Fire and ice—Demands for thermal and frost injury care from extreme weather

Dear editor:

Fluctuations in weather patterns have become increasingly common and affect all geographies and populations within the US; no region or person is spared from the threat of fire and ice. While much has been considered about how fluctuations in weather increase the likelihood of respiratory and infectious illness [1], less attention has been given to the direct and indirect effects on thermal and frost injuries. Injuries from extremes of temperature result in extensive soft tissue necrosis, often requiring urgent care and surgery. Not infrequently, moderate to severe cases lead to loss of limb and life. Over 70 years ago, mass casualty incidents including the Cocoanut Grove Fire (1942) and Texas City disaster (1947) ushered the organization of treatment centers that deliver specialized care for thermal injury and frostbite [2]. In the current era of extreme weather, fire and ice pose major injury risk, necessitating a renewed focus on organized regional burn care.

1. Fire:

Thermal injuries arise directly through periods of intense heat which kill by heatstroke and heat-related illness. Heat waves also lead to extreme surface temperatures, which are magnified on asphalt and sand—reaching temperatures upwards of 140 F in direct sunlight. In regions previously unaccustomed to these patterns (Pacific Northwest and Northeast), 2nd and 3rd degree contact burns are now commonplace.

Forest fires and fire season result from prolonged periods of heating and drought combined with US urban development that has built into regional forest/vegetation. The West Coast forests of the Sierra Nevada and Cascade Mountains along with the Rocky Mountains have repeatedly seen severe forest fires. While most loss of human property does not result in loss of life, deaths from forest fires occurs yearly, and major burn patients heavily stress capacity despite high occupancy in West Coast burn centers. Caring for major burn patients is one of the most labor and resource intensive endeavors in medicine, requiring multi-month inpatient stays and upwards of 10–20 operations per admission. A single fire can saturate centers for months.

2. Ice:

Periods of extreme cooling and unpredictable snowstorms are problematic for regions of the US not prepared for freezing temperatures. Frost injuries, often combined with systemic hypothermia, require resuscitation and stabilization including the use of extracorporeal life support. Isolated frost injuries, while not as extensive as thermal burns, often cause deeper tissue damage and result in loss of digits and limbs. The Texas Freeze of 2021 exemplifies severe unpredictable cooling that resulted in morbidity and death [3]. Not only did individuals suffer the direct effects of prolonged freeze, capacity limitations and failure in the regional power grids left tens of millions without energy and safe heating. Reliance on non-traditional methods of heating such as sleeping in automobiles with idling engines further exacerbated death tolls from carbon monoxide poisoning—often treated at regional burn centers.

3. Disproportionate effects on the homeless:

Those most likely affected by freezing are also the most vulnerable. The epidemic of homelessness in the US has multifactorial roots and affects all regions; nevertheless, most unsheltered populations reside in geographies with temperature climates—the West Coast, Mexican Gulf Coast, and the Southeast. Atypical severe cooling across the West Coast and southern latitudes results in multiple frost injuries. Unlike flame injuries which present acutely, many patients with frost injuries are challenged in accessing early care for ischemia reversal (thrombolysis), which results in major tissue loss including amputation.

Ironically, cold spells also result in thermal injuries when unhoused persons sleep with space heaters or open flames. Most the year, those living in temperate areas can forego external heating sources; however, sporadic cold fronts bring freezing temperatures which threaten the unhoused. External heating devices that rely on convection were not designed for use in tents or proximity, resulting in contact burns. Similarly, traditional camping tents are not designed for open flames which can result in disastrous fires [4].

4. Solutions:

Prevention is the hallmark strategy for thermal injury at both extremes and is responsible for the significant reduction in temperature related death in the US over the past 50 years. Actionable prevention measures from a health systems perspective are summarized (Table 1). Initiatives led by regional organizations and non-governmental agencies such as the Safe and Warm campaign [5] epitomize the primary prevention efforts to educate the homeless on safe heating and provide physical clothing, blankets, and shoes.

Table 1 –

Framework for addressing the challenges of fire and ice injury in the US.

Category	General Public	Burn Providers	Policy Makers
Prevention	-. Fire prevention strategies including urban planning and forestry stewardship-. Public announcements surrounding dangers of pavement contact burns, heat stroke, and frostbite-. Safety fairs-. Equipment (for the homeless)	-. Advocacy efforts	-. Resources to mitigate homelessness-. Emergency housing
Injury care		-. Regional, national burn care coordination-. Stockpiles of specialized products (thrombolytic agents, specialized dressings)-. Augment capabilities at nonspecialized centers-. Leverage telemedicine capabilities when feasible to assist in triage and treatment	-. Provide emergency funding (FEMA) and extra resources for care centers during fire and freeze events
Post-injury care	-. Access resources for temporary housing, jobs	-. Integrate with primary care-. Develop medical home care model for vulnerable populations-. Leverage secondary injury prevention strategies	-. Funding to support reintegration efforts

Regional variation in weather asymmetry such as deep freezes in the South or extreme heat waves in the Northwest demand targeted education. For example, while residents of Texas may be familiar with the dangers of walking on asphalt during a heat wave, the same may not be true for residents of northern Washington. Burn centers and regional prevention organizations must expand typical flame and scald burn prevention messaging to also educate the public on the dangers of pavement contact burns and heat stroke. Similarly in the South, deep freezes are uncommon, and prevention messaging must include education on avoiding frostbite during a freeze. For burn centers that may not treat much if any frostbite, burn providers should have periodic education on how to manage these injuries including indications for anticoagulation and rapid rewarming.

Mass casualty events must also be anticipated, as large-scale vegetation and forest fires can spread into populated areas. Any area in the US with significant vegetation carries a risk for large fire; therefore, these areas must have established plans for evacuation and containment. Further, regional burn organization as practiced in parts of the US should be ubiquitous to maintain knowledge of pooled bed capacity in the event of mass casualty and need for triage of large volumes of severely burned persons. Organized injury care and post-injury care require thoughtful organization and communication among existing burn center structure and resources as demonstrated by the American Burn Association [6]. Extreme weather will continue to ravage society in multiple domains. We must plan and act to avoid the morbidity and loss of life on society.