/
/

The firedisaster in Gothenburg the night October 29–30 October, 1998 – KAMEDO-report 75

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.

This report is entirely in Swedish. Only summary in English.

Summary

The fire

Late in the evening of October 29th 1998 a fire, which later turned out to have been started deliberately, broke out in the premises of the Macedonian Association in the Hisingen area of Göteborg. That particular evening the premises had been hired by young people who had organised a discotheque. Around 390 young people, a large number of whom had an immigrant background, were in the building at the time when the fire broke out. The fire started at the emergency exit and spread very quickly. Panic erupted when the young people tried to escape. The only exit was soon blocked by young people who had collapsed. Some young people managed to escape through the windows, the bottom edges of which were approximately 2.2 metres above floor level. From some of the windows it was possible to jump down onto the roof of a lower building. However, these windows were the first ones to be reached by the flames. Some of the survivors were able to escape from the other windows at an early stage by jumping or being pushed out down to the street level approximately 6 metres below.

The rescue operations

The first emergency 112 call to the SOS Alarm emergency service centre reporting the fire was received at 23.42 from a mobile phone. The first rescue force was dispatched approximately three minutes later. An ordinary ambulance and an OLA ambulance (mobile intensive care unit) were dispatched immediately afterwards and the police command centre was informed. SOS Alarm also dispatched a medical team from Östra Hospital. A little later the accident and emergency departments at Sahlgrenska, Mölndal and Kungälv Hospitals were alerted. When further phone calls had been received by SOS Alarm, as well as a report from the rescue unit on the scene, a major alert was issued with call-outs from several fire stations and further ambulances.
The total time of action (from receipt of alert to arrival at the scene of the accident) was approximately six minutes for the first force. This force encountered total chaos. The whole of the open space in front of the building was full of screaming young people, who were blocking the path of the fire engines. People were jumping from windows. The primary task was to save lives. The smoke divers forced their way into the premises through the entrance and windows.
Those whom the smoke divers succeeded in bringing out at an early stage were suffering from mild smoke poisoning and slight injuries. Of those rescued later, most had severe fire gas poisoning, were unconscious and had more or less severe burns.
It is estimated that approximately 390 people were in the premises at the time when the fire broke out. Approximately 260 had managed to get out by themselves before the rescue service arrived. Around 150 of these were suffering from fire gas poisoning or were injured in some other way and were transported to hospital. Of the 120 people estimated to have still been in the building when the rescue work started, approximately 60 were rescued by smoke divers. Around ten of these died from their injuries. A total of 63 young people died and 213 were transported to hospital.
Altogether 50 firemen and 19 police patrols with a total of 42 police officers worked at the scene of the fire during the first few hours. They had three main tasks: life-saving, cordoning-off and supervision of the casualty assembly point. When the fire had been extinguished, the police took over the main responsibility for the scene of the fire.

The ambulance operations

Two ambulances were initially dispatched, one of which was an OLA ambulance. Altogether 16 ambulances became involved, two of which were OLA ambulances. The first ambulance arrived at the scene of the fire at 23.50 and the first OLA ambulance (which became the forward ambulance control unit) at 23.53. A first provisional casualty assembly point was set up in the open air alongside the wall of a building. Attempts at using priority slips and treatment cards proved unsuccessful because of the chaos. The mood around the forward ambulance control unit was at times frenzied. At first the range of injuries consisted mainly of those with slight inhalation injury who had managed to leave the building themselves through the exit and those who had jumped through the windows. When the smoke divers managed to remove the "plug" of people who were blocking the exit, the persons who had severe inhalation injury and burns came out. Many of the firemen with medical training had to alternate between being firemen and ambulance staff.

Medical care at the scene

The doctor on call in Göteborg (the city on calldoctor) arrived at the scene of the fire just before midnight. Approximately half an hour later a mobile medical team arrived with a doctor from Östra Hospital. The casualty assembly point was gradually moved to a car showroom. No medical director on-scene was ever called. One medical team from Sahlgrenska Hospital and one from Mölndal Hospital arrived at the scene of the accident too late, when all the patients had left.
In general, first aid was given to start with, particularly to clear the airways, and casualties were transported to hospital as quickly as possible. The less seriously injured were placed in groups and had to share oxygen, which was not sufficient for everyone. When the severely injured came out, more advanced actions were performed such as intubation and CPR (cardio-pulmonary resuscitation) which, however, was not successful. Those with severe burns were given intravenous fluids. No other specific treatment was given.
A total of 213 young people were transported to hospital, of whom 85 were taken by ambulance. The others were driven to hospital in buses, taxis and private cars.
During the work at the scene, individuals among both the rescue service personnel and the ambulance personnel were subjected to verbal threats and in a few cases more palpable violence involving kicks and punches. The injuries sustained were bruising/abrasions and in one case broken ribs. The perpetrators in the majority of cases were attempting to enforce priority in the treatment of "their" nearest and dearest. In one case it has been reported that medical personnel were prevented by bystanders from discontinuing CPR (cardio-pulmonary resuscitation) despite judging that there was no chance of success.
During the night it was decided that ambulances would be used to transport the deceased to the mortuary at Sahlgrenska Hospital. The last corpse was left at the mortuary at eight o'clock in the morning.
Most of those who died at the scene had more or less severe burns, but the most common cause of death was carbon monoxide poisoning. Many also had high levels of cyanide in their blood, which in itself could also have been the cause of death.

The hospital operations

One of the most important tasks at Sahlgrenska Hospital was firstly to separate the injured from relatives and friends and then the slightly injured from the more seriously injured. By around 2 am, 48 patients had been registered at Sahlgrenska Hospital. The influx of patients to Östra Hospital was so great and so rapid that all treatment took place under emergency triage.
One hundred and fifty people were admitted to the hospitals in the Göteborg region. Seventy-four of these at first required care in the intensivecare unit. Everyone was able to receive adequate treatment for injuries due to fire gases and burns as a result of resources being transferred from surgical departments and extra intensive-care beds being provided in wards outside the intensivecare units. In addition to those admitted as in-patients, another 63 young people were able to leave the hospital after medical examination. Five young people attended a health centre during the first 24 hours.
By around 6 pm on Thursday October 31st, 63 patients were left at the four emergency hospitals in Greater Göteborg (Sahlgrenska, Östra, Mölndal and Kungälv Hospitals). Twenty-two of them were being treated in intensivecare units. Thirteen patients, after initial care at the hospitals in Göteborg, had been transported to burns units at other hospitals in Sweden and Norway (Uppsala University Hospital, Karolinska Hospital in Stockholm, Linköping University Hospital, Malmö General Hospital, Haukeland Hospital in Bergen in Norway). On Monday November 2nd it was reported that two of the patients being cared for in hospital had died, one in Bergen and one at Sahlgrenska Hospital. Two weeks after the disaster, a total of 26 patients were being cared for in hospitals, of which 12 were at other hospitals in Sweden and 14 at hospitals in Greater Göteborg. The last patient was discharged from hospital in Göteborg on April 13th 1999.
Information went at an early stage from SOS Alarm to the accident and emergency departments at the affected hospitals. However, it has been impossible to clarify precisely what information was passed on, when this happened and who received the information at the particular hospital. It is clear that, at first, the correct information was not obtained on either the extent, the precise location or how the incident had developed. The situation was handled somewhat differently at the various hospitals. No disaster alert was ever raised at Sahlgrenska, Östra or Mölndal Hospitals, only at Kungälv Hospital.
The bodies of all 63 young people who died were transported to the mortuary at Sahlgrenska Hospital. All the police work was conducted here, with description of the deceased, police identification, an opportunity for relatives to pay their last respects, ablution and placing in coffins. Altogether, this involved more than 250 visits to the mortuary by individual relatives or groups of relatives during the course of seven days. The forensic examinations were conducted in the autopsy department at Sahlgrenska Hospital.

Psychosocial operations

It was clear early on that there would be a very heavy burden on PKL activity (psychological disaster management group) at the hospitals over the next few days, and it was therefore decided that priority would be given to dealing with injured/uninjured young people and providing support to relatives in identifying bodies and paying their last respects.
Heavy pressure was put on coordination of the resources of society for psychological support to relatives and survivors with representatives of various religious communities and non-profit organisations. At first it was feared that the multicultural composition of the group affected would pose particular problems. However, Swedish society had ample capacity to deal with this. The greatest problem instead was that such a large group of young people had been affected. In addition, cultural differences between generations came to light, not least with regard to behaviour in the event of losses of close relatives/friends. Great cohesion within several youth groups was a notable feature of the collective mourning in the initial period following the disaster.
The ritual ablution was an important part of the taking care of the many deceased Muslim young people. A good solution was found through cooperation between the pathologist and the imams concerned. Although Muslim tradition prescribes that burial has to take place as soon as possible after death has occurred, the relatives did understand that a delay was unavoidable.
The municipality of Göteborg contributed with an interpreter service and various types of financial support for the affected families. This made it possible for relatives from the country of origin to come to Sweden to visit the injured or attend funerals. The municipality also paid for phone calls to relatives in other countries.
The psychosocial work after the fire took place to some extent in cooperation between representatives of the medical services and the municipality and various organisations, including immigrant organisations. Imams, a Macedonian priest, and a Catholic priest and representatives of associations with political or cultural roots in various immigrant groups took part in the work during the initial period at Sahlgrenska Hospital. The Swedish Church also played an active role at the hospitals and out in the districts of the city where cooperation with representatives of the municipality also took place. A Muslim support operation started at Hammarkullens School a few hours after the fire. Those persons who volunteered to take part in this operation also played an active role in several large-scale ceremonies after the disaster.
A large number of media-related issues arose. A major issue in the subsequent debate and research has been the relationship between central crisis communication and the disruptions which have taken place within the multicultural community. Light has also been shed on disaster journalism in several studies.

Experience

• Rescue service, ambulance and medical personnel worked very well in the difficult situation they encountered.
• At first, medical resources were meagre to cope with the need to provide adequate medical care, triage and transportation of the large number of casualties. A chaotic situation therefore developed in the early phase, something which probably cannot be avoided.
• It became possible to set up acasualty assembly point as more and more rescue and medical personnel arrived at the scene of the fire. It is important to set up a casualty assembly point, but this cannot be done until sufficient personnel and equipment is present.
• The instructions given to the medical services on dispatching mobile medical teams and medical director on-scene must be given high priority and the routines must be improved. No medical director on-scene was called in. It is essential that when major incidents occur it is possible to dispatch one or more mobile medical teams to the scene. It is also important to have a preparedness for dispatching a person trained in directing medical operations to the scene. Specially trained medical directors on-scene should be on standby if possible. An important effect of a medical director on-scene is that he or she takes over medical responsibility for the activity and relieves the other personnel of this responsibility. If there is no trained medical director on-scene in the organisation (or none is available), the person best trained to direct medical operations at the scene of an accident should take on this task.
• Doctors who man emergency cars should be familiar with the medical disaster organisation and how medical care on scene is organised before commencing such service.
• There was a great need for oxygen treatment for those who had been mildly or seriously affected by fire gases and in particular carbon monoxide. Regardless of the need for oxygen treatment, it certainly had a calming effect on many patients. Access to large quantities of oxygen is important at the scene of fires.
• Carbon monoxide poisoning was present in most of the deceased. The concentration of cyanide in the blood of the vast majority of the deceased was in itself also sufficiently high to be capable of causing severe poisoning. While taking care of persons exposed to fire gases indoors, consideration should be given to the risk of cyanide poisoning, and cyanide antidote should be given as soon as possible.
• Persons who have suffered cardiac arrest on being evacuated from a burning building and who display clear signs of exposure to cyanide and carbon monoxide (soot in the airways) have probably been exposed to lethal concentrations of one or both of these gases. The prospects of successful cardio-pulmonary resuscitation must be regarded as very slight, and in a mass casualty situation, priority should be given to those with preserved circulation.
• The large number of casualties both with severe and with less severe injuries required maximum utilisation of ambulance transport. Because of the shortage of ambulances, these were used for several patients at a time, and buses, taxis and private cars were used to transport those with mild injuries to hospital.
• The state of alert was never raised at the larger hospitals, although it ought to have been. Experience from previous accidents (as reported in several KAMEDO reports) show that there is a disinclination to raise the state of alert at an early stage. However, it is better to at least create a reinforcement situation at an early stage and then call off the alert than to call a disaster alert too late. The thought of possible financial consequences must not prevent the state of alert from being raised.
• Work carried out in mortuaries/autopsy departments should be included in disaster plans, and mortuary/autopsy attendants should be on duty. Well established forms of cooperation with undertakers facilitate operations in a disaster with many deaths. Contacts with religious and other groups should be prepared and be included in the disaster planning.
• PKL activity (psychological disaster management group) as well as POSOM activity (community based psychological disaster management) were undertaken on a large scale following the accident. The multicultural composition of the group of people affected and their affiliation to various religious communities made new and heavy demands on these activities, something which must be taken into account to a far greater extent in the future.
• The treatment of the injured was made more difficult by occasional threats and even violence. One of the main tasks of the person who has responsibility for directing the medical services at the scene is to ensure that his or her own personnel are not injured during the rescue work. A decision to use protected breaking points should be taken as soon as possible in consultation between the police incident officer and the medical director on-scene/forward ambulance control unit.
• The security departments of hospitals should plan for how to handle a large influx of relatives at the time of major accidents and disasters. There is also reason to consider whether the general prohibition on the use of mobile phones inside most Swedish hospitals should remain in place, or whether this prohibition can be limited to intensive-care units and other technology-intensive departments.
• The command organisation must be thoroughly familiar with the rules applicable to confidentiality. This applies both to rules which exist to protect personal integrity and rules which in certain situations permit confidentiality to be broken. It is therefore important to have access to legal expertise in an emergency situation so that correct judgements can be made.
• It is important that journalists and photographers are trained in disaster journalism and disaster psychology. It would be of great value for such aspects to be included in state training courses for journalists.

Read the full Summary