” Prometheus heretofore went up to Heaven ,and stole fire from thence. Have not I as much Boldness as he?”
–Cyrano De Bergerac
Throughout the ages, fire has had the dual distinction of being part sword and part plowshare,part friend and part foe.
As a tamed and controlled entity it continues to serve humankind well. When it is let loose, whether by accident or design, it becomes an unpredictable and destructive force consuming everything in its path; causing injury, death and property destruction.
On November 28, 1942 at 10:15 pm in Bay Village, Boston, the Cocoanut Grove Nightclub was the scene of the deadliest nighclub fire in history, killing 492 people (32 more than the building’s authorized capacity) and injuring hundreds more.
The club, a vintage post-Prohibition and reputed gangland hangout, was known for its South Seas-like ambience with a decor consisting of leatherette, rattan and bamboo coverings on the walls, heavy draperies, and dark blue satin canopies and covering on the ceilings.
Support columns in the main dining area were made to look like palm trees, with light fixtures resembling cocoanuts.
A combination of highly flammable decorative materials and a flaunting of fire regulations and laws, which included avenues of escape being bolted shut, led to the deadly events and unprecedented tragedy.
Patrons and workers alike succumbed to toxic combustion by-products present in smoke and flame induced burns.
This tragic event shocked the nation and even briefly replaced the events of WW II in the newspaper headlines. It led to a reform of safety standards and codes across the U.S., and to major enhancements in international burn treatment and rehabilitation.
Victims were taken to both Massachusetts General Hospital and Boston City Hospital which accepted a multitude of burn and smoke inhalation victims,and borne out of this tragic event, were new methods and techniques for burn care. Surgeons Francis Daniels Moore and Oliver Cope at Massachusetts General Hospital pioneered fluid resucitation techniques for burn casualties. This event also spurred one of the first human uses of the then newly developed antibiotic, penicillin, administered to the Cocoanut Grove burn victims to stave off Staphylococcus aureus infections of skin grafts.
From a psychosocial viewpoint, famed psychiatrist Erich Lindemann, studied the families and relatives of the deceased victims and published a sentinel paper “Symptomatology and Management of Acute Grief” and Alexandra Adler worked with more than 500 survivors of the fire and conducted some of the earliest and groundbreaking research on post-traumatic stress disorder (PTSD).
Decades later, The Station nightclub fire occured on February 20, 2003 at approximately 11:00 pm in West Warwick, Rhode Island. The Station fire resulted in 100 deaths (96 on site,4 subsequent to hospitalization) and 230 non-fatal injuries. The fire was caused by pyrotechnics set off by the tour manager of the evening’s headlining band Great White, which ignited plastic foam uses as sound insulation in the walls and ceilings surrounding the stage. A fast-moving inferno with intense and toxic black smoke engulfed the club in 5 1/2 minutes.
Once again a fatal combination of thick ,black smoke laden with toxic combustion by-products, heat, illegal blockage of exits and exceeding regulated occupancy, made escape for most impossible. In addition, panic and a resulting stampede further hindered escape and injured occupants attempting to escape.
The mechanisms of injury included thermal trauma and burns, toxic smoke inhalation, crush and trampling related injuries.
Because it was a high -casualty fire caused by illegal indoor usage of outdoor fireworks, the Station Fire disaster shares similarities with other fires occuring in diverse areas of the globe, such as the 2015 Colectiv nightclub fire in Bucharest, Romania .
The Station fire event activated the Southern New England Fire Emergency Assistance Plan -Mass Casualty Incident component and the Rhode Island Mass Casualty Disaster Plan. The scope and magnitude of the disaster resulted in 583 Fire, EMS, and Police first responders on scene and the system -wide overtaxing of local and regional emergency medical and burn capacity ,as well as mass fatality capabilities, ie medical examiners office.
Survivors’ injuries and autopsy results can reveal accurate scientific representations of conditions inside a burning structure. Hospitals reported 273 treated, most with inhalation burns and smoke inhalation; 40%-plus with full-thickness burns of the face, upper extremities and upper body. An October 2003 Health Care Industry publication noted that 17% of 196 burn victims were admitted into intensive care on ventilatory support.
The medical examiner’s 2003 grand jury testimony, released in 2007, revealed postmortem examination results for 98 victims. Each specified the main cause of death listing any significant factors the medical examiner felt were contributory, noting the victim possibly could have expired without suffering the contributing factor. Eighty-six causes of death were from the “inhalation of products of combustion and a super-heated, oxygen-deficient atmosphere”. All 86 listed significant thermal burns as a significant factor. The medical examiner also testified 20 deceased had significant levels of hydrogen cyanide, a toxic combustion by-product and systemic asphyxiant associated with synthethics fueled fires, eg polyurethane.
Accidental fires account for thousands of deaths per year in the U.S. alone, especially in residential settings, however, intentional fires set by arsonists also contribute to injury, deaths and property losses.
In the realm of terrorism and asymmetric threats, much can be extrapolated from conventional fires and fire related disasters and mass casualty incidents that can apply to emergency and crisis management of incendiary attacks.
Explosive events involving either accidental (e,g. gas or industrial explosion) or intentional (military action or terrorism ,ie IEDs, conventional high explosives, Molotov cocktails) have an incendiary component involving the release of thermal energy which can result in severe thermal injuries and the inhalation of toxic by-products of combustion.
The Philips Petroleum pertochemical facility fire on the Houston, Texas Shipping Channel in 1989 is one of the major examples of an industrial explosion and fire which generated significant and severe burn casualties requiring airlifting to local and regional hospitals and burn centers.
The September 11, 2001 terrorist attacks also produced an injury matrix involving inhalation injuries and burns with victims being transported to the New York Hospital-Cornell Medical Center Burn Unit where elements of a specialized DHHS Disaster Medical Assistance Team burn trauma unit from the National Disaster Medical System (NDMS) were engaged and integrated into the local burn care response.
The Bali nightclub bombing in 2002 resulted in over 500 injured, most with severe burns, with 62 burn patients transferred to Australia and all its burn beds were filled (Australia has 12 burn centers with 146 beds).
On March 11, 2004, in Madrid, Spain 10 bombs exploded on the trains and train stations generating mass casualties and fatalities, many with combined blast and burn injuries. Smoke quickly accumulated obliterating visibility and creating a toxic atmosphere.
Also in 2004, the Asuncion,Paraguay supermarket explosion and fire resulted in 424 deaths at scene, 360 admitted to hospital with a 5% death rate among those admitted.
On July 7, 2005, the London Underground transit system was attacked using three bombs and one bomb on a double-decker bus leaving 52 dead at the scene and over 700 injured.
The long and deadly war and reign of terror led by the militant Irish Republican Army direct action forces against members of the Protestant community and occupying British forces saw use of “petrol bombs” (Molotov cocktail incendiary devices) and IEDs against civilian, paramilitary and military targets.
All mass casualty burn disasters pose potential challenges to first responders, emergency, crisis and disaster managers and health care providers.
Let us imagine and consider one scenario which this author has proposed to emergency planning committees in the past. The scenario involves the hijacking or theft of fuel trucks in several locations with the intent of either crashing them into crowded public venues or possibly detonating the tankers loaded with fuel.
A carefully laid out tactical plan by a band of determined operatives would create a multifocal disaster that could generate scores of burn casualties requiring emergent and on-going burn care and rehabilitation.
What if a trend develops that utilizes attacks with caustic chemicals such as nitric or sulfuric acid or highly alkaline caustics? Chemical burn management will also require decontamination assets. What if stationary radiological devices are covertly placed in businesses, schools, places of worship, theatres or countless other venues and individuals are irradiated? The emergency services and health care system will now be dealing with cutaneous radiation injury in the form of radiation burns, as well as radiation exposure leading to Acute Radiation Sickness (ARS).
Wound healing related to radiation burns, especially if the immune system is compromised and there are other co-morbidities present, becomes delayed and chronic care will be required which may overtax health care resources, including rehabilitative and long term care facilities.
The effects of a an explosive radiological dispersal device (RDD) would cause blast, thermal and, possibly radiation injury by incorporating radionuclides via physiological routes of exposures. An explosive RDD event will also require responder, victim and environmental decontamination capabilities.
If a terrorist faction could produce, deploy and disperse a militarized vesicant agent (“blister agent”) such as a sulfur or nitrogen mustard agent or Lewisite, or even white phosphorous, specialty burn care centers will be critical to manage the casualty load.
Lastly, the tactical or strategic use of a nuclear weapon would produce an unfathomable amount of burn casualties with concomitant radiation exposure and traumatic injuries. In addition, both pre-hospital and medical facility elements would be limited due to damage to the critical healthcare infrastructure and death and injuries among first responders and health care personnel.
Burn care is highly specialized and time-and resource intensive, and involves expert staffing levels and specialized medical supplies and equipment.
To summarize, burn mass casualty events may overwhelm a single national healthcare system due to resource constraints resulting in limited surge capacity ,so an international cooperative response may be required.
EMS and hospital planning coordination,with consideration of stockpiling burn related supplies and equipment to support initial burn care response prior to transfer to burn center and to sustain care for an extended period, if necessary
Training of all non-burn unit personnel in the basics of burn care and management.
Community based and integrated institutional drills and exercises.
Prehospital scene management includes scene safety and security first and always, proper triage of victims and distribution of casualties to area hospitals using the Incident Command System (ICS).
In our current threat environment,the possibilities of fire and chemical burn agents being used to generate fear, panic, mass casualties and fatalities will persist .
The death,disability and destruction created by structural fires, wildfires and industrial/technological fire or explosion related disasters will continue to challenge our emergency services, health systems and other resources.
In most countries,burn center capacity is limited. In the U.S. alone there are fewer than 10,000 dedicated burn beds; closer to 8,000 available slots.