2016 Ghost Ship Warehouse Fire (Oakland, CA)
· Incident: Ghost Ship Warehouse Fire
· Topic: Inhalation Injury, Toxicology (CO/CN), & Mass Casualty Triage
· Date: December 2, 2016
· Location: 1305 31st Avenue, Oakland, California
· Casualties: 36 Fatalities / 2 Injuries
· Cause of Death: Asphyxia due to Smoke Inhalation (Carbon Monoxide and Hydrogen Cyanide Toxicity)
I. Introduction
Hello everyone. I’m Brendan. For those who haven’t trained with me before, my background is Navy Medicine—I spent time with the Marines in Helmand—followed by years in hospital management and EMS operations. I tell you that not to impress you, but to let you know that what we discuss today is rooted in the reality of the field, not just a textbook.
Today, we are discussing the Ghost Ship Warehouse Fire. This is a heavy topic. Thirty-six people went out for a night of music and community and never came home. It remains the deadliest fire in the history of Oakland and the deadliest in California since the 1906 earthquake.
We study this tragedy to understand the pathophysiology of the environment. As medical providers—whether you are an EMT, a nurse, or a layperson with a med-kit—we often focus on the patient. But in a structure fire, the environment is the weapon.
My goal today is to bridge the gap between tactical awareness and clinical medicine. We are going to break down exactly how smoke kills on a cellular level and how we manage that in the chaos of a Mass Casualty Incident (MCI).
I want this to be interactive. Ask questions. Challenge the protocols. If something doesn't make sense, stop me. Let’s get to work.
II. Incident Brief: Clinical & Tactical Timeline
To treat the patient, you have to understand the mechanism of injury. In this case, the mechanism was a "perfect storm" of structural negligence.
The Environment
The "Ghost Ship" was a converted warehouse acting as an artist collective and unpermitted living space. The interior was a labyrinth. It was filled floor-to-ceiling with wooden pallets, old furniture, pianos, and tapestries.
· Tactical Nightmare: The layout was improvised. There were no sprinklers. There were no fire alarms.
· The Choke Point: The only access to the second floor (where the party was held) was a makeshift staircase made of wooden pallets—narrow and unstable.
The "T-Minus" Timeline
This event highlights how little time we actually have when a fire transitions to flashover conditions.
· T-0 (23:20): Smoke is spotted on the first floor. A small fire begins in the back of the warehouse, likely electrical.
· T+2 Minutes: The fire climbs the highly combustible "clutter" and reaches the ceiling. The power fails. The warehouse plunges into pitch darkness.
· T+3 Minutes: Panic ensues on the second floor. The smoke layer descends. Attendees attempt to flee, but the pallet staircase acts as a bottleneck.
· T+5 Minutes: This is the critical physiological window. The smoke—laden with plastics and treated wood chemicals—becomes so dense that visibility is zero. Victims are now inhaling lethal concentrations of toxins.
· T+10 Minutes: Fire crews arrive. The roof is already compromised. The thermal load is too high for entry.
Tactical Lesson: Situational Awareness
The takeaway here is Egress Analysis. When you enter a venue—especially a "pop-up" or non-standard venue—look for the exit that isn't the one you came in. If the layout feels like a maze and the walls are covered in kindling, your internal alarm bells should be ringing. In tactical medicine, we say: "Scene safety is dynamic." If the environment prohibits a rapid exit, the scene is not safe.
III. Medical Analysis: Physiology & Pathophysiology
Let's move to the clinical side. The media often reports "died of smoke inhalation." But as clinicians, we need to be more precise. These victims didn't just "run out of air." They were chemically poisoned.
We are dealing with the "Toxic Twins": Carbon Monoxide (CO) and Hydrogen Cyanide (HCN).
1. Carbon Monoxide (CO): The Oxygen Thief
The Analogy: Think of your red blood cells as a fleet of delivery trucks (Hemoglobin). Their job is to pick up packages (Oxygen) at the lungs and deliver them to your organs.
· The Physiology: CO is a bully. It binds to Hemoglobin with an affinity 200 to 250 times stronger than Oxygen.
· The Result: Imagine the delivery truck pulls up, but CO hijacks the driver's seat and locks the doors. The Oxygen can't get in. The truck drives around the body, but it's delivering nothing. The patient suffocates while their blood is circulating, because the blood can't carry the cargo.
2. Hydrogen Cyanide (HCN): The Engine Breaker
Hydrogen Cyanide is a byproduct of burning plastics, foam, and synthetic materials (all present at Ghost Ship).
The Analogy: Let’s say a few Oxygen molecules manage to sneak past the CO and get to the destination (the cell). They walk into the factory (the mitochondria) to start working.
· The Physiology: Cyanide shuts down the factory machinery. Specifically, it inhibits Cytochrome C Oxidase in the electron transport chain.
· The Result: This is called Histotoxic Hypoxia. The cell has plenty of oxygen delivered to its doorstep, but it cannot use it to create energy (ATP). The cell switches to anaerobic metabolism, lactate spikes, and the cell dies.
Mechanism of Injury Summary:
The victims at Ghost Ship experienced immediate disorientation (CO) followed by cellular asphyxiation (CN). This causes rapid loss of consciousness, often before thermal burns (fire) actually reach the body.
IV. Standards of Care: The MARCH Algorithm
We are going to run this as if we are the Triage Group Supervisor or a Paramedic on the first arriving ambulance. We use MARCH because it prioritizes what kills the patient fastest.
M - Massive Hemorrhage
· The Danger: In a fire/stampede scenario, you may have lacerations from broken glass or internal bleeding from crush injuries (trampling).
· Signs/Symptoms: Bright red spurting blood, pooling blood.
· Intervention:
o Do a blood sweep.
o Apply CAT Tourniquets high and tight for limb hemorrhage.
o Note: In this specific fire, this was secondary, but never assume.
A - Airway
· The Danger: Thermal burns cause edema (swelling). The throat can swell shut in minutes.
· Signs/Symptoms: Soot around the nose/mouth (carbonaceous sputum), singed nasal hairs, hoarseness, or Stridor (a high-pitched whistling sound).
· Intervention:
o Aggressive Early Management. If you hear stridor, they need an airway now.
o In a BLS setting: NPA/OPA (if unconscious).
o In an ALS setting: Rapid Sequence Intubation (RSI) using a video laryngoscope (Glidescope) because soot will obscure your view. Don't wait for them to crash; secure the tube while you still can.
R - Respiration
· The Danger: The "Toxic Twins" (CO and CN).
· Signs/Symptoms: Shortness of breath, confusion, cherry-red skin (rare, late sign for CO), or simply being pulled from a smoke-filled structure.
· Crucial Note: Pulse Oximetry (SpO_2) Lies. Standard finger probes cannot tell the difference between Oxy-hemoglobin (good) and Carboxy-hemoglobin (bad). A patient can have a lethal CO level and read 100% saturation.
· Intervention:
o High-Flow Oxygen: 15 Liters/min via Non-Rebreather Mask (NRB) for all smoke inhalation patients, regardless of SpO_2 reading. This reduces the half-life of CO in the blood.
o Monitor utilizing Waveform Capnography (EtCO_2).
C - Circulation (and Toxicology)
· The Danger: Shock from cyanide poisoning and fluid loss from burns.
· Signs/Symptoms: Tachycardia (fast heart rate), hypotension (low blood pressure), altered mental status.
· Intervention:
o IV/IO Access: Two large-bore lines (18G or larger).
o The Antidote: If the patient was in a closed-space fire and has altered mental status or cardiac arrest, we treat for Cyanide.
o Drug: Hydroxocobalamin (Cyanokit).
o Dose: 5g IV infusion over 15 minutes.
o Mechanism: It binds to cyanide to form Vitamin B12, which is harmlessly peed out. (Warning: It turns the patient and their urine bright red/purple).
o Fluids: Lactated Ringers (LR). If there are significant burns (>20% TBSA), initiate Parkland Formula protocols, but start with a bolus to maintain radial pulses.
H - Hypothermia / Head
· The Danger: Burn patients lose the ability to regulate body temperature. Also, head trauma from falling debris.
· Intervention:
o Stop the burning process.
o Keep them warm. Use foil blankets or active warming. A cold trauma patient is a dead trauma patient (Coagulopathy).
o Assess GCS (Glasgow Coma Scale).
V. Closing Thoughts
The tragedy at Ghost Ship was a collision of negligence and physics. The building was a fire trap, but it was the toxicology of the smoke that claimed 36 lives.
Your 3 Takeaways:
1. Respect the Smoke: In modern structure fires with synthetics, the smoke is a chemical weapon. It kills faster than the heat.
2. Trust Your Gut (and check your exits): Situational awareness is not paranoia; it’s survival. If the ingress is sketchy, the egress will be fatal.
3. Treat the Toxin: In fire survivors with altered mental status, do not trust the Pulse Ox. Blast them with 100% Oxygen and consider the Cyanokit early.
This job is hard. We see the worst days of people's lives. But by studying these events, we sharpen our skills so that when the bell rings for the next one, we are ready.
Stay safe, watch your six, and keep learning.
Works Cited
1. Official Investigative Report:
o Alameda County District Attorney’s Office. (2016). Investigative Report: 31st Avenue Fire. (Referenced via Alameda County Superior Court documents regarding People v. Almena).
2. Clinical/Medical Citation:
o Joint Trauma System (JTS) Clinical Practice Guideline (CPG). (2024). "Inhalation Injury and Toxic Industrial Chemical Exposure." Defense Health Agency.
o Journal of Emergency Medical Services (JEMS). (2017). "Cyanide Toxicity: The unseen killer in structure fires."
3. News Reports:
o Fuller, T., & Dougherty, C. (2016, December 4). "Death Toll in Oakland Warehouse Fire Rises to 36." The New York Times.
o Sernoffsky, E., & Ho, V. (2016, December 6). "Ghost Ship fire: The desperate final moments." San Francisco Chronicle.
