Station Nightclub Fire and Disaster Preparedness in Rhode Island, The

Station Nightclub Fire and Disaster Preparedness in Rhode Island, The

Gutman, Deborah

The Station nightclub fire in Warwick, Rhode Island occurred at 11:12 pm on February 20, 2003. It ranks as the fourth deadliest nightclub fire and the ninth deadliest public assembly fire in the United States. The fire consumed the entire building within 3 minutes. Ninety-six people were killed immediately and hundreds were sent to area hospitals. Four subsequent hospital deaths occurred over the next few weeks. In 1992 we marked the 50th anniversary of the Cocoanut Grove nightclub fire in Boston. Four hundred ninety-two people died that day, making it the second deadliest public assembly fire in United States history. That fire spurred the first comprehensive descriptions of inhalation injury, and many other improvements in all aspects of bum treatment.1 The Station fire, like the Cocoanut Grove fire, can improve our medical care and planning by focusing attention on the disaster response needs of severely burned patients.

A fire and mass casualty incident is an uncommon event, but in this era of disaster planning for terrorist events, mass casualty burn events are expected. In 2001 there were 6,196 civilian fire deaths, 2,451 of which were due to the events of September 11.2 Other terror-related events generating multiple burn victims include the Oklahoma City bombing (1995) and the Bali nightclub bombings (2002). Eight percent of patients admitted to the hospital after the Oklahoma City bombing sustained burns.3 The Bali nightclub bombing killed at least 190 people and seriously injured more than 500: the majority of injuries were severe burns.4

Even in natural disasters like earthquakes, burns may be a problem. In the earthquake in Duzce, Turkey, in November 1999 there were a significant number of burn patients secondary to scald injuries caused by hot water spill during the earthquake, because it occurred in the evening while families were preparing dinner.5 Mass casualty burn injuries may occur secondary to vehicular accidents, industrial or domestic events as well as terrorist activities. While each event causing mass burn casualties will be unique, common features allow for advance planning. The need to distribute limited burn resources emphasizes the need for specialized planning in the areas of command and control, coordination and communications, triage, initial resuscitation and patient transfers.

Many of the Rhode Island hospitals were involved in the Station Fire response and most received some type of pre-notification from Emergency Medical Services, although several hospitals noted that they were not given any notification at all, or limited/incorrect information about numbers of patients to expect and severity of injury. Communication between hospitals was also limited. There was no clear indication of the total number of victims expected, or to which hospital(s) they were being transported. Improved communication from the scene to a central command center could help determine the number of hospital personnel and extent of resources needed to cope with the disaster. A central command center could also assist with the assessment of available beds and resources (“surge capacity”) at each of the area hospitals and match the distribution of patient types/ severity to each hospital. This would decrease the need for multiple patient transfers between hospitals. It would also help coordinate patient transfers out of state.

The time elapsed between notification and arrival of patients was brief for most hospitals. This occurrence is anticipated in the Centers for Disease Control Mass Trauma Preparedness and Response documents, which predict that in a mass disaster 50% to 80% of all casualties will arrive within 90 minutes of the first arrival to the closest medical facilities. As predicted, less-injured patients left the scene and presented independently to the nearest hospital. The prediction average of 3 to 6 hours for casualties to be treated in the ED6 was realized during the Station fire.

Mackie and Koning reviewed 11 mass casualty burn disasters: in all cases patients arrived within 1-2 hours of the fire. In descriptions of the Bradford [England] football stadium fire in May of 1985, where a football stand caught fire and was engulfed within four minutes, patients began to arrive at the nearest hospital within minutes of the fire by taxi, private car, on foot and by ambulance.7 Within 3 hours all of the patients had been admitted or treated and released. Similar numbers are described for the Cocoanut Grove fire in Boston in 1942. The first casualties arrived 15 minutes after the fire started. It is estimated that one casualty arrived at Boston City Hospital every 11 seconds for a total of more than 300 patients in two hours. More recently, in February 1999 an industrial explosion resulted in the transfer of 11 patients to Baystate Medical Center (BMC) in Massachusetts. Seven of the most severely burned arrived at BMC 5 to 18 minutes after the initial 911 call. Eleven patients arrived in the ED 25 minutes after EMS initiated transfers from the site and were dispositioned within 3 hours after arrival.8 The hospitals who received the majority of patients after the Station fire had similar experiences.

For each of the aforementioned disasters and the Station fire there were only a few minutes between the incident and the first patients’ arrival in the emergency departments. This is a very small time window for establishing effective communication between the scene and all the area hospitals. This emphasizes the need for improved information systems/networks as part of our disaster planning. For example, in New York State after September 11th the State Department of Health implemented an enhanced statewide system known as the Hospital Emergency Response Data system that allows hospitals to communicate over a Web-based secure system during a crisis.9 This type of system, if it were in routine use, would augment communication during a disaster.

In their review, Mackie and Koning observed a difference between outdoor and indoor fire disasters. Outdoor disasters result in a greater percentage of hospital admissions with larger surface area burns and a higher hospital mortality rate; however, indoor disasters (such as the Station nightclub) had a higher cumulative death rate with a greater proportion of immediate deaths at the scene (attributed to inability to escape and rapid hypoxia from inhalation injury) and a lower hospital mortality rate.10 This is important to disaster planning because victims presenting after indoor fires have consistently lower burn surface areas and more inhalation injury and may not necessarily require immediate evacuation to a burn specialty center, but they may require higher levels of immediate airway management and ventilatory support. The nature of burn injuries from an indoor fire disaster may allow for a greater time window to triage patients to specialized burn centers because those with the worst injuries tend to die immediately. The nature of indoor fires also complicates initial hospital triage secondary to the large number of dead or nearly dead at the scene. One of the major obstacles during the Cocoanut Grove fire was the large number of dead or near-dead transported to Boston City Hospital that prevented efficient care of those with survivable injuries.

Perhaps the largest obstacle to appropriate burn management in disasters is the need for referral to specialized burn centers. Triage becomes essential to the distribution and use of limited resources such as air evacuation, burn beds, and operating rooms. Where should the assessment and triage of burn casualties occur and who should do it? As evidenced by the Station nightclub fire, even a moderate disaster is capable of filling all local burn beds and requires evacuation to regional burn centers. The timing and coordination of the transport of burn patients requires effective and efficient communications between hospitals and burn centers.

During the initial response to the Station nightclub fire there was limited triage at the scene until several ambulances had arrived. Initial patients were transported to the nearest hospital. The patients were rapidly distributed to multiple area hospitals, primarily Kent County Hospital and Rhode Island Hospital, but there was no means for hospital coordination and prioritization of helicopter transfers of critical burn patients to burn centers. Ten medical transfers by helicopter occurred from 4 different hospitals in the first few hours after the fire. This utilized all of the air medical resources available in New England for that time period.

In a review by Slater et. al of 437 acute burn patients transferred to a burn center in Pennsylvania over a 15-month period they noted that many of the burn patients transferred to their facility by air may have been safely transported by appropriately staffed ground transportation. They believed there was an over utilization of helicopter services for burn patients.11 In addition to the air medical transports there were approximately 23 ground transfers within the next 24 hours. No discussions took place between the Rhode Island hospitals to coordinate out-of-state transfers. Future planning will need to address procedures for prioritizing and coordinating both ground and air medical evacuation of patients to specialized burn centers. The majority of burn care can be initiated at non-burn center hospitals as long as there are adequate resources for airway management, fluid resuscitation, analgesia and wound dressing. Decisions to transfer to specialized burn centers can possibly be delayed for the initial 24-hour resuscitation period. This would allow time for centralized decision-making and triage by burn/ trauma specialists within the state regarding which patients should be transferred and by what means.

Sixteen hospitals in both Rhode Island and Massachusetts cared for 196 burn victims from this disaster, 35 (about 17%) of whom required intensive care and ventilatory support. (Table 1). Kent County Hospital, the closest facility to the disaster site, saw the largest number of patients (82). Approximately 50% of those were treated and released, 25% were admitted and 25% were transferred to other hospitals. For the second time in its 80-year history Shriners Hospitals for Children opened its doors to the adults. (The first time was directly following the World Trade Center tragedy on September 11, 2001, although no victims were admitted to the hospital at that time.) Shriners received 17 victims from Rhode Island area hospitals. Rhode Island Hospital received 68 patients; approximately 63% were admitted. Half of them required ventilatory support and intensive care. Only 4 of the 196 patients admitted to hospitals after the fire died, consistent with observations made about indoor fires and also attributable to the airway management skills of Rhode Island’s emergency physicians and emergency medical technicians. Many advances have followed the lessons learned about burn management from the 1942 Cocoanut Grove fire.

The Station Fire demonstrated that the resources and expertise of prehospital providers, multiple Rhode Island hospitals of various sizes and with variable resources, emergency staff and surgeons can be used to stabilize and treat multiple burn casualties. It has brought highlighted the issue of mass casualty burn care in future disaster planning. Lessons learned from this event include the need for a clearly demarcated command and triage center, improved prehospital communication, as well as inter-hospital communication regarding available beds, services and supplies, and coordinated use of air and ground transfer of patients to specialized burn centers.

REFERENCES

1. Saffle JR. The 1942 Fire at Boston’s Cocoanut Grove Nightclub. Am J Surg 1993. 166:581-91.

2. Karter MJ. Fire loss in the United States during 2001. NFPA J November 2002.

3. Mallonee S, Shariat S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City Bombing. JAMA 1996;276:382-7.

4. McGuire D. Terror in Paradise. EMS March 2003:55-9.

5. Ad-El DD, Engelhard D, Beer Y, et al. Earthquake related scald injuries -experience from the IDF field hospital in Duzce, Turkey. Burns 2001;27:401-3.

6. http://www.ht.cdc.gov/. CDC Public Health Emergency Preparedness and Response. Accessed April 20, 2003.

7. Sharpe DT, Roberts AH, Barclay TL, et al. Treatment of burn casualties after fire at Bradford City football ground. Brit Med J 1985;291:945-8.

8. Leslie CL, Cushman M, McDonald G, et al. Management of multiple burn casualties in a high volume ED without a verified burn unit. Am J Emerg Med 2001; 19:469-73.

9. Berman MA, Lazar EJ. Hospital emergency preparedness-Lessons learned since Northridge. NEJM 2003;348:1307-8.

10. Mackie DP, Koning HM. Fate of mass burn casualties: implications for disaster planning. Burns 1990;16:203-6.

11. Slater H, O’Mara MS, Goldfarb IW. Helicopter transportation of burn patients. Burns 2002;28:70-2.

Deborah Gutman, MD, MPH, Walter L. Biffl, MD, Selim Suner, MD, MS, and William G. Cioffi, MD

Deborah Gutman, MD, MPH, is an emergency physician, Rhode Island Hospital.

Walter L. Biffl, MD. Affiliation previously cited.

Selim Suner, MD, MS, is Assistant Professor, Department of Surgery, Brown Medical School.

William G. Cioffi, MD. Affiliation previously cited.

CORRESPONDENCE:

Deborah Gutman, MD, MPH

Rhode Island Hospital

593 Eddy Street

Providence, Rhode Island 02903

Phone: 444-4247

Fax: 444-6662

Email: Dgutman@cox.net

Copyright Rhode Island Medical Society Nov 2003

Provided by ProQuest Information and Learning Company. All rights Reserved