Preparing for the Burn Surge and its Unique Challenges
Recent crises have challenged medical professionals to consider their options when burn and trauma disasters may be too big to handle.
On the night of Feb. 20, 2003, Dr. William Cioffi and his staff at Rhode Island Hospital in Providence had a crisis on their hands. They were changing shifts at roughly 11 p.m., and while doctors’ and nurses’ guards were down, they were notified that there would be an immediate surge of patients with severe burns and other trauma. Hundreds of people had been killed or injured in a nightclub fire minutes earlier in West Warwick about a dozen miles away.
The fire at The Station nightclub began around 11 p.m. when the manager of the band Great White set off pyrotechnics that ignited foam on the ceiling and walls. The building was consumed in fire and smoke within minutes. Of the approximately 462 people in attendance, 96 people were killed at the site and four more died later. Hundreds more were hospitalized for burns, smoke inhalation and internal injuries caused from being crushed while trying to evacuate.
Staff at Rhode Island Hospital estimated initially that about 100 wounded were on the way. The estimates turned out to be inflated. Cioffi, the hospital’s surgeon-in-chief, said fewer than
70 people injured at the concert were treated at the hospital that night — but that’s still a considerable number. The hospital handled all patients with a 100 percent survival rate, which Cioffi attributes to great planning and a bit of luck. “Because it happened just prior to change of shift, we had some forewarning,” he said. “We were able to keep the evening shift and gain the night shift personnel to increase our immediate number of allied professionals and nurses.”
The hospital received the first wave of patients around 11:30 p.m. “We took our trauma intensive care unit — 10 beds and [an] 11-bed step-down unit — and made it into a 21-bed burn [intensive care unit] and then took another ward and made it into a 34-bed burn ward,” Cioffi said. The hospital sent excess patients to a Boston burn center.
Not all medical facilities had the same experience receiving patients. Many were notified by emergency medical services, but others weren’t. And some received limited or incorrect information about the number of patients to expect and the severity of their injuries. Sixteen hospitals from Rhode Island and Massachusetts cared for 196 burn victims, but communication among the hospitals was limited. Some had no idea where victims were being transported or how many were en route. “We found out we really didn’t have a good state trauma system,” Cioffi said.
The disaster didn’t exceed the surge capacity at his hospital or local burn centers, but it came close. “What should our plan be for 300, 400, 500, 1,000 burn patients?” he asked. “How would we, nationally, care for that number of patients?”
The Station nightclub fire wasn’t the first disaster that tested the medical community, nor was it the worst. When a terrorist attack sent American Airlines Flight 77 crashing into the Pentagon in Arlington, Va., on 9/11, doctors and nurses experienced their own trial by fire. According to an after-action report prepared for Arlington County and released in July 2002, the plane made impact at 9:38 a.m. By 2 p.m., 106 survivors were taken to medical facilities, and only one of them died. The report’s authors wrote that “prompt and professional” treatment saved lives.
But they also wrote that “mass casualties numbering in the hundreds” would have challenged the capacity of treatment facilities, especially when it came to burn bed availability.
After two planes crashed into the World Trade Center’s Twin Towers in New York City, other facilities faced the same issue, including New
Jersey’s St. Barnabas Medical Center. “The day of 9/11, the burn center at St. Barnabas was put on notice to receive 200 burn patients,” said Kathe Conlon, a registered nurse at the medical center. “I don’t care how large your facility is, nobody can take 200 patients, let alone 200 specialized patients.”
And just like in Rhode Island, Virginia had communication problems. The Arlington County Emergency Communications Center was flooded with radio traffic and 911 calls, which impeded attempts to alert hospitals of incoming patients. In some cases, technicians used their personal cell phones to get through. Victim transport began within an hour of the crash, but some hospitals felt it was disorganized. Hospitals made inquiries independent of one another to discern the area’s capacity to treat burn victims.
Recent tragedies raised the issue of handling mass casualties simultaneously.
“It didn’t get on people’s radar screens,” Cioffi said. “Well, 9/11 changed that and everybody understood that preparation was important.”
People have been more cognizant of burn surge capacity in recent decades. “The second Gulf War got the government interested, along with 9/11, in terms of what would happen if we generated
500 burns tomorrow through some event,” Cioffi said. “Whether it be something in the Middle East, something on our home shore — how would we know what burn beds are available?”
There were 125 burn centers in the United States listed in the 2009 report, three fewer than listed in the 2007 edition, for a country with a population of more than 310 million people. Barriers may impede the opening of more.
“They are generally [a] cost center for the hospital,” said Elaine Barrett, program director for the American Burn Association’s (ABA) Advanced Burn Life Support training. Uninsured burn victims can be cost-prohibitive for facilities. “Those that happen in meth labs and things of that sort are largely uninsured,” she said. “Those are severe burns, and they often take a full year to recover. Medicare, Medicaid and insurance companies — the monies are just not available to them. That’s a barrier.”
Current treatment is often sufficient, but it’s not always perfect. Sometimes there’s confusion at a trauma scene about where a victim should be taken. It’s possible that a badly burned victim needs a trauma center first and a burn center later if he or she has other injuries, Conlon said. “It tends to be kind of a knee-jerk reaction. People see burn and they think, burn center, and yes, that’s good, but are they breathing? Do they have trauma? Because for all the reasons burn patients should go to burn centers, trauma patients need to go to trauma centers.”
And not all burn centers are created equal. Some are equipped to handle both trauma and burns, and others only treat burns. St. Barnabas, for example, is a burns-only facility that’s ABA verified, a distinction given by the ABA and American College of Surgeons to burn centers that deliver high-quality care according to their standards. Only 56 burn centers out of the 125 listed in the National Burn Repository in 2009 report were ABA verified.
But most burn centers are probably the best places to take patients when hospitals don’t cut it. “Most ER and trauma centers are not prepared for a burn disaster,” Barrett said. But help exists. Barrett’s Advanced Burn Life Support Provider Course helps physicians deal with burn victims. Conlon said St. Barnabas has provided clinical education to emergency medical services and hospitals on stabilization for burn patients. The ABA has published recommendations on when burn patients should be referred to burn centers.
Looking to Tomorrow
If such large-scale disasters have taught the trauma community anything, it’s that collaboration is essential. Cioffi, who is on the ABA’s
Government Affairs Committee, has seen an increase in attention regarding burn disasters. That’s evident in the meetings he attends, which he said didn’t occur 15 years ago. “I just think there’s been a shift in attitude over 20 [or] 30 years in that regard,” Cioffi said. “I think you can say that in health care in general. It’s not unique to burns or trauma.”
Cioffi has a kindred spirit in Dr. Steven Phillips, director of specialized information services and associate director of the National Library of Medicine at the National Institutes of Health. He was an author of the 2009 paper, When Disaster Strikes, which stresses the need for the medical community to prepare before the next catastrophe hits.
The lynchpin of his argument is organization and partnership. “If there’s a nuclear power plant accident or a nuclear bomb, there really is no one hospital set up to take care of 100 patients who may have radiation exposure,” he said.
Phillips is involved in a congressionally mandated program to create robust hospital partnerships, or networks that will allow medical facilities to respond to major disasters as teams instead of individuals. Phillips wrote about the Bethesda Hospital Emergency Preparedness Partnership (BHEPP) in Maryland that was created in 2004 and comprises Suburban Hospital, the National Naval Medical Center and the National Institutes of Health Clinical Center. The National Library of Medicine joined in 2007 as the fourth partner. Congress set aside a four-year funding stream of $12.9 million for the project’s development and plans for it to be a model for future similar partnerships.
The partnership’s goal is to provide coordinated collaboration to respond to natural or man-made disasters. Activities thus far include purchasing shared equipment and supplies for greater surge capacity, communications interoperability, and addressing transportation and water vulnerabilities. Another parameter, cross-credentialing hospital staff, is something Phillips supports. “We probably should have some sort of national credentialing system,” he said. A broader medical credentialing system could allow doctors to move more freely between different medical facilities, an ability that could come in handy during a crisis. “I practice mostly in Iowa, and if I had to go to Missouri, I couldn’t practice there if I didn’t have a Missouri license.”
Conlon said mass casualty incidents make patient transfers more difficult than they would be during normal, day-to-day events. “Some states have no burn centers. Some states have one burn center,” Conlon said. “So how do you move patients across state lines? Who has the qualifications, the certifications? Do we even have the physical equipment to move a burn patient from New Jersey to New York or vice versa?”
When Disaster Strikes noted that, from 1996 to 2006, visits to emergency rooms increased from 90.3 million to 119.2 million annually, while the number of emergency departments decreased from 4,019 to 3,833.
Phillips hopes the BHEPP and projects like it help remedy gaps in patient care, whether they include burns or not. “If there’s a fire and three or four people are burned fairly badly, the ambulance people and the emergency responders know where to take them,” he said. “But if there were a hundred people, like in Rhode Island, who were burned, you’d be overwhelmed.”
Although the medical facilities in the BHEPP are located in Maryland, there are plans for the model to be adapted to other areas of the country. It was reported that funding has already allowed the project to research and develop prototypes for 11 other projects in 2009 and 2010.