The patients treated at The Canberra Hospital represented all the cases of serious injury and most cases of significant injury from the fires. Minor injuries were treated by general practitioners in private surgeries and evacuation centres, and almost no fire-related cases were seen at Calvary Hospital, the public hospital on the north side of Canberra, during the first day.

Our description of patients is based on data from the Emergency Department Information System (EDIS), medical records, and the debriefing process. As part of the response, clerical staff identified disaster-related cases on arrival; these were later audited by the authors and other ED staff. Usually, the relationship to the fires was obvious, but, in doubtful cases, the definition was a clinical decision that the patient would not have presented had the fires not occurred.

Over the 6 hours from 16:00 to 22:00, the ED treated 139 patients, 105 of whom had fire-related problems (Box 3). This represents 90 more patients than average, or one additional patient every 4 minutes. As in similar Australian fires, respiratory and ophthalmological problems were more prevalent than burns3,4 (Box 4). Only two patients required transport to interstate burns centres, and there were no deaths in hospital.

Unlike many disasters, a significant feature was the continuation of “background” ED workload (Box 5). Even during the critical 6 hours, there were 34 non-fire-related presentations, and the expected fall in other workload did not occur until the following day. There was little opportunity to divert patients elsewhere, as The Canberra Hospital is the major tertiary hospital in the region and offers the only paediatric, acute orthopaedic, neurosurgical and major trauma services.

Twenty-one people presented requesting supplies of their usual medications, as their homes had been destroyed or were inaccessible. These requests were concentrated in the first 16 hours. Medications commonly required were insulin, antipsychotics, antihypertensives and home oxygen. This was also reported as a major problem by a general practitioner (GP) working in one of the evacuation centres. The hospital’s GP liaison was contacted about this problem on the morning after the fires, after which GPs visited the evacuation centres and provided prescription and other services.

The fires occurred during school holidays and the hospital’s medical changeover period, when junior staff move to new positions, often interstate. Many regular staff were out of the city, and many of the previous year’s staff had already left.

During the disaster, the ED medical workforce was boosted by staff working overtime and by 14 staff not rostered to the ED that day, including four from outside the hospital. Some of the staff contacted were unable to attend because of fire in or near their homes, and some responded without returning home, working while unsure whether their properties had survived. A major contribution was also made by a small number of relevant hospital specialists (plastic surgery, general surgery, respiratory medicine) and outsiders, including an emergency physician who travelled from Sydney.

The major issues that became apparent from the disaster were transport and communication difficulties, both of which are well recognised.

Use of private transport: Sixty percent of disaster patients and 30% of those who required hospital admission arrived by private vehicle (including the two most critically ill). Although this made little difference to the hospital response on this occasion, it might be a major problem when multiple hospitals are involved, and pre-hospital personnel have the task of balancing workload between institutions. The experience was similar in the Granville rail disaster (1977)5 and Cyclone Tracy,6 and had been specifically predicted as a problem in the most recent Canberra Hospital disaster exercise.

The high use of private transport during this disaster is an important lesson for the national capital, where exposure to chemical, biological or radiological weapons is considered a real threat. As there appears to be no realistic prospect of containing an exposed population, services must plan around patients presenting by private transport and requiring decontamination at hospitals.7

Communication difficulties: Communication was hampered by disruption of the mobile phone network, and also by the lack of a television, radio or adequate mobile phone coverage in the disaster control room, which was therefore moved to a more appropriate location. It should perhaps be noted that mobile phones were not a significant means of communication when the disaster plan was last activated (the landslide at the Thredbo ski resort, 19978). Communication lines with the ACT Emergency Control Centre remained open, but little or no information relevant to the hospital response was available, as the Emergency Services Bureau experienced significant command and control problems.2 In addition, it was found that the key hospital staff were unfamiliar with the two-way radios provided as part of the disaster plan, and that there was no STD telephone in the room designated for relatives, both of which increased the load on the hospital switchboard.

Electricity supply: Fluctuations in the electricity supply caused by the fires led to frequent power outages. In retrospect, the hospital should have continued to use its emergency generators until the disaster was over.

Operating theatre standby for “major cases”: All non-urgent surgery was cancelled, and operating theatres set up to receive “major cases”. This proved unnecessary, as no such cases presented, and also significantly delayed surgery, particularly acute orthopaedic surgery, increasing hospital bed use.

Emergency department triage officer: Within the ED, it was found that experienced triage nurses provided a more appropriate triage service than the ED registrars designated in the disaster plan. While senior medical input may be required (for example, when a decision is needed about withholding care because of “expectant death”), triage and other tasks should generally be allocated to the most experienced staff.

External liaison: A need for prescription and other GP services at evacuation centres became apparent. GP after-hours services should be opened early, and GPs should be asked to attend evacuation centres early in the course of a disaster.

Photographic documentation: A less important failure was the lack of any photographic documentation of the disaster response for historical and teaching purposes. Although volunteers, such as medical students, were available, none were allocated to “camera duty”.

Hospital evacuation: Fire came to within 2 km of the hospital campus (Box 1), but little thought was given to the possibility that it might reach the hospital. Although unlikely, this is a potentially catastrophic event which should be included in future planning. In light of The Canberra Hospital experience, detailed plans were drawn up for the evacuation of Calvary Hospital when fire threatened the northern suburbs of Canberra a few days later.