Burn Lessons Learned From the Whakaari White Island Volcanic Eruption

New Zealand's most active volcano, Whakaari White Island was a common tourist attraction prior to its eruption on December 9, 2019. At the time of the eruption, there were 47 people on the island from 3 tour groups. Thirty-nine people survived the initial eruption and were extracted. Thirty-one entered into the New Zealand National Burn Service across four hospitals. The median age of the patients treated at the National Burn Centre was 45.5 years (range: 14-67 years) and median TBSA burn was 49.5% (range: 9%-90%). The 3-month survival of this eruptive event was 55%, which subsequently fell to an overall rate of 53% following one late death of an early survivor after repatriation home. Of the patients who survived the initial eruption for long enough to be admitted to the National Burn Service, the overall survival rate was 71% at 3 months. We describe 12 lessons we have learnt from our management of the survivors. The key surgical lessons among these are: 1) The injuring mechanism combined ballistic trauma, thermal and acidic burn components, with the acid component being the most problematic and urgent for management; 2) Volcanic ash burns result in ongoing burn depth progression, deep underlying tissue damage and significant metabolic instability; 3) Early skin grafting was not successful in many cases; 4) Reconstructive strategy needed adjusting to cope with the high operative demand and limited donor sites in all patients; 5) Protect yourself from potential dangers with additional personal protective equipment in an unfamiliar setting.