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Disaster management preparedness: A plan for action

S.K. Dheri

Chief Fire Officer, Delhi Fire Service Risk in urban areasThe dynamics of change in urban settlements due to large scale migration has led to the evolution of high-risestructures, mixed land use, high population density, growth of cottage ad hazardous industries, cross country gaspipelines, bulk oil storage tank farms and thermal power stations. These increase losses during disasters. Therecent earthquake in turkey caused rippling of electric poles. Collapse of buildings, refinery fires, and blocked

roads of so that rescue teams from Switzerland, U.S.A Greece and Germany struggled to reach victims. Morethan 10,000 died. The situation would be the same in developing countries unless loss patterns are controlledthrough co-ordinated disaster management plans.

Concept of mitigationMitigation embraces all measures taken to reduce both the effect of the hazard itself and the vulnerable conditionsto it, in order to reduce the scale of a future disaster and its impacts. Mitigation also includes measures aimed atreducing physical, economic and social vulnerability. Therefore mitigation may incorporate addressingcommunity-related issued such as land ownership distribution, etc. Depending on their purpose, mitigationmeasures can be categorized as being 'structural' or non-structural.

Active preparedness measuresBoth structural or non-structural mitigation measures may be termed either 'passive' or 'active'. Active measures

are those which rely on providing incentives for disaster reduction. They are often more effective than passivemeasures which are based on laws and controls. For example, while codes and land use planning may provide alegal context for mitigation, they are ineffective unless rigorously enforced. Instead, measures which provideincentives such as government grants or subsidies, lessening of insurance premiums for safer construction andprovision of government technical advice are more effective.

Preparedness effortsStructural mitigation measures relate to those activities and decision making systems which provide the contextwithin which disaster management and planning operates and is organised. They include measures such aspreparation of preparedness plans, training and education, public education, evacuation planning, institutionbuilding, warning systems, and land use planning.

Disaster response

Coping with the effects of natural disasters is called Post Disaster Management. It deals with problemsconcerning law and order, evacuation and warnings, communications, search and rescue, fire-fighting, medicaland psychiatric assistance, provision of relief and sheltering, etc. Once the initial trauma of the natural disaster isover, the phase of reconstruction and economic rehabilitation is taken up by the people themselves and by thegovernment authorities. Thereafter, the occurrence of the disaster is relegated to historic memory until the nextone occurs.

Preparedness plans the foremost stepThe existence of a disaster-preparedness plan is blessing. Distraught officials have at hand, a set of instructionthey can follow to issue direction tot heir subordinates and affected people. This speeds up the rescue and relief operations and boosts the morale of victims. Disaster plans are also useful pre-disaster operations, whenwarnings have been issued. Time, which might otherwise be lost in consultations with senior officers and gettingformal approval, is saved.

Response plans are formulated by different agencies that need to co-ordinate during emergencies. For example,the electricity supplying authority would be responsible for preparing an action plan, which would be usedfollowing a disaster event to restore full services quickly. The contingency Action Plan (CAP) already exists at thenational level that lists out in detail the actions to be taken at various levels of government at the time of calamity.There is, however, a need to carry out a comprehensive revision of CAP followed by clear cut operationalguidelines. Recently, a high power committee has been established to prepare a disaster management plant adCentral/State and district levels.

National policyThe Natural Disaster Management Division in the department of agriculture and co-operation. Ministry of Agriculture, Government of India deals with the post disaster relief operations. a contingency plan has been



prepared for dealing with the natural calamities as a part of the national policy for the subject. The importantissued of the contingency plans are:

Types of CalamityNatural Calamities, as contained in the plan, have been broadly grouped into major and minor types dependingupon their potential to cause damage to human life and property. Earthquakes, droughts, floods, and cycloneshave been identified as major type of while hailstorms, avalanches, landslides, fire accidents, etc. whose impact islocalized and intensity of the damage being much less are categorized as minor calamities.

Role of the Central GovernmentIn the federal set up of India, the responsibility to formulate the Government's response to a natural calamitymajor or minor is essentially that of the State Government concerned. The Center, however, supplements, to theextent possible, these efforts by way of providing financial and material assistance for effective management of the situation in accordance with the existing scheme of finance and relief expenditure depending upon the gravityof the calamity.National Crisis ManagementNational Crisis Management Committee (NCM), with cabinet secretary as its chairmen is the supreme body at thecenter that operates to provide policy response and/or administrative response.

The Crisis Management Group (CMG) headed by the Relief Commissioner deals with the matters relating to relief in the wake of major natural calamities. The CMG is responsible to:

1. Review every year the contingency plans formulated by the Central Ministries/Departments.2. Review the measures required for dealing with a natural calamity.3. Co-ordinate the activities of the Central Ministers and the State Governments in relation to disaster

preparedness and relief and4. Obtain information from the Nodal Officers of all the Ministers/Departments such measures.

State Crisis Management Group (SCMG)The SCMG works under the chairmanship of Chief Secretary and State Relief Commissioner. The groupcomprises of senior officers from the Departments of Revenue and Relief, Home, Civil Supplies. Power, Irrigation,Water Supply, Local Self Government, Agriculture, Forests, Public Works and Finance and is primarilyresponsible to formulate action plans for dealing with different natural calamities in the state and co-ordinate withCMG at the Center. The SMCG will also have district level plans for relief operations formulated by collectors anddeputy commissioners that provide specific tasks and agencies for their implementations for different calamites.

Mitigation strategyThe plans recognize the fact that effective community involvement and public awareness can largely minimize theimpact or disasters and community based mitigation strategy would go along way in strengthening and stabilizingthe efforts of the administration. The focus would be on community capacity building including formation of community Emergency Response Teams (CERT)

The mitigation strategy also focuses on micro risk assessment and vulnerability analysis including hazardmapping, applied research and technology transfer to improve the quality of forecast and disseminate warningquickly. It also highlights the need for a disaster management legislation and relief and rehabilitation policy thatwould define specific roles and responsibilities as well as set-up permanent administrative structures andinstitutional mechanisms for disaster management. The importance of land use planning and regulations for sustainable development, which include development and implementation of building codes; principles of sage

special laws. Structural and non-structural measures to avoid damage during disasters are given in the mitigationstrategy document.

Training strategyTraining of the key community and social functionaries is essential element for the successful execution of aDisaster Management Action Plan. The DMAP cannot be fully operationalised without a training strategy Manualsfor warning and evacuation, Emergency Operations Center (EOC) and District Control room, (DCR) have beenprepared keeping this in mind. The manuals list the tasks to be undertaken by branch authority responsible.Information on the important contact persons and emergency officials has been provided in the manual. The stateand the district plans also specify guidelines for the community as well as NGO's and local community basedorganizations in the advent of any disaster.



Community based preparedness strategyFor calculated response in case of a disaster a plan for community preparedness is essential. The plan mustincorporate.

1. Clearly perceived hazard and development hazard profile of the community and its neighborhoods.2. Assessment of risk and vulnerability.3. Identification of individual and community resources.4. Like any other plan it must, be clear and simple, specific in details, define duties and responsibilities of

each member, earmark various escape roots, and locate shelter sites.5. The pan has to be written and so that we do not have to refer to it when emergency arises, a simple

concise 'checklist' is needed.6. The Panchayat resilient focal communities. This however is possible only with concerted efforts and

conscious policy at top level.

Mutual aid schemeFor an effective response, identification of resources and development of mutual aid agreements with neighboringresource providers at district, state, country, and international level for the extent and terms for sharing of resources during emergencies.

Periodical mock drills to test and update the plan are of importance. Since a community is a dynamic entity, noplan can be static document.

Geographic Information System (GIS)Disaster planning involves predicting the risk of natural hazard and possible impact. The use of GIS can be madesuccessfully in communication, risk and vulnerability assessment and study of loss patterns, search etc.

Hazard maps could be created for cities, districts, state or even for the entire country. They prove helpful for analysis and determination of hazard zones and likely affects during disasters. The maps can be successfullyused in establishing response priorities, developing actions plans, quick disaster location assessment, for carryingout search and rescue operations effectively, zoning them accordingly to risk magnitudes, population details andassets at risk. The GIS and RS (Remote Sensing) facilitate record keeping and obtain status or on going workswhich are the most critical task disaster management.

Conclusion

Disaster can not be prevented totally. However, timely warning and planning can minimize the affect of adisasters. An accurate disaster management plans needs to be prepared. The use of modern technology like GISand RS can be of vital importance in the preparation of plans. Keeping records of vulnerable areas, monitoring of rescue and relief operations deciding response, managing the data base etc. Mutual aid schemes shall be of great help in mobilization of resources while mock drills shall ensure the efficiency and affectivity of response.Training of the various functionaries, and an effective public awareness and education campaign involving thecommunities will ensure that the plans are disseminated to the lowest levels.

Bibliography

1. R.K. Celly, T.NGupta, Dimensions of Natural Disasters Management in India.2. V.K. Sharma Status of Preparedness Planning in India for Disaster Mitigation.3. TAranjot K. Gadhok, Risk Assessment - A. Key to Prevention.

4. Ravi Gupta, GIs and Remote Sensing for Natural Disaster Prevention.5. N.K. Jain, Role of Egos in Community Based Disaster Preparedness.6. Mohan Krishan, Disaster Management Action Plans for State of Maharashtra : A Review of its Unique

components.7. S.K. Dheri G.C Mishra Fire Risk as an Aftermatch of Natural Disaster.8. Shelter, Special issue on World Disaster Reduction Day, October 1999, HUDCO HSMI Publication New

Delhi.





FIRE DISASTER AND BURN DISASTER: PLANNING AND MANAGEMENT

Masellis M., Ferrara M.M., Gunn S.W.A.

Divisione di Chirurgia Plastica e Terapia delle Ustioni, Ospedale Civico, Palermo Mediterranean Club for Burns and Fire Disasters - WHO Collaborating Centre

SUMMARY. Disaster planning and response require ever more scientific elaboration. All phases of the rescue processneed

an efficient managerial system, from prediction and prevention to preparedness, immediate medical response, assistance, andrehabilitation. Definitions are given of the various types of disaster. A thermal agent disaster is "a disaster causing severe

losses in liuman lives and material goods as a result of massive heat production." Burn disaster can be defined as "the overall

effect of the massive action of a known thermal agent on living beings. It is characterized by a high number of fatalities and

of seriously burned patients with a high potential rate of mortality and disability." Any health management plan in the eventof a burn disaster must include: a) rapid evaluation of the extent of the disaster; b) specific and rapid health assistance

response on site; c) assessment of the capacity of local specialized structures to receive burn victims; d) selective evacuation

of the injured away from the disaster zone. Disaster plans, like those for any other types of rescue operation, will be no more

than empty words unless they are tested in training programmes, made intelligible to the general public, supported by

adequate resources, and updated as necessary. The acquisition of emergency capability by ordinary people is a sign of civil

and cultural progress, but the most important factor of all is disaster preparedness.

Introduction

All disasters, whether flood, earthquake, cyclone, drought or extensive fire, inevitably cause upheavals

not only in the physical but also in the social and economic context where they occur.If a disaster is of major proportions, as may be the case in an earthquakes or flood, an entire region or

extensive national territory may be involved.

The study and analysis of factors that cause a disaster, the characteristics that shape its evolution, theeffects on the population and the natural environment, the instruments that can mitigate their effects, and

the various ways of reestablishing the optimal living conditions of the persons and communities

involved have led to the creation of the new science of Disastrology, which studies disasters from all points of view and establishes guidelines for their management.

"Disaster medicine" considers the health aspects of disasters, in particular the study and collaborative

application of the various health disciplines involved, i.e., from paediatrics, epidemiology,communicable disease, nutrition, public health, emergency surgery, social medicine, community care,humanitarian relief, and international health, to the prevention, immediate response, and rehabilitation of

the health problems arising from disaster, in co-operation with other disciplines involved in

comprehensive disaster management.1-3

These approaches have led to the scientific elaboration of disaster planning and response. This has been

gradually transformed from a combination of ad hoe and humane actions for the stricken persons into an

efficient managerial system throughout all the phases and aspects of the disaster, from prediction and prevention to preparedness, immediate medical response, assistance, and rehabilitation. 2,4

Fire disaster

Although a fire disaster need not necessarily reach catastrophic proportions, it will present some of the

characteristic aspects of a disaster because of the highly destructive action of fire and of the considerablenumber of victims. The surviving casualties will have mainly serious and extensive burns requiring

immediate rescue procedures that cannot always be provided by local resources.

A fire of vast proportions can moreover cause damage to the surrounding environment by the massive

production of heat and the emanation of burn gases and fumes. 5



Smoke and gas, because of their suffocating action and their direct action on the airways, represent other

specific danger elements. The danger of smoke and gas is generally underestimated by the population.

One factor that makes all fire disasters dramatic is panic. Anybody close to a sudden fire is affected by panic. This is due to the realization that the fire can kill within a few moments, cause injuries and

permanent disfigurement, and inexorably destroy everything in the vicinity. When a violent fire breaks

out, there is an initial moment of psychological paralysis, generally followed by total incapacity for logical thought, and this leads to instinctive behavioural reactions whose one aim is to save oneself and

all that is most dear, and reach safety. 6This sequence of actions not infrequently serves only to worsen the extent of damage caused and to

create an even more dramatic and tragic situation. In animals this may indeed be the only reaction possible, which is purely instinctive, but in man there is another option which at first sight may seem

almost paradoxical: to keep calm and take rational decisions. This can be achieved only in one way:

through information about the risks involved, through understanding of the dangers, and throughinstruction about how to behave in case of fire.5,6

A fire disaster has very special characteristics if one considers the particularities of the causative agent

and the type of damage it produces in living beings. When fire comes into contact with objects andmaterials it burns or destroys them in a relatively short time.5,6

The action of fire on a living organism can be lethal within a few seconds. In man, if not immediately

lethal, fire determines a pathological condition, the burn, which is considered to be the most complextrauma that can strike the human body. 5,6

For the above reasons, burn disaster management must, besides prevention, be mainly directed towards

planning and application of measures necessary to mitigate the damage caused to man, to prevent its

aggravation, and to promote healing.5,6

It is therefore useful to bear in mind some specific aspects of a fire disaster, briefly summarized as

follows: 5

• the number of persons involved is usually high;

• the burns tend to be extensive, and the general condition of the victims precarious;• the burn is often associated with other serious pathologies, such as wounds, fractures,

electrocution, and blast or inhalation lesions;• hypovolaernic shock, a characteristic feature in the first phase of the burn illness, as early as

within three hours of the trauma, induces a state of tissue hypoxia, with irreversible damage to

the various organs and systems; the time interval between the burn accident and initiation of

resuscitatory therapy must be less than two hours;

• the inhalation of combustion gases, fumes, and hot air causes damage to the airways and this

alone can jeopardize survival;

• the place where the disaster occurs is not always easily accessible, and speedy care andassistance may be inadequate;

• triage in loco of the victims must be carried out by specialists, as only experts are able to

evaluate the immediate gravity of the burn and the measures to take;

• besides the number of dead, the overall assessment of the severity and damage must be made onthe basis of the number of persons in a condition of potential mortality and severe risk of

disability;

• the rapid assessment and care of the viable and potentially curable victims is paramount.

Thermal agent disaster, burn disaster

In the light of the above considerations, and in order to have at our disposal precise points of reference

as regards the management of rescue operations, in 1990 we proposed to differentiate precisely the two

concepts of "thermal agent disaster" and "burn disaster". Although these two concepts are linked by the



common denominator of heat, they refer to events which, in view of the different darnage caused,

require operational rescue phases with differing commitments. We propose the following definitions. 5,6

Thermal agent disaster: a disaster causing severe losses in human lives and material goods as a result of massive heat production. This definition expresses the relationship between a generic cause of the event

(massive heat production) and the consequences for human beings and material goods. It is an

exclusively mathematical expression of the damage caused, i.e. of the number of the dead and injured,and the extent of damage to material goods.5,6

Burn disaster can be defined as the overall effect of the massive action of a known thermal agent onliving beings. It is characterized by a high number of fatalities and of seriously burned patients with a

high potential rate of mortality and disability. Its extent may be aggravated if appropriate rescueoperations are delayed. Some decisive factors involved here are the type of causal agent, the type of

pathology caused, the overall characteristics of the harmful action of the thermal agent, the immediate

evaluation of its gravity in relation to emergency care, and the modalities of rescue operations.5

In burn disaster, two concepts are therefore involved: the pathological condition, i.e. extensive burns, as

well as the high number of persons injured. Its extent depends on the potentially high number of

fatalities, which is related to the considerable number of persons involved, the seriousness of their condition and, above all, the early initiation of emergency therapy. 2,5

The formulation of two different definitions of "burn disaster" and "thermal agent disaster" proves

useful at both the didactic and the operational levels. The formulation in fact allows a clearer understanding of the two events in the vast chapter of disasters; it offers more specific indications for

drafting of preparedness plans and alerting and management of the problems connected with the

emergency; and lastly it suggests a more effective programme for the mitigation of human suffering. 5,6

The plan for disasters

The Gunn Multilingual Disaster Dictionary defines in global and concrete vision the term Disaster management as follows: "all phases of prevention, planning, preparedness, training response, relief,

rehabilitation and reconstruction of a major emergency or disaster situation".1,5

The planning of health management of a disaster must take into account the results of studies on the

risks that can cause them and on the predictable damage in the environment and human population.7,14

Planning must therefore indicate what instruments are necessary to prevent, avoid, or reduce the

immediate effects on the population and on society (physical suffering, disability, life-endangeringtrauma, hospital conditions). All this must be related as far as possible to every kind of expected

pathology: there must be adequate programming for every kind of disaster, i.e. specific responses in

health, communication networks, transport of casualties, use of medical and nursing personnel,

management of resources. 2,5,6 Everything must be planned with a view to effective preparedness for theevent. Plans must also take into account measures necessary for the most rapid return to normal

conditions for the affected population.

In this way planning will have a more scientific approach, because it will not be mainly dependent onthe actual disaster but rather on the results of predictive studies of the causes and risks of disasters, on

studies regarding the prevention of potential damage to the population, on emergency responses to the

damage that has occurred, and on action to restore conditions of normality. 2,6,7,8,9,10,11,15,16

The plan for burn disaster

The drafting of an operational rescue plan for a burn disaster cannot fail to take into account two points:

1. the victim's pathological picture, i.e. the presence of extensive burns, inhalation lesions, and

polytrauma;

2. the type of intervention required.



Plans must be developed along three lines: immediate care; medical rescue within three hours; use of

specific equipment and means for the rescue of the burned patient.

The timeliness and the effective impact of relief work depend on both general and local factors. In the particular case of "burn disaster", as defined earlier, the particular circumstances - such as the moment

when the disaster occurs (e.g. night, daytime, public holiday, weather conditions), the place of the

disaster (residential area, skyscraper, night club, isolated locality), the degree of accessibility, thedistance from operational rescue forces - all acquire importance because any delay will prevent relief

work from being immediately available. 5,6A decisive role is therefore played also by local intervention factors that chiefly depend on the behaviour

of the people present at the scene of the disaster and on the speed and action of the operative teams thatarrive on the scene. 5,6

The peculiar nature of the burn disaster therefore dictates well-defined chronological and qualitative

operative phases. A person with burns of the airways and associated trauma needs immediate care of adifferent type from that given to the victim of an earthquake, flood, or cyclone. It is also of fundamental

importance, for prognostic reasons, that pending the arrival of organized relief some medical and/or

surgical first aid be given within a very short time, according to the type of lesion present.2,4,6,17,18,26

For the above reasons the basic points of any health management plan in the event of a burn disaster

must include:

A. rapid evaluation of the extent of the disaster

B. specific and rapid health assistance response on siteC. assessment of the capacity of local specialized structures to receive burn victims

D. selective evacuation of casualties from the disaster area.

A) Rapid evaluation of the extent of the disaster

A rapid evaluation of the extent of a burn disaster is essential for calculating the size of the rescue forcesthat need to be involved (teams operating on the spot, teams brought up to the operative area, local first-

aid units, regional/interregional/intemationaI units, etc.) for health assistance to the injured.19

The death of 25-30 persons indicates a burn disaster of very severe proportions, especially consideringthe high number of additional burn patients that can be expected.A burn disaster certainly requires specific management as local rescue forces are most often unable to

cope with the initial health impact and conditions are unequal: consider that in the event of a disaster in

an urban area the resources available may be greater than those available in a rural or isolated area; but itshould not be forgotten that faced with a high number of burn victims even the most sophisticated Burns

Centre may prove inadequate.14

When a burn disaster causes hundreds of burn casualties it may be necessary to call on not only regionaland interregional health forces but also national and international organizations. Link-ups with

international organizations, with their specific experience in this type of rescue work, must be included

in disaster management planning. 2,20,21

The number of dead and injured, the types of pathology involved, the availability on the spot of materialand personnel capable of providing assistance, local environmental conditions as regards access to the

disaster area - all these factors are essential information for the assessment of the initial gravity of a

disaster.The persons on the spot, who provide immediate aid, must be able to provide rapid information on local

conditions and the extent of the disaster for the use of local authorities in charge, i.e. fire brigades,

police, etc. These will in turn send the alert to local hospitals, specialized centres, ambulance services,helicopter rescue, etc.19

All these persons must be able to assess, even if only approximately, the time necessary for the arrival of

fullscale first-aid support.



A more accurate assessment will be possible later when the first experts arrive on the scene, e.g. the fire

brigade. The real extent of the disaster can then be notified to the operation control centres.

B) Specific and rapid health assistance response on site

Three distinct phases can be defined in rescue operations: immediate care, medical first aid, andorganized relief. 5,6

1. Immediate care. This is provided by persons present at the scene of the disaster: relatives, friends,

passers-by, uninjured survivors - all persons who witness the disaster or who arrive immediately on the

scene. Generally speaking, their help is an automatic reaction derived from affection, friendship, and aspirit of human solidarity.2,4

In the event of burn disasters, in particular, it is important that the first people to provide assistance

should be fully aware of what they have to do.2The behaviour of the rescuers in immediate care can be summarized as follows: 2,4

1. Self-control

2. Self-protection

3. Reduction of the fire4. Extraction and transfer of victims to the open air

5. Appropriate action when clothing is on tire

6. Removal of burning clothing7. Emergency treatment of burned areas

8. Knowledgeable action pending more complete relief

9. Dealing with chemical burns

10. Dealing with electrical burns

To acquire the necessary experience and know-how, rescue teams must have attended specific training

courses, taken part in civil defence and disaster simulation exercises, and attended emergency health

courses for persons of all backgrounds and ages, starting from school age. 5,6The occasional rescue workers must be able to perform, even if only in summary fashion, an initialassessment of the damage that has occurred and activate the first triage procedures.

In a disaster with great numbers of burn patients and other casualties occurring in a rural or isolated

area, with predictable delays in the arrival of the first rescue workers, the persons present on the spotshould mark out a safe place as an area for assembly of the injured. This area should be accessible to

vehicles already in the vicinity or on their way (ambulances, helicopters, private cars, etc.). This will

facilitate the task of the first rescue workers who arrive as they will be able to proceed immediately totheir task and perform initial triage and initial resuscitatory treatment.5,6

2. Medical first aid. This refers to the action of trained persons present in the immediate vicinity who

have already received experience in rescue operations and who organize and go into action very rapidly,within 2-3 hours. They may be physicians, nurses, EMS paramedics, members of voluntaryorganizations, etc. They are supported by public and private organizations in the area - hospitals,

casualty departments, clinics, fire brigade, police, etc. - co-ordinated by the local authorities. 5,6,22

The authorities provide guidelines on specific stockpiles in convenient locations, the management of ambulance services, traffic control, the use of local and regional mass media, general means of transport,

and other relevant services.5

The kind of trained assistance provided by these first rescuers is of primary importance for the prognosis

of the casualties. They must carry out the first triage of urgent cases and the many polytraumatized patients. Given the particular evolution of burn disease, particularly worsening hypovolaemic shock,



they must also initiate all medical and surgical procedures necessary for preliminary resuscitatory

therapy and the initial local treatment of burns. 6,15,17,23,40,41 These first-aid groups could be supported by

other teams of physicians, nurses, and specialized technicians with appropriate equipment for thespecific care of burn patients. These teams, sent in by air, would represent an outpost for organized relief

when it arrived. 6,14,25

It must be stressed that it is of fundamental importance that the particular procedures regarding bothmedical assistance and general behaviour, which rescue workers have to carry out, must be based on

specially prepared protocols publicized through information media, education campaigns, refresher courses, and training sessions aimed at citizens of every social group, starting at school age. 6

The following are ten points that these medical firstaid teams must follow: 6

1. Immediate triage of all victims

2. Inspection of the upper airways

3. Qualitative assessment of the burns4. Quantitative assessment of the burns

5. Intravenous resuscitatory therapy

6. Analgesic therapy

7. Bladder catheterization

8. Pressure-relieving incisions9. Examination of the patient with particular attention to respiratory capacity

10. Hospital transfer

3. Organized relief. This refers to the mobilization of all civil defence, military and volunteer forces thatare ready to intervene in the event of a large disaster. These forces arrive on the site as rapidly as

possible, but mostly not within the first three hours, equipped with the necessary means and structures

able to perform rescue action within the first 48-72 hours after the disaster, until all the wounded have been evacuated. These units will be involved in triage of the victims, i.e. stabilization of the condition of

serious victims, separating the less injured, preparing a preliminary evacuation plan, contacting

dispatching stations, selecting means of transport, organizing first-aid posts, and clearing the dead.5,19,25,41

Such forces are used less now due to increased rapid air transport.Air transport is also the rule in maxi-emergencies or when the disaster occurs at some distance from

urban areas, with large numbers of casualties necessitating extensive triage and complex evacuation

problems. 26

Specialized triage can save human lives, facilitate a more functional evacuation of the injured, and makemore rational use of specialized bed availability. Triage must bear in mind prognosis. Absolute priority

is given to injured persons who will die unless treated. Those injured persons who will survive even

without therapy, and those who will die even if treated, are given second priority.In other words, the priority of casualty selection in a disaster is radically different from the priority

followed in normal rescue conditions, where the most seriously injured are given priority, whatever the

prognosis. 14,19,21,22,26,28,38

Burn casualty triage is conditioned by the number of patients, the gravity of the burns, the age of the patients, the presence of respiratory complications, and the availability of beds.

In burn disasters, it is useful to distinguish action for patients according to gravity categories: 19,29

• Minor burns/noncritical sites (<10% TBSA for children; <20% TBSA for adults): dress wound;tetanus prophylaxis; out-patient care.

• Minor burns/critical sites (hands, face, perineum): admit, early operation, special wound care,

short hospital stay.

• 20-60% TBSA: burns unit, trained personnel; requires intravenous fluids/careful monitoring.



• Extensive burns (>60% TBSA); mortality high

• Minor burns/inhalation injury/associated injuries; administer oxygen, measure

carboxyhaemoglobin and/or intubate, ventilate, care of injuries.

Some Centres suggest simplifying triage by the use of certain flexible formulas. For example, thegravity of burns can The expressed in terms of extent and age: where the sum of the age and extent of

burns is greater than 90, there is an empirical 50% chance of survival. By extending this number up or

down, depending on the overall situation, one can increase or narrow the number of burn casualties whoought to be transported first.19

Triage must be looked upon as a continuous and dynamic process.

It begins on the spot and continues wherever the patients are transferred. A second level of triage may be performed in a decentralized, safer area, where casualties have been assembled, for example outside a

hospital. A third level may be necessary in the hospital itself before sending on patients to the specialist

treatment units. 12,19,27

Once the patients have been selected on the basis of the gravity of their condition, they should be

labelled with cards or other clearly recognizable means of identification in relation to the priority of

health care.

Burn victims should never be marked on the skin with visible signs or by the application of adhesives to

the forehead.A widely adopted method is to attach tags of various colours, in relation to priority of health care and

critical condition. There is no standard system but the following is quite practical: 12,27

• red tag = immediate treatment for very serious lifeendangering lesions• green tag = secondary priority with urgent but stable trauma

• yellow tag = less urgent lesions

• black tag = deceased or fatal lesions

There is some disagreement as to the use of coloured tags. Some use a higher number of categories in

order to avoid problems in the second and third phases. Others believe that this system can work

satisfactorily only in urban rescue conditions, and that its use is debatable in disasters in rural areas. 27,28Language and cultural differences also complicate their use on the international level.The Pan American Health Organization of WHO uses a colour system: 27,30

• Red tag = First priority for evacuation: burns complicated by injury to the air passages.

• Green tag = Second priority for evacuation: seconddegree burns covering >30% T13SA; third-

degree 10% T13SA; burns complicated by major lesions to soft tissue or minor fractures; third-degree burns involving such critical areas as hands, feet or face but with no breathing problem

present;

• Yellow tag = third priority for evacuation: minor burns, second-degree covering less than 15%TBSA; third-degree <2% TBSA, first-degree <20% TBS/ excluding hands, feet and face;

•

Black tag = dead.

C) Assessment of the capacity of specialized and nonspecialized structures for the treatment of burn

victims

The planning of burn disaster management must include the following:

1. mapping of hospital facilities, private clinics, and reanimation and emergency centres in the

entire region; 31

2. list of the larger hospitals in the region having burn centres, including bed capacity;



3. list of smaller regional hospitals with burn unit, including bed capacity;

4. indications for the use of regional data banks used by the provincial and regional emergency

health services. Inter alia, these give information on the availability of beds by sectors and bytype of emergency, updated periodically. In some countries this aspect is already operational, e.g.

INFOBRUL in France; NDMS in the U.S.; Argo in Italy; 32,33

5. guidelines for the use of specialized and nonspecialized hospital structures (interregional,national, and international) for the organization of transport and transfer of casualties in disaster

emergencies;6. guidelines for the internal organization of hospital facilities in the event of disaster, including fire

disaster.

Every hospital must be ready to set up an Emergency Co-ordination Operational Centre responsible

for:31,11

• making available specialized and non-specialized beds and organizing patient transfers and

discharges on the basis of predictions of mass arrivals of injured and burned patients; 8,9,17,34-37

• organizing emergency rota systems for medical and nursing staff,

• organizing a central collection point for new victims arriving in order to organize a second

triage;• organizing availability of operating rooms and beds (especially for respiratory reanimation), out-

patient rooms, and areas for less serious patients requiring local burn treatment and therefore

internal means of transport;

• alerting laboratory and analysis services, radiology, blood bank;• alerting pharmacy services and laundry for supplies of medical and surgical material;

• arranging consultancy services with other departments (neurosurgical, ophthalmic, orthopaedic,

pneumological, paediatric, etc.);

• organizing an office for contacts with patients' relatives and friends;

• organizing an office for contacts with foreigners, if any are involved, to help them with language

problems and bureaucratic matters related to the repatriation of the dead and injured; 20

•

organizing an office for press relations in order to supply up-to-date reliable information on theevolution of the disaster and the conditions of patients, issuing medical bulletins at intervals;

• organizing a liaison office with civil defence operative centres, fire service, police, provincialand regional emergency health services, helicopter rescue service, and other hospital facilities;

• collaborating with the Chief of the Burns Centre or Burns Unit in order to integrate nursing

personnel on the spot, with a view to optimal distribution of burn patients in the various

departments and to the despatch, if necessary, of more personnel to the scene of the disaster.

D) Selective evacuation of casualties from the disaster area

This is certainly the most complex phase on both organizational and operational grounds.

Selective evacuation depends on three factors:

I. quality of triage already done (and continuing) on the spot;

II. the means of communication with the disaster area;III. availability of transport for the injured.

I. As specialized burn care centres are few and far between and their beds are nearly always all

occupied, the first phase of triage is of vital importance for orderly evacuation of the injured and

rational use of beds. Triage, particularly after a burns disaster, must be as specialized as possible,dynamic, and give priority for transfer of patients who need stabilizing, resuscitatory therapy and



attention to conditions quoad vitam. This clearly concerns the majority of the patients. Such

procedures will facilitate the task of the physicians in the reception centres. 14,16

Triage is not static; the need for further careful triage can be related to the high number of burn patients, the evolution of the victims' condition, or the lack of experience or specialized

personnel on the spot. This will lead to risky and less accurate evacuation of casualties.

The "load and go" evacuation system must never be used, especially in burn disasters. It causesgreat hold-ups in transport, a chaotic use of specialized beds, and considerable risks for patients

who receive resuscitatory treatment only after long delays.II. The efficiency of the communication system is of great importance here. If the fire and police

services are not immediately alerted following the disaster, the entire rescue operation risks being delayed and jeopardized.

Disaster planning must give precise indications as to how to organize immediate and

uninterrupted links between the disaster zone, especially if this is not in an urban area, and theoperating centres of the fire brigade, police force, emergency health services, hospitals, and civil

defence. 19,33

Efficient communications are imperative in order to follow the initial phases of a disaster, whichrequire co-ordinated and rapid responses in every aspect.

Apart from normal communication services (telephone, fax), there must be radio links with the

EMS, local and national police, fire brigade, voluntary organizations, regional emergencyservices, the army, and helicopter rescue.

Efficient communications between the disaster area and specialized local structures will also

make it possible to activate, pending the arrival of specialist teams, a system of medical

radioconsulting to initiate emergency resuscitatory treatment. Experience from previous disastersand civil defence drills has highlighted the serious difficulties that occur in road connections

between the disaster area and immediate response operating centres and hospitals. This can be

avoided by isolating the affected area and creating a direct approach route for the arrival anddeparture of ambulances and rescue teams.

Particular care must be taken to control the influx of family members and bystanders. Traffic

jams and other hold-ups will occur if the main access routes are not kept clear.

III. The rational evacuation of burn disaster victims is closely related to the condition of the injured,to their numbers, to the type and number of transport available, to the distance to be covered, and

to the availability of facilities at destination.37 Land transport is to be preferred if the patients'

condition is stabilized and requires only maintenance treatment, the roads are free, and properlyequipped ambulances are available. 39

Planning must include a census of all ambulances, the public and private emergency health

services in the territory, and the type of assistance they can provide in transit.Patients with minor burns and light trauma who are able to walk can use buses, private cars, and

covered trucks and lorries (these have to be requisitioned).

If greater distances have to be covered in a limited time, air transport will have to be used. Themost practical means is the helicopter, although its use depends on appropriate weather and

visibility conditions and on the presence of landing strips in the area. 26,38

A census of fixed-wing aircraft and helicopters available in the region makes it possible to haveupdo-date information on the number of air facilities and the time necessary for their arrival on

site.

Such aircraft should offer resuscitation systems on board and be equipped for the transport of

stretchers, patients, and medical and normal passengers.Aircraft with resuscitation systems are used for the transfer of burn patients with life-threatening

conditions, in a grave toxic state, and requiring a transport time of less than 60 minutes.

Aircraft should also be used for patients with stabilized conditions requiring resuscitatorytherapy in flight and who have to cover greater distances to reach specialized centres. In



maritime areas rapid boat ambulances are helpful.

Other means can be used for the evacuation of less seriously injured persons and to transfer

specialist teams and first-aid material to and from the disaster area.

Disaster preparedness

We have several times mentioned prediction and prevention of disasters, planning, management, the

need for an effective response to disaster, and the appropriate measures for restoring normal livingconditions. We have stressed the need for specific training in health management, particularly in burndisasters and public education as regards immediate aid. We have also referred to the responsibilities of

the community in guaranteeing effective and efficient technical health services for immediate rescue

operations and for the restoration of basic living conditions after the disaster.

All this, translated into operative terms, means "preparedness", which is defined as: "The aggregate of measures to be taken in view of disasters, consisting of plans and action programmes designed to

minimize loss of life and damage, to organize and facilitate effective rescue and relief, and to

rehabilitate after disaster. Preparedness requires the necessary legislation and means to cope withdisaster or similar emergency situations. It is also concerned with forecasting and warning, the education

and training of the public, organization, and management, including plans, training of personnel, the

stockpiling of supplies, and ensuring the needed funds and other resources. 1,2,21In order to be effective, disaster management must therefore be based on serious preparedness.

The more appropriate and realistic this is, the more valid will be the combination of actions to prevent,

to diminish the risk, and to reduce the harmful effects of disasters.

The technical and managerial progress achieved in recent years is undeniable. Sophisticated methods,instruments, experience, and research have made possible the science of Disastrology, which is already

proving useful in natural and man-made disasters. It is now more possible to reduce and mitigate their

effects, and even to prevent some of them.One of the ways to reach this goal is training: training of the population at large and training of

specialists. 5,7,17

In the past, the traditional response to disasters has been more of chance and goodwill than of

knowledge. While an expression of personal, national, or international solidarity has often broughtcomfort to stricken populations, the effective results have usually been hampered by a lack of trained

personnel at all levels.The citizen has to be trained to know what to do and when and how to do it.

The procedures initiated to assist the victims of a burn disaster, either by the first rescuer present on the

spot or by the better-organized relief forces arriving soon after on the scene, are of paramount

importance.In fire disasters, all assistance to exposed persons or who have extensive burns must be specific, precise,

considered, and timely.6

At the same time rescuers must protect themselves against the risks of fire and be fully aware of thedifficulties they face when saving fire victims.

Health education and training programmes thus acquire particular importance. These have to tackle three

aspects of disaster:

• the technical aspect, aimed at the nature and extent of the damage caused by the fire and of theimmediate behaviour of the people directly involved

• the clinical aspect, assessing the extent of the trauma to the person, the deterioration in the

various phases of the burn, and the specific type of therapy these call for

• the operational aspect, concerned with coordinated and effective relief, ranging from self-relief

to immediate assistance and specific first-aid measures. 5,6



Conclusions

To conclude, it will be sufficient to repeat some basic concepts:

• Because of the particular characteristics of the pathological conditions affecting burn victims

(extensive burns, respiratory complications, associated polytrauma) a burn disaster is differentfrom other type of disaster.

•

The evaluation of deterioration in the first phase of burn pathology requires immediate medicalresponse that must be specific, precise, considered and timely.

• Immediate assistance spontaneously and humanely offered by persons on the spot, and first

medical aid provided for a limited time period (2-3 hours), are fundamental for prognosis.

• In order to have scientific rigour and organizational discipline, burn disaster planning must be

divided into different phases: prediction of risks, prevention and attenuation of immediate effectson the population, specific health measures, rehabilitation.

• The effectiveness of an operative health response, in terms of mitigation of suffering, incapacity,

invalidity, and death, is closely related to a population's level of preparedness. As in every other type of disaster, plans for rescue operations also in a burn disaster may just remain words on

paper unless they are tested in training programmes, made intelligible to the general public,

supported by adequate resources, and updated as necessary.• The acquisition of emergency capability by ordinary citizens is a sign of civil and cultural

progress.

This article was received on 18 June 1998.

Address correspondence to Prof. Michele Masellis,

Divisione di Chirurgia Plastica e Terapia delle Ustioni,

Ospedale Civico, Via C. Lazzaro, 90127 Palermo, Italy.Tel.: +39 091666 36 61 - 666 36 34; Fax: +39 09159 64 04;

E-mail: [email protected]

mailto:[email protected]

mailto:[email protected]

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