The Aliamanu fireworks blast just after midnight on New Year’s, a mass casualty event, set new precedents in emergency health care response in Hawaii.
The explosion was unprecedented, according to Gov. Josh Green during a news conference earlier this month, with numerous hospitals stepping up to coordinate care for the patients.
That night, the Straub Benioff Medical Center’s Burn Care Unit admitted 10 patients, the largest number admitted from a single event in its 42-year history, surpassing the nine admitted from the 2023 Maui wildfires.
These were in addition to other patients already under care at the unit, and all hands were on deck as the Aliamanu patients were rushed to various hospitals around Oahu.
“We typically can care for a lot of different injuries,” said Green at the Jan. 13 conference. “We also prepare for what comes next … and needless to say, Straub and Queen’s are always caring for huge numbers of patients in their ICUs.”
But Hawaii hospitals were overwhelmed by the number of severely burned patients all at once, and the need became greater than capacity.
Upon Green’s request, six of the severely injured patients — five from Queen’s and one from Straub Benioff — were transported by military jet to the Arizona Burn Center- Valleywise Health. These six had injuries beyond burns, he said.
This helped local hospitals maintain capacity for other patients, officials said, underscoring the need to prevent another tragedy of this magnitude from happening again.
Like a battlefield
The aftermath of the Aliamanu fireworks blast, which resulted in the deaths of three women and a 3-year-old boy, has been equated to the scene from a battlefield.
Honolulu Emergency Medical Services set up a triage and sent more than 20 patients to various hospitals, including Straub Benioff, The Queen’s Medical Center and Kaiser Permanente Moanalua Medical Center among others.
It was a night of urgency, with nurses and doctors called to come in during early-morning hours.
Queen’s, the state’s only Level 1 trauma hospital, cared for some of the burn patients for up to four days.
Straub Benioff, which runs the state’s only burn unit serving Hawaii and the Pacific, receives more patients around New Year’s on average than any other time of the year and prepares for this in advance, but this was unprecedented.
The specialized team has managed more than 20 patients at a time, but the number it can care for depends on each patient and the severity of their burns, according to Dr. Robert Schulz, the Burn Care Unit’s co-founder and medical director.
“Our Burn Care Unit, like the entire medical center, is built to be flexible,” said Schulz in a statement. “We have a highly trained team of about 100 and a majority are Advanced Burn Life Support certified. So, when we have tragedies with mass casualties, such as the Lahaina wildfires or the recent fireworks accident, we can expand our specialized care into other spaces at Straub Benioff.”
Consortium at work
The transfer of patients was possible thanks to the Western Region Burn Disaster Consortium, which is made up of burn centers that coordinate care during a mass casualty incident.
More than a dozen states with 27 burn centers are members of the consortium, including Alaska, Arizona, California, Oregon, Washington and Hawaii.
Dr. Kevin Foster, director of the Arizona Burn Center, which took in the six patients Jan. 4, said it was the first such transfer of multiple patients from Hawaii.
Foster said in a recent update that the six were still intubated and sedated but had undergone multiple surgeries and were “on course” in the recovery process. In addition to thermal burns, the six suffered wounds from flying shrapnel.
Fireworks injuries, overall, make up fewer than 1% of burn patients at the center, he said. They do occur during New Year’s and the Fourth of July but are usually small injuries that don’t require hospitalization.
“But every couple of years or so, there seems to be a big incident where we get multiple patients with big injuries — and so this year was New Year’s in Oahu,” said Foster.
Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, called the Aliamanu fireworks explosion “an extraordinary event” without precedent.
While the Maui wildfires resulted in 102 tragic deaths, the fireworks explosion is “the biggest single burn incident in Hawaii history” that he is aware of.
“We’ve never had to fly multiple patients at a time,” he said.
Straub Benioff’s burn unit, he said, is the only facility in the state with the equipment, doctors, nurses and other medical personnel trained to treat burns.
When patients are cared for in other hospitals ICUs, however, it means those beds are not available for others, such as stroke and heart attack patients. Another challenge is that burn patients stay in a hospital for much longer due to the extensive healing process.
In general, patients spend one to two days in the hospital for every 1% of their body that’s burned, according to Foster. The six patients in Arizona experienced burns to 50% or more of their bodies so are looking at months, plus additional time for rehabilitation.
The initial moments of treating severely burned patients is crucial, according to Dr. Schulz, as burns are a unique type of trauma.
“A patient can walk into the emergency room with a burn they do not think is too serious, and if they don’t immediately receive appropriate treatment, you can lose them,” he said.
Within 24 hours, for instance, the physiological changes brought on by the burned skin can become potentially lethal.
“The essential bacterial barrier and thermoregulation are lost,” he said. “Toxic products from the burn lead to vascular changes that require very large amounts of IV fluid. If not provided, the blood pressure will drop to shock levels, and kidneys will fail.”
Beyond the initial trauma, treating burns is a complex and lengthy process, said Schultz. The skin grafting process can extend some hospitalizations up to nine months.
Straub was able to discharge one of the Aliamanu patients but continues to care for some of the most serious and critically injured ones. Some have required several surgeries and will continue to undergo multiple skin grafting procedures.
Injuries rising
Data from the state Department of Health shows a spike in fireworks injuries over the New Year’s holiday — from Dec. 31 to Jan. 1 — over the past decade.
For the New Year’s holiday in 2024-2025, 110 injuries including the Aliamanu explosion were treated in emergency departments in Hawaii, compared with 29 a decade earlier in 2014-2015.
In 2023-2024, DOH’s EMS &Injury Prevention branch recorded 60 fireworks injuries, up from 54 the previous New Year’s holiday. The lowest number recorded, 23, was in 2011-2012, after a stricter permitting system was implemented on Oahu.
The most common injuries over the most recent New Year’s were burns to the hands, head or face, affecting 58% of patients. More than half, 52%, suffered from blast injuries, and 26% suffered both burn and blast injuries.
At least 27 patients were hospitalized, DOH said, a record high, compared with an average of six over previous years. The patients ranged in age from 1 to 83. Doctors have said most of the patients at Straub Benioff and in Arizona are in their 20s and 30s.
The injuries have risen despite efforts to put out messages on fireworks safety.
Ever year, county fire departments send out reminders about firecracker permits, hours of permitted use and safety tips, like never allowing children to play with or ignite fireworks, and only lighting them one at a time. The Honolulu Fire Department recommended glow sticks as alternatives.
The U.S. Consumer Product Safety Commission says even sparklers, often perceived as less hazardous, have caused severe burns as they can reach 2,000 degrees Fahrenheit — hot enough to melt some metals.
An estimated 9,700 fireworks-related injuries were treated in U.S. emergency rooms in 2023, 700 of them for sparklers, according to the CPSC.
Green urged Hawaii residents to stop using illegal aerials, saying “we are just going to have to do that as a society” to prevent another tragedy from happening.
“As a health care provider, I’ve just seen too much of it,” he said. “So please help us to turn the corner.”
