The los alfaques disaster: A boiling-liquid, expanding-vapour explosion

Burns,7. 233-25 1

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The Los Alfaques expanding-vapour

233

Disaster: a boiling-liquid, explosion

GGsta Arturson Burn Centre, University

Hospital, Uppsala, Sweden

Summary

On I I July 1978. a road tanker carrying liquefied, flammable gas ran into the Los Alfaques camping ground south of Tarragona on the east coast of Spain and exploded [what is called ‘a boiling-liquid, expanding-vapour explosion’ (BLEVE) resulted]. The road tanker was loaded with about 45 rn’ of propene (propylene). For some unknown reason it ran into the ditch against the wall of the camping ground, whereupon the tank split and large quantities of propene were ejected into the surrounding area and were gasified. The cloud of gas. mixed with air, was ignited, causing a violent explosion. For the ftrst f hour, there was total chaos on the site of the disaster. The injured were removed in a completely unorganized fashion and without any triage. The number of ambulances was insufficient and long delays, about 3 hours, elapsed before the last victim was driven away. The burning tanker blocked the road, thus effectively dividing the injured into two groups one being taken northwards and the other southwards, there were hospitals with similar standards at comparable distances in both directions. On the road to the north, the injured received adequate medical care. once they had reached either the cottage hospital at Amposta or the hospital at Tortosa. At this stage, the fmal destination of 58 severely burned patients was the Francisco Franc0 Hospital in Barcelona. which has a burn unit with 3 I beds. Eighty-two severely burned patients were taken south to the La Fe Hospital in Valencia, which has a burn unit with I4 beds. In most cases no medical steps of any importance were taken during the journey. Several of the injured developed severe shock on the journey and had no measurable blood pressure on arrival. One hundred and two people died at the site of the explosion. Their identification -a very complicated task-was made more difficult by the efforts of unskilled helpers,

A comparative study of the group of 58 patients taken to Barcelona and the group of 82 patients taken to Valencia reveals the fotlowing facts. There is no significant difference between the two groups with regard to the patients’ ages and the extent and depth of their bums. The only certain difference is that the patients taken to Barcelona received adequate medical treatment during the journey, unlike most of the patients taken to Valencia who received no medical treatment at all during the journey. The medical treatment given at the two burn units in Barcelona and Valencia is first-class and is, in all essentials, the same at both units. During the 4 days immediately following the disaster, the survival rate declined to 93 per cent for the patients taken to Barcelona and to 45 per cent for those taken to Valencia. The reason for the signiftcantly greater mortality in the Valencia patients must be the unsatisfactory medical treatment given en route to the hospital. Twenty-seven of the 3 I patients who died during the first few days at the La Fe Hospital in Valencia had deep bums covering >90 per cent of the body surface. The remaining 4 deaths were also those of very severely burned patients. A very large number of the victims were domiciled in France, Germany, Belgium and Holland. In the week immediately following the disaster. these patients were evacuated to their own countries. The ev*acuation took place as soon as possible and was carried out in an exemplary fashion. A follow-up study of all the patients reveals that there was an insignificant difference in the survival rate between the Barcelona and the Valencia groups two months after the disaster. This must be interpreted as indicating that the patients were so seriously injured in the disaster that the more adequate treatment given at an early stage to the Barcelona group only extended the survival time by a week or so for a large number of patients. Taking into account the 102 who died at the site, the mortality 2 months after the disaster was about 85 per cent. On some points our view differs from that of our

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Spanish colleagues. This refers to the psychological care of very severely burned patients whose lives, it was considered, could not be saved. We believe that, as far as possible (but considerately and truthfully), the questions asked by these patients and their relatives should be answered. The care of the relatives of the severely burned patients imposed too heavy a burden on the hospitals. No satisfactory arrangements had been made to provide waiting rooms and information desks at the hospitals. Communications with the mass media were not properly prepared and organized either. This led to misunderstandings and to a number of newspaper articles containing inaccurate and negative criticism of the way in which the clinics had managed the nursing and evacuation of some severely burned patients. It must be pointed out that this was a very serious disaster which occurred in the countryside, where one cannot expect there to be in existence a disaster plan dimensioned for several hundred victims. If a similar disaster should occur in Sweden, on the west coast north of Gothenburg, for example, all the intensivecare units (6) at the hospitals within a radius of about I50 km from the site would be needed for severely burned patients. Furthermore, at least 4 surgical wards would be needed for the somewhat less severely burned patients. In addition, we would have to reckon that all the beds in Sweden’s special intensive-care units for bum cases (20) would be occupied for several months to come.

INTRODUCTION IN SWEDEN a Committee

for Disaster Medicine (KAMEDO), including representatives of the Swedish Red Cross, the Medical Board of the Swedish Armed Forces, the National Social Welfare Board, the Civil Defence Board and the Defence Staff, has been established since 1965. The purpose of the Committee is to collect information and experience of all kinds of disasters all over the world and to make the information available to all organizations concerned with disaster medicine and to all authorities responsible for disaster planning. I was sent by KAMEDO to the Los Alfaques disaster area in order to study the following features: 1. The scene of the disaster, including what happened and the number and types of casualties. 2. The organization at the scene of the disaster, as regards the control, rescue, release, triage and transport ofcasualties. 3. The organization at the hospitals designated for the handling of casualties arising from the disaster. 4. The evacuation of patients to their home countries.

5. The survival rate of patients involved in the disaster in a follow-up investigation. THESCENEOFTHE

DISASTER

The Los Alfaques camping ground lies some 3 km south of the town of San Carlos de la Rapita and about 190 km south of Barcelona on the Playa de Alcanar. It consists of a building containing a reception office and a restaurant, together with parking lots and camping sites in two large areas separated by a park containing a belt of deciduous woodland about 60 m wide. The half of the camping ground which was totally destroyed by the fire is situated between the coast road (N340) and the shore of the Mediterranean (Fig. 1). The area varies in width between 100 and 60 m and is about 200 m long. The part which was ravaged by fire has an area of some 10 000 m* (Fig. 2). It was divided into double rows of sites for cars, caravans and tents, with pathways about 2 m wide between them. About 60 motor vehicles were parked in this area at the time of the disaster. To the south of this area, there are bungalows, which were also ravaged by fire. The camping area is separated from the N340 road, which is about 10 m wide, by a brick wall, about 1.5 m high, on a concrete foundation. To the west of the main road, just in front of the devastated camping ground, there is a park area in which there was a discotheque (Las Cantelas), which was completely destroyed (Fig. 3). Two detached villas were also seriously damaged. In addition, the Cerramar restaurant, about 300 m from the road, was damaged by that part of the tank which was flung in its direction by the rocket effect (Fig. 4). All the camping sites were occupied at the time (about 800 persons had registered). Probably, there were, in all, 500-600 people within the area at the time of the disaster, of whom 350-400 were within the devastated part when the fire broke out. The disaster occurred during the siesta, which meant that many people were inside their caravans or tents. A few bathers were out in the water and on the beach. A light, north-easterly wind was blowing off the sea. THE COURSE

OF EVENTS

The disaster was caused by a road tanker of the trailer type (a traction unit towing a tank trailer) carrying a load of about 45 m3 of propene (propylene), a liquefied petroleum gas, i.e. a condensed, flammable gas. The tank was marked ADR (the European designation used in

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The Los Alfaques

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Disaster LOS

-

The

Rcrtou-

ALFAOUES

CAMPING

GROUND

--__

&

rant

Fig. I. Sketch of the site of the disaster. The dashed lines show how the tanker ran off the road, how the traction unit was steered up onto the road again and how part of the tank was hurled away by the rocket effect and came to rest against the wall ofthe Cerramar restaurant.

Fig. 2. General picture of the Los Alfaques camping ground atier the disaster, when the victims had been removed.

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Fig. 3. The remains ofthe Las Cantelas discotheque.

Fig. 4. The Cerramar

restaurant, with the rear part of the tank, which was hurled there by the explosion. The tank is marked ADR, together with figures & (see the text).

the transport of dangerous goods on public highways), the signs showing & (Fig. 4.). The two upper figures indicate gas (2) and the risk of fire (3). The lower group of figures indicates the product, in this case propene. At the time ofthe disaster, the sun was shining and the temperature was over 30 ‘C; for this reason the pressure in the tank may have been abnormally high. According to some reports, the tank contained 3 tonnes too much; according to other reports, liquid ammonia had previously been transported in the same tank and the tank had not been cleaned sufficiently well afterwards. There were also reports that the tank showed signs of corrosion. The tank was constructed as one unit, divided internally by two bame plates with holes in the centre. The valves for the gas and liquid phases were underneath, between the axles. As far as could be ascertained, there were no safety valves against over-pressure. No eyewitness appeared who was in a position to give a reliable account of what happened just before the tank burst. It has been stated that smoke was seen coming from one of the tanker’s wheels before it ran into the ditch and against the brick wall. However, this ‘smoke’ may have been dust which swirled up when the tanker ran into the ditch. Someone in a coach which was travelling a short distance behind the tanker stated that it swayed from side to side before it came to the site of the disaster. It is thought possible that the driver had fallen asleep at the wheel. The wheel tracks at the site indicate that the traction unit ran obliquely into the ditch and

against the wall of the camping ground. One theory is that the driver succeeded in righting his vehicle onto the road again. However, the trailer carrying the tank had twisted itself loose and went on over the wall. The tank then split from below upwards and was burst by the overpressure into three parts. Large quantities of propene were thrown out into the surrounding area and were gasified. One kg of liquified propene produces about 500 1 of gas. The cloud of gas, mixed with air, was then ignited and this resulted in a violent explosion. A summary of the reports of the eyewitnesses indicates that the ignition took place about 5 seconds after the tank burst. The most likely cause of the ignition would seem to have been one of the many gas cooking-stoves found on the site. The time of the disaster is given variously as between 14.15 and 14.30. Judging by the times when the alarms were given, eyewitness statements and the wrist-watches found on the site, it is most likely that the tank burstat 14.26. The fire may be divided into three phases. First, the explosion and the cloud of burning gas, lasting for about 1 minute. Then a raging fire, lasting for 20-30 minutes, in the area covered by the liquefied propene. Finally, secondary fires on a moderate scale in car tyres and petrol tanks and from bottles of liquefied petroleum gas whose safety valves had melted. The vegetation and parts of buildings outside the camping ground were ignited by radiant heat from the cloud of burning gas. The fire was, generally speaking, under control within 2 hours after the explosion and was fmally extinguished at about 19.00.

Arturson:

The Los Alfaques

Disaster

From the accounts given by eyewitnesses, it can be established that three distinct sounds of different characters were heard within the course of 3-5 seconds. The first, a crash, occurred when the tank broke through the brick wall into the camping area. The second, a bang, occurred when the tank split and the third, also a kind of bang, when the cloud of gas ignited. The eyewitnesses also state that they saw, besides the cloud of burning gas and a continuous area of fire on the camping ground, patches of fire outside the camping ground, partly on the water and partly on the roadway. These burning patches probably derived from liquid propene which was ejected when the tank burst and from burning debris from the tanker, which was found up to 100 m from the site of the crash. The fire was spread to the area surrounding the camping ground mainly by radiant heat from the cloud of burning gas, which is estimated to have had a maximum diameter of40-60 m. The light, north-easterly wind carried the cloud of gas south-westwards over the main road. In this direction, fire damage was found on the ground over a radius of about 150 m from the site of the disaster. The upper parts of trees, wooden telegraph poles, etc. show that the radiant heat produced temperatures of 200-300 “C up to 400 m away from the camping ground. When the propene tank burst, parts of it were hurled with great force in various directions and inflicted serious injuries on 2 persons. Apart from burns. a serious fracture of the skull and an open wound in the abdomen were observed in the victims who were killed immediately. About two-thirds of the tank (the rear part) were blasted away from the rest in one piece and propelled by the rocket effect across the main road up to a height of 7-8 m. This part of the tank broke power lines at this height about 100 m from the site of the explosion and plunged to earth some 50 m further away. It then continued along the ground, tearing up trees by the roots and breaking off tree trunks, before coming to rest against the wall of the Cerramar restaurant, about 350 m from the camping ground (Fig. 4). The damage caused by the pressure wave consisted chiefly of broken windows in buildings around the camping ground up to a distance of about 200 m. Major structural damage was caused to 2 toilet blocks on the camping ground, to a bungalow south of the camping ground, to the Las Cantelas discotheque and to 2 dwelling-houses on the western side of the main road, just in front ofthe site ofthe crash.

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EMERGENCY SERVICES No legislation on emergency services has been enacted in Spain. In practice, however. the fire brigades are summoned by the police in cases of major accidents. There is no central fire-service authority with responsibility for emergency services either. The administrative authority of the province in which the disaster area is situated is based in Tarragona, some 89 km north of Los Alfaques. The chief official is the governor (gobernador civil). The administrative departments chiefly concerned with the disaster are, as regards the fire and rescue services, the Protection Civil. and, as regards medical care, the Ministerio de Sanidad y Seguridad Social. The municipal administration and the local court of law have corresponding departments in the town hall and the court house respectively at Tortosa, which is about 33 km north-west of the disaster site. Other local bodies are the policia municipal. who are under the command of the comizaria de policia. and the Guardia Civil. including the policia de traflco. The fire brigades are run by the municipalities. They work independently but are subordinate to the civil defence organization (Defensa Civil and Protection Civil) in the event or serious accidents and disasters. San Carlos and Amposta, the towns nearest the site of the disaster, have no fire stations. The nearest fire brigade is the voluntary one at Tortosa (about 33 km from Los Alfaques). The ambulance service is run mostly by the Spanish Red Cross. There are also a number ot private ambulance companies. The Red Cross ambulance crews consist largely of military personnel. Their training is stated to take about 7 weeks. The ambulances are stationed at special Red Cross depots, located along the highways and in the towns. According to information received, there were 5 ambulances at Tortosa, where the nearest Red Cross depot to the site of the disaster was situated. In order to call an ambulance, one has to ring the telephone number of the depot. There is no common alarm centre. The police, fire brigade. ambulance, hospital, etc. must be called in turn. In certain provinces, it may be necessary to ring about 30 different numbers in order to reach all the relief organizations concerned. The hospital organization in Spain consists partly of units in the public health and medical services (belonging to the Ministerio de Sanidad y Seguridad Social) and partly of municipal. cooperative and private clinics of varying sizes.

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4

To the south, at Vinaroz, 16 km from Los Alfaques, there is a small cottage hospital with about 30 beds. At Castellon, 97 km from Los Alfaques, there is a county hospital with 400 beds. The Residencia Sanitaria La Fe in Valencia is a university hospital. It has a modern burn unit (14 beds) giving treatment of a high standard. INITIAL SITE

ACTION

AT THE

DISASTER

The chronological sequence of the rescue efforts given by different authorities and relief units varies. A summary of the most probable time schedule is given in Table I. Command I

Valencia

C

Fig. 5. Map showing the distances from the site of the disaster to various medical- care units to the north (N) and the south (S). Medical- care units: Amposta, small cottage hospital 20 beds; Tortosa, main hospital 250 beds; Tarragona, county hospital 325 beds; Barcelona, university hospital with burn unit; Vinaroz, small cottage hospital 30 beds; Castellon, county hospital 400 beds; Valencia, university hospital with bum unit.

levels of specialization and standards of treatment. There is a similar hospital structure at comparable levels both to the north and to the south of the site of the disaster (Fig. 5), as the following description shows: To the north, at Amposta, 13 km from Los Alfaques, there is a large cottage hospital with a few beds and a staff of about 10 doctors. There are several clinics with various degrees of differentiation in Tortosa, 33 km from Los Alfaques. The main hospital is the Residencia Sanitaria Virgen de la Cinta, which has approximately 250 beds and about 50 doctors, IO of whom are specialists. Tarragona, 89 km from Los Alfaques, has 7 small clinics and a large hospital with 325 beds and a considerable degree of specialization (Residencia Sanitaria San Juan). The Francisco Franc0 Hospital in Barcelona is a modem university hospital, which has a bum unit (3 1 beds) giving treatment of a very high standard.

of rescue operations

According to information received, there was no overall command of the rescue operations (commander of rescue operations) at the site of the disaster. The chief civil defence officer in Tortosa (site commander) arrived at the site at about 15.30 and, according to his own statement, took command of the incoming firebrigade units. Later, as the remaining fires were extinguished, he had the area searched. He also organized the removal of the dead without waiting for identification. He then set up an information centre in the reception office and arranged for buses to take the homeless to Tortosa. The provincial administration at Tarragona set up a command centre as soon as the extent of the disaster was known. It was from here that the ambulance journeys from Tortosa and Vinaroz to other hospitals were directed. A local command centre was also organized in the town hall at Tortosa. The rescue teams sent in

All the police forces-policia armada, Guardia Civil (including the policio de trafico) and policia municipal-in the province of Tarragona were called out. The police’s actions consisted chiefly in cordoning off the site of the disaster, assisting in the care of the injured, directing traffic, setting up road blocks in order to give ambulances and other rescue vehicles a free passage to the hospitals, and maintaining radio communications, These tasks were very well executed by the police. Once the ambulance transports were completed, the police took responsibility for the removal of the dead, the collection of their belongings and their identification. The first fire-engine arrived at the site of the

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The Los Alfaques

Table 1. The chronological

239

Disaster

sequence

of the

rescue efforts in the Los Alfaques disaster

Time after the disaster 0 min

Event and time 14.26 14.27 14.28 14.29 14.30 14.35 14.35 14.35 14.37 14.45

30 min

14.45 14.50 14.55 15.00

3 hr

15.00 15.00 15.05 15.15 15.20 15.45 17.00 17.25

5 hr

18.00 19.30

1 hr

The road tanker runs off the road, the tank strikes the brick wall and bursts. The cloud of gas is ignited Intense fire over the central part of the camping ground Telephone call to the Guardia Civil at San Carlos First turn-out from the police station at San Carlos Telephone call to the ambulance and fire station and the Virgen de la Cinta Hospital in Tortosa Telephone call to the Shell oil-drilling depot at San Carlos with a request for an ambulance The frrst Red Cross ambulances start from Tortosa for the site Police cars from the Guardia Civil reach Los Alfaques Private cars carrying burned patients drive to Amposta Alarm sent to the hospital at Tortosa (Protection Civil) Fresh fire alarm sent out by the Civil Defence sirens The Shell ambulance reaches the site (the first ambulance to do so) The first turn-out of fire-fighting vehicles from Tortosa Private cars and taxis carrying patients reach the Servicio Medico Cooperativo hospital in Amposta Reinforcement with fire-fighting units and ambulances ordered by the provincial administration in Tarragona Disaster alarm sent to the Francisco Franc0 Hospital in Barcelona The first patient arrives at the main hospital in Tortosa The first Red Cross ambulance from Tortosa arrives at the site Disaster alarm sent to the La Fe Hospital in Valencia The first fire-engine from Tortosa reaches Los Alfaques The Shell ambulance reaches the hospital in Tortosa The first patient reaches the La Fe Hospital in Valencia The last ambulance transport from Los Alfaques (the Shell ambulance’s second journey) with 6 less seriously injured persons The last patient reaches Tortosa The first patient arrives at the Francisco Franc0 Hospital in Barcelona

disaster at about 15.20, i.e. almost an hour after the fire had broken out. The fire was then of moderate intensity, as probably all the flammable liquid had had time to burn away. On the other hand, there were small, scattered fires over a fairly large area. These fires were extinguished without difficulty. Liaison

The first alert from the site of the disaster came by telephone. However, tile telephone connection was broken by the fire a few minutes later. After this, the radio-telephones in the police patrol cars were used to request further help and to send information about the extent of the disaster. When the first fire-engine arrived from Tortosa at about 15.20, its radio was used on the civil defence frequency to send messages to the town hall in Tortosa, from whence the information was relayed by telephone to the

provincial administration centre in Tarragona, where a command centre was established. However, the telephone links with the main hospital, the town hall and the court house in Tortosa became overloaded at an early stage, the lines being completely blocked at times as a result. According to information received, the telephone company arranged 3 priority lines solely for outgoing calls from the town hall and the hospital. Nevertheless, it has been stated that there were great difftculties in getting telephone messages through. On the other hand, directions were passed to ambulances and helicopters in a satisfactory fashion. The efforts of amateur radio operators were of great importance in getting important messages through. Special problems arose by reason of the great numbers of inland and overseas telephone calls from the mass media and from relatives seeking

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~

information about the dead and injured. Centres were set up to receive these inquiries and to compile lists of names both in the town hall at Tortosa and in the provincial administration centre at Tarragona.

,,.,, “““i

BARCELONA( 58 1 Zarragoza

7’4

Primary medical care at the site

The descriptions ofthe situation on the camping ground after the fireball had burned out (in the course of a minute or so) are unanimous. Naked, severely burned people rain aimlessly about, screaming with pain and crying for help. Some had plunged into the sea in a desperate attempt to escape the fire. Many had to be prevented from running into the remaining fires to look for their relatives. One hundred and two people died at the site of the disaster. One hundred and forty-eight were burned, at least 122 very severely, i.e. they received full-thickness burns covering 50 per cent or more of the body. There is no medical preparedness for major disasters in the area. There is no disaster plan either at the cottage hospital in Amposta or at the hospital in Tortosa. Nor was there any intention to send medical aid to the site of the disaster. The medical treatment provided at the camping ground was given by Red-Cross-trained laymen, who rendered some first aid, and by some private practitioners, who, inter alia, gave Valium injections. There were no facilities for any significant medical treatment at the site throughout the entire time taken to remove the injured, i.e. almost 3 hours. Transport

of the injured from the site

Within 10 minutes of the disaster, there were three police patrols on the scene. They immediately tried to arrange transport for the injured. During the first f hour, the injured were driven away completely at random, without triage, in taxis and private cars to the nearest hospitals. Only one ambulance, the private ambulance from the Shell oil-drilling depot, was available at this time. It took 8 patients on the first journey. The burning tanker blocked the road, which meant that the injured were divided into two groups, one group in the northern part of the camp, who were taken to hospitals to the north of Los Alfaques, and one group in the southern part, who were taken to hospitals to the south (Fig. 6). Members of families were thereby separated, depending on where they were at the time of the explosion. Adequate medical care was provided on the

VALENCIA

; 82

I

Fig,

6. Summary of the numbers of burned patients who were taken from the site of the disaster north-

wards to Barcelona and southwards to Valencia.

road to the north, once the patients reached the cottage hospital at Amposta or the hospital at Tortosa. At Amposta, about 20 of the injured received skilled first aid, including sedation and intravenous fluid therapy. The patients were then taken on to Barcelona, the majority ‘stopping off at the hospital in Tortosa which became a centre for the organization of ambulance and helicopter transports. Notwithstanding that there was no disaster plan for this hospital, the chief physician succeeded, with little delay, in assembling about 50 doctors in the emergency department. Altogether 56 severely burned persons, most of whom had passed through the cottage hospital at Amposta, were treated here. Central venous catheters were inserted into practicaliy all the patients by subclavial catheterization. Treatment for shock was given primarily by administering a physiological saline solution, followed by dextran. Dolantin (meperidine = pethidine) was used as analgesic. Bladder catheters were inserted and the urine production was checked. Penicillin, gammaglobulin and anti-tetanus vaccine were also administered. The further transport of the patients from Tortosa was by ambulance (4 1) or

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Dlsastet

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helicopter (I 5). Forty-nine patients were taken to Barcelona, 43 direct and 6 via Tarragona. Fifteen patients were treated in Tarragona on the first night, after which they were taken to the burn clinic at Barcelona. Three of these came directly from Los Alfaques. The final destination of 58 patients at this stage was the Francisco Franc0 Hospital in Barcelona. In addition, 2 patients were taken to a hospital in Zarragoza and 6 directly to France and Holland. On the southern route, the patients travelled for a long distance before any medical assistance of significance was provided. The first treatment was given at the hospital in Castellon, 97 km from Los Alfaques, to I9 patients. Fifty-eight patients were taken straight to the burn unit in Valencia, a journey of over 160 km. The cottage hospital in Vinaroz, where the injured from the southern part of the area were first taken, evidently received such a large accumulation of patients that action was somewhat paralysed. No medical treatment of importance was given. Instead a coach was prepared, in which 45 patients were conveyed, lying down or sitting up. to Valencia, a distance of about 150 km. Many of them developed states of severe shock, due to their burns. Some had no measurable blood pressure on arrival. In all, 82 injured persons were finally taken to the La Fe Hospital in Valencia. HOSPITALS HANDLING

DESIGNATED FOR THE OF CASUALTIES

The division of the severely burned patients between the two burn units in Barcelona and Valencia proved unfortunate. The La Fe Hospital in Valencia, with 14 beds for burn cases, had to accept 82 patients, while the Francisco Franc0 Hospital in Barcelona, with 31 beds for burn cases, received ‘only’ 58 patients. However, both these clinics have two wards each for plastic surgery, connected with the burn unit and containing beds which could be used for burned patients. The Francisco Franc0 Hospital,

Barcelona

The burn unit at the Francisco Franc0 Hospital is only 5 years old and is one of the most modern and best-equipped in Europe. It is on the top (9th) floor in the hospital block devoted to plastic surgery. It is ‘self sufficient’-it has its own operating theatre, kitchen, rehabilitation rooms, storage spaces, etc. It has 10 beds for intensive care and 21 for the care of patients with less serious burns and burns in the healing

and reconstruction stages. A visitors’ corridor surrounds the whole unit. From this corridor, visitors can see the patients through a glass window and speak to them by telephone. Each intensive-care place consists of an isolated room with an air-lock and a separate ventilation system. Each patient is supervised day and night by a nurse in sterile clothing, who remains in the treatment room. In addition, there is a central supervision room for the entire unit, with a monitoring system which includes supervision by television and surveillance of the electrocardiogram and the blood pressure. The patients in intensive care are nursed in an ambient temperature of 30- 40 “C. The relative humidity is 30 per cent. The guiding principle for ‘resuscitation’ is the use of Brooke’s formula [( I.5 ml crystalloid solution x % burned area x kg body weight) + (0.5 ml colloid solution x O/o burned area x kg body weight)]. All treatment is open. Flamazine (silver sulphadiazine) is used for treating local wounds. Intravenous antibiotic therapy is never given prophylactically but only when there are indications of sepsis. The guiding surgical principles are excision and transplantation as early as possible, preferably within the first week after the accident, even in cases of very extensive injuries. Cimethidine is generally administered to all patients with burns covering >30 per cent of the body surface as prophylaxis against stress ulcers. Patients with burns covering up to 85 per cent of the body surface have had their lives saved at the unit. which indicates that the treatment is of a generally high standard. Situation at Francisco Franc0 Hospital at time of the disaster, preparations and emergency care of injured

When the news of the disaster at the Los Alfaques camping ground reached the hospital at about 15.00 on 11 July, 24 patients were being treated in the burn unit. The message read: ‘Major disaster, many severely burned, prepare 30 beds’. The hospital has no disaster plan. Professor Jose Banuelos. the head of the Department of Plastic Surgery, took the responsibility of organizing the preparations. All but 6 of the patients in the burn unit could be transferred to other wards or sent home. The 2 plastic-surgery wards on the 7th and 8th floors beneath the burn unit could also be almost cleared of patients. The air-conditioning system in these wards was switched off, so as to raise the air temperature sufficiently for the treatment of

242

burns. All the patients on the waiting list at the Department of Plastic Surgery had their appointments cancelled for the following week and all planned operations were postponed. Ten doctors and 60 nurses were on duty within 3 hours. All these doctors and most of the nurses had experience of the treatment ofburns. At 19.30 (5 hours after the disaster), the first patient arrived at the hospital. During the next 8 hours, a total of 43 patients arrived, all severely burned. In all, 53 patients arrived during the first 24 hours, 2 more on the second day and 3 on the third. A basketball pitch adjoining the hospital was temporarily converted into a helicopter landing pad. Unfortunately, the helicopters were unable to land there because of dense fog. Instead they landed at an airfield on the outskirts of Barcelona, the injured being taken to the hospital by ambulance. The patients arrived in a constant stream and were treated without any delay arising from congestion. They were divided up in such a way that all who had a reasonable chance of survival were taken to the burn unit, while patients with deep burns covering more than 90 per cent of the body surface were placed in the 2 plastic-surgery wards. All 58 patients were given an intravenous supply of fluid, the majority via central venous catheters, on arrival at the hospital. This obviously made their treatment easier. Further course of events at Francisco Franc0 Hospital

When all the 58 patients had arrived at the hospital, the situation was as follows. One patient was dead on arrival. The other patients were distributed between the burn unit and the 2 plastic-surgery wards. The situation was already under control on the first night after the disaster. The doctors worked in 24-hour shifts and the nurses in 12-hour shifts. All 3 wards were cleaned continuously, according to a fixed system, from 08.00 to 22.00 by several teams of cleaners who relieved each other. This system meant that as soon as the team of cleaners on duty had finished cleaning the last room the cleaning of the first room began again, in accordance with the schedule. On the whole it was possible to maintain the usual routines for patient supervision (taking of blood samples, etc.). A careful examination of the patients’ burns on admission showed that 36 of the 58 patients had deep burns covering a90 per cent of the body surface. The mean value of the extent of the burns was 85.5 +- 19.5 per cent (Fig. 7).

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,O

20

30

40

50

60

% deep

70

80

90

100

burn

Fig. 7. The extent of deep bums in the 58 patients treated in Barcelona.

None ofthem showed signs ofburns to the lungs. Nor were other injuries observed for certain, either to the soft tissues or to the skeleton. The age distribution of the patients is shown in Fig. 8. The mean age was 26.3 t 17.0 years. The patients’ nationalities are shown in Table II. Twenty-seven came from France. After the disaster, the situation of the burned patients changed, as shown in Table III. During the second day, another patient died and 1 patient was transferred to another hospital. The day after that, yet another patient died and 3 were transferred elsewhere. During the next 3 days, 3 patients died and 40 in ail were sent back to their own countries. The majority of these patients had very severe burns and the idea behind their repatriation was that they should be allowed to die in their own country. The situation one week after the disaster (on 18 July) was that 7 patients, all Spaniards, were being nursed in the burn unit, 6 had died and 45 had been transferred to burn units in France, Belgium, Germany and Holland. The ages ofthe 7 remaining patients and the extents of their burns are shown in Table IV. The first 3 died a few days later. The La Fe Hospital, Valencia

The La Fe Hospital has a Department of Plastic Surgery with two wards and a special burn unit with 14 beds. Six of these beds are intended for cases of severe burns which require isolation and

Arturson:

The Los Alfaques

10

243

Disaster

Tab/e //. The nationalities of patients admitted to the burn clinic at the Francisco Franc0 Hospital in Barcelona

1

0

lo

20

30

50

40

Age,

Fig. 8.

60

70

Nationality

No

Spanish French German Belgian Dutch Unknown

13 27 7 4 3 4

Total

58

80

yeor

The age distribution of the 58 burned patients

treated in Barcelona. Table!//. The number of burned patients day by day at the Francisco Franc0 Hospital in Barcelona

Date 11/7 12/7 13/7 14/7 15/7 16/7 17/7 18/7 26/7 27/7 Summary

Admitted to the hospital

Nursed at the hospital

53 2 3

53 54 55 51 45 17 8 7 7 4 0

Mortality rate Francisco Franc0

(1) (1) (1) (1)

Other hospitals in Spain

Holland

1

:

(2)

Transported to France Germany Belgium

1 19 7

1 3 6

2 1

1

(2) (1) (9)

Number of deaths within brackets. The mortality rate 2 months after the disaster was 7 1 per cent (41 out of 58).

intensive care. There is a central supervisory unit for these 6 beds. The principles followed in the treatment of burns are, generally speaking, the same as those at the burn unit in Barcelona. Situation disaster, injured

at La Fe preparations

Hospital at time of the and emergency care of

When the news of the disaster at Los Alfaques reached the hospital at about IS. 15, 8 patients

were being treated in the burn unit. The La Fe hospital has a disaster plan, which was drawn up primarily by Dr Vincente Mirabet Ippolito, the head of the Department of Plastic Surgery. As soon as the extent of the disaster became clear, at about 15.30, the disaster plan was put into effect in full. This meant that a gymnastics and rehabilitation hall (about 200 m2) on the ground floor of the hospital was prepared with made-up beds, infusion equipment hung on the

244

Burns Vol ~/NO. 4

Tab/e IV. Patients treated in the burn clinic at the Francisco Franc0 Hospital in Barcelona on 18 July 1978

Sex

Age

M M M M F F F

13 43 58 297 38 2

Body surface covered by deep burns (%)

Nationality

98 90 90 50 40 40 30

Spanish Spanish Spanish Spanish Spanish Spanish Spanish

wall bars, dissection sets, infusion solutions, etc. Similar steps to those at the Barcelona clinic were taken in the Department of Plastic Surgery: the patients were discharged or transferred to other clinics, operations were cancelled, admissions from the waiting list were suspended, etc. Fourteen doctors from the intensive-care and surgery block and about 50 nurses were on duty within 2-3 hours. The first patient arrived at about 17.00. Within 6 hours, some 60 severely burned patients had been taken to the ‘gymnasium’. The first 40-50 patients had not received any treatment en route. Only a few of the patients admitted to the hospital during the evening and the night had received analgesics and been put on intravenous fluid therapy. In these cases, the treatment had been given at the hospital in Castellon (68 km north of Valencia). The small group of patients whose treatment had been commenced included the 5 who were transported by helicopter from Tortosa to Valencia. Altogether 82 patients were taken to Valencia, 56 of them directly to the La Fe Hospital and 7 via the University Hospital in Valencia, while 19 spent the first night at Castellon. As soon as an initial triage of the injured had been made and the treatment started, the patients were taken from the ‘gymnasium’ to the Department of Plastic Surgery. They were divided into three groups: those with a reasonable chance of survival were taken to the burn unit; those with burns covering 70-90 per cent of the body surface were taken to one plasticsurgery ward; and those with burns covering >90 per cent of the body surface were taken to the other plastic-surgery ward. The principles as regards the intravenous fluid therapy varied somewhat, depending on whether

0

10

20

30

40

50

60

70

“b deep

80

90

100

burn

Fig. 9. The extent of deep bums in the 82 patients treated in Valencia.

the doctor who gave the primary treatment was a plastic surgeon, an orthopaedic surgeon or an intensive-care specialist. This meant that some patients were treated with Evans formula [( 1 ml of crystalloids x % burned area x kg body weight) + an equal quantity of colloids], others with Brooke’s formula and others again only with Ringer solution (3 ml x % burned area x kg body weight). Further course of events at La Fe Hospital

When all the 82 patients had been taken care of at the La Fe Hospital, the situation was as follows. No less than 14 patients died within 24 hours of the disaster. The rest were divided between the 3 wards, as described above. The examination of the patients on arrival at the hospital showed that 53 of the 82 had burns covering a90 per cent of the body surface. The mean value of the extent of the burns was 8 1.2 -+ 24.0 per cent (Fig. 9). Three had suffered injury to the upper respiratory tract. These

Arturson:

The Los Alfasues

Disaster

245 Table V. The nationalities of patients admitted to the burn clinic at the La Fe Hospital in Valencia

1 0

SO

Age,

Fig 10. The age distribution treated in Valencia.

60

yea,

70

NO! identified

of the 82 burned patients

patients had almost 100 per cent bums and were treated by inserting a pharyngeal tube and giving oxygen. One of them was intubated. Two patients had burns of moderate extent with deep, circumferential burns on the forearms. As an emergency measure, longitudinal, relieving incisions were made in these patients, in order to improve the circulation in the hands. Otherwise, no injuries to the soft tissues or the skeleton were noted. The age distribution of the patients is shown in Fig. 10. The mean age was 28.0 t 16.2 years. The patients’ nationalities are shown in Table V. Thirty-six patients came from France. After the disaster the situation of the burned patients changed as shown in Table VI. Between I I July and 14 July inclusive, a total of 3 1 patients died and 30 were evacuated to their respective home countries. The situation one week after the disaster (on 18 July) was that 18 patients were being nursed at the clinic, 32 had died and 32 had been transferred to burn units in France, Belgium and Germany. The ages of the remaining 18 patients and the extents of their burns are shown in Table VII. IDENTIFICATION OF CASUALTIES At the site of the disaster

The 102 people who died immediately at the scene of the disaster were taken during the first 24 hours to the cemetery at Tortosa. The bodies

Nationality

No.

Spanish French German Belgian Dutch Unknown

7 36 19 17 1 2

Total

82

were greatly charred and unrecognizable. No attempts at identification were made by recording the place where the body was found or its association with a vehicle before removal. The Spanish authorities succeeded in establishing the identities of 10 of the dead immediately. The rest were said to be impossible to identify. The Spanish regulations prescribe that the burial of the body must take place within 48 hours of death. However, after making representations to the authorities concerned, the French and German officials succeeded in getting this period extended to 7 days. This extension was conditional upon all the charred bodies being drenched in formalin. On the day after the disaster, a party of German detectives arrived at the site and began to examine the wrecked cars, to record the make and type of vehicle, the registration numbers and the accessible chassis and engine numbers, and to draw up sketch maps showing where the vehicles were found. The medico-legal investigation was carried out by a German identification committee consisting of 25 persons (20 detectives and 5 experts in forensic medicine). The group of detectives came from the Federal Criminal Investigation Department (Bundeskriminalamt) in Wiesbaden. It included specialists in photography, fingerprints, clothes and remains of motor vehicles, etc., technicians, clothing, administrators and assistants to the experts in forensic medicine. The medico-legal group came from the Institute of Forensic Medicine (Institut fur Rechtsmedizin) in Mainz. Both groups brought with them complete equipment for the task-radiographic and photographic apparatus, office metal detectors, tools, instruments, materials and personal safety equipment.

Burns Vol. J/No. 4

246 Table VI. The number of burned patients day by day at the La Fe Hospital in Valencia Transported to Date 11/7 12/7 13/7 14/7 15/7 18/7 17/7 18/7 19/7 20/7 24/7 28/7 30/7 14/10 Summary

Admitted to La Fe

Mortality rate atLaFe

82 79 45 34 21 19 18 18 16 8 6

(3) (13) (10) (5)

4 3 1 0

(1) (1)

Other hospitals in Spain

France

17

Germany

4

:

7

(1) (1) (1) (2) (1)

(39)

1 1

6 1 1

: c%

Number of deaths within brackets. The mortality rate 2 months after the disaster (65 out of 82).

Tab/e VU. Patients treated in the burn clinic at the La Fe Hospital in Valencia on 18 July 1978

Age

F M E

342

F

15

rz F F F F F M M M F

39 20 13

Body surface covered by deep burns (%) 65 100

:; 16 14 17 40 38 42 23 8

Holland

1

$5,

Sex

Belgium

;: 60 95 100 80 80 45 85 80 90 80 95 E 90

Nationality Spanish French French German German German German German German German German Belgian Belgian Belgian Belgian Belgian Dutch

The conclusions reached by the identification committee in December 1978 were that, of the 88 corpses examined, 43 were female and 43 male, while in 2 cases the sex could not be deter-

A

was 78

A

per cent

mined. Fourteen were boys and 17 were girls, all under the age of 14. The nationality could be determined in 20 cases-2 Belgians, 12 Germans and 6 Dutch. The dental status was the most valuable means of identification. In no case could fingerprints be obtained. At the hospitals

The identification of the severely burned patients treated at Barcelona and Valencia was complicated by the fact that practically none of them had any means of identification. All their clothes had been burned. In addition, confusion arose by reason of language difftculties. Names were misunderstood. For instance, it was not always possible to distinguish between Christian names and surnames and, owing to this, family relationships could not be clarified. Moreover, certain patients were in poor condition and were confused when they were taken into care. The burn unit at the Francisco Franc0 Hospital in Barcelona has a visitors’ corridor running round the entire unit. This corridor was opened for a certain part of the day, so that relatives could communicate with the patients by telephone. However, there was at first no organized contact between relatives and doctors or nurses. No rooms were made available where relatives could gather or talk to the almoner or the chaplain in order to get help with various

Arturson:

The Los Alfaques

Disaster

247

problems. The information which reached the relatives and the mass media in various ways was at times very deficient, and was occasionally misunderstood because of language difficulties. Similar conditions occurred at the La Fe Hospital in Valencia. It had not been possible to look after and inform the relatives in a satisfactory fashion there either. FOLLOW-UP

OF CASUALTIES

Through further contacts with the Francisco Franc0 and La Fe Hospitals, information has been obtained about the course of events with regards to the 25 patients (7 in Barcelona and 18 in Valencia) who were being treated at these 2 hospitals a week after the disaster. In order to fmd out what happened to the patients who were evacuated to their own countries, letters were written to the heads of altogether 23 burn centres in Europe. Replies were received from practically all of them, independently of whether they had taken care of patients from the Los Alfaques disaster or not. A summary of these inquiries shows that altogether I27 named patients were evacuated from Spain (65 to France, 26 to Belgium, 31 to Germany and 5 to Holland). An examination of all the lists of patients treated at the Francisco Franc0 and La Fe Hospitals shows that 114 of these 127 patients had been treated at these two hospitals before evacuation. Eight patients were taken to Holland and France without passing through Barcelona or Valencia (2 of these were treated at Zaragozza). In the middle of September, two months after the disaster, the situation of the victims was as follows. Of the 148 patients who were alive immediately after the disaster and who were taken to Barcelona (58), Valencia (82), Zaragozza (2) and directly to their own countries (6). only 40 were still alive. The most common cause of death was sepsis, often with complications from the respiratory tract and the kidneys. Of these 40 patients, 8 had little chance of surviving. If we add to the 108 patients who died in hospital the 102 persons who perished at the site of the disaster, the total mortality 2 months after the disaster becomes 210 out of 250, i.e. approximately 85 per cent. No account has been taken of the unknown number of slightly injured patients who did not need hospital treatment. DISCUSSION Previous disasters of this kind

The effect of a cloud of burning

gas similar to

that at Los Alfaques is known from a series of previous explosions of this kind in the USA and Europe, including one at Feyzin in France in 1966. A tank of liquefied petroleum gas burst during a fire, causing 16 fatal casualties, injuring about 50 persons, mainly firemen, and causing great material damage over a wide area. In 1968, at the site of an oil refinery at Pernis in Holland, a cloud of gas exploded, killing 2 persons and injuring about 50 seriously. Great material damage was caused by the pressure wave in housing areas 3 km from the refinery. In 1974, a cloud of gas over a petrochemical works at Flixborough in England was ignited, starting a fire in which 28 persons were killed and 100 injured. The material destruction was so great that about 3000 persons living in housing areas at distances of 3-5 km had to be evacuated. A similar accident also occurred in Sweden in 1970. During a fire at the Norra Hammar works a tank containing liquefied petroleum gas burst. Owing to the fact that the area around the tank was evacuated quickly there were no fatal casualties, in spite of the fact that the cloud of burning gas was of the same magnitude as that at Los Alfaques and reached a height of over 200 m. A boiling-liquid, expanding-vapour explosion (BLEVE)

When a tank containing condensed, flammable gas bursts and the gas is ignited, a ‘fire-ball’ with a diameter of 40-80 m is quickly formed; it may rise to height of 200-300 m above the ground and be driven by the wind while still burning. Besides the direct burns caused within and in the immediate vicinity of the ‘fire-ball’, radiant heat may give rise to burns and ignite flammable materials up to 200-300 m from the flames. With the right mixture of air, the maximum temperature of the flames may be over 1900 “C in the case of propene. The external temperature of a cloud of burning gas of this kind would seem to be anything up to 1000 “C, as is confirmed by the fact that damage due to melting was encountered within the area of the fire. The speed of combustion in the cloud of gas may vary from a very rapid and violent explosion with the right mixture of gas and air to smaller explosions when the gas is ignited before a large amount of gasification has taken place. When a tank containing condensed gas bursts, gas in the ‘liquid phase’ may also be thrown out on account of the over-pressure and the explosion, and may burn here and there in patches at distances of 50-100 m from the site ofthe burst.

248

The rescue work at the site of the disaster A certain amount of criticism, especially in the

foreign press, was levelled at the way in which the local authorities and social-welfare agencies handled the situation. Some factors may be mentioned in justification of such an attitude. The fact that vehicles carrying heavy and hazardous loads were allowed to pass through a densely inhabited area of this kind had already for several years past aroused oppositions, especially among the local people. Two accidents involving road tankers had occurred in the same district during the previous 5 years. Fortunately, in these cases the consequences to human life had been only slight. During the holiday season, this district is very popular and is consequently overcrowded by a large, temporary increase in population. In view of this, the state of preparation for fires and other accidents must be considered to be rather poor. Judging by Swedish standards, the times which the municipal rescue services took to reach the site were too long. The fire brigade did not arrive until an hour after the explosion. The municipal ambulances too a good half an hour to get there. There were no facilities for giving any medical treatment on the site. It was about 3 hours before all the injured were taken to hospital. The fact that the disaster took place during the siesta probably contributed to the delay. However, it must be pointed out that the situation which arose was very chaotic, with a particularly large number of severely burned people running about in panic. Altogether, several hundred people must have been moving about immediately aRer the explosion. Even with a high degree of preparation, it would have been difftcult to get the confused situation under control in the initial phase. In the circumstances the efforts of the police patrols, especially as regards traffic control, were praiseworthy. The requirement that they should be able to cope quite satisfactorily with ambulance transport of this order of magnitude would entail an almost unreasonable dimensioning of all the local ambulance organizations. However, one cannot help reflecting on the suffering which the injured people had to undergo during their long wait for attention, particularly as hardly any medical aid of any importance could be offered them. As there was no medical direction, it would seem that no meaningful priority could have been allocated to them either. Owing to the fact that the road was blocked by the fire, the decision whether to transport the

aurns VOI. 71~0.4 injured northwards or southwards was made by chance. On this account, the large number of patients came to the burn clinic which had the smaller capacity. Because of blockages in the telecommunications system, the central control staff in Tarragona had difftculty in getting basic information on the distribution, especially ofthe patients from Tortosa. However, in the later phase, the patients were transported from there only after adequate medical consideration and with medical supervision during the journey. The patients were not sent away until their respiratory and circulatory functions had been stabilized. They were transported mainly by ambulance. Helicopters, both civil, military and police, were also used at this stage for the transport of 15 patients. Care at hospitals

The primary care given at the nearest hospitals shows an obvious difference in quality between those who were transported northwards and those who were transported southwards. On the road to the north, 20 of the injured received an adequate degree of care, at the cottage hospital in Amposta, before being transported further. At the county hospital in Tortosa, admirable treatment was also carried out, with the aim of stabilizing the patients’ circulation and respiration before they started off on the journey to the burn clinics. There were no real respiratory problems. Children were given the highest priority in treatment. The early medical care of the injured who were transported northwards was in stark contrast to that ofthe injured who were taken southwards. Thus, at Vinaroz, a coach was loaded with 45 patients, who had to endure the 150 km journey to Valencia without treatment or medical supervision, either lying down or sitting up. Naturally, the medical consequences soon appeared and states of severe shock supervened. Only one patient was intubated on arrival at Valencia. The reason was probably hypoxic cerebral injury due to shock and accompanied by respiratory insufficiency. The burns themselves produced difficulties in breathing in 2 patients. These patients were treated with oxygen via a pharyngeal tube. Consequently, there were comparatively few complications from the respiratory tract. The victims who were transported via Castellon received, after a journey of 100 km, adequate care at the hospital there during the first night. They were then taken to the burn clinic at Valencia. The specialist treatment given to the patients

Arturson:

The Los Alfaques

Disaster

at the burn clinics at Barcelona and Valencia was of very high class. This applies particularly to the clinic at the Francisco Franc0 Hospital, which is one of the most modern in Europe. At both hospitals, early excision and transplantation are performed on patients with deep burns not exceeding 40 per cent of the body surface. For the diagnosis and treatment of burns exceeding 40 per cent of the body surface there are, above all, advanced laboratories of clinical chemistry and bacteriology and a well organized blood-donor centre. At the Francisco Franc0 Hospital, the laboratories are equipped with a large number of autoanalysers and the results are processed at a computer centre. Evacuation countries

of injured persons to their own

If modern principles can be applied in the treatment of patients with severe burns, even long journeys at an early stage are no longer a great problem. This applies on condition that medically trained staff accompany the patients on the journey and see that their respiratory tracts are open, that the supply of intravenous fluid is adequate, that their bums are protected against contamination and that the heat loss is kept low. It is very important that patients who are seriously injured in foreign countries should be put in touch as quickly as possible with the medical services in their own countries. French and Dutch colleagues, who had travelled to Barcelona and Valencia and taken charge of victims of the Los Alfaques disaster, have pointed out in letters that the patients and their relatives were extremely grateful for and relieved at this assistance. This applies not only to patients who have a reasonable chance of surviving but also to dying patients, who often have a strong desire to be allowed to die at home. Unnecessary and often tragic misunderstandings due to language barriers or prejudices can be avoided if the home country can make a rapid effort to help. However, it is important to point out that such action should be taken tactfully and judiciously. A country in which a major disaster, involving injuries to people from other countries, takes place is often subjected to harsh criticism from these countries - often also due to misunderstandings. This sometimes results in arguments about national prestige and in unreliable reports. The above-mentioned problems are also to be found in the wake of the Los Alfaques disaster and have resulted, among other things, in some

249

newspaper articles containing incorrect and negative criticism of the way in which the Barcelona clinic dealt with the treatment and evacuation ofsome severely burned patients. If we compare the assessment of the degree of seriousness of the bums which was primarily made at the Francisco Franc0 and La Fe Hospitals with the assessment which was made later at the respective burn clinics in the patients’ own countries, we fmd that there is good agreement. Only in a few cases was the extent of the burn over- estimated in Spain. The medical care which was given to the patients in Spain has been described by several specialists who have taken over the care ofthese patients as extremely fine. A large number of evacuated patients who had already died or were dying were taken directly to the hospital nearest to their homes instead of to the burn clinic. Care of relatives

Neither at the Francisco Franc0 Hospital nor at the La Fe Hospital had satisfactory arrangements been made to provide waiting rooms and. information desks for relatives. The results was that relatives who were kept waiting in the corridors and on the staircases of the hospital were worried and sometimes displeased at the lack of information. Rumours and misunderstood or incorrect lists of patients increased the confusion. However, this must be considered in the light of the facts that most of the patients had names that were difficult to interpret and that both hospitals had to admit a much larger number of severely burned patients than there were facilities for in the bum clinics. Psychiatric disaster

and psychological

views of the

It is always very difficult to picture the dreadful tragedies which take place in connection with a disaster. In the present case, the disaster has some distinctive features which must have made it particularly difficult to face up to, both for the patient and his or her relatives and for the hospital staff. One such feature is the very large number of victims suffering from severe burns who did not die at the site of the disaster but had scarcely any chances of surviving in the long run. These patients seldom understand how seriously injured they are. They are unaware of their illness, they are usually quite conscious for several days and they often do not even feel any appreciable pain. Their relations often misinterpret this pathological picture, do not understand

Burns Vol. ~/NO. 4

250

Barc.lonlI

0

(55palienls)

I 4

5

12

16

20

24

I 60

20 Days

after

burning

Fig. 11. Comparison of the survival rates among the burned patients primarily treated in Barcelona and Valencia respectively. the doctor’s pessimistic view of the patient and sometimes question his expert knowledge and opportunities of giving treatment. In this case the part played by the medical staff- chiefly the responsible doctor-in relation to both the patient and the relatives is a very difficult one. Whole families going on holiday together frequently travel to a camping site, often far from their own country. This was also true at Los Alfaques. The characteristic features of this disaster were therefore, on the one hand, that several members of families and in some cases whole families were severely burned and, on the other, that most of them were in a ‘foreign country’. The situation was also made worse by the fact that the families were split up and ended up in the 2 different burn clinics, which are 350 km apart. In the wake of the chaos which arose at the site of the disaster anxiety about the relatives was increased. There were several examples of bums being made very much worse by people trying to protect or to rescue one of their relatives. It is important that the hospital staff should be able to take care of the serious psychological and psychiatric problems which often predominate over the purely somatic problems in connection with a disaster of the kind which we experienced in this case. Comparative study of results of treatment between injured taken to Barcelona and Valencia

In spite of the fact that most of the patients who survived their acute injuries had such extensive

and deep bums that the ‘final mortality’ was very high, a comparative study of the two groups of patients who were transported to Barcelona and Valencia respectively yields some interesting information. The 58 patients who were taken to Barcelona and the 82 who were taken to Valencia during the days immediately after the disaster form 2 groups of patients with burns of similar extents and similar age distributions (the Barcelona material 85.5 f 19.5 per cent and 26.3 +- 17.0 years respectively and the Valencia material 8 1.2 f 24.0 per cent and 28.0 +- 16.2 years respectively). The transport distance is also approximately the same (Los Alfaques is 190 km from Barcelona and 165 km from Valencia). However, there is one important difference. All the patients who were transported to Barcelona were taken care of, a short time after the disaster, at the hospital in Tortosa, where rapid, adequate and exemplary initial treatment was given. This meant that the circulations of these patients were stabilized before the long journey to Barcelona by helicopter and ambulance. Few of the patients taken to Valencia received any treatment either before or during the journey, which was also made, for the most part in private cars or motor coaches, without any skilled medical staff accompanying the patients. The percentages of survivals plotted against the time after the burns were received for the two groups of patients, they are shown in Fig. 11. During the 4 days immediately after the disaster

Arturson: The Los Alfaques Disaster

251

the survival rate fell to 93 per cent for the patients taken to Barcelona and to 45 per cent for the patients taken to Valencia. After this the ‘Valencia curve’ levels out, while the ‘Barcelona curve’ continues to fall, so that after a month, the survival rate is 35 per cent in the Barcelona group, as against 25 per cent in the Valencia group. After a further month the difference between the survival rates in the two groups is only 7.3 per cent. As the principles of treatment were very similar at both hospitals, the reason for the obviously higher mortality during the first 4 days among the Valencia patients must be ascribed primarily to the inadequate initial care. On the other hand, the better initial treatment of the Barcelona patients seems only to have prolonged the survival time for a few weeks for a large number of patients. The fmal survival rate is roughly just as tragically low in both the groups, owing to the fact that most of the burns were very extensive and deep. An examination of the 3 1 patients who died at the La Fe Hospital during the first 4 days after the disaster shows that 27 of them had deep bums covering > 90 per cent of the body surface. The remaining 4 patients were burned to the following extents: one 70 per cent, two 80 per cent and one 85 per cent. The chances of any of these patients surviving must be considered to be very small CONCLUSIONS

Near-accidents and near-disasters in connection with the transportation of dangerous goods, chiefly flammable, poisonous and corrosive substances, have become increasingly common in recent years in most countries. It is therefore important to circulate information about the European convention entitled European Agreement Considering the International Carriage of Dangerous Goods by Road (ADR), which is administered by the United Nations Economic Commission for Europe in Geneva and refers both to road safety and to the special conditions for the transportation of dangerous goods. In summary, these conditions involve the following requirements: Requirements made of the sender. I. To give the correct information about substance, class and number. 2. To use the right container. 3. To use the right notices and signs. 4. To give correct information in the freight documents. 5. To supply a route card (goods sheet containing information). Keque.vrs /i)r reprints .shou/d be addressed to:

GijstaArturson.

Requirements made of the haulier. 6. To check on container, marks and documents. 7. To use the right vehicle and equipment. 8. To use correct vehicle signs. 9. To be responsible for the correct loading and separation of substances. 10. To ensure that the vehicle is properly manned. 11. To be responsible for getting permission to unload and load. 12. To give the vehicle driver information about current requirements etc. However, even if all the above-mentioned requirements are met, serious accidents may still occur, for example, through collisions and driving into ditches. Even though certain roads may be assigned to this kind of transport, this does not preclude the possibility that a road tanker may, on account of the driver taking the wrong route or for some other reason, get into a road or street where it constitutes a serious threat to the environment. In every country there should, for this reason, be disaster plans for use in the event of catastrophes like that at Los Alfaques. Such a disaster plan has been outlined for an imaginary, road-tanker disaster similar to that at Los Alfaques taking place north of Gothenburg on the west coast of Sweden. This study shows that we would have to use 6 intensive-care units and 4 surgical wards at altogether 6 different hospitals and all the special intensive-care beds for the treatment of burns (20) available in the whole country in the initial phase, in order to be able to take care of the victims of the disaster. In addition, a large part of the other surgical work at these hospitals would have to be restricted to a minimum and a considerable number of extra staff would have to be engaged. The medical-care units would be heavily loaded for a long period to come. An important part of the improvement in preparedness for disasters in general is the exchange of information and experience between countries. It is also important that the burn centres in different countries should actively assist each other when a disaster happens. There have been increased opportunities for working along these lines since the International Society for Bum Injuries formed a Disaster Planning Committee on the recommendation of the Director of Emergency Relief Operations in the World Health Organization.

Paper accepted 19 December 1979.

Burn Centre. University Hospital, Uppsala. Sweden