ED handles 30 burn patients after plant fire and explosion in Georgia
ED and ICU utilized before some transferred to burn center
On Feb. 7, a fire and explosion rocked the Imperial Sugar Co. plant in Port Wentworth, GA. When about 30 of the victims arrived at Memorial University Medical Center in nearby Savannah, the ED "did an incredible job" of stabilizing and treating them until the most severely burned could be transported to a specialized facility, says Robert F. (Fred) Mullins, MD, FACS, medical director of the Joseph N. Still Burn Center at Doctors Hospital in Augusta, GA.
In fact, Mullins says, the entire response of the key players in the emergency system there should provide ED managers with a good model for how they, the EMS, and local emergency management agencies (EMAs) should deal with similar events. For example, Mullins says he was contacted just 30 minutes after the event occurred by the EMA director in Savannah.
"They initially told me over 100 people were injured, and whenever there are more than four or five, we actually go to the site and take a team with us," he notes. The team, which flew to Savannah by helicopter, included Mullins, an anesthesiologist, a nurse anesthetist, and three surgical physician assistants.
The original estimate was based on the total number of plant employees, Mullins says. It was not as important that it be accurate as it was that it indicated the size of the event.
"We knew they would at least be triaged at a hospital and that this was not your typical 'we-have-two-burn-patients-coming-your-way' kind of call," he explains. "That count made us realize it was significant enough to go down there."
When he and his team landed at the scene, "They had asked us to come to the hospital, and we let them direct us," Mullins recalls. They arrived about two hours after the accident. "There were still a few patients in the ED, and the 18 who were upstairs in the ICU had been intubated and were just starting fluid resuscitation."
ED director in charge
Jay Goldstein, MD, FACEP, acting medical director of the ED at Memorial, made sure the phone tree swung into action. "In events like these, the [disaster response] command calls the ED charge nurse, she alerts the ED doc, they alert me, and I start the process," he explains.
Goldstein's first call was to the president of the medical staff, who then called the other hospitals in area to let them know there was a mass casualty event. The president also started the physician phone tree so every available specialist would be contacted. "At the same time, the ED [charge] nurse also alerts the hospital administrator on call and the nursing administrator of the ED," he says. There are separate trees for facilities management, nursing, radiology, lab, respiratory therapy, etc., says Goldstein. "On the facility side you have security, blood banks, food resources, all the way down the line, so the initial two or three calls exponentially grow until the whole hospital is notified."
Managing the patients
Goldstein was not in the ED when he received his call, and he went directly to the department rather than to the scene. The burn center was contacted by the attending trauma physicians, he says, and he coordinated on-the-scene efforts by keeping in close contact with Frank Davis, MD, a trauma surgeon.
"In essence, by the time I got to the ED, the patients had all been removed from the scene, and it was only about a 20- to 25-minute drive for EMS," Goldstein recalls.
When the patients arrived, the facility's mass casualty plan was initiated. "We have three different levels of plans, with the least serious being multiple patients. This was our highest level," explains Goldstein, adding that burn care "is such a specialized level of care, requiring a prolonged course of management."
The site triage team was under the direction of Goldstein. "As acting medical director, I was the initial triage officer," he explains.
Goldstein oversaw the initial triage stage. From there, the patients were directed to certain areas within the hospital depending on the level of injury. "Teams were established to care for individuals injured, and these teams were established prior to the patients 'entry into the hospital," he says. "The teams essentially consisted of ED RNs, respiratory therapists, ED MDs or trauma MDs, and ED techs."
The initial concern of the staff, he says, was "airway, airway, and airway." "Half the patients we saw were intubated on arrival," Goldstein notes. Next came a focus on fluid resuscitation and pain management.
Once the patient was stabilized, he or she was transferred to another area of the hospital depending on what level of intervention was performed on them. "If they went to the main ED or an operating room or were critical, they then were treated by a specified team: the main physician responsible there, a nurse, and a float nurse," Goldstein says. "Some were administered meds, some got intubated, and they started fluid, but they also made sure the patients stayed warm because [if you are a burn victim,] you lose the ability to keep your core temperature up."
In addition, he says, sterilized bandages were used to make sure the patients' burns did not become infected. "This was all part of our protocol," Goldstein says.
Burn leader impressed
When Mullins first saw the Memorial patients, he quickly noted that the treatment team had everything organized. "Patients had been cared for right away," he says. "They were receiving appropriate fluids in warm rooms with warm blankets, and vitals were being monitored."
Burn center beds are short resource in almost all states, so a skilled team is necessary to determine which patients needed to be transported to the burn center. "You look at the wounds and other critical aspects — for example, whether they have inhalation injuries, the percentage and degree of their burns [10% or more of the body with second-degree burns], and whether they are in overwhelming pain." Mullins notes.
Ultimately, 18 patients were transferred to the burn center by helicopter. "It took three flights, and we staggered them 15-30 minutes apart," Mullins explains. "This gave our team the time to get each group of patients assessed, do the appropriate intervention, and get them in a room and tucked in before the next group came in."
ED managers, should have a pre-plan and contact information for the closest burn center handy, says Mullins. "We have a number they call, and it comes straight to me 24/7," he says. Once they are in contact, the ED or triage director can describe the burns and discuss interventions that should be started, he says. "We have them talk to us from the scene and from the ED, so they know to put them in a warm room, get warm blankets, and use the appropriate IV catheters and fluids on the patients," Mullins says.
In addition, says Mullins, the ED manager should have at least one predetermined team leader (one for each team), a secretary, and a coordinator (the emergency manager) to interface with the burn center. The secretary is necessary to coordinate the reports from the team leaders, as well as the communications with the burn center, Mullins explains. The team leaders report to the emergency manager, who in turn communicates with the burn center. "You want to put as much order into this chaos as possible," he says.
Mullins has one caveat for ED managers when it comes to evaluating burn victims. "When you see these types of patients, you need to look beyond burns," he advises. "Burns won't kill you right away, but associated injuries will."
It's important to know the details of the incident, he says. "In this case, where there were two explosions, patients needed to be screened for associated internal injuries," he explains.
Goldstein's own experiences bore out such concerns. "Because there are so many industrial plants in the area, we learned that you need to know what chemicals the patients could be potentially exposed to," he says. "We knew there would be blast injuries, but we were not sure if we had to worry about chemical injuries [which would have necessitated decontamination procedures using warm water]."
Goldstein's staff had to make numerous calls before it could be determined that there were no dangerous chemicals in this plant. Goldstein says his disaster response plan now is being modified to prevent such confusion in the future.
"We are in the process of contacting all the regional industrial factories to inquire about the potential for any exposure of their employees if a disaster were to happen," Goldstein shares. "We will then formulate a list so we will always have access to it and know what type and extent of decontamination would need to be performed in the event of a disaster at that facility."
Sources
For more information on responding to disasters involving burn victims, contact:
- Jay Goldstein, MD, FACEP, Emergency Department Medical Director, Memorial University Medical Center, Savannah, GA. Phone: (912) 350-3849.
- Robert F. (Fred) Mullins, MD, FACS, Medical Director, Joseph N. Still Burn Center, Doctors Hospital, Augusta, GA. Phone: (877) 863-9595. E-mail: [email protected].
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