospital churches. There were some 400 psychosocial workers at Sahlgrenska Hospital alone, which is the largest hospital involved, and it was here that most of the relatives and friends gathered for information. During the first days after the disaster, relatives and friends paid 3–4000 visits daily and at no moment during the initial days were there <1200 visitors present. These visits generated a great need for information, which was partly satisfied by repeated informative briefings in the assembly-hall of the hospital. In parallel, hospital personnel underwent supportive debriefing by informed staff from the Swedish defense forces and from the hospital’s senior staff members. During the following weeks, the supportive work had to be expanded also to include child psychiatric clinics, schools, and different religious congregations. The whole society of Gothenburg became involved in this work and within a few days of the fire disaster, 109 Crisis Centers had been established.

3. Discussion Indoor fire disasters reported from around the world often have several characteristics in common [10]. The fire often starts in an unguarded area of the compound where a fire alarm is lacking. In a majority of incidents, the alarm is not raised in time and the evacuation is delayed due to a number of well-established psychological factors [11]. The fire-escape routes are often insufficient, locked or blocked as was the case in the current disaster in Gothenburg where the organizers, in order to create better space on the dancing floor, moved chairs from the main floor of the discotheque and piled them in the emergency exit staircase. Moreover, maladaptive stress behavior [11] or disorientation due to toxic fumes [10], are common causes used to explain why so many fire victims end up in closed compartments, such as lavatories and cloakrooms where the escape route is blocked. In the present fire, 23 youth tried to exit the disco through the cloakroom (Figs. 2 and 5), but failed and were later found dead. The fire investigative team soon revealed that the fire had started in a corridor leading to the emergency exit staircase and that it probably was the result of arson. They also found proof suggesting that flammable liquid and paper had been used to ignite one of the chairs. With the help of information obtained from survivors and criminal investigations at the scene of fire, police were able to arrest and charge four young men of having started the fire. The incident was apparently preceded by a quarrel inside the discotheque, forcing the organizers to intervene and discharge the youth involved from the club. This incident may have been the inciting factor to the arson, although the full spectrum of mechanisms turning adults into arsonists is still poorly understood [22]. The four arsonists, were later convicted of setting the fire and sentenced to long-term imprisonment.

The fact that the fire started in the semi-closed staircase (lower door open, upper closed) proved to be a limiting factor on the progress of the fire which soon began to smolder and produce toxic gases due to the limited supply of oxygen producing incomplete combustion. When the fire was first detected, there was a substantial accumulation of smoke and gases in the upper part of the staircase but only a limited fire. This situation was rapidly and devastatingly changed when several of the youth opened the upper emergency door on several occasions and finally left it open thereby feeding the fire with oxygen and igniting the flammable gases. This maladaptive disaster behavior, which is common and most probably the result of lack of previous experience from similar situations [11], was the single most important factor contributing to the explosive development of the fire [10]. A partly suffocated fire in wooden materials has been shown to produce up to 50 times higher levels of carbon monoxide (CO) than a well ventilated fire [10], which also explains the fact that a vast majority of the victims who succumbed in the discotheque fire died as a result of CO intoxication and lethal levels of cyanide. This outcome is in line with other major indoor fires during the past 25 years [10] showing that the victims from these fire disasters, with very few exceptions, succumb to the toxic fumes rather than to the flames [23,24]. In the present disaster, the increasing heat inside the club caused the windows to blow out at a certain stage of the fire, allowing fresh air to enter the discotheque, which most probably saved the lives of many by interrupting the accumulation of toxic fumes. Yet, some may have succumbed to the dramatically increased temperatures [12] as a result of the same oxygen pouring into the fire site. This underlines the importance of installing smoke detectors [25] and sprinkler systems in sections of public buildings not under frequent or constant surveillance, which would have raised the alarm at a far earlier stage of the fire. Moreover, use of automatic door closures is a simple mean of increasing fire safety [26]. This was proven during the current fire disaster, where the fact that the emergency door was left open proved to constitute the most prominent factor for the spread of the fire [10]. The technical investigation revealed however that a door closer was installed on the emergency exit door but had been tampered with, rendering it unusable. Interviews with the survivors highlighted a number of reasons for the late evacuation of the facilities [10]. The disc jockey did indeed turn off the music shortly after smoke started to leak out through the emergency door and announced on the loudspeakers that a fire had been detected and asked everybody to leave the building. The reason why many hesitated to leave the building was that one of the guests went on stage immediately after the warning and started to dance and joke with the audience, making many of them think that the disc jockey’s warnings were not seriously meant. The use of artificial “disco smoke” was another reason why several youth had misjudged the situation, confusing it with the smoke of the fire. Many describe their hesitation in the initial phase of the fire by the fact

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that they simply were unable to imagine anything like that happening to them. Put together, these factors contributed to the late evacuation and disastrous outcome of the fire. A powerful fire alarm coupled to smoke detectors [25] would most probably have reduced the hesitance experienced by the fire victims. Another crucial factor for the outcome was the fact that the main entrance door was obstructed due to a number of causes [10]. One was a table placed by the organizers in the narrow hallway leading to the main entrance, which was already compromised by a radiator and a fire hydrant. Another was the pressure from behind causing several of the victims to fall to the floor and others to pile on top of them. Had a number of the survivors not acted decisively and with great resolution started to drag people trapped inside the entrance door into the staircase, the death toll would most probably have been significantly higher. This experience from the discotheque fire and similar findings of obstructed emergency exits in other indoor fires [10] stresses the importance of always keeping the exits free from all kind of obstacles. After the initial difficulties by the SOS Alarm to identify the fire site, the time lag before transfer of crucial information to the city’s fire brigades took place was unacceptably long and contributed to the delay in the arrival of fire fighter units to the place of fire. Obviously, adequate routines for transferring such information between SOS Alarm and the Alarm Central of the fire brigades were inadequate or insufficient. This is even more disturbing considering the fact that the city of Gothenburg has substantial fire fighting resources and that double the number of fire fighters could have been allocated to the fire scene without compromising the preparedness for additional fire incidents [10]. A similar situation was reported in the case of the ambulances. Initially, only a limited number of ambulances were ordered to the fire scene (only six ambulances were in place within the first 20 min of the alarm), significantly hampering rescue efforts on the fire grounds as well as the delivery of injured to nearby hospitals. Larger numbers of ambulances should have been sent to the site of fire at a much earlier stage of the disaster. As was the case with the delayed and insufficient arrival of fire fighting teams to the fire grounds, a plausible explanation for the deficient number of ambulances could be the lack of coordination between the SOS Alarm and the Fire brigades Alarm Central, responsible also for the ambulance emergencies. Moreover, the lack of adequate communication between the alarm facilities, the rescue units on the fire grounds and the hospitals, significantly contributed to the chocking encounter and lack of mental preparedness experienced by the people involved in the rescue operations [20,21]. The Swedish Board of Accident Inquiry therefore found good reason to recommend improved and extended education of the staff of the Rescue Services (ambulances and fire fighters) including more training and better leadership capabilities. A deficit in the organization of the rescue operations, often mentioned by the medical rescue teams, was the fact

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that a chief physician educated in disaster medicine was not ordered to the fire site. This was obviously due to a misunderstanding. The Head of the Rescue Organization took it for granted that such a doctor would be sent to the discotheque fire along with the rescue teams he had ordered, which never happened. Instead, a massive load was put on the shoulders of the first doctor to arrive to the disaster area. Despite being a general practitioner with insufficient education and experience in disaster medicine, she managed to organize the initial rescue efforts assisted by ambulance orderlies and fire fighters and give instructions on the level of rescue efforts in individual cases. Not until 1 h after the initial alarm did a second doctor arrive to the fire grounds. He described the total chaos and the difficult working conditions he and his colleague were forced to work under, partly due to lack of medical staff on the site of fire with adequate training in disaster medicine. Another shortcoming was the fact that the rescue teams very soon ran out of oxygen, fluids, blankets and other crucial equipment used in the resuscitation of the injured. This should have been obvious to the local Head of Rescue Services on the grounds, as judged by the fact that ambulances upon delivery of injured to hospitals tried to keep up with the mounting needs on the fire scene by bringing back such equipment from the hospitals. Despite this, a special disaster cart carrying medicine and resuscitation gear for 40 people did not arrive to the fire grounds until after an hour. The routines for the cart have since been transformed, the cart being sent automatically on first alert to the site of disaster and returned if not needed. A major task for society in the sequel of any kind of disaster is the laborious process of rehabilitating the injured and comforting the families of the deceased. This kind of process requires that substantial human resources are mobilized and made available during a lengthy period of time. Experience from a previous catastrophe, i.e. the sinking of the ferry Estonia in the Baltic Sea killing 796 people [8], had added to the preparedness of Swedish society for such an event. Lessons drawn from the aftermath of the Estonia disaster thus contributed to the fast actions taken by the psychosocial committees and the subsequent establishment of a large number of crisis centers throughout the city. The fact that most of the victims in the discotheque fire came from so many different cultural backgrounds and represented all major religions imposed an unprecedented challenge to the psychosocial teams and added to previous experience of disaster management in Sweden. In conclusion, Sweden is a country with relatively few major burn accidents. This is probably due to continuous information to the public and strict safety regulations. In the disaster presented here, these measures proved insufficient due to the fact that the organizers of the Halloween party disregarded safety regulations. This has also been the case in other major indoor fires [27] and should prompt society to reform routines for better controlling that the safety regulations are adhered to. Education and information on

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fire prevention must thus continue unabated in schools, through public institutions and by the aid of e.g. insurance companies. In this particular case, which proved to be the result of arson, continued research on the psychopathological mechanisms of arsonists is important if society is to prevail in subduing this type of behavior present both in children and adults [22]. The importance of efficient and fast communications between the alarm and rescue organizations was highlighted in the present disaster, where deficient communication routines proved detrimental for the rescue efforts. Preparedness by continuous evaluation and re-evaluation of existing disaster plans parallel to upgraded education and repeated training of staff proved a crucial factor in the success of past [11] and most likely future rescue operations. References [1] Buerk CA, Batdorf JW, Cammack KV, Ravenholt O. The MGM Grand Hotel fire: lessons learned from a major disaster. Arch Surg 1982;117(5):641–4. [2] Das RA. 1981 circus fire disaster in Bangalore, India: causes, management of burn patients and possible presentation. Burns Incl Therm Inj 1983;10(1):17–29. [3] Elkington A. Theatre fire. Br Med J 1971;2(764):769. [4] Gu TL, Liou SH, Hsu CH, Hsu JC, Wu TN. Acute health hazards of firefighters after fighting a department store fire. Ind Health 1996;34(1):13–23. [5] Weinstein J. The secure restaurant. Part I. Employee & customer safety. Restaurants Inst 1992;102(22):102–3, 108, 112 passim. [6] Lorin H. Disaster medicine studies in Borås. The hotel fire, 1978 June 10. Kamedo report no. 39. Issued by National Board of Health and Welfare, Sweden; 1979. [7] Almersjö O, Ask E, Brandsjö K, Brokopp T, Hedelin A, Jaldung H, et al. The fire on the passenger liner “Scandinavian Star”, 1990 April 7. Kamedo report no. 60. Issued by National Board of Health and Welfare, Sweden. SoS report no. 3; 1993. [8] Brandsjö K, Häggmark T, Kulling P, Lorin H, Lundin T, Skjöldebrand A. The Estonia disaster. The loss of the M/S Estonia in the Baltic on 1994 September 28. Kamedo report no. 68. Issued by National Board of Health and Welfare, Sweden. SoS report no. 15; 1997. [9] van Vugt A. Disaster medicine: lessons from Enschede and Volendam. Ned Tijdschr Geneeskd 2001;145(48):2309–12.

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