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Christina Catlett, MD, FACEPAssociate Director, Johns Hopkins Office of Critical Event Preparedness and Response (CEPAR)Director, Johns Hopkins Go TeamSenior Medical Officer, MD-1 DMATAssistant Professor, Johns Hopkins Department of Emergency Medicine

The Taiwan Water Park Inferno

Today’s Objectives

• Understand the magnitude of the Formosa waterpark explosion disaster

• Discuss the challenges faced by the Taiwanese health care system in responding to the disaster

• Become familiar with current burn surge capacity in the U.S.

• Describe evolving strategic plans to create burn surge capacity

• Discuss the importance of training and education in dealing with burn mass casualties

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Introduction: Case Study #1

Cocoanut Grove Nightclub fire (1942, Boston)• 492 people killed, 166 injured• Factors: over capacity; lack of sprinklers and

smoke detectors; rapidly moving fire and toxic gasses; jammed revolving door at main exit; other exit doors locked, blocked or blacked out

• BCH received 300 victims in 1 hour and MGH received 114 victims in 2 hours

• Deadliest nightclub fire in the world• Led to reformed safety standards and codes

www.Bostonfirehistory.org 3

Source: Wikipedia, Boston Globe4

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Introduction: Case Study #2

Station Nightclub Fire (2003, Rhode Island)• 100 dead, 230 injured• Great White concert• Factors: over capacity; illegal pyrotechnics;

stampede; narrow primary exit and blocked emergency exits

• Resulted in revision of fire codes on sprinklers and crowd management in nightclub-type venues

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https://medium.com/homeland-security/safety-in-numbers-38f97efe6c7d6

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Case Study #3: Formosa Water Park Disaster, Taiwan, June 2015

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Location

Formosa Fun Coast Water Park

www.Google.com/maps8

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The Event

Saturday night, June 27, 9 p.m.: Color Play Asia

www.facebook.com/colorplayasia/9

Event Video

Warning: graphic, may be disturbingStage viewhttps://www.youtube.com/watch?v=gYtljIbh0xkAudience side viewhttp://www.theguardian.com/world/video/2015/jun/28/footage-moment-fire-engulf-revellers-taiwan-water-park-videoAftermathhttp://www.cnn.com/videos/world/2015/06/28/taiwan-water-park-blast-novak-lok.cnn/video/playlists/taiwan-water-park-explosion/http://www.dailymail.co.uk/news/article-3142035/I-saw-lots-people-skin-gone-Witnesses-hell-Taiwan-water-park-explosion-injured-500.html

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Initial Response

• Emergency calls began ~ 9:30 p.m.• Pathways in park too narrow for rescue vehicles• Participants carried victims to parking area• Scene command was assumed by the Fire Service

(EOC command later transferred to Ministry of Health and Welfare)

• Patients were put into ambos, private vehicles, taxis, etc., and sent to nearest hospital or designated hospital

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Initial Response (cont.)

Sample ED: Cheng Hsin General Hospital (970 beds)10:20 p.m., 14 cases>80% TBSA-3 cases-3 ETT>60% TBSA-2 cases-2 ETT>50% TBSA-2 cases-1 ETT>40% TBSA-1 case>20% TBSA-2 cases<10% TBSA-4 cases

Source: Drs. Chuan Hsun Chang , Tsai Shen Kou

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Initial Response (cont.)

• ED resuscitation– Airway– Access– Ventilator management– Fluid resuscitation– Pain management– Emergent escharotomies– Initial burn wound management/dressings

• Distraught families, the press, etc.

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Initial Response (cont.)

• 499 victims• 128 total burn beds nationwide, 43 of which

are burn ICU• 393 admissions, and >200 patients need burn

ICU care

…NOW WHAT??

http://www.taipeitimes.com/News/taiwan/archives/2015/07/03/2003622167

Initial Response (cont.)

Sample hospital #1: Tri-Service General Hospital (military hospital)• 1700 beds; 14 burn beds (6 ICU, 8 stepdown)• Received 52 patients from the disaster

Sample hospital #2: Shin Kong Wu Ho-Su Memorial Hospital• 921 beds; 3 burn beds• Received 31 patients

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Our Delegation/Mission

Our Delegation

• Coordinated through the Ministry of Health and Welfare (MOHW) representative to Taiwan in Washington, D.C.

• Report as of 7/6/15:– 291 still in ICU with 235 in critical condition– Of the inpatients:

• Average TBSA burn 50%• 253 patients > 40% TBSA• 32 patients > 80% burns

Source: Dr. Daniel Lu18

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Our Delegation (cont.)

• Johns Hopkins Go Team–Deployable medical asset for Johns Hopkins

Medicine–~200 providers on the team; multidisciplinary–Tremendous amount of expertise and reachback

capability–Requirements to deploy: formal request, well

defined mission, logistics in place

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Our Delegation (cont.)

Members of our “strike team”• Director of the Johns Hopkins Burn Center (MD)• Director of Critical Care Medicine (MD)• Plastic surgery resident and burn researcher (MD)• Burn unit nursing coordinator (RN)• Director of burn rehab (PT)• Emergency physician and disaster expert (me)

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Our Delegation (cont.)

Mission• International collaboration and support• Subject matter expert exchange• Needs assessment

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Activities of Our Mission

• Picked up in California by the President of Taiwan on his plane and flown to Taipei

• Met with the MOHW, Taiwan’s CDC, and the Presidents of the Burn Association and Society of Plastic Surgeons

• Visited 12 hospitals across Taiwan in 6 days• Subject matter expert exchange via case

conferences, bedside rounds on the unit, and cases in the OR

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Challenges in Mass Burn Critical Care Faced by the Taiwanese Health Care System

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Massive ICU Needs

• Fluid resuscitation• Coagulopathy• Electrolyte imbalance• Pulmonary injuries and

complications• Intensive wound care• Burn wound sepsis

Sourece: Dr. Hao-Yu Chiao24

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Overwhelming Surgical Needs

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Autograft vs. Allograft

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Extensive Nursing Care Needs

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Long Term Physical Therapy Needs

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Psychosocial Support Needs

• Significant long-term mental health effects

• Cultural considerations• Spectrum of effects• ? Under-recognized vs.

unacknowledged in staff• Using proxy markers to

identify needs

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Burn Capacity in theUnited States

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Current Burn Capacity in U.S.

As of 11/5/2014:• 128 burn centers with 1917 beds across the

United States• 1 burn center for every 44 hospitals• 1 “burn bed” for every 477 hospital beds=LIMITED CAPACITY for a large scale event

Source: ABA and AHA statistics31

REMINDER: 500 BURN CASUALTIES!!!

Perspective

Mapfight.com

California• ~12 times the size

of Taiwan• 14 burn centers• 209 burn beds

Maryland• Roughly the same

size as Taiwan• 2 burn centers• 20 burn beds

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Hospital Surge Capacity

• What is hospital “surge capacity”? –The amount of additional patient care (both

inpatient and outpatient) a hospital can provide when pressed into extraordinary circumstances, such as during a disaster

• What is “burn surge capacity” per the ABA?–Ability to manage a surge of 50% above the

reported capacity of the burn unit

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Hospital Surge Capacity (cont.)

Disaster resources include the “4 S’s”:• Space to care for patients • Staff to deliver medical care• Stuff to implement care: medication,

supplies and equipment• Systems for coordination

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Hospital Surge Capacity (cont.)

• 3 tiers defined by the literature (Hick et al, 2009):–Conventional–Contingency–Crisis

• In 2014, Kearns, Hubble et al adapted this for burn care

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Surge Capacity: Space

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Surge Capacity: Space (cont.)

• Elective admissions and procedures were cancelled–Especially elective plastic surgery cases–Loss of revenue

• SICUs (and in some cases MICUs) became BICUs and surgical floors were turned to burn wards

• Unstaffed licensed beds were opened

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Surge Capacity: Staff

• Staff planning — ways to augment hospital staff–Staff in management positions–Physicians/nurses in independent practice–Staff in research positions–Retired staff–Use of volunteers

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Burn Surge Capacity: Staff

• Many surgical subspecialites were recruited to do debridements, dressing changes, etc.

• Medical nurses became surgical nurses• Plastic surgeons in private practice volunteered or were

recruited to help• Residents and others stayed in hospital for 5-6 days

straight• Retired burn nurses returned to practice to serve as

nursing subject matter experts• Use of just-in-time training

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Surge Capacity: Stuff

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Time to Plan!

http://www.zmescience.com/

Burn Surge Capacity Planning

• 2004: ABA framework for national burn disaster planning strategies

• New York Plan: first peer-reviewed burn surge plan for a city/state

• Southern Region Burn Disaster Plan: first peer-reviewed regional plan

• Others: LA County, MI, NJ, NC, etc.

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Burn Surge Capacity Planning (cont.)

• Every hospital should be able to manage burn patients for 24 to 120 hours (based on the New York plan)

• “Bypass strategies have been replaced by absorption strategies” (Kearns et al, 2014)

• Need to develop:– Policy/procedures document;– Annex or appendix to existing EOP; or– Stand alone plan

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Planning Process

• Identify your planning team with key stakeholders (first responders, first receivers, etc.)

• Review your HVA• Evaluate your current capacity and surge ability• Develop the plan• Implement, test and revise the plan

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Planning Process (cont.)

• 3 important components to plan– Institutional– Interfacility– Interstate/regional

• Coordination with ESF-8 based on the NRF• Requires MOUs, transfer agreements, EMACs,

etc.

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Sample Planning Tools Available

North Carolina Hospital Burn

Surge Plan (BSP) Checklist

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Sample Decision Tools Available

Triage decision tables • Saffle (2005) used data from the ABA’s National Burn

Registry to predict outcomes based on age and TBSA burned, then Yurt (2008) translated the data to level of care needed

Saffle Yurt47

Burn Surge Strategies

• Build cache of burn supplies at non-burn centers

• Use Trauma Centers that are not co-located with Burn Centers to care for less severe patients

• Proactive daily regional burn bed counts during critical events

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Training and Education

Burning Man 2014

Training and Education

A recent survey found that fewer than 50% of clinicians who work in either a hospital or as part of EMS felt either ‘‘comfortable’’ or ‘‘very comfortable’’ with their knowledge, skills, and abilities to manage one burn-injured patient with >20% TBSA involvement • Kearns, Holms and Cairns, 2013

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Training and Education (cont.)

• For first responders/receivers, initial care and treatment – Burn triage– Airway management– Fluid resuscitation (e.g., Parkland formula, Brooke)– Escharotomies– Basic burn wound care and dressings– Estimating TBSA– Ventilator management– Pain management

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Training and Education (cont.)

• ABLS (Advanced Burn Life Support)–6-8 hour course (pre-hospital vs provider)–$225-350 for course–Worth CEU and CME = carrot!

• ABLS Now©–Online learning course and case studies–$100-300 for course–Worth CEU and CME = carrot!

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Training and Education (cont.)

• Need to train providers not only in burn care but also in the Burn Surge Capacity Plan

• Tabletop exercises, disaster drills, etc.

Source: fema.gov

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Conclusion

• Mass burn events are uncommon but can completely overwhelm the health care system

• Burn surge capacity in the United States is limited• Planning has been underway in some parts of the

U.S. for ~5-10 years but is largely untested• Non-burn centers are ill prepared for caring for

significant burn victims• Training and education are critical

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References

• Burn Care Facilities United States. ABA, 11/5/2014. Available at http://www.ameriburn.org/BCRDPublic.pdf. Accessed Sept 8, 2015.

• Conlon KM, Ruhren C et al. Developing and implementing a plan for large-scale burn disaster response in NJ. J Burn Care Res 2014;35:c14-20.

• Gamelli RL, Purdue GF et al. Disaster management and the ABA plan. J Burn Care Rehabil 2005;26:102-106.

• Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep 2009;3:S59–67.

• Kearns RD et al. Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center. J Burn Care Res 2014;35:c1-13.

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References

• Kearns RD et al. Hospital bioterrorism planning and burn surge. Biosecurity and Bioterrorism 2014;12(1):20-28.

• Kearns RD, Hubble MW et al. Disaster planning: transportation resources and considerations for managing a burn disaster. J Burn Care Res 2014;35:e21-32.

• Kearns RD, Cairns BA, Holmes I, et al. The North Carolina Burn Surge Disaster Plan for Emergency Medical Services and Hospitals. Chapel Hill, University of North Carolina, 2012, 85.

• Kearns R, Homes J, Cairns B. Burn disaster preparedness and the southern region of the US. Southern Med J 2013; 106(1):69-73.

• Kearns R, Holmes JH et al. Disaster planning: the past, present and future concepts and principles of managing a surge of burn injured patients for those involved in hospital facility planning and preparedness. J Burn Care Res 2014; 35:c33-42.

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References

• North Carolina Hospital Burn Surge Plan (BSP) Checklist. Available at http://ncburndisaster.org/oldsite/documents/NCHospital%20Burn%20Surge%20Plan%20Checklist%20and%20Resources%20Ver4-0b.pdf. Accessed 9/28/15.

• Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil 2005;26:478-482.

• Vandenberg V, Amara R, Crabtree J, et al. Burn surge for Los Angeles County, California. J Trauma 2009;67(2 suppl):S143YS146.

• Yurt RW, Lazar EJ, Leahy NE, et al. Burn disaster response planning: an urban region’s approach. J Burn Care Res 2008;29:158Y165.

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Questions?

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Thank you

Christina Catlett, MD, FACEPccatlett@jhmi.edu