A deadly New Year’s Eve fireworks explosion at a Salt Lake home inundated Hawaiʻi’s only burn center with the largest volume of patients from a single event in the unit’s 42-year history.

Six of the most critically injured survivors will fly on a military aircraft Saturday to Arizona for specialized treatment to help absorb some of the load, according to the governor’s office.

Honolulu’s Straub Benioff Medical Center has four beds to serve severe skin and tissue damage in burn patients from across the North Pacific, including Guam and Micronesia. In an emergency, the unit’s capacity can surge, absorbing beds from the ICU to handle upward of 20 patients with injuries from heat, electricity, radiation, infection, disease or chemicals.

But its capacity buckled on Wednesday, when a fireworks blast at a Salt Lake home just after midnight left three people dead and seriously injured more than 20. A fourth person died in a fireworks-related incident in Kalihi on New Year’s Day.

Hilton Raethel, chief executive of the Healthcare Association of Hawaiʻi, described the New Year’s event as extraordinary because so many were badly burned in one incident.

“We can handle a bunch of heart attacks, we can handle a bunch of broken bones, we can handle a bunch of strokes, we can handle a lot of things all at once and really surge the capacity,” he said Friday. “We can handle a pandemic because it builds over time and we have time to plan. But this event was even worse than even the Maui wildfires.”

The rush of patients were sent to The Queen’s Medical Center, the state’s only Level 1 trauma center, where staff assessed and stabilized the patients, sending 10 of the most critically injured to the Straub burn unit. These patients arrived at Straub in the early morning hours to find a unit already providing specialized care to 11 other burn patients admitted before the New Year’s blast. As of Friday, a burn unit that typically has four beds had swelled to care for 21 patients.

“Some of them will probably pass away because the burns are so extensive,” Gov. Josh Green, who is also a medical doctor, said Friday.

Emergency responders delivered some of the blast victims from Queen’s to other area hospitals, including Kaiser Permanente Moanalua and Tripler Medical Center. None of these facilities, however, offer the specialized care required to treat severe burns.

Hawai’i needed an immediate plan to fly people from Honolulu to out-of-state burn centers. Within hours of the explosion, Green authorized the Hawai’i National Guard to use its military aircraft to transport patients to the mainland.

The six patients expected to board a C-17 military aircraft to an Arizona burn care facility Saturday are the most critically injured of the blast victims doctors expect can survive the flight. 

“I would expect that some patients who are going to be here will have 10 or 20 surgeries perhaps over the next several months, and the same thing is to be said of the patients that will go to Arizona,” Green said. “One person lost 90% of their skin; they have to be kept unconscious and intubated for months now. A facility like the one in Arizona, they’re built for huge numbers of people in the worst, most critical state like this.”

All told, 10 burn patients from the fireworks explosion are receiving care at Straub’s burn unit, according to Green.

Travis Clegg, the medical center’s chief operating officer, said in a statement that burn care unit staff is working closely with other hospitals across O‘ahu to help determine the best course of treatment for every injured burn patient receiving care outside of Straub.

It’s possible additional patients will need to relocate to hospitals on the mainland for specialized care or long-term rehabilitation, a state official said. Major burns can take months or years to fully heal, not to mention treatments needed for other trauma injuries from the blast. In addition to severe burns, Green said some of the victims of the Salt Lake explosion suffered internal organ injuries.

“You could theoretically occupy a whole ICU team with this many patients that are this severe,” Green said. “This is why I humbly ask everyone to stop using fireworks. If we had another incident and we had seven more people hurt, it could really cause a serious problem.” 

Regional Burn Group Lends Support

The decision to expand treatment outside Hawai‘i was made in coordination with the Western Region Burn Disaster Consortium, which includes 27 burn centers across 13 states. There are 453 burn beds in the region, with roughly 150 to 180 open beds available on a typical day, according to the consortium’s Burn Mass Casualty Operations Plan. 

Annette Newman, the burn disaster coordinator for the consortium at the University of Utah Health Burn Center, said the consortium tracks the number and location of open burn beds in the nation every Tuesday to speed up patient transport logistics when an emergency strikes.

The group considers the Salt Lake fireworks a burn mass casualty incident, which it defines as any event where the fragility of local medical capacity endangers patient care.

A burn mass casualty event in any state consumes many resources and it’s not uncommon for a burn center to collaborate with other units in an emergency to augment capacity, Newman said. But the issue is more serious in Hawai‘i, where the nearest neighboring burn center is 2,500 miles away

Straub’s burn unit has four licensed beds with a 12-bed surge capacity, according to the consortium’s operations plan. Pediatric patients generally receive treatment at Kapiʻolani Medical Center for Women & Children, where the Straub burn unit’s three plastic surgeons also work. Kapi’olani Medical Center does not have designated burn beds, however.

The distribution of burn centers in the west ranges from 13 in California, which has a population of 39 million and more burn centers than any state, to zero in Montana and Wyoming, which have populations of 1.1 million and 580,000, respectively. It’s not unusual for patients to spend several hours on an airplane en route to a burn center with greater capacity to meet their needs, Newman said.

When multiple family members suffer severe burns and need to be transported to another facility, as is the case in the Salt Lake incident, Newman said the group strives to keep them together. This can be tricky when there are adults and children who were burned in the same incident since only a small number of burn units accept pediatric patients.

“If there are burn centers that take adults and pediatric patients, and there’s a mother and a child,” Newman said, “we would send them to that center and so then the father doesn’t have to choose which burn center he goes to or whether to visit his child or his wife.”

Burn Unit Was Tested During Maui Fires

Recently, the deadliest wildfire in the U.S. in more than a century put Straub’s burn unit to the test. Nine patients received care at the unit in the immediate aftermath of the devastating Lahaina fire on Maui in 2023. The death toll was 102.

At that time the consortium was ready to help assist in transporting patients from Honolulu to the mainland, but all nine patients were treated locally, according to Newman, who has helped coordinate patient transport between western region burn centers for 15 years. 

“Had all of those people not died, had they been injured, there would have also been more burn patients than there are burn beds in Hawai‘i,” Newman said. 

Civil Beat’s community health coverage is supported by the Cooke Foundation, Atherton Family Foundation and Papa Ola Lokahi.