Injury (1990) 2 I, 41-44 Printed in Great Brifain 41

Management of burns in major disasters

D. T. Sharpe Director, Plastic Surgery and Bums Research Unit

I. T. H. Foo

Research Fellow

University of Bradford, UK

This paper discusses the problems of handling major bums in disasters with parficular r@rence to the disaster fhaf occarred in Bradford. Several major f&ares of the Bradfard fire, in which 56 people died, made ifs management much simpler than might be expecfed in sttbsequenf bums disasters; these are discussed. JI.~ssons that have been learnedfrom handling this disusfer are indicated.

On 11 May 1985, an end of season football match between Bradford City and Lincoln City was played at Bradford City Football Ground to celebrate Bradford’s promotion in the League. Shortly before half-time, a small fire broke out in the main stand. It was observed by the crowd with interest and growing horror as it spread rapidly through the main stand and roof in the space of 4 min (Figure I). Some spectators were evacuated onto the field but many were unfortunately directed to the back of the stand from which there was no escape as the turnstile doors were locked. Almost imme- diately first aid was given by the St John Ambulance Brigade and off-duty ambulancemen, firemen and other spectators. At this stage no major accident plan was initiated at the local hospital, the Bradford Royal Infirmary. There were problems communicating the scale of the incident to the hospital as a result of police radios and telephone lines at Ambulance Control being jammed by the vast volume of information that was being transmitted. So the first warning Bradford Royal Infirmary had of the scale of the disaster was when a large number of people, both patients and relatives arrived at the casualty department a few minutes after the fire started. In the subsequent hour, over 200 injured were present in casualty. Most of these arrived by car, police car or bus. As the match was being televised, many of the local medical staff turned up to help in the disaster. By the time the major disaster plan was initiated, there were already many staff in the casualty department and treatment plans were well under way.

There were several fortunate coincidences in that an anaesthetic meeting was taking place and consultant and registrar anaesthetists were available to put up drips in casualty. The staff in casualty, although not being accus- tomed to deal with disasters on this scale, had experience in treating small bums in bums clinics which were regularly held in this department.

0 1990 Butterworth & Co (Publishers) Ltd 002&1383/90/010041~4

Figure 1. The main stand at the height of the fire.

Triage was initially undertaken by the Senior House Officer in Plastic Surgery and he was rapidly superseded by the Senior Registrar and Consultant Plastic Surgeon on duty. However, much of the credit-for organizing the doctors and nursing staff who were accustomed to dealing with such injuries must go to the Senior House Officer for his common sense and bums experience. The predominant bums were of the radiant heat type as a result of the enormous fireball in the roof of the stand and these mainly affected the scalps and backs of the hands, with several burns to the face, back and legs. There were relatively few flame bums. This resulted in most of the 256 people who were injured having well circumscribed bums of easily recogniz- able depth and extent. Triage was in part conducted by the staff at Bradford Royal Infirmary but was also performed most effectively at the ground by the ambulance crews. Two bums of over 30 per cent area were transferred directly to the Regional Burns Unit at Pinderfields. There was no opportunity in this instance for a senior plastic surgeon to go to the site of the accident, and in most disasters it would seem that this was very rarely either achievable or desir- sable, except in cases of entrapment.

A total of II major bums were treated at the Regional Bums Unit of which four died. This was within the predicted outcome of Bull’s probability table (Bull, 1971). The remain- ing burns injuries were dealt with by the Bradford Royal Infirmary and St Luke’s Hospital, where the Plastic Surgery

42 Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No. 1

unit is based. Several made their way to neighbouring hospitals including St James’s Hospital, Leeds, Pinderfields Hospital, Batley General Hospital and the Royal Halifax Infirmary. Following this the bums were assessed by teams of plastic surgeons and nurses. These were dressed and those not requiring admission were discharged to return on the Monday (2 days later) to be seen in the clinic.

The criteria for admission were more than one hand injured and bums totalling more than 6 per cent. Patients with bums accompanied by any significant injury were also admitted. By 7 o’clock, 40 patients were admitted at Bradford Royal Infirmary and a further 20 or more at St Luke’s Hospital. By this time casualty was largely cleared except for a residuum of relatives who were being looked after in the physiotherapy gymnasium and these relatives included a large proportion who had been unable to trace their loved ones. This paper will be confined to the treatment of the bum victims, and the methods of dealing with relatives and the identification of the deceased will not be dealt with any further. It should, however, be emphasized that subsequent to the Bradford fire disaster much has been learned about the sympathetic management both of the bereaved and those suffering the severe psychological trauma consequent on any major disaster.

Late in the evening of II May, it became clear that the majority of the cases that had been admitted had discrete, well circumscribed bums which could be dealt with by early tangential excision and grafting. A plan was formulated so that this surgery could be carried out as was the normal practice between the 2nd and 5th days. This time was chosen as it had been the authors’ experience that hand bums fared best when the excision and grafts were performed when the fluid and oedema had dissipated by the 2nd day. In order to achieve the task of dealing with the 53 patients deemed fit and suitable for surgery on the Monday morning, an extensive plan of organization and administra- tion was necessary. On the Sunday morning, I day after the disaster, all patients were transferred to St Luke’s Hospital where wards had been evacuated and a total of 75 patients were contained within four wards. Most of these patients had hand bums and had their arms in slings. Those patients for whom surgery was not appropriate, because they were unfit for an anaesthetic or because the burns were assessed as being more superficial, had their bums dressed in Bunyan bags and elevated. Those for surgery had their hands dressed in normal tulle and tripe dressings and the hands again elevated. It was felt that it was not necessary to keep the hands mobile in those instances were surgery was going to take place within a few hours and no further dressings were anticipated until surgery was performed.

Clearly with some 100 individual sites requiring surgery (one dorsum of the hand constituting one site, one scalp another and the other areas of the limbs a further site), the number of surgeons required to perform this number of procedures within the J-day period was going to be large. Surgery was therefore organized into four theatres with teams of up to six surgeons per theatre. Of this number at least three per theatre had experience in plastic surgery and were either consultants or registrars and above. A further four plastic surgeons were employed on the Monday morning in the outpatient clinic to decide which patients required surgery. In total 13 plastic surgeons of considerable experience were used in the initial stages of the burns disaster management and were essential for the smooth running, diagnosis and treatment of the burn conditions. Many of these surgeons, who constituted 10 per cent of the

trained plastic surgeons in the United Kingdom, had come from other units in the North of England including Man- chester, Newcastle and Leeds. Many offers of help were received from further afield and abroad. Without this generous donation of time and expertise it would not have been possible to manage the patients in one centre. It was felt desirable that the patients were kept in one unit and that expertise should be concentrated there as the burns fitted into easily manageable categories and this method was most effective in time and materials. It was also more convenient for the patients to be treated in their home town. In this particular instance it was most successful but it would not necessarily apply to other major burns disasters where there were many burns of a large percentage area. These are dependent on a high staff-to-patient ratio.

Surgery proceeded on the Monday moming and con- tinued until Wednesday evening. A total of 53 patients were operated on. Many more patients received surgery after this period, most of these being transferred from other hospitals and also included were patients who had been diagnosed as having superficial burns to the backs of the hands which subsequently required grafting. Organization of dressings was undertaken by a very senior experienced plastic surgeon who had recently retired from the hospital and without his great expertise and knowledge, this treatment would not have proceeded so successfully. Dressing clinics are very expensive of time and expertise and the first dressings took as long as the first surgical procedure on the patient. This required the attention of the physiotherapist to make hand splints, an anaesthetist to ensure analgesia and several nurses and a plastic surgeon.

It will now be appropriate to discuss the results from early surgery. Unquestionably the results of the early excision of the hand eschars were very good and 90 per cent of patients with hand burns had 100 per cent take of grafts. This was independent of the variety of methods used by different surgeons, ranging from application of grafts before or after the tourniquet was released, whether the grafts were meshed or unmeshed, to the various methods of securing the graft to its bed. The scalp burns on the other hand were not so successful (Dickson et al., 1988). Of the 23 patients who had early excision, 56 per cent required further grafting. The conclusion to be drawn from this is that although in the case of the Bradford fire no detriment occurred to many of the patients as they were having an anaesthetic for the treatment of the bums to their hands, this method of early tangential excision would not be recommended for scalp bums alone, as it proved to be no quicker than late grafting.

With the success of early grafting of the hands it was possible to discharge many of the patients home by the end of 3 weeks (Figtrre2). Much of the success in the mobility achieved by the patients subsequent to grafting must be attributed to the physiotherapist who worked with the patients on the ward and intensively afterwards. At this point, it would be reasonable to discuss the high level of morale that existed on the wards, which must have contributed to the success of the surgery. Unquestionably a large number of patients with similar interests who are in hospital at the same time and undergo similar trauma and surgery are subsequently able to encourage their fellows and it was only after many patients had left the unreal world of the hospital ward that they experienced difficulties in coming to terms with their own horrific experiences. During this period social workers and psychologists were able to benefit the patients most. Although we shall not discuss the psychological aspects of a disaster of this nature, we should

Sharpe and Foo: Management of bums in major disasters 43

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Figure 2. Number of patients remaining in hospital.

stress the tremendous importance of the psychological backup and counselling required in disaster management.

Having discussed what we did at the time of the Bradford fire, it is probably appropriate now to discuss what we failed to do or what was unsuccessful in our management. Probably the most unsuccessful aspect of the treatment of bums was the management of the scalp, which by early excision failed to achieve good take of grafts in 56 per cent of cases. Part of this must be due to the method of immobilization of the scalp grafts themselves and the difficulty of maintaining an occipital graft in position without it being rubbed of by the patient or the dressings.

Management of the major bums at Pinderfields Hospital proceeded according to expectations, and it is not appro- priate for the present authors to comment on the success or otherwise of their treatment as they were not present at the Regional Bums Unit. The enormous workload involved in managing 11 patients burnt at the same time in a bums unit was overcome by the great efforts of both the medical and nursing staff.

The circumstances that make the Bradford fire disaster especially easy to deal with amongst recent disasters were the nature of the bum injury and the absence of many of the complicating factors which would commonly be associated with major disasters. First, there were relatively few respir- atory bums. The disaster was out of doors and virtually no one who survived had severe smoke inhalation damage. There was also no foam or toxic chemicals in any quantity involved in the fire. It was not necessary to ventilate any of the patients admitted to the Bradford hospitals.

Second, there were very few associated fractures. The two patients who sustained fractures were dealt with on the same day by the orthopaedic surgeons. There were very few soft tissue injuries which would have considerably compli- cated the planning and execution of the surgical treatment.

Third, the disaster occurred near a hospital well used to dealing with bum injuries and all the equipment necessary to initiate management of the victims was present, although a much larger quantity was required very rapidly once treatment had begun.

Fourth, Bradford is a city which is small enough for most physicians and surgeons to know each other and this

resulted in good cooperation, tolerance and assistance, and the plastic surgeons were able to call upon help from their colleagues. This was freely and readily given both in evacuating wards and managing the patients.

Having established that the Bradford fire, although massive in numbers of casualties, was relatively simple to manage, it is still worth pointing out some of the lessons that could be passed on to those yet to experience their first disaster. One useful method of doing this is by using the word COMMUNICATION as a mnemonic.

C =Chaos 0 =Order M = Most experienced plastic surgeon M = Make available adequate resources U = Update casualty figures at regular intervals N = No points for economizing I = Inpatient needs C = Capitalize on goodwill A = Accommodation T = Team leader I = Invite outside help 0 = Outpatients N = Nursing officer

‘C’, chaos can normally be expected and is inversely proportional to the warning the receiving hospital has of the impending patient numbers. Thus, at Bradford large num- bers of patients arrived without any warning whatsoever, whereas at Piper Alpha, the very efficient evacuation of casualties onto the ship, i%zros, and their triage by experts on this platform enabled waves of fully assessed patients to arrive at regular intervals at the receiving hospital, Aberdeen Royal Infirmary. The time that elapsed between notification of the disaster and the first patients arriving was 6 h in the case of Aberdeen but 4 min in the case of Bradford.

‘0’, order can be achieved from this chaos only by adequate and efficient triage and this should be performed by the Most (which is the ‘M’) experienced plastic surgeon. This is particularly important because a decision must be made about allocation of resources and whether certain patients have a survivable burn. It would be highly inappropriate to take up a bums unit bed with a bum in the mortal category, although this patient should perhaps be admitted to an intensive care ward. It is also important to be able to assess whether the burned patient requires admission or not.

The next ‘M’, is make available adequate resources. This is a fairly obvious statement, but in planning for major disasters a military style operation is necessary to ensure the availability of equipment and manpower.

‘U’, update casualty figures at regular intervals. This is vital to ensure that the receiving hospital is not over- whelmed by numbers which cannot be dealt with within the resources made available to it. Under this heading, it is also important to find out the bed availability of the nearest neighbouring bums unit and major hospitals. At some point a decision must be made about the maximal number that can be coped with at the base hospital. This decision is arrived at chiefly by the number of major burns arriving at the hospital as these are the most manpower intensive. It is quite possible to use surgical wards for the majority of bums of less than 20

per cent. These beds are to be found in any district general hospital after adequate evacuation plans have been set in motion.

‘IV, no points for economizing. There is absolutely no credit to be obtained in failing to order adequate resources and this applies particularly with regard to dressings and

44 hb-y: the British Journal of Accident Surgery (1990) Vol. 21/I%, 1

instrumentation, and right from the outset these need to be obtained. The onus should be delegated to an efficient person, normally a nursing officer who is experienced in obtaining supplies. This also applies to plasma and arm slings, etc. It is far better to have more than less of any vital piece of equipment or supplies.

‘I’, inpatient needs. Under this heading one must think of needs other than the immediate medical requirements of the patient. Nursing needs are paramount in terms of assistance, particularly in patients with hand bums. They will be unable to feed themselves and manage their own personal hygiene. Equally important are extra telephone lines on the wards, for communication with relatives and the administration.

‘C’, capitalize on goodwill. In this age of intense media interest in disasters, it is vital to ensure that the goodwill mobilized by media coverage is utilized to the best advantage not only to the patients but also to the hospital and subsequent facilities. Fortunately at Bradford, there were several philanthropists and through their generous help it was possible to set up a Plastic Surgery and Bums Research Unit which has subsequently been able to help in other major disasters such as Piper Alpha. It is an unfortunate fact of life that after a very few days, the interest in preventing disasters and accidents seems to wane as the interest turns to the legal and compensation aspects of the disaster.

‘A’, is accommodation. Rooms should be set aside for the enormous number of concerned relatives and friends arriving at the hospital where they can be attended to by sympathetic and skilled social workers.

‘T’, is team leader. He must be in a position to organize and delegate responsibilities and remain free from too much clinical burden. Unless there is an easily identifiable person to whom personnel can report progress, much time and effort can be duplicated or wasted.

I’, invite outside help. In major bums disasters the expertise necessary to deal with major burns is fairly limited throughout the country and often it is more appropriate to collect this expertise at several centres rather than to transfer patients. We were fortunate in Bradford because of the large press coverage on television, many offers were received from other units. But occasionally it is necessary to ask for help which is always freely given.

‘0, outpatient needs. It is only after the initial hustle and bustle of managing the major casualties is over that the need for outpatient facilities becomes apparent. Most injuries that occur in major disasters are small but numerous and most of these can be managed as outpatients. Therefore large rooms and centres need to be set aside to deal with these and expertise must be available to deal with them efficiently. It is necessary to cancel or redirect the normal outpatients to accommodate this large additional workload.

Finally, as it was appropriate in Bradford, ‘N’ stands for nursing administrator. Management of any disaster is a team effort. One of the most vital members of that team is the senior nursing administrator, who has the power to organize the numbers of nurses required and simple equipment such as drip stands and bandages. He or she would also be able to recruit nursing help from other hospitals. It is vital that this person is very much a member of the team managing the crisis,

It is quite clear that the scale of any disaster can never be completely anticipated and that each is quite different. The management of the Bradford football ground fire proved much simpler than one could reasonably expect, and it should not be assumed that all such disasters would be as easy to cope with. Plans must exist but they need not be slavishly adhered to.

References

Anonymous (1978) Facilities for bums treatment in the United Kingdom. Bwns 4,297.

Bull J. P. (1971) Revised analysis of mortality due to bums. Lancet

2, 1133. Dickson W. A., Sharpe D. T. and Roberts A. H. N. (1988)

Tangential excision of scalp bums: experience from the Brad- ford fire disaster. Berms 14, 151.

Requesk for reprirzk AouM be addressed to: Mr D. T. Sharpe OBE MA

FRCS, Director, Plastic Surgery and Bums Research Unit, Univer- sity of Bradford, West Yorkshire, UK.