The Pentagon attack of September 11, 2001: a burn center's experience

Military Burn Care and Burn Disasters

Mass-casualty incidents can occur because of natural disasters; industrial accidents; or intentional attacks against civilian, police, or in case of combat, military forces. Depending on scale and type of incident, burn casualties often with a variety of concomitant injuries can be anticipated. The treatment of life-threatening traumatic injuries should take precedent but the stabilization, triage, and follow-on care of these patients will require local, state, and often regional coordination and support.

Determining Immediate Burn Bed Availability to Support Regional Disaster Response

Determining burn bed availability from the start of a disaster is critical to emergency response efforts, yet continues to be one of the most elusive aspects for planners to anticipate. Healthcare providers agree that, over time, burn centers (BCs) can and will move patients, activate staff, and bring in supplies to meet surge needs. The real challenge lies in identifying how many beds will be immediately available to handle any initial surge of patients. A consortium of 27 BCs in the northeast participates in a telephone bed census program. Although only accurate at the time of each call, clinical staff is asked to report the number of open ICU and/or step-down beds. Retrospective review of 86 Burn Bed Census (BBC) reports was conducted over an 8-year period. Data were statistically analyzed for total, absolute minimum, mean, SD and linear trend analysis. The mean for immediately available beds from January 2009 through December 2016 is 72; with monthly averages ranging from 62 (7%) average available beds in January to 78 (9%) average available beds in November. Monthly SDs range from 6 in July to 17 in November. One goal for disaster planners is to approximate a number of immediately available beds without overwhelming any one BC with too many patients. Utilizing this model enables planners and clinicians throughout the northeast to predict potential burn bed availability and make more reliable decisions about when and where to initially send patients.

District of Columbia Emergency Healthcare Coalition Burn Mass Casualty Plan: Development to Exercise Date

The District of Columbia Emergency Healthcare Coalition (DC EHC) brought together a Burn Task Force to tackle the issue of mass burn care in a metropolitan area in light of limited local burn center resources. This article outlines the development of the mass burn care plan. Using a tiered treatment approach, mass burn victims would be transported first to burn centers within the area, followed by nonburn center trauma centers, and finally to nonburn and nontrauma center acute care facilities. Once activated the Burn Task Force would triage and coordinate transfer of mass burn patients within the District for further care at burn centers using a strong link with the Eastern Regional Burn Disaster Consortium. This plan was exercised in the spring of 2014 to test all of the components. To strengthen mass burn care, this plan, put in place for the District of Columbia, has been expanded to include the National Capital Region as well.

Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century

The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI."

Advanced Burn Life Support for Day-to-Day Burn Injury Management and Disaster Preparedness: Stakeholder Experiences and Student Perceptions Following 56 Advanced Burn Life Support Courses

Educational programs for clinicians managing patients with burn injuries represent a critical aspect of burn disaster preparedness. Managing a disaster, which includes a surge of burn-injured patients, remains one of the more challenging aspects of disaster medicine. During a 6-year period that included the development of a burn surge disaster program for one state, a critical gap was recognized as public presentations were conducted across the state. This gap revealed an acute and greater than anticipated need to include burn care education as an integral part of comprehensive burn surge disaster preparedness. Many hospital and prehospital providers expressed concern with managing even a single, burn-injured patient. While multiple programs were considered, Advanced Burn Life Support (ABLS), a national standardized educational program was selected to help address this need. The curriculum includes initial care for the burn-injured patient as well as an overview of the burn centers role in the disaster preparedness community. After 4 years and 56 classes conducted across the state, a survey was developed including a section that measured the perceptions of those who completed the ABLS educational program. The study specifically examines questions including whether clinicians perceived changes in their burn care knowledge, skills and abilities, and burn disaster preparedness following completion of the program? including whether clinicians.

Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center

In 2005, the American Burn Association published burn disaster guidelines. This work recognized that local and state assets are the most important resources in the initial 24- to 48-hour management of a burn disaster. Historical experiences suggest there is ample opportunity to improve local and state preparedness for a major burn disaster. This review will focus on the basics of developing a burn surge disaster plan for a mass casualty event. In the event of a disaster, burn centers must recognize their place in the context of local and state disaster plan activation. Planning for a burn center takes on three forms; institutional/intrafacility, interfacility/intrastate, and interstate/regional. Priorities for a burn disaster plan include: coordination, communication, triage, plan activation (trigger point), surge, and regional capacity. Capacity and capability of the plan should be modeled and exercised to determine limitations and identify breaking points. When there is more than one burn center in a given state or jurisdiction, close coordination and communication between the burn centers are essential for a successful response. Burn surge mass casualty planning at the facility and specialty planning levels, including a state burn surge disaster plan, must have interface points with governmental plans. Local, state, and federal governmental agencies have key roles and responsibilities in a burn mass casualty disaster. This work will include a framework and critical concepts any burn disaster planning effort should consider when developing future plans.

Disaster planning: transportation resources and considerations for managing a burn disaster

A disaster scenario with a significant number of burn-injured patients creates a tremendous challenge for disaster planners. Directing the transport of patients to the most appropriate receiving facility as soon as reasonably possible remains the aim. This review focused on both the overall process as well as an analysis of one specific state (as an example). This included the capability and limitations of the intrastate and interstate resources should a burn disaster occur. Although the results for one state may be interesting, it is the process that is essential for those involved in burn disaster planning. An overview of the quantity and quality of available ambulances and how to access these resources is provided. Ground-based ambulances have an array of capacities and levels of services ranging from basic life support to advanced (paramedic) services and include ambulance buses. This review also included private and hospital-based specialty care ambulances and aeromedical services. Finally, the review identified military or federal resources that may be an option as well. There are various local, state, and federal resources that can be called upon to meet the transportation needs of these critically injured patients. Yet, there are barriers to access and limitations to their response. It is just as important to know both availability and capability as it is to know how to access these resources. A disaster is not the time to realize these hurdles.

Burn care in disaster and other austere settings

In some circumstances, burn care must be delivered in a simple manner without the luxury of modern resources. Such circumstances include care in low- and middle-income countries, war zones, and mass casualty incidents. Triage decisions need to be made carefully, allowing the focus of limited personnel and equipment on those most likely to survive. Simple techniques can be used to help many burn victims, such as utilizing oral resuscitation formulas for burn resuscitation. Although even the best attempts at preparation often fall short, there are many benefits from planning and training.

Disasters; the 2010 Haitian earthquake and the evacuation of burn victims to US burn centers

Response to the 2010 Haitian earthquake included an array of diverse yet critical actions. This paper will briefly review the evacuation of a small group of patients with burns to burn centers in the southeastern United States (US). This particular evacuation brought together for the first time plans, groups, and organizations that had previously only exercised this process. The response to the Haitian earthquake was a glimpse at what the international community working together can do to help others, and relieve suffering following a catastrophic disaster. The international response was substantial. This paper will trace one evacuation, one day for one unique group of patients with burns to burn centers in the US and review the lessons learned from this process. The patient population with burns being evacuated from Haiti was very small compared to the overall operation. Nevertheless, the outcomes included a better understanding of how a larger event could challenge the limited resources for all involved. This paper includes aspects of the patient movement, the logistics needed, and briefly discusses reimbursement for the care provided.

Examining disaster planning models for large scale burn incidents--a theoretical plane crash into a high rise building

BACKGROUND

The escalation of global terrorist attacks has resulted in a rise of traumatic injuries. Planning for mass casualty incidents (MCIs) is critical to decrease the morbidity and mortality that ensues after large-scale terrorist attacks. This study provides criteria for the management of burn victims following large-scale disasters.

METHODS

Mass casualty outcomes from three disasters involving commercial aircraft crashes were analyzed. The three events included the El-Al cargo Aircraft crash near the Amsterdam Schiphol Airport in 1992, the World Trade Center attacks in New York and the attack against the Pentagon in Washington, DC on 9/11/01.

RESULTS

Using the data obtained from these events, the severity of injuries in patients were determined. The result is a general template that may be customized with locally or regionally specific data, in order to evaluate the preparedness of a specific burn alignment for such a scenario.

CONCLUSION

Recommendations based on the analysis of previous MCI's were put forth. Based on the needs recognized during these past events, suggestions were made to enhance the preparedness of burn units, hospitals and national agencies as well as municipal authorities.

Burn Disasters—An Audit of the Literature

All events that result in disasters are unique, and it is impossible to become fully prepared. However, through thorough planning and preparedness, it is possible to gain a better understanding of the typical injury patterns and problems that arise from a variety of hazards. Such events have the potential to claim many lives and overwhelm local medical resources. Burn disasters vary in scope of injury and procedures required, and are much more labor and resource intensive than non-burn disasters.

This review of the literature should help determine whether, despite each event having its own unique features, there still are common problems disaster responders face in the prehospital and hospital phases, what recommendations were made from these disasters, and whether these recommendations have been implemented into practice and the current disaster planning processes.

The objective of this review was to assess: (1) prehospital and hospital responses used during past burn disasters; (2) problems faced during those disaster responses; (3) recommendations made following those disasters; (4) whether these recommendations were integrated into practice; and (5) the key characteristics of burn disasters and how they differ from other disasters. This review is important to determine why, despite having disaster plans, things still go wrong.

Multidisciplinary team response to a mass burn casualty event: outcomes and implications

OBJECTIVES

To describe the characteristics of patients with burn injury admitted to a major trauma hospital in Melbourne following the Black Saturday bushfires of 7 February 2009, and to provide a detailed analysis of the hospital's response to the crisis.

DESIGN, SETTING AND PARTICIPANTS

A retrospective chart review of ambulance and hospital records of patients admitted to the Victorian Adult Burns Service (VABS) at The Alfred Hospital (The Alfred) following the bushfires.

MAIN OUTCOME MEASURES

Patient characteristics and outcomes: age, sex, total and full thickness body surface area burnt, type and site of burn, hospital and intensive care unit length of stay (LOS) and receipt of standard burn care practices. Estimated glomerular filtration rate, theatre time and LOS data for the bushfire cohort compared with corresponding data for historical cohorts from VABS and from a similar institution in New Zealand.

RESULTS

Nineteen patients were admitted to VABS over the first 48 hours after the bushfires. Of these, nine patients were subsequently admitted to The Alfred's intensive care unit. Most patients (74%) were men with a mean age of 52.7 years (SD, 12.4 years). Seventeen patients (89%) underwent at least one surgical procedure, which resulted in 4355 minutes of theatre time for the bushfire cohort in the first week. Hospital LOS was similar for the bushfire and New Zealand cohorts. Compared with the VABS historical cohort, there was a higher incidence of abnormal renal function among the bushfire cohort patients.

CONCLUSIONS

Although relatively few patients with severe burns were admitted to VABS, significant increases in resource allocation were required to manage them in terms of additional theatre time, consumables and staffing. The experience of VABS may aid planning for future mass burns casualty events.

Creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events

OBJECTIVES

US hospitals are expected to function without external aid for up to 96 hours during a disaster; however, concern exists that there is insufficient capacity in hospitals to absorb large numbers of acute casualties. The aim of the study was to determine the potential for creation of inpatient bed surge capacity from the early discharge (reverse triage) of hospital inpatients at low risk of untoward events for up to 96 hours.

METHODS

In a health system with 3 capacity-constrained hospitals that are representative of US facilities (academic, teaching affiliate, community), a variety (N = 50) of inpatient units were prospectively canvassed in rotation using a blocked randomized design for 19 weeks ending in February 2006. Intensive care units (ICUs), nurseries, and pediatric units were excluded. Assuming a disaster occurred on the day of enrollment, patients who did not require any (previously defined) critical intervention for 4 days were deemed suitable for early discharge.

RESULTS

Of 3491 patients, 44% did not require any critical intervention and were suitable for early discharge. Accounting for additional routine patient discharges, full use of staffed and unstaffed licensed beds, gross surge capacity was estimated at 77%, 95%, and 103% for the 3 hospitals. Factoring likely continuance of nonvictim emergency admissions, net surge capacity available for disaster victims was estimated at 66%, 71%, and 81%, respectively. Reverse triage made up the majority (50%, 55%, 59%) of surge beds. Most realized capacity was available within 24 to 48 hours.

CONCLUSIONS

Hospital surge capacity for standard inpatient beds may be greater than previously believed. Reverse triage, if appropriately harnessed, can be a major contributor to surge capacity.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia

OBJECTIVE

To examine the response of the Victorian State Trauma System to the February 2009 bushfires.

DESIGN AND SETTING

A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires.

RESULTS

There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity.

CONCLUSIONS

Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Pathophysiology, management and treatment of smoke inhalation injury

Smoke inhalation injury continues to increase morbidity and mortality in burn patients in both the third world and industrialized countries. The lack of uniform criteria for the diagnosis and definition of smoke inhalation injury contributes to the fact that, despite extensive research, mortality rates have changed little in recent decades. The formation of reactive oxygen and nitrogen species, as well as the procoagulant and antifibrinolytic imbalance of alveolar homeostasis, all play a central role in the pathogenesis of smoke inhalation injury. Further hallmarks include massive airway obstruction owing to cast formation, bronchospasm, the increase in bronchial circulation and transvascular fluid flux. Therefore, anticoagulants, antioxidants and bronchodilators, especially when administered as an aerosol, represent the most promising treatment strategies. The purpose of this review article is to provide an overview of the pathophysiological changes, management and treatment options of smoke inhalation injury based on the current literature.

Mass-casualty incidents: how does an ICU prepare?

Despite the ever-present risk of mass-casualty incidents (MCIs) in all geographical regions, there is a limited body of literature detailing specifically how an intensive care unit (ICU) prepares for such an event. When responding to an overwhelming volume of severely injured victims, the intensivist must make a paradigm shift away from providing complete care to all patients to one of preferentially administering care to those with the greatest likelihood of survival. To do this effectively, ICU directors must possess a detailed understanding of the entire disaster response, including organization, triage, staffing, and treatment. This article provides a comprehensive review of each of these topics, as well as a framework on specific elements of critical care and treatment based on published literature and expert opinion to assist the clinician in directing care to where it is most appropriate.

[Treatment strategies for acute smoke inhalation injury]

Most fatalities from fires are not due to burns, but are a result of inhalation of toxic gases produced during combustion. Fire produces a complex toxic environment, involving flame, heat, oxygen depletion, smoke and toxic gases such as carbon monoxide and cyanide. As a wide variety of synthetic materials is used in buildings, such as insulation, furniture, carpeting, electric wiring covering as well as decorative items, the potential for poisoning from inhalation of products of combustion is continuously increasing. The present review describes the pathophysiologic effects from smoke inhalation injury as well as strategies for emergency treatment on scene and in the intensive care setting.

Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center

Marking the fifth year after the attack on the Pentagon, staff at the burn center in Washington, DC, memorialize in a contemplative frame of mind. These reflections are drawn from members of the extended burn team and render an interwoven sketch in prose that previously has not been heard.

Planning for burn disasters: lessons learned from one hundred years of history

The terrorist attacks of September 11th have prompted interest in developing plans to manage thousands of burn casualties. There is little actual experience in the United States in managing disasters of this magnitude. As an alternative, lessons may be learned from the historical experiences of previous civilian burn or fire disasters occurring in this country. A review of relevant medical, fire service, and popular literature pertaining to civilian burn or fire disasters occurring in the United States between the years 1900 and 2000 was performed. In the 20th century, 73 major U.S. fire or burn disasters have occurred. With each disaster prompting a strengthening of fire regulations or building codes, the number of fatalities per incident has steadily decreased. Detailed examination of several landmark fires demonstrated that casualty counts were great but that most victims had fatal injuries and died on the scene or within 24 hours. A second large cohort comprised the walking wounded, who required minimal outpatient treatment. Patients requiring inpatient burn care comprise a small percentage of the total casualty figure but consume enormous resources during hospitalization. Burn mass casualty incidents are uncommon. The number of casualties per incident decreased over time. In most fire disasters, the majority of victims either rapidly die or have minimal injuries and can be treated and released. As a result, most disasters produce fewer than 25 to 50 patients requiring inpatient burn care. This would be a rational point to begin burn center preparations for mass casualty incidents. A robust outpatient capability to manage the walking wounded is also desirable.

Blast injuries: from triage to critical care

Injuries from explosions are multilayered. Although blast injuries are thought of most often in a military context, all nurses need to be prepared to care for these casualties. Awareness of the multiple levels of injuries and the need to modify care based on the underlying pathology have reduced morbidity and mortality in patients who have complex and very critical injuries.

The Southern Region Burn Disaster Plan

A regional burn disaster plan for 24 burn centers located in 11 states comprising the Southern Region of the American Burn Association was developed using online and in-person collaboration between burn center directors during a 2-year period. The capabilities and preferences of burn centers in the Southern Region were queried. A website with disaster information, including a map of regional burn centers and spreadsheet of driving distances between centers, was developed. Standard terminology for burn center capabilities during disasters was defined as open, full, diverting, offloading, or returning. A simple, scalable, and flexible disaster plan was designed. Activation and escalation of the plan revolves around the requirements of the end user, the individual burn center director. A key provision is the designation of a central communications point colocated at a burn center with several experienced burn surgeons. In a burn disaster, the burn center director can make a single phone call to the communications center, where a senior burn surgeon remote from the disaster can contact other burn centers and emergency agencies to arrange assistance. Available options include diversion of new admissions to the next closest center, transfer of patients to other regional centers, or facilitation of activation of federal plans to bring burn care providers to the affected burn center. Cooperation between regional burn center directors has produced a simple and flexible regional disaster plan at minimal cost to institute or operate.

Surgeons and scars: differences between patients and surgeons in the perceived requirement for reconstructive surgery following burn injury

BACKGROUND

Reconstruction of the burn patient presents a challenge to the burns surgeon. The variety of issues and the timing of surgery can be a daunting task. A group of 11 patients who were injured 1 year previously at the time of the Bali bomb blast were reviewed.

METHODS

A customised assessment form was developed in order to quantify the patient's perceived need for reconstruction. Each patient was asked to prioritise, in order of preference any injured area they might consider for further surgery. These patients were then assessed independently by a consultant plastic and reconstructive surgeon and a senior trainee, using an identical form. The surgeons were asked to prioritise, in order of preference any area they might consider for further surgery and to indicate from a list the procedure they would employ. This list ranged from simple excision to free flap encompassing the entire reconstructive ladder.

RESULTS

The patients all showed a strong reluctance to undergo further reconstruction. However there was a strong correlation between the surgeons, concurring on issues of function but there were discrepancies regarding "aesthetic" reconstruction.

CONCLUSIONS

This study highlights the absolute need for secondary burns reconstruction to be a patient driven service.