Texto

The ABC Daycare Disaster of Hermosillo, Mexico

David G. Greenhalgh, MD,* Philip Chang, MD,* Pirko Maguina, MD,*
Elena Combs,* Soman Sen, MD,* Tina L. Palmieri, MD*

On June 5, 2009, the ABC Daycare facility in Hermosillo, Mexico, caught on fire with an
estimated 142 children and 6 adult caregivers inside. The purpose of this article is to de-
scribe the factors contributing to the disaster including care of the survivors, tertiary burn
center triage, patient transport, and treatment for this international mass casualty event.
Finally, the results of an investigation performed by the Mexican Government are reviewed.
A summary of the Mexican Governments investigation of the circumstances of fire and an
examination of prevention lapses in other Mexican daycare centers was obtained from their
public Web site. The demographic and clinical characteristics of the children transported to
the burn center were obtained from the patients medical records and transport data sheets.
The ABC Daycare had many fire safety breaches that contributed to the severity of the trag-
edy. Twenty-nine children died at the scene and more than 35 children were hospitalized
throughout Mexico. A total of 12 children were transported to two Shriners Hospitals, 9 to
Sacramento, and 3 to Cincinnati. The mean age of patients sent to the Shriners Hospitals
was 2.9 ! 0.16 years (2 4 years), with 5 being male and 7 female. The mean duration be-
tween injury and arrival was 9.2 ! 2.1 days, the burn size was 43.0 ! 6.8% TBSA (6.5
80%), and there were 3.75 operations per patient. Four had fourth-degree burns requiring
finger amputations (2), flaps to cover bone (1), or a through-knee amputation (1). Ten pa-
tients were admitted to the intensive care unit, and nine patients (seven with inhalation in-
jury) required mechanical ventilation for a mean of 23.6 ! 10.3 days. All the surviving chil-
dren were discharged after a mean length of stay of 45.9 ! 8.7 days. In the first year
postinjury, seven children were readmitted a total of 11 times for reconstructive surgery,
wound care, or rehabilitation. Ultimately, a total of 49 children died. A review of other
daycare centers in Mexico revealed similar safety lapses that could lead to future major di-
sasters. This burn disaster in Hermosillo was potentially preventable with adherence to
standard prevention principals. The young age of the victims and the need for an interna-
tional medical response posed special problems. Prevention efforts need to be improved to
prevent future disasters in Mexico. (J Burn Care Res 2012;33:235241)

Burn disasters are unfortunate realities that affect not
only the local community but also the entire country.
Disasters from massive fires have had a profound in-
fluence on burn care and have stimulated advances in
burn care. Clearly, the Cocoanut Grove fire was in-
From the *Burn Department, Shriners Hospitals for Children
Northern California; and Department of Surgery, Burn
Division, University of California, Davis, Medical Center,
Sacramento.
Presented at the 15th Meeting of the International Society for Burn
Injuries, Istanbul, Turkey, June 25, 2010.
Address correspondence to David G. Greenhalgh, MD, Shriners
Hospitals for Children Northern California and UC Davis
Medical Center, 2425 Stockton Boulevard, Sacramento,
California 95817.
Copyright 2012 by the American Burn Association.
1559-047X/2012
DOI: 10.1097/BCR.0b013e3182335948
strumental in the early formation of the burn centers
in Boston.1 An air disaster in 1972 inspired local fire-
fighters to start our adult burn unit in Sacramento,
California. Fortunately, prevention measures have
been adopted to reduce the incidence of fire disasters in
many regions of the world. Although the frequency has
decreased, fire disasters still kill and injure large number
of people.2 Unfortunately, the same prevention mea-
sures have not kept pace in developing worlds. Poor
construction, lack of safety codes, and poor economies
lead to a greater potential for disasters.
On June 5, 2009, a large daycare facility (the ABC
Daycare) in Hermosillo, Sonora, Mexico, ignited
trapping young children and a few supervising adults.
Ultimately, 49 children aged 3 years or younger died.
Children were dispersed throughout Mexico, and 12
children were sent to two Shriners Hospitals for Chil-

235

236 Greenhalgh et al
Figure 1. A schematic layout of the ABC Daycare revealing the location next to the paper warehouse. Just north of the ABC
was a tire store and the other side of the paper warehouse housed a car license warehouse. A gasoline station was just across the
street but fortunately did not ignite during the daycare fire.
dren in the United States. As with any fire disaster, an
investigation was initiated by the Mexican Govern-
ment. The results were made available to the public
through a Web site.3 Herein, we present information
about our experience with triage, transportation, and
treatment of the children involved in this mass casu-
alty event. The goal of this article is to present the
causes of the fire, describe the dilemmas found in
triage and treatment, and finally to improve safety
efforts at schools to prevent future disasters.
METHODS
After obtaining permission from the University of
California, Davis Human Subjects Review Commit-
tee patient data were collected from medical records
from two of the four Shriners Hospitals for Children
Burn Hospitals (Northern California and Cincin-
nati). (Boston did not receive any patients, and the
fourth Burn Hospital in Galveston was closed at the
time because of hurricane damage.) Data concerning
the Mexican Governments investigation were ob-
tained from their public Web site.3 This Web site,
written in Spanish, was translated by one of the au-
thors (P.M.) who grew up in Peru and who is fluent in
Spanish. Some information was provided by the local
press (El Imparcial, Hermosillo) and by interviews
with patients and people present at the time of the
disaster. Some pictures were obtained from the Web
site and others by the authors during subsequent vis-
its. Many details of the actual fire and the actual res-
Journal of Burn Care & Research
March/April 2012
cue of the children are quite sketchy; so many details
such as the sites of all of the deaths are not known.
RESULTS
Factors Contributing to the Fire
Hermosillo, Mexico, is in the heart of the Sonora
Desert where the temperature, in June, commonly
rises over 100F (37.8C) and has been known to
reach 122F (50C). The ABC Daycare is a part of a
series of daycares within Mexico that provides care for
children of working Mexican citizens. The daycare
was not owned by the government but we believe that
it was subsidized by the government. The Hermosillo
ABC Daycare managed up to 150 children in one part
of a warehouse that was a four complex structure
(Figure 1). The warehouse had 24 rooms but only
had 3 exits. Of the three, two doors were locked with
the keys reportedly being located in an administrative
office desk. The keys were never found. The only exit
was through the administrative office. East of the day-
care were two large rooms with the adjacent room
being a document warehouse and the farthest east
being a license warehouse. Just north of the daycare
was a tire store.
The daycare and the warehouse shared a common
wall that was made of cinderblocks without concrete
filling. Only the daycare had drywall on the inside
walls. The wall, according to code, was supposed to
be a 2- to 3-hour fire retardant wall but the daycare
was out of compliance. A large door between the
Journal of Burn Care & Research
Volume 33, Number 2 Greenhalgh et al 237

Figure 2. The floor plan of the ABC Daycare reveals the multiple rooms and the sites of the fire (taken from the Mexican
Governments website). Rooms 11 and 12 were next to the site where the fire started. As a result of being the first rooms to
be engulfed, 12 children died in room 11 and 20 died in room 12. The sites of entry created by driving a truck into the wall
are identified. The identity of each room is included: 1, Reception, main door; 2, Infirmary; 3, Toddler room A; 4,
Administration; 5, Kitchen; 6, Pantry; 7, Staff restrooms; 8, Staff breakroom; 9, Small infant restroom; 10, Classroom; 11,
Toddler room B1; 12, Toddler room B2; 13, Toddler room C1; 14, Toddler room C2; 15, Infant feeding room; 16,
Educational materials; 17, Patio; 18, Infant room A-B; 19, Infant room A-B; 20, Infant room C; 21, Play area; 22, Office; 23,
Maintenance; 24, Multipurpose with circus PVC tent ceiling.

daycare and warehouse had been closed with cinder-
blocks with the repurposing of the daycare (Figure 2).
The roof was made of tin and was lined inside with
polyurethane foam. There were ceiling tiles in the
daycare rooms and in the large central area was a
polyvinyl chloride circus tent cover. These materi-
als were highly flammable.
The Fire and Resulting Injuries
The children, estimated to be 142 in number, were
almost all less than 5 years of age. Supervision was
provided by six adults. The fire started in a cooler (a
form of air conditioner) in the paper warehouse (the
building next to the daycare). The temperature on
that day was 43C (109F), so the cooler was running
continuously. Investigation of the fire revealed that
the damage to the coolers motor was more severe
than its casing confirming that it was the source. Mo-
tor coils melted and likely caused sparks to ignite the
engine. In addition, there were hand-twisted wires
connected to the motor which was plugged into an
extension cord with multiple plugs. The fire rapidly
traveled to the nursery through the single wall and it
is likely that the polyvinyl chloride circus tent ceil-
ing rapidly flashed over to create an explosive fire.
In addition, the investigators felt that the ceiling tiles
also ignited creating a rain of fire that involved
many of the rooms near the paper warehouse.
There were several factors that impeded the rescue
of the children. The only door that was open was
through the administrative office and the key to the
other door was in a drawer and was unable to be
found. Rescuers and family members arrived but were
frustrated by the inability to enter the facility. Fire-
fighters attempted to use sledge hammers to break
down the wall. One parent used his truck as a batter-
ing ram to create four holes in the cinderblock wall.
Rescuers used these holes to extract the children.
Most of the deaths occurred deep inside the daycare
next to the document warehouse. Because this area
was farthest away from the entry sites of the rescuers,
it is likely that delays in finding these children con-
tributed to their mortalities.
Of the 148 people estimated to be inside the day-
care, 29 children died at the scene (14 boys and 15
girls). All of the deaths were in very young children (7

238 Greenhalgh et al
children aged 3 years, 21 children aged 2 years, and 1
infant aged nine months). All but one child died of
inhalation injury with the other child dying of his or
her burns. Of the 131 people injured in this fire, 75
children and 6 adults sustained burns. The adult in-
juries were relatively minor. Seventy-six had inhala-
tion injury and were treated as outpatients. The chil-
dren were sent to six local hospitals (Hospital Chavez,
4; Clinica del Noroeste, 2; Hospital General del Es-
tado, 15; Centro Internacional de Medicina, 4; Hos-
pital Infantil de Sonora, 12; and Clinica 36, 2), and
eventually some were sent to other hospitals in Mex-
ico (Guadalajara Centro Medico del Occidente, 8;
Obregon Hospital de Especialidades Numero 1, 5).
Twenty-eight children were treated in hospitals and
survived. Ultimately, 20 more children died in hospi-
tals, with 18 dying in Mexico and 2 expiring in 2
different Shriners Hospitals (Northern California and
Cincinnati). Thus, the total number of deaths ulti-
mately reached 49. There were 75 children and 6
adults injured, leading to a total of 131 people suf-
fering from some form of injury.
The Shriners Hospital Experience
Starting the day after the fire, transfers of the most
severely burned children to the Shriners Hospitals for
Children in the United States began. The Shriners
Hospitals provide free care to children with burns in
North America, including Mexico. Normally, the
Galveston and Northern California Hospitals are the
pediatric tertiary referral centers for Mexico but at
this time Galveston was still closed after damage from
Hurricane Ike. The Northern California Hospital is
the primary referral site for the Hermosillo region.
Transfer of patients to a Shriners Hospital is at the
request of the referring physician. The process is ini-
tiated with a phone call, and if the patient is younger
than 18 years, acceptance is universal. The triage for
this disaster was orchestrated by one of the burn sur-
geons (T.L.P.) who triaged patient referrals to the
Shriners Hospitals based on acuity. To assist with
triage, one of the Shriners surgeons (P.M.) traveled
to Hermosillo, Guadalajara, and Obregon. The hos-
pitals in the latter two cities did not wish to transfer
any children (except one who was sent in extremis
later in her hospital course). A total of 12 children
with the most severe burns were transferred to two of
the Shriners Hospitals over approximately 2 weeks
after the fire. The Mexican Air Force transported
most of the children. Cincinnati accepted three pa-
tients (45, 48, and 61% expired). The experience
with the 12 children transferred to Shriners Hospitals
for Children Northern California and Shriners Hos-
pitals for Children Cincinnati will be described in
Journal of Burn Care & Research
March/April 2012
Table 1. Characteristics of the 12 children transferred
from the ABC Daycare to the Shriners Hospitals for
Children, Northern California and Cincinnati
Age (yr) 2.92 ! 0.16 (24)
Male/female 5/7
Time between injury and 9.2 ! 2.1
admission (d)
Burn size (%) 43.0 ! 6.8 (6.580) TBSA
ICU length of stay (d), N " 10 30.6 ! 9.5
Ventilator days (d), N " 9 23.6 ! 10.3
Total length of stay (d) 42.5 ! 8.2
Deaths 2
Length of stay of survivors (d) 45.9 ! 8.7
Values expressed as mean ! SE of the mean (range).
ICU, intensive care unit.
more detail (Table 1). The first child arrived in Cali-
fornia 1 day after the disaster. One or two of the
children arrived daily for the ensuing week. The first
few were transported by the Mexican Air Force and
the rest were transported by private transport compa-
nies. Cincinnati received their first patient 1 week
after the fire with the other two arriving around 3
weeks after injury. One of the patients transferred to
Cincinnati was in such critical condition that she died
within 24 hours of arrival.
The mean age of the 5 boys and 7 girls transported
to the Shriners Hospitals was 2.9 years (2 4 years).
The mean burn size was 43% (6.5 80%) TBSA. The
faces and hands were severely affected with many
needing finger amputations. Ten patients were ad-
mitted to the intensive care unit and seven had smoke
inhalation injury. The mean number of ventilator
days was 23.6 (range 1 86) days, mean intensive care
unit stay of 22.9 (range 1 86) days, and the mean
length of stay was 45.9 (range 194) days. Because of
the distance away from home and the ability for the
Shriners Hospitals to keep children in an outpatient or
inpatient facility, many children stayed at the hospital for
therapy or social issues. All the children required surgical
excision and grafting of their burn injuries. On the av-
erage, each child required 3.75 operations (range 0 9).
The one girl required nine operations including multi-
ple local flaps performed to cover exposed lower ex-
tremity bones. Two children required amputations of
fingers, and one child from Cincinnati required a
through-knee amputation. Two children died of sepsis
and multiple organ dysfunction syndrome, one died 50
days after admission in Northern California, and one,
transferred in extremis, died the day after admission in
Cincinnati (21 days after burn).
During the first year after their burns, seven chil-
dren required readmission for various reasons. There
Journal of Burn Care & Research
Volume 33, Number 2
were nine reconstructive procedures performed dur-
ing these admissions. One child required readmission
for a chronic scalp wound and another required read-
mission for rehabilitation. In the ensuing 6 months,
several children required further reconstructive pro-
cedures. The majority of these procedures have been
for hand or facial reconstruction. Most of these chil-
dren will require further reconstructive procedures to
optimize their functional and cosmetic outcomes.
Safety Evaluation of the ABC Daycare and
Other Mexican Daycares
The ABC Daycare disaster incited outrage through-
out Mexico. In response and as per routine, the Mex-
ican Government performed an evaluation of the
safety practices in the ABC Daycare and daycares
throughout Mexico. The results of these evaluations
are published on a Web site produced by the govern-
ment review.3 The review revealed profound safety
lapses. At the ABC Daycare, there were no smoke
detectors, no fire extinguishers, no fire alarms, no
emergency exits, no valid license to operate a daycare,
no municipal inspections, no fire marshal inspections,
and improper building materials (highly flammable
materials circus tent ceiling). These lapses existed
despite a report of passing an inspection on May 26,
2009 (10 days before the tragedy).
These findings prompted a government inspection
of another 1480 daycares throughout Mexico. The
results of this inspection were just as dismal. Overall,
53% had no valid license to function as a nursery and
32% had no license to have a business in the building.
In addition, 70% had no fire inspections, 75% had no
fire drills, 72% had unacceptable electric installations,
and 52% had unacceptable gas installations. Of those
that were inspected, 85% failed at least one inspec-
tion. The inspections revealed that 43% had a smoke
detector, 6% had no emergency exit, 13% had an
emergency exit greater than 40 m from the class-
room, 86% had doors that pushed outward, and 6%
had fire extinguishers. Of those who failed inspection,
77% did not implement any changes.
DISCUSSION
There have been many fire-related disasters involving
hundreds to even more than thousand deaths.2,4 11
Documenting the causes of each disaster is essential
to prevent future tragedies. These lessons should be
translated into laws and codes that prevent similar
lapses leading to more disasters. The ABC Daycare
disaster has many characteristics that are very similar
to previously reported fire disasters. The best docu-
mented disaster was the 1942 fire at Bostons Cocoa-
Greenhalgh et al 239
nut Grove Nightclub.1 An excellent summary of the
disaster was chronicled by Dr. Jeffrey Saffle in 1993.
This summary reveals striking parallels to the ABC
tragedy. The nightclub was overcrowded and filled
with flammable materials. Similar to the tent-like
ceiling in the ABC Daycare, the nightclub had a
highly flammable blue satin ceiling in the room where
the fire started. Once the fire started, many doors
were locked or difficult to find. The main exit was a
rotating door that rapidly became blocked by people
crushed by the crowds desperately pushing others to
escape. Another exit had a door that opened into the
room and so it was also blocked by the crush of ter-
rified occupants. Those inside the building mainly
died from hypoxia and smoke inhalation injury.
Those who escaped also had severe inhalation injury
as documented by people showing up in Emergency
Departments and suddenly dying in front of provid-
ers. Similar stories were reported in Hermosillo. We
were told that children arrived at the hospitals just
seemed to stop breathing and died. As for Her-
mosillo, the Cocoanut Grove Nightclub had recently
passed fire code inspections, but there were reports of
violations that were ignored with possible political
implications (not so for the ABC Daycare).
Of the many other fire disasters, the stories are very
similar. People are trapped inside a building with
flammable materials rapidly flashing over to create a
major fire. In the panic to escape, people are trapped
because the available exits are inadequate or are
blocked so that people are crushed and overcome by
the toxic and hypoxic smoke. The lessons learned in
developed countries have led to many building codes
and regulations that have been strictly enforced.
These laws have led to a decrease in the numbers of
deaths in disasters between the first and second halves
of the 20th century.2 Fire inspections are much
stricter in the industrialized countries than in coun-
tries with lower economic status. Clearly, Mexico has
knowledge of safety codes, but the compliance and
enforcement of these codes is very lax. The survey of
other daycare centers confirmed major problems in
burn prevention regulations in the country. Unless
major changes occur, a similar disaster awaits Mexico.
Mexico has suffered from previous fire tragedies.
The most notable disaster occurred in 1984 in San
Juanico.12 This town, 20 km north of Mexico City,
was next to a major liquid petroleum gas storage fa-
cility. Over the course of years, houses had been built
within 130 m of the facility. Some of the houses were
constructed illegally (too close to the facility) and
the streets were very narrow. In addition, there
were no water pipes in the town to use for extin-
guishing fires. On November 19, 1984, a boiling-

240 Greenhalgh et al
liquid expanding-vapor explosion occurred to ig-
nite several of the storage tanks. Clouds of explosive
vapor leaked and spread toward the town and then
ignited. The explosions started at 5:35 AM in the
morning in a sleeping village. In the end, 300 people
died at the scene and another 250 died in hospitals.
The review describes 7230 people injured with 1970
hospitalized and 625 suffering from severe thermal
injuries. The injured were treated in various trauma
and burn centers. One center, Centro Medico, was
described as having a 48-bed burn unit but had re-
ceived 37 patients from another silo explosion 3
days before the San Juanico disaster. They received 88
more burn patients from the liquid petroleum gas ex-
plosion. In the end, there was an admirable gathering of
resources to treat the burn victims of this disaster.
There have also been several fire disasters at schools
which have resulted in hundreds of deaths in chil-
dren.2,13 On March 8, 1908, 176 children died in the
Lakeview Elementary School, Collingwood, OH. On
May 17, 1923, 76 children died at the Cleveland
Rural Grade School in Camden, SC; and on Decem-
ber 24, 1924, 36 more died in Babbs Switch School
in Hobart, OK. In an explosion with no subsequent
fire, 298 children died in the New London School-
house in 1937. In 1958, at the Our Lady of Angels
(an appropriate name) School in Chicago, a fire
trapped many children resulting in 95 deaths and 93
injuries (many from children jumping out of windows
from the second floor).13 Locked exits also contrib-
uted to the high mortality rate in this fire. The ABC
Daycare disaster in Hermosillo has many of the same
characteristics as the previous pediatric tragedies.
Children, especially the very young, are more vulner-
able because they lack many of the decision capabili-
ties of adults. The ABC Daycare was especially vul-
nerable because most of the children were under 3
years of age and thus were dependent on adults for
assistance with escaping the fire. Inadequate super-
vision, based on the low number of adults super-
vising, undoubtedly contributed to the deaths in
these children. These school disasters also make it
very clear why fire drills are extremely valuable to
train children as what to do in case of a real fire.
Many factors were against the children; lack of su-
pervision, extremely flammable materials, lack of
fire alarms and fire drills, and lack of adequate and
appropriate exits all made the odds of surviving the
Hermosillo daycare disaster very slim. One must
hope that improvements are enforced in schools in
the future. Mexico must examine its laws, codes,
and regulations to ensure the safety of children in
schools. Even more important will be the enforce-
Journal of Burn Care & Research
March/April 2012
ment of the laws and punishment of those schools
which do not follow the codes.
What became evident with the ABC Daycare di-
saster was the limited amount of resources for burn
treatment in the Northwestern region of Mexico.
As a matter of fact, the number of burn care facil-
ities in the entire country seemed to be inadequate.
One positive effect of the ABC Daycare disaster is
the willingness of the country to address the burn
care shortcomings. One must give credit to the
government for examining other daycares to deter-
mine how extensive the shortcomings really are.
Clearly, there are severe problems with the safety in
these facilities. A second benefit is the govern-
ments recent efforts to improve Mexicos ability to
treat burn patients. There is a move to develop
more burn care facilities in several communities
including Hermosillo. The government has also
supported the training of burn team members in
burn units in the United States (including ours). A
fellowship to train burn surgeons, supported by the
Mexican Government, has been started in the Sac-
ramento, California, burn program.
CONCLUSION
A disaster is tragic enough because of the loss of
potentially productive citizens. A burn conflagra-
tion involving very young children is even more
tragic. What would be worse, however, is if a disas-
ter does not stimulate changes that might prevent
future similar disasters from occurring. The ABC
Daycare disaster had all the characteristics of many
previous disasters that have occurred throughout
the world. Let us hope that lessons can be learned
to prevent future disasters from recurring not only
in daycares and schools but also in all regions of the
world. One can only hope that the disaster spurs
better prevention strategies and better burn care
facilities in Mexico.
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