Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia

The Victorian bushfires in February 2009 rank second among Australia’s worst natural disasters (Box 1)1 and among the top 10 wildfires/bushfires in the world with respect to fatalities (Box 2).2 Before the “Black Saturday” fires of February 2009, bushfires in Australia had resulted in 642 recorded deaths.3 Despite these tragedies, little has been published on bushfires (wildfires or firestorms), associated patient demographics and emergency medical responses.

On Saturday 7 February 2009, the state of Victoria experienced its hottest day on record, with the temperature in Melbourne reaching 46.4°C (116°F). Bushfires that had started in the heat across the state on that day intensified as a cool change came through in the afternoon, backed by winds gusting at up to 100 km/h. The major fires occurred in 14 different geographical regions and burnt an area of over 350 000 hectares (Box 3).

As part of its state emergency management arrangements, the state of Victoria has a mass casualty burns plan that aims to provide a clear framework for optimal care of burns survivors of a mass casualty incident.4 The state response is linked in with a national burns plan (AUSBURNPLAN).5 The importance of disaster planning exercises has been established,6 and practice exercises have been conducted throughout the state.7 The Black Saturday event represented an opportunity to critically examine the state’s medical disaster response.

Our report examines the response of the Victorian State Trauma System to major bushfires from the perspective of the state adult burns centre and summarises the pattern of hospital presentations associated with the Black Saturday fires over the initial 72-hour period.

The second-worst natural disaster in Australia’s history and the worst since the introduction of the Victorian State Trauma System tested the emergency medical response and the burns plan of Victoria. Presentations of patients with severe burns were relatively few compared with the massive number who died in the fires. The statewide and national responses were triggered early and allowed the acute care medical system to cope well. Even though the number of patients with serious burns was small, the possibility of specialist burns and intensive care units reaching capacity was high.

There have been few reports on acute medical responses to bushfires. Carroll and Raiter reported on the 1918 Cloquet Fire in Minnesota,10 while more recently Richardson and Kumar reported on the 2003 Canberra bushfires11 and Vilke and colleagues on the firestorm in San Diego County, California, in 2003.12 All three reports commented on the weaknesses in previous planning, and especially on the large numbers of patients presenting with minor injuries.

The capacity of Australian hospitals to respond to disasters has previously been questioned.13,14 A major feature of the response to the February 2009 Victorian bushfires was effective prehospital triaging. This enabled the state’s major referral centres to maintain considerable surge capacity. Other factors contributing to the relatively small numbers of injured patients presenting to the major trauma centres and statewide burns services included the presence of a rehearsed major burns plan, early communication, the significant distance of the major referral centres from the bushfires (thus enabling effective triage and minimising “walk-ins”), and a large number of supportive surrounding hospitals. Although TBSA ≥ 30% was set as the initial triage criterion for referral to the major burns centres when the total number of burns victims was unknown, this was not followed, as it became apparent that the number of surviving victims was significantly less than first estimated. The value of varying normal criteria for referral to a burns centre requires further discussion, as patients may be disadvantaged by delayed referral.

There have been multiple reports on the stresses placed on burns centres during the September 11 terrorist attacks in the United States.15,16 In a worst-case scenario,5 Australia may need to be able to cope with a surge capacity of up to 300 severely burn-injured patients, in addition to the background incidence of severe burn injury (about 50 cases per week nationally). The AUSBURNPLAN template directs that each state and territory have a burns/mass casualty disaster plan to manage any acute surge of patients locally within the template. In a large-scale disaster, the Australian Health Disaster Management Policy Committee should play a key consultative role by liaising with all key stakeholders.

The early deaths in this disaster were most likely from direct effects of the fires, flames and radiant heat. There is little information regarding the effects of improvements in prevention and early warning systems on the patterns of burn injuries from bushfires. However, evidence from other natural disasters suggests that improved early warning systems would result in lower mortality and a higher number of patients reaching hospitals, with lower overall deaths.17-21 It is hoped that the mortality profile from future bushfires will change in a similar way.

Our study was limited in that the data were not verified from all sites. It was unlikely that surgery for burns was performed outside the major burns referral centres, but this could not be confirmed. Examining the immediate impact on the primary care sector, which has been shown to be substantial in the past,22 was beyond the scope of our report. Significant psychological effects of bushfires have been previously reported23 and will require continued surveillance.

There are subtle differences between traditional management of major burns and management in the setting of a mass casualty disaster. The reception and resuscitation of the burns patients at The Alfred in February 2009 followed a standard approach (Box 7). As expected, most patients were hypovolaemic, and initial fluid resuscitation addressed this.24 Wound management was performed according to standard practice, but on a much larger scale. First aid measures included the use of Burn Aid (Rye Pharmaceuticals) or plastic cling wrap to cover burn wounds before definitive wound assessment could be carried out by medical and nursing staff. In view of uncertainty regarding total numbers of patients and the extent of injuries, there were some variations from usual early operative management practice:

• Usual surgical practice (immediate transfer to the operating theatre for excision of burn wounds and wound closure with skin substitutes) was not instituted.

• Patients with a coherent history, clean partial-thickness burn wounds of < 10% TBSA and no history of dam immersion had their wounds cleaned and dressed in the E&TC. Escharotomies were performed in the E&TC on unconscious patients.

• Patients with extensive or contaminated burn wounds were transferred to the operating theatre for wound debridement, escharotomies and dressings.

• Definitive surgical management was planned and instituted once all patients for whom it was indicated had undergone “damage control” surgery (completed within the first 24 hours).

Patients requiring admission to the ICU were noted to differ from “usual” burns victims in two respects:

• The degree of early multiorgan system failures was higher than expected for the degree of burns; and

• The severity and extent of serious airway burns was much greater than usually seen, and was presumably related to the severe heat generated by the fires and the inhalation of dust and debris.

Most victims of the Victorian bushfires either died or survived with minor injuries. As a result of the coordinated response, the small number with serious burns did not overload the acute health care system. This pattern may change with improvements in forecasting and disaster planning, which could result in more survivors and greater stress on the acute health care system.

Moreover, the Australian Bureau of Meteorology has predicted warmer conditions in Australia’s south-eastern states in the future, making it likely that the conditions that led up to the Victorian bushfires will be repeated. Should fires occur and advance into more built-up areas, there may be a much higher number of deaths and severe injuries.

Lessons from the February 2009 tragedy (Box 8) as well as previous natural disasters must be used to strengthen prevention and medical response systems.

3 Fires in Victoria on 9 February 2009*

* Reproduced with permission from The Age (Melbourne), Fairfax Media Services and the Country Fire Authority, Victoria.

5 Major burns and trauma presentations in the first 24 hours of the Victorian bushfires

* One patient with non-bushfire-related severe burns was admitted to The Alfred intensive care unit.