The Cocoanut Grove Fire—the deadliest fire in Boston’s history and seventh deadliest fire in the history of the United States—took place eighty years ago today on Saturday, Nov. 28, 1942.

The quick-moving fire in the overcrowded nightclub resulted in the loss of 492 lives. Many of those who survived the fire suffered severe injuries.

A small silver lining to the tragedy can be found in the advances in burn care that were made in treating survivors at Massachusetts General Hospital—advances that were made possible through research.

The hospital’s well-coordinated response to the event also highlights the importance of disaster training to prepare medical personnel for a sudden influx of critically injured patients.

A Quick and Deadly Fire

The Cocoanut Grove was located at 17 Piedmont Street in the theater district of Boston and was one of the most popular clubs in the city in the early 1940s.

More than 1,000 patrons—well over the club’s legal capacity —were at the club on Saturday, Nov. 28th when a small fire broke out the basement lounge and spread quickly across the tropical-themed décor covering the ceiling.

The fast-moving fire spread flames, smoke and panic through the overcrowded club within minutes.

The club’s main exit—a revolving door at the front, quickly became jammed with panicked patrons, and a second door that opened inward into the facility also became blocked.

Additional exits in the club had either been locked (to prevent patrons from leaving without paying), obstructed or hidden, compounding the tragedy and adding to the death toll.

The patrons who did not escape the club in the first few minutes of the fire were not likely to survive, overcome by smoke inhalation or by the fire itself.

Mass General Mobilizes in Response

Massachusetts General Hospital and Boston City Hospital treated the vast majority of survivors that night—Mass General took in 114 victims while BCH took in 300.

Both hospitals were well-prepared for a mass casualty event, as medical facilities across the Eastern seaboard had drawn up emergency plans in preparation for potential attacks in the wake of the attack on Pearl Harbor in December of 1941.

BCH and Mass General had both received grants after the Pearl Harbor attack to study burn injuries and had stockpiles of supplies to treat patients.

The city of Boston had also run a disaster response drill the weekend before the fire.  

Despite this, the majority of survivors taken to both hospitals either died on arrival or did not make it through the first night. At Mass General, only 39 of the 114 victims survived until Sunday morning. At BCH, only 114 of the 300 victims were still alive.

Nevertheless, the training and preparation of the Mass General staff allowed for the rapid triaging of patients and the quick isolation of survivors to prevent infection.

“The importance of anticipating a disaster cannot be overemphasized,” wrote Oliver Cope, MD, in a 1943 article in the New England Journal of Medicine recounting the hospital’s response to the fire.

Cope, who headed the burn research project at Mass General noted that at one point the hospital was receiving a new casualty once every 50 seconds that night, and staff members quickly had to remove the dead in order to treat the living.

When it was suspected that the number of casualties would overwhelm the emergency ward, the decision was made to clear out one floor in the surgical ward of the White building and use that as an isolation ward for the victims.  

Centralizing and isolating the patients helped to reduce the risk of infection and made it easier to supervise survivors for symptoms of shock and anoxia (a lack of oxygen due to damaged lungs).

Within three hours of the fire, all 39 of the surviving patients were settled on the recently cleared surgical floor, with their surface burns covered with dressings and were receiving oxygen for anoxia and IV plasma for shock.

This rapid response was made possible by having adequate number of doctors and nurses on hand—the fire had occurred at the time of a shift change.

“But the number of personnel is of secondary importance to having a prearranged plan of action,” Cope noted in his NEJM article. “Without forethought…confusion will reign.”

Respiratory Complications

According to Cope, the majority of the Cocoanut Grove victims who arrived at Mass General were either maniacal or unconscious.

“At first, the mania was mistaken for hysteria aggravated by pain,” Cope writes. “Subsequently, it was realized that in many it was due to anoxia.”

The majority of the anoxia experienced by victims was due to damage to the lungs and respiratory tract caused by breathing in smoke and toxic fumes from the fire.

Patients with anoxia were treated with oxygen, which brought some initial relief, though the impact of pulmonary injuries increased by the hour in the immediate aftermath of the fire.

Seven patients died between in the three days following the fire due to a combination of respiratory obstruction and edema (the leaking of fluid into the lungs).

The peak of pulmonary complications occurred on the third or fourth day and eased after that. Strict isolation on the surgical ward helped to reduce the risk of pulmonary infection, Cope writes.

Shock

Shock—a life-threatening condition brought on by a drop in blood flow in the body—was another key concern for fire victims brought to Mass General.

The primary phase of burn shock was thought to be neurogenic—brought on by the nervous system due to the pain of the burns. This was treated with morphine.

The secondary phase of burn shock comes on more gradually and is caused by the seepage of blood plasma out through the capillaries into burned areas. This was treated with infusions of blood and saline, though care had to be taken that the fluids did not worsen symptoms of edema in the lungs.

Surface Burns

Perhaps the most significant clinical innovation to come from Mass General as a result of the Cocoanut Grove fire was the treatment of surface burns.

For the two years prior to the fire, Mass General had been conducting research into burn treatments and had pioneered a new approach that centered on the belief that the most effective way to prevent infection was to immediately cover up the wound

In the years prior to the fire, it had been common practice to debride all such wounds to remove any dead skin or blisters. The injured skin was then scrubbed with soap and water and rinsed to remove any infectious bacterial—an extremely painful process that frequently required anesthesia and could also cause shock.

Debridement was a carryover from the previous treatment strategy of treating burns with tannic acid.

For the surface burns of the victims, the protocol was as follows, Cope writes:

● Personnel were carefully masked to prevent the transmission of infection

● All exposed burn surfaces were covered with sterile towels

● When patients were transferred from stretchers to beds, the burns were covered with sterile sheets

● No debridement or cleansing of any surface was done

● Once in isolation, the sterile sheets were removed so that the burned surfaces were covered with boric-ointment and gauze

● Pressure bandages were applied to the wounds

● As a final but integral part of the surface treatment, each patient received two grams of an antibiotic (sodium sulfadiazine).

“When it was first suggested a year ago that we should not debride a burn wound, this was objected to by all those concerned with infection,” Cope writes. “However, the results of this simplified treatment were gratifying—all second-degree or incomplete thickness burns of the skin healed without evidence of infection.”

Legacy of the Cocoanut Grove

“When the Cocoanut Grove went up in flames in November 1942, the 171 victims who made it alive to Boston City and Mass General hospitals became subjects in the most comprehensive clinical trial in the annals of burn treatment,” writes Barbara Ravage in her book Burn Unit: Saving Lives After the Flames.

“The patients exhibited every imaginable burn complication, making it possible to study this most complex of injuries in great detail,” Ravage writes. “New ideas were tried, old methods discarded, and the agenda for burn research was set for the next quarter century.”

Eighty years after the fire, Mass General investigators are continuing to explore new ways to improve treatment for burn patients.

In September of this year, for example, researchers from the Center for Engineering in Medicine and Surgery introduced a first-of-its kind hydrogel for second-degree burns that can be dissolved quickly and easily to reduce the pain of wound dressing changes in burn patients.

The gel, which is now being developed for the consumer market, also reduces the risks of infections, sepsis and multi-organ failure.

About the Mass General Research Institute
Research at Massachusetts General Hospital is interwoven through more than 30 different departments, centers and institutes. Our research includes fundamental, lab-based science; clinical trials to test new drugs, devices and diagnostic tools; and community and population-based research to improve health outcomes across populations and eliminate disparities in care.
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