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L. B. Nosanov and A. Cochran
3 7. Theurer L, Bashshur R, Bernard J, Brewer T, Busch J, Caruso
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Chapter 18
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Burn Disasters
WendyY.Rockne, VictorC.Joe, andJamesC.Jeng
Introduction: Disasters, Mass Casualty
Incidents, andBurns
Disasters, which can generally be defined as sudden events
that cause great damage or loss of life [1], are a part of the
human experience to varying degrees. The intersection of
hazards (natural, human-made, or a combination of both)
with vulnerable populations resulting in severe damage or
destruction will likely be witnessed, if not experienced, by
most people during the course of their lifetimes [1].
Over the past two decades, disasters and specifically mass
casualty incidents (MCIs) have been increasingly present in
the public eye. Technologic advances such as the advent and
now omnipresence of social media allow early and widespread
dissemination of national and worldwide events, including
photographs, eye-witness accounts, and even real- time video
footage on a global scale as never before in human history.
Although these advances may have broadened our
relationships and networks as a global community, disasters
remain fundamentally local events that then expand to
W. Y. Rockne · V. C. Joe · J. C. Jeng (*)
Department of Surgery, University of California Irvine,
Orange, CA, USA
e-mail: wrockne@hs.uci.edu; vcjoe@hs.uci.edu; jcjeng@hs.uci.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_18
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involve communities, regions, and nations [2, 3]. Because of
this, robust MCI planning at the local level is crucial to minimize loss of life.
While the term MCI may be assumed to be synonymous
with massive numbers of casualties, it is actually applied independently of casualty numbers. Rather it is used to denote an
event that overwhelms the local healthcare system, i.e., where
the number of casualties vastly exceeds the local resources
and capabilities in a short period of time [4]. This is a threshold that can be quickly reached in the case of burn disasters;
while burn mass casualty incidents (BMCIs) may not be common, they entail significant morbidity and mortality when
they occur.
In light of this, practicing medical professionals should
have a working knowledge of the available resources for burn
disasters. This background knowledge enables appropriate
response activation, early management, and adequate triage
of injured patients in the event of a BMCI.The purpose of
this chapter is not to offer detailed descriptions of how to
care for burn patients in the acute setting, but rather to provide a brief synopsis of available resources for BMCIs.
Burn Disasters
The phrases “burn disaster” or “burn mass casualty incident”
may bring to mind such events as structure fires, forest fires,
or fires at the urban interface. However, it is worth bearing in
mind that not all BMCIs result from catastrophic fires [5]. For
example, the Oklahoma City bombing in 1995 is frequently
precluded from BMCI analysis because no actual fire occurred
after the explosion [6]. However, nine victims had thermal
burns covering up to 70% of their body surface area, ranging
from partial- to full-thickness burns [7], in essence meeting
the criteria for a BMCI.
In addition to burns suffered during the initial disaster
event, emergency responders commonly suffer burns during
rescue operations. Rescue workers in both the Oklahoma
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City bombing and 9/11 terrorist attacks sustained chemical
and thermal burns while working on the rubble pile [8]. These
additional injuries add to the strain on healthcare systems
and can contribute to the evolution of a BMCI.
Many other types of disasters, including industrial
accidents, earthquakes, and radiation-related disasters, can
result in a BMCI despite not being directly associated with a
catastrophic fire [9–13]. Typically, BMCIs can be stratified
into four broad categories: mass gatherings with a sudden fire,
natural disasters, industrial accidents, and purposeful hostilities [14, 15]. While it is important to remember that disaster
planning needs to be developed first in terms of MCI, leaving
more specialized planning tailored to specific disaster type as
a secondary consideration [16], a general familiarity with
major BMCIs that have occurred in the recent past is essential in understanding and developing a plan for future BMCI
response.
Mass Gatherings
New Taipei Water Park Color Dust Fire: 2015
In June of 2015 a “Color Play Asia” party, inspired by the
colored powder used in the Hindu Festival of Colors, was
held at a water park in Taiwan. As nearly 4000 partygoers
danced on a large stage and swimming pool emptied for the
occasion, concert organizers deployed colored corn starch
powder into the air over the crowd using air blowers and
compressed gas canisters. The airborne corn starch caught
fire resulting in a large deflagration. This was worsened when
staff sprayed carbon-dioxide fire extinguishers toward
participants, resulting in dispersal of the burning starch into
multiple widespread dust clouds [17].
The fire reportedly lasted 40s and burned approximately
500 people, killing 15 and leaving almost 200in critical condition [18]. Patients were taken to over 50 hospitals across
Taiwan, transported by nearly 300 emergency vehicles
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(including emergency medical services, military vehicles, personal vehicles, and taxis) and accompanied by a total of 1235
first responders [19]. The influx of hundreds of burn patients
arriving at already busy hospitals created substantial difficulty for anyone to receive care consistent with the conventional standard of care (also known as the “crowd out
effect”) [20].
Despite these challenges, prompt and coordinated disaster
response resulted in tremendous patient outcomes; after
3 months, the overall mortality rate was an unprecedented
2.4%, a stark comparison to the predicted 26.8% [19]. This
incident demonstrated not only the incredible amount of
resources needed to adequately respond to large-scale BMCIs
but also the necessity for alternative transport means when
standard EMS systems are overwhelmed. The impressive
patient outcomes from this event further highlight the effectiveness of coordinated preparedness response, both on the
national and international levels [18–20].
Station Night Club Fire: 2003
In February of 2003 at a nightclub in West Warwich, Rhode
Island, pyrotechnics accompanying the evening’s headlining
band, Great White, ignited flammable acoustic foam in the
ceiling and walls surrounding the stage. The fire reportedly
reached flash point in under a minute, resulting in rapid fire
growth and vision-obscuring toxic black smoke. This, when
combined with illegally blocked egress points, resulted in the
deaths of 100 people with an additional 230 injured [21, 22].
Natural Disasters
Black Saturday Bushfire: 2009
In February of 2009 in the State of Victoria, Australia,
extreme heat, high winds, and the effects of years of drought
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combined to create one of the worst wildfire disasters worldwide, costing over four billion Australian dollars and claiming
173 lives. The majority of these fatalities were due to radiant
heat and smoke inhalation. An additional 24 patients were
sent to major burn centers in serious condition; three of these
patients died [23, 24]. Notably, although an immense number
of people were exposed to the bushfire and a fair percentage
sustained major burns, it was later determined that only 10%
of these received appropriate first aid for their injuries [25].
Industrial Accidents
Chernobyl Nuclear Power Plant Accident: 1986
In April of 1986 a nuclear accident occurred during a safety
test on a nuclear reactor in the Chernobyl Nuclear Power
Plant near the city of Pripyat in the Soviet Union. A combination of unstable conditions and reactor design flaws resulted
in an uncontrolled nuclear chain reaction, causing two explosions which ruptured the nuclear reactor core and destroyed
the reactor building. These were followed by an open-air
reactor core fire that released airborne radioactive contamination for over a week, precipitating onto portions of the
USSR and Western Europe before final containment.
In the disaster and immediate response, 134 people were
hospitalized with acute radiation syndrome incurred from
absorbing high doses of ionizing radiation. Of these, 28 died
within days to months; all of the fatalities in this acute period
were among station operators and firefighters, many who had
sustained large total body surface area (TBSA) beta burns
from the continued wearing of dust-soaked uniforms [11].
While it is impossible to know the overall fatalities due to this
event, model predictions with the greatest confidence values
of the eventual total death toll as a result of Chernobyl radiation exposure exceed 4000. Nuclear cleanup is ongoing and
currently scheduled for completion in 2065 [12].
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Purposeful Hostilities
9/11: 2001
On September 11, 2001, four commercial airliners traveling
from the northeastern United States to California were
hijacked midflight by al-Qaeda terrorists. Two of these planes
were crashed into the World Trade Center towers in NewYork
City, one was crashed into the west side of the Pentagon in
Virginia, and one crashed into a field in Pennsylvania
(diverted from its intended target in Washington, D.C.). This
attack resulted in nearly 3000 fatalities with an additional
6000 injured and remains the deadliest terrorist attack in
human history [25, 26]. Approximately one-third of those
injured sustained severe burn injuries [27, 28]. These devastat-
ing attacks served as a “galvanizing calamity” of sorts, spurring interest in the development of national frameworks to
respond to MCIs on a massive scale [16, 29].
The Atomic Bombings ofHiroshima
andNagasaki:1945
Although infrequent, radiation-related disasters represent
novel and challenging threats that can put health care systems at great risk [2]. The nuclear weapons detonated over
the Japanese cities of Hiroshima and Nagasaki during World
War II not only killed more than 100,000 people but also left
an equal number of people with acute radiation illnesses [30].
As technology continues to advance, fissile weapons with
similar yield can now be concealed in containers as small as a
suitcase, raising the alarming potential for their use in
terrorism [31]. Planning models demonstrate that with the
detonation of such a device over a populated area, 30% of the
surviving injured are expected to have burn wounds from a
variety of mechanisms, including the initial blast, radiation
injury, structure fires that occur as a result of the blast, and
injuries incurred during the aftermath of such a disaster [32].
This could produce tens (and potentially hundreds) of thou-
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sands of patients with burn injuries which would rapidly
overwhelm traditional resources for an extended period,
even in countries with robust MCI/BMCI systems in place.
BMCI Response Requirements
Burn Injuries
Most BMCIs produce fewer patients than expected that will
require inpatient burn center care [6]. Reviews of injury/fatality patterns from catastrophic fires resulting in multiple casualties over the past century show that most fatalities occur at
the initial scene, en route to the hospital, or shortly after
hospital arrival. Many of the injured are treated and released
at the scene or after evaluation in the emergency department
without involvement of a burn care team [6]. While it is
tempting to interpret such data at face value, the impact of
BMCIs on patients, communities, and health care systems
extends far beyond fatalities.
While it is true that patients with significant burn injuries
generally represent a small subset of injured patients in many
MCIs, their higher injury severity and complexity result in a
disproportionate impact on healthcare systems [2]. A disaster
that results in “only” ten severely burned patients requiring
hospitalization produces an immense drain on hospital
resources that continues for months after the actual disaster
has passed [6]. Unlike most traumatic injuries, burn trauma
remains resource-intensive over an extended period of time,
with ever-changing requirements that fluctuate throughout
the course of each patient’s treatment [33].
In order to create a relevant disaster plan, the point at
which a local or regional healthcare system would be overwhelmed by a BMCI must be known. This necessitates developing a thorough understanding of resources required in both
the acute phase of a BMCI (where operative requirements
are greatest) and the more protracted phase (where rehabilitation needs increase) [33]. On average, a mean of 0.3 opera-
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tions and 22.8min of operating time is needed per percent
TBSA burn, and length of inpatient stay roughly equates to
1.1days per percent TBSA burn [33]. Additionally, although
burn centers may not be directly involved with the cohort of
“walking wounded” on the day of injury, the resulting need to
locate and provide these patients with ongoing outpatient
burn care creates a vast and ongoing logistical and personnel
burden for burn centers [6, 34].
Capability
Two major determinants to success of disaster response are
adequate assessment and planning for a healthcare system’s
capability and capacity. Capability refers to the types of clinician available to render appropriate care for the wounded
and the specialized equipment for this care [2]. When discussing BMCI, this can specifically refer to burn specialty teams
including experienced burn surgeons and nurses, staff familiar with the unique needs of burn patients, and experienced
critical care personnel.
In contrast to trauma patients, seriously injured burn
patients do not necessarily require expedient surgical intervention. As the major concern in large burn injuries is hypovolemic shock, the priorities of treatment for patients in the
acute setting are stabilization, prevention of organ damage,
and prevention of wound progression or infection [16].
Ideally, patients with serious burn injuries should be
promptly sent to and managed at burn centers, where specialized burn care teams and resources are available [35].
However, during a disaster that involves significant numbers
of burn patients, this may be difficult if not impossible to
achieve, especially in the first hours and days following the
inciting incident. The first receiver for most burn mass casualties will therefore likely be a hospital without a burn center,
where it may be necessary for seriously burned patients to
remain for days [33].
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Previous incidents have demonstrated that burn patients
from BMCIs tend to be distributed across several hospitals
on the day of the disaster [6]. This offsets the initial burden on
the burn center in the acute phase, but later adds to the workload as hospitals appropriately request transfer of burn
patients to the burn center for specialized care. This may
require secondary triage by burn centers, allowing redistribution of patients to other qualified burn centers and activation
of multijurisdictional/multiagency response to augment burn
center staff with experienced burn specialty teams [34].
Additionally, as burn trauma is a long disease process with
complex treatment needs, a multidisciplinary approach is
necessary for optimal care in both the short- and long term.
Therefore, the development of a robust outpatient burn treatment capacity is vital to BMCI response [6].
Capacity andBurn Surge
The American Burn Association (ABA) defines burn surge
as 50% more burn patients than normal capacity at any given
time in a single burn center [16]. Capacity refers to the quantity of resources available for response, including staff, space,
and supplies [2]. Key factors that determine capacity include
both readily available, routinely used resources as well as key
assets that can be flexed to accommodate MCI needs (e.g.,
outpatient facilities, conference rooms, temporary structures,
and holding areas) [2]. One important measure of scalable
capacity is the ability to increase hospital bed availability by
expanding by 20% within 4 h to accommodate the highest
acuity patients in an MCI [14].
When discussing capacity as it specifically relates to
BMCIs, it includes such vital resources as ventilators, burn
beds, and surgical suites [36]. In 2011, the American Hospital
Association identified 5795 hospitals with 944,277 staffed
beds, and 123 self-identified burn centers reported 1895 beds
collectively, yielding a ratio of approximately one burn center
for every 47 hospitals (or one “burn bed” out of every 498
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