R.I. physician recalls trial by fire

There had never been a night like Feb. 20 at Kent Hospital in Warwick, R.I., when a parade of ambulances delivered 40 profoundly injured club patrons in just the first hour.

The chief of the hospital's intensive care unit provides a graphic portrait of that night in an account in today's New England Journal of Medicine, as well as in an interview with the Globe. Dr. Michael J. Dacey for the first time sketches four hours of what he called "well-oiled chaos" as physicians moved from patient to patient, opening swollen airways, dipping into small green buckets of morphine, and praying that they could outrun death.

"I thought for sure we'd lose people in those first couple of hours," Dacey said yesterday in a telephone interview. "I don't have any explanation for why we didn't."

"There were many, many more critically ill patients than doctors in that first 90 minutes," he said. "You had to sort of choose which critically ill patient to treat first and hope they were there when you got to them next."

Dacey was watching the TV news that Thursday night in his Warwick home when the first bulletins aired about the blaze. Nothing prepared him for what he would encounter at the hospital.

"A friend of mine who was a firefighter before he became a doctor rushed to the scene and saw scores of injured and panicked people," Dacey wrote. "He called the hospital and, over the poor connection of a cellphone, told us, `The state won't have enough resources -- never mind just the hospital.' "

About a month before the fire, the 359-bed hospital had participated in a disaster drill with a scenario involving 50 patients injured in a mock act of bioterrorism, which Dacey credited for helping to prepare the staff for what came through the door that night. Although the hospital has no trauma ward or burn center -- facilities typically found at major research medical centers like Massachusetts General Hospital -- Kent does have a bustling emergency room, and its proximity to T.F. Green Airport means the hospital regularly conducts disaster exercises.

Still, no hospital can afford to have resources -- squadrons of specialists, dozens of beds -- permanently on guard in the event of a once-in-a-generation calamity.

When Dacey arrived at the hospital, two emergency room physicians were just finishing their shifts while two more were coming on the clock. All four began treating the injured, joined by Dacey and two other doctors who were in the hospital.

That made for seven physicians, but they confronted a surge of 25 patients with respiratory injuries so severe that they needed immediate aid just to keep breathing.

So the doctors rapidly assessed who needed the most help. As Dacey moved from patient to patient, he recalled, his senses were assaulted by the overwhelming stench of smoke coating the emergency room and the increasingly persistent cries of pain from the burned.

On a typical day, Kent specialists might place breathing tubes in two or three patients. In those few hours in February, they placed the tubes in 25.

And the doctors exhausted Kent's entire supply of morphine. "If you look at the whole scene, you'd say this is hopeless, forget about it," Dacey said in the interview. "So you focus on one person at a time. You take care of that patient and you move on and you decide what the next priority is.

"At that point, I felt patients were going to die in the emergency room because we couldn't get to them in time. Fortunately, that didn't happen."

The fact that it didn't is testament both to the skill of the medical team at Kent and to advances in technology, said Dr. Robert Sheridan, codirector of the burn ward at Massachusetts General Hospital. Bigger intravenous lines can now be inserted directly into major arteries, rather than the smaller veins of the arm, allowing more fluids, antibiotics, and painkillers to be delivered more swiftly. At the same time, smaller, more agile breathing tubes can be threaded down the throats of even the most grossly swollen patients. The fire claimed 100 lives, with 96 of the dead found amid the ruins of the nightclub. Four more died days later in hospitals. Stephen Smith can be reached at stsmith@globe.com.