The Feb. 20 fire at the Station nightclub in West Warwick, R.I., has already achieved grim distinction as one of the nation's worst fire disasters. The fire killed 98 people and injured 186; about 60 people remain hospitalized, 29 in critical condition.
The latest victim died on Saturday, but burn experts say the toll could have been much worse if emergency workers had not been trained to deal with mass casualties under a statewide disaster response plan adopted after the Sept. 11, 2001, attacks.
The training included procedures to quickly assess the medical needs of large numbers of burned or poisoned people, to clear routes to hospitals and to activate a communication system linking government, medical and rescue agencies.
The training paid off in the Station fire. Burn experts credit the speed and precision with which rescue workers got the injured to appropriate hospitals with saving many lives, especially those of the more than 50 people with inhalation burns.
"Successful burn treatment requires a team approach," said Dr. Robert J. Spence, of the Burn Injury Rehabilitation Model System at Johns Hopkins University in Baltimore, one of four centers developing national burn care protocols.
Rhode Island's disaster plan before Sept. 11 emphasized more routine events, like hurricanes and bus crashes. After Sept. 11, state officials added terrorist attacks with hundreds of dead, maimed and burned victims, using a Justice Department grant for drills at the state airport. Hundreds of actors were hired to play screaming victims, panic-stricken relatives and terrorists bent on escape. State officials borrowed the war games theater at the Naval War College in Newport to practice with computer simulated disasters, said Lt. Gov. Charles J. Fogarty, chairman of the state's Emergency Management Advisory Council.
"We never expected this kind of test," Mr. Fogarty said. "But there is no question that all the training and focus on terrorism helped our readiness and capacity to respond."
Patients with severe burns are one of the greatest challenges in trauma care, particularly those burned over more than 20 percent of their skin surface. Virtually every organ system is taxed as the body goes into overdrive to try to heal huge areas of destroyed tissue.
Beyond damage to a patient's skin are potentially life-threatening injuries to kidneys, lungs, heart and brain as blood volume drops precipitously and metabolism goes haywire. In a frantic effort to close the wound, the body will cannibalize healthy tissue, including muscle, to obtain protein to fuel this exaggerated healing response. The lungs may be seared, interfering with breathing. Because burns are almost always contaminated by soot, debris and dead tissue, infection is often a complication.
Fire rescue workers are routinely trained to gauge the severity of burns and when they see evidence of inhalation burns, to keep the patient's airway open, because swelling can quickly close it. But the sheer volume of inhalation injuries from the Station fire would have overwhelmed rescue workers if they had not had the mass casualty drills.
Experts say the Rhode Island emergency system is certain to be studied for lessons in improving regional and national responses to such catastrophes. The American Burn Association is already working on ways to improve communication and triage at disaster sites, said Dr. Roger W. Yurt, an association spokesman and the director of the Hearst Burn Center in New York.
"One of the things we realized in 9/11 is that communications were not particularly good, either locally or nationally," Dr. Yurt said. The collapse of the World Trade Center towers knocked out the emergency services communication system for greater New York, and there was no backup. First responders were uncertain where to send burn victims.
Capt. Peter T. Ginaitt, the first rescue worker to arrive at the Station fire, said he was initially skeptical of Rhode Island's disaster drills. But his experience amid the agony and panic of the fire victims on Feb. 20 convinced him of their value.
"In the hour and a half that it took us to ferry 140 people out of there, there was never one responder who second-guessed the organizational system," Captain Ginaitt said. "Everybody followed the plan, and as a result we were able to get a large number of severely injured people to the appropriate hospitals very, very quickly."
The training kicked in for Captain Ginaitt as his truck arrived at the flaming nightclub.
"I looked ahead and saw at least 50 people in the road wandering around aimlessly, a lot with obvious burns," he recalled. He quickly activated a special radio frequency, calling in a "mass casualty incident." In minutes, rescue trucks and private ambulances throughout Rhode Island and from border towns in Massachusetts were speeding to the scene. A firefighter set up a staging area for arriving rescue trucks so those loaded with injured could get out.
Rhode Island's 15 hospitals, meanwhile, activated internal Code 99's, to begin recalling evening shift workers to augment the night shift, and they got emergency departments and intensive care units ready to receive the injured. Kent Hospital, a community hospital less than three miles from the nightclub, ordered additional ventilators from a medical equipment rental company to augment the hospital's stock. The state's only trauma center, the 710-bed Rhode Island Hospital in Providence, prepared to receive the more severely burned, but also alerted burn centers in Boston and Worcester, Mass., to expect patients.
"We knew the numbers were too high and the injuries too severe for our hospital," said Dr. Robert Baute, Kent Hospital president. "So we took the less injured, and stabilized the severely burned patients for transfer to better-equipped hospitals."
Helicopters flew five to Massachusetts burn centers immediately. Sixteen were sent to Rhode Island Hospital within two hours of the fire.
Captain Ginaitt was making similar triage decisions at the fire site.
"I knew if I stopped to treat one, I might lose 10, so the basic fire rescue training went out the window," Captain Ginaitt said. Instead, he used mass casualty protocols, looking for victims with blackened faces, indicating inhalation burns, which made them a high priority for evacuation. He also used the so-called Rule of Nines to assess depth and extent of skin burns. The rule divides the body into commonly recognized parts, each representing an amount of skin area expressed in multiples of nine. A burned leg, for example, represents 18 percent of total skin area; head and neck account for 9 percent; each arm is 9 percent; the chest and the back are each 18 percent.
For the more severely burned, Captain Ginnait sent rescue trucks directly to Rhode Island Hospital, about 15 minutes north. "We did not want to overload any one emergency department," he said. "That would have just stacked up the patients, and many of them needed attention right away."
At Rhode Island Hospital, the staff moved surgical patients to convert the surgical unit into a burn center. The thermostat was set at 95 degrees because loss of skin hinders the body's ability to regulate temperature.
Dr. William Cioffi, chief of surgery at Rhode Island Hospital and a burn specialist, knew fluid loss would be an early life-threatening complication for the burn patients, so he began stockpiling saline solution.
"Sixty years ago, what killed burn patients was kidney failure because we did not realize the importance of maintaining fluid volume in these patients," Dr. Cioffi said. Severe burns cause capillaries to leak plasma for about 24 hours before they reseal. This dangerously reduces blood. So in the first 24 to 36 hours, burn patients need large amounts of intravenous saline solution.
Other facets of burn care include nutritional support, infection control and early surgery to clear dead tissue and close wounds with grafts of healthy skin. Burn patients need many more calories than healthy people to provide energy for healing. If nutrition is inadequate, the body will consume healthy tissue, leading to muscle and limb atrophy.
Those injured in the Station fire face long roads to recovery.
"Once you have had a major burn, your life is changed forever," said Dr. Spence, of the John Hopkins burn center. "The goal at the reconstruction and rehabilitation end is to try to get the person back as much as possible to their previous life."
This may involve more skin grafts and treatment to minimize scarring, with physical and psychological therapy to cope with disability and disfigurement. Despite the life-altering consequences of severe burns, Ann Acton, director of Phoenix Society of Burn Survivors, a national group, says, results are often better than burn victims and their families can imagine.
From The New York Times on the Web (c) The New York Times Company. Reprinted with Permission.