Nightmare In A Nightclub

"Keeping our fingers crossed" seems to be an apt metaphor for how America is dealing with its aging and ailing infrastructure. Chillingly, this applies to our emergency management and public health system, as well. Years of hospital cost cutting and slim state healthcare budgets have taken their toll. In a mass-casualty event, our healthcare system will almost certainly fail us.

The September 11 attacks didn't reveal how frail our emergency care capabilities have become for the tragic reason that virtually all the victims in the air and on the ground died before they could receive medical assistance. Emergency rooms standing on full alert had few admissions. But 17 months later, a freak accident at the Station nightclub in West Warwick, R.I., exposed just how poorly prepared the world's most expensive healthcare system is to handle a surge of patients with serious injuries. That night the heavy-metal band Great White kicked off its show to a packed house with its signature pyrotechnics display, but something went terribly wrong. As soon as the fireworks went off, the wall behind the stage burst into flames, kicking off a major fire. In the crush that followed, several people were trampled to death. The ensuing blaze killed 100 people and injured more than 215.

Facility cutbacks. Rhode Island's statewide emergency management system, unfortunately, failed this real-world test. Emergency responders had little communication with receiving hospitals, so patients were brought to emergency rooms unannounced. Some ambulance units were unaware of how many victims hospitals could care for. And since more than 100 victims had second- and third-degree burns, the needs were immense. Treating serious burns requires highly specialized medical training and facilities, which are expensive to maintain.

Over the past decade, many U.S. hospitals have been trimming back their burn units. Sixteen U.S. burn centers closed between 1991 and 2003, and many others-including the U.S. Army Burn Center-were downsized. And there weren't many beds to start with: The United States had 1,966 burn beds in 1991 but only 1,897 at the time of the Rhode Island fire. Hospitals have also cut back on extra supplies. Today it isn't uncommon for trauma centers to have just one week's worth of silver sulfadiazine, which is used to prevent infections in patients with second- and third-degree burns. A few years ago, several months' supply was standard.

This trend to cut back even emergency medical supplies is driven by a desire to reduce the cost of routinely replacing expired medicines and other materials with short shelf lives. As a result, the hospital industry is now as enthusiastic about "just in time" delivery as retailers like Wal-Mart. Arrangements are often in place for suppliers to deliver medical materials soon after they're ordered. This works out fine if the demand isn't too large and the roads and airports are running smoothly. But during a major catastrophe, needs skyrocket and transportation is almost always one of the first casualties.

The night of the Warwick fire, transportation wasn't a problem as much as hospitals already operating at their maximum. Kent Hospital, the nearest hospital to the club, already had a full emergency room when the blaze began. Virtually every emergency medical helicopter in New England and some from Long Island, N.Y., were mobilized to transport victims to 13 different facilities in Rhode Island and Massachusetts. Seventeen of the most severely burned patients were sent to Massachusetts General Hospital in Boston, the largest burn unit in New England. This influx stressed the hospitals' medical staff to its limits, something that should give Boston-area emergency planners pause when they contemplate how they might cope with a terrorist attack on a liquid natural gas tanker in Boston Harbor. -
Stephen Flynn, from The Edge of Disaster: Rebilding a Resilient Nation

By Stephen Flynn