The overall goal of the emergency medical services (EMS) system is to reduce overall mortality and morbidity at nominal or reduced costs. To accomplish this goal an EMS system uses many subcomponents, each with specialized skills, integrated so as to insure a competent continuum of care. Questions inevitably arise about the ability of EMS systems to deliver the intended results. While discussions of mortality and morbidity tendencies are meaningful measures of outcomes and, perhaps, the “bottom line,” these two criteria are a total system measurement. They are not subsystem measures, and, therefore, offer little insight into the reasons for success or failure of the EMS system.

As a field commander attacks an emergency medical incident, his thought processes depend upon information gathered during the incident and information about the effect of resources and competencies upon past incidents. The decisions which determine treatment and patient survival, as well as rescuer safety, are a direct function of this tactical thought process. This paper examines how this thought process is formed and how it may be improved through the use of a mechanistic system evaluation model.

In 1966, the first major step toward a systematic delivery system for EMS was taken when a U.S. government report recommended that a nationwide program be established that would form non-traditional “EMS regions.” These regions would be the foundation for a comprehensive systematic approach to the problem of unnecessary death and disability in the prehospital setting (1).

In the last few years various departments of the University Hospital “A. Gemelli” have been engaged in dealing with disasters of different kinds: the earthquakes of Belice, Friuli and Irpinia, the fire of the Todi antique exhibition, and various terrorist attacks. In these events the organization of the care of the survivors took the following four aspects into account: 1) Type and kind of lesions related to the nature of the event. 2) Criteria and collection areas of the injured, casualty clearing and treatments. 3) Distance of the disaster from the treatment center. 4) New structures to be set up for improving efficiency in the future.

1) The most frequent clinical problems encountered burns and crushing injuries, and those affecting the musculoskeletal, cardiorespiratory and neuro-muscular systems. In a second phase, together with the possible lack of water, food, clothing, shelter and toilet facilities, infectious diseases of the respiratory and gastro-intestinal tract appear, particularly in old people and children. The treatment of the injured in the emergency phase requires a series of interventions at a very high technological level. In the subsequent phase, which may last for months, the treatment needed comes under normal preventive and clinical care.

2) In the emergency period, which in our experience does not generally last longer than ten days, the medical and surgical departments of our hospital mostly concerned were the intensive care units (18 beds), the orthopedics and traumatology sections (122 beds), the surgical wards (309 beds), the transfusion center and the hemodialysis service.

The need to arrange the assistance beforehand and therefore prepare for the prevention of damage to people and property that may result from accidents or events of considerable magnitude occurring inside the University Hospital, “A. Gemelli,” has led to several laws of the Constitution of the Italian Republic (Article 35), the Criminal Code (Articles 437 and 451), and the Civil Code (Article 2087): The law of Feb 12, 1955, #51 (Official Gazette 54, March 7, 1955); Decree 547 of April 27, 1955 “Regulations for the prevention of industrial accidents” and Decree 302 of March 19, 1956.

The study of these assistance procedures has led to the formulation of an emergency plan divided into two basic parts: prevention of accidents, and rescue operations.

By prevention we mean: a) The training of all staff and Managing Bodies of our Faculty/Staff to take effective action in the case of an intra-hospital accident, b) The need for detailed information on the various procedures to be used depending on the gravity of the event, c) Awareness of the civil and criminal responsibilities relating to the various management and non-management levels in case of emergency.

The training plan for the whole staff, approved by the management administrative, technical and medical bodies, consists of theoretical and practical courses. These courses, which started in June 1983 are “modular.” The staff will take part in them as homogeneous groups, for a period of time which will vary, in regard to the number of hours and kind of instruction, and in relation to what each group has to learn about work safety, fire prevention and emergency measures.

The topic of this paper is not only of concern to people interested in transplantation. The organization described stemmed from the experience of the earthquake in southern Italy in 1980, in which physicians of our transplant center participated only as surgeons. We feel that a tranaplant team could be useful in a mass casualty situation with the intent to help in the triage of the seriously injured, select patients with brain death, and transport selected donors to transplant centers.

The problem of triage in mass casualties is by itself a difficult and complex ethical and practical issue (1). The first hours after any disaster has occurred are crucial in dividing patients into different categories and in putting them into the care of specialized physicians, according to their primary lesions. Often severely traumatized people are discovered late and do not get the primary intensive assistance which will allow them to stabilize their clinical condition (2).

According to the type of disaster, the percentage of head trauma patients varies greatly, reaching its peak in case of earthquakes (approximately 4% of victims died of head trauma), air crashes and building destructions (3). It is reasonable to think that often head trauma is associated with multiple traumas and that in some cases (direct trauma of the most important organs, crush lesions, etc.) this may represent a contraindication to considering the patient as a donor. Generally, however, head trauma with brain death, even associated with different lesions but without metabolic, septic or cardiovascular alterations, must at least be considered for organ donation (4).

DePauw University operates yearly mission projects in disaster areas of Central and South America. Since 1976, 26 missions in 8 countries have been conducted. With the guidance of international health and engineering professionals, over 500 undergraduate student volunteers have managed the planning, execution, and outcome review aspects of the projects. This paper examines and summarizes the work to date, emphasizing the vital interactions between volunteers and the local health communities. We conclude that ongoing disaster relief projects such as ours serve a useful purpose in the delivery of disaster relief services.

At the Second World Congress on Emergency and Disaster Medicine in Pittsburgh in 1981, Professor Negovsky talked about the Science of Resuscitation. Science is defined as systematic and formulated knowledge. Therefore, to be a science, resuscitation must be presented in accurate and concise terms. The introduction of Standards in the methodology of Resuscitation has achieved this. In 1977, the American Heart Association published Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care (1) and revised them in 1980 as Standards and Guidelines (2). Organizations in other countries have also introduced such standards: the Canadian Heart Foundation, the Heart Foundation of New Zealand, the Australian Resuscitation Council, and the Resuscitation Advisory Council in the United Kingdom; they all have systematic and formulated methodologies. The value of these standards and guidelines in Resuscitation methods can only be gauged by the results of various individual surveys. The definition of Resuscitation as a science runs into problems when one begins to examine these results. This paper will illustrate the difficulties of evaluating Resuscitation results.

Figure 1 shows a comparison of survival rates in5 centers (3-7) when Cardiopulmonary Resuscitation (CPR) was initiated by a rescue team or a bystander. It would appear that Seattle had the best overall survival rate, followed by Oslo. But Thompson and colleagues (5) from Seattle studied survival from cardiac arrest only when ventricular fibrillation was present when the paramedical personnel arrived. Lund and Skulberg (7) from Oslo did not state their type of victim, whereas Cobb and his colleagues (4) in suburban Seattle, with the lowest survival rates, looked at all forms of cardiac arrests.

The easy availability of small aircraft for charter, has been accompanied by increasing willingness on the part of insurance companies to pay the costs for the use of these air ambulances. Operators of aircraft in the United Kingdom and Europe were becoming increasingly worried about the moral, medical and legal implications of carrying seriously ill or injured passengers. In late 1980 the UK Air Taxi Operators Association (ATOA) began to formulate Guidelines for air ambulance operations, and in 1981 these were incorporated into the studies of the same subject by the International Business Aircraft Association (IBAA), Europe. This paper presents the Guidelines adopted by the ATOA and ratified by IBAA Europe. The Guidelines are designed not to hamper the development of aeormedical rescue, but to bring it within a proper medical aeronautical framework for the safety of the patients, and medical and aircraft crews.

During the last 30 years development of the international travel market in Europe has resulted in many patients becoming ill or suffering injuries many miles from their own home. In the past these people would have remained in a local hospital and received treatment by the locally available facilities. There has been a revolution in the technology of medical transport, providing skills and equipment which allows the most seriously injured people to be transported over long distances. The public demand has pressed insurance companies to offer as part of travel packages the possiblity of medical repatriation. The number of new serious medical cases abroad reported to Europ Assistance in London, rose from 736 in 1978 to a projected 3,500 in 1983.

The Somali government has had to deal with serious health problems in the refugee population, especially malnutrition, tubercolosis, malaria, schistosomiasis, and parasitic diseases, arising from changes in environment and living patterns, the process of migration itself, lack of food, and the settlement in special camps. Emergency health plans have therefore been formulated by the Ministry of Health in concert with international agencies, foreign governments, and private aid organizations. An original contribution has been made by the Department of Community Health at the Faculty of Medicine at the National University, in the field of health education and health care. A number of problems were encountered, originating from varying philosophies of intervention and from the particular cultural characteristics of the population. The authors compare their experience with the period of mass resettlement during and after the 1974-75 drought in order to arrive at recommendations for the planning of health services in similar situations.

Italian physicians who, from Oct. 1979 to April 1981 directed an emergency medical team in the Ogaden refugee camps of the Qorioley district of Somalia, report on location, general set-up, vital statistics, health aspects, water and food supply, sanitation, disposal of waste matter, health hazards, spread and control of diseases, health education, and planning of health services and health teams.

Invited by the Caritas of Somalia and the United Nations High Commissioner for Refugees (UNHCR) office in Mogadishu, Somalia, from October 15, 1979 to December 31, 1980, two Italian medical teams of the Associazione Universitaria per la Cooperazione Internazionale (AUCI) worked among the Ogaden Refugees in 3 camps of the Qorioley District, lower Shabelli Region of Somalia. Each team consisted of one physician and 2 registered nurses. The Qorioley district, about 140 km SW of Mogadishu, has high day-time temperatures and high humidity throughout the year. The day to night temperature gradients are high. Strong winds are blowing to and from the Indian Ocean.

The 3 camps had been set up in the bush, on the right bank of the Shabelli river, about 8 km NW of Qorioley Town. The refugees in these camps were of Somali extraction and of Muslin culture and religion. They were housed in large military tents, aqal (round roofed skin covered hut of nomads), “mundul” (circular grass-thatched hut built around a central pole) and “arysh” (rectangular hut, corrugated iron tile roofs), aggregated at a very high density. More than 5000 people lived on one hectar. It was so crowded lhat there was no more space than 1.5 m2 of shelter per person. They lacked all hygienic services.

Each camp had a food storage hut (mud walled with corrugated iron roof) and 2-3 water collection ponds, fed from the river. At the time of our arrival, two “arysh” with a total of 20 beds were in use for non-ambulatory patients. Scattered in the camps there were 6 “medical posts.”

Migration of whole populations, driven by natural calamities or war in search for safe territory, has come to the attention of International Organizations. The sanitary situation of refugee camps in Somalia which take care of the nomad populations arriving from the contested Ogaden territory, has been studied in Nov.-Dec. 1980 at the refugee camp of 3alalaksi. A study of the environment and organization of the camp was made to examine housing, water supply, sewage and alimentation. The nutritional state of refugees was recorded. The anthropometric data of 1185 children, including weight, height and arm circumference according to age and sex have provided interesting comparisons.

The nutritional status of children in the 3 refugee camps at Qorioley, Somalia, was studied in Dec, 1979-3an 1980. Out of the 13,000 children under 5 in a total camp population of 49,000, a sample of 1700 was selected for measurements. Food and water supplies and environmental hygiene were also evaluated. Growth in weight was near normal from birth to 7 mo. age, slowed sharply during 7-24 mo. (as compared with reference curves), and picked up during 24-60 mo., to become nearly parallel to, although lower than, the normal curve. The arm circumference curve was similar. Growth curve for height, on the other hand, was closer to the reference curve. The curve for head circumference was normal. These data clearly point to malnutrition one of the major indices of poor health. Food supply for 3000 cal daily per child was theoretically available (not counting medically ordered supplements), but in many cases did not reach the children because of cultural food taboos and it having been sold to obtain other goods.

Since the Cambodian refugee emergency of 1979, refugee emergencies continue to be a global problem. Health care workers returning from the Cambodian emergency relief presented the need for improved predeparture training and orientation to the Second World Congress on Emergency and Disaster Medicine in Pittsburgh and elsewhere (1,2). The special training needs of health professionals working in such emergencies have come to the attention of the National Council for International Health in the US (NCIH) whose role is to increase US effectiveness in international health in developing countries (3,4,5). NCIH, established in 1971, is a private non-profit organization. Membership includes individuals, private and voluntary organizations, health and medical associations, universities, governmental agencies, foundations, corporations and consulting firms.

Worldwide today, more than 10 mill. refugees have been forced to leave their homelands because of political and civil disturbances, war, famine, earthquakes, floods and other disasters. Host governments are often unable to deal with these situations and rely on international relief to provide for the various physical, humanitarian and other needs of these victims.

Providing health care is a complex process that takes place in phases within political, economic, social and cultural constraints that are unfamiliar to health care workers without prior experience or special training. Unfortunately training to meet these emergencies is either non-existent or consists of brief predeparture sessions. Only a fraction of those with prior experience are available at short notice. In Thailand, for example, organizations were forced to recruit medical professionals who were inexperienced in refugee relief.

The Emergency Medical Services (EMS) system response to a multiple victim disaster can be preplanned to identify various components, such as scene authority, communications, triage, vehicular staging, and point-of-entry of patients to area hospitals. On 1/23/82, a DC-10 airplane carrying 210 people, slid off the runway while landing at night on ice at Boston's Logan airport. The plane broke into two pieces after it slid into Boston Harbor; 33 patients required definitive medical management and were transported to 7 area hospitals. The Boston EMS system, coordinated through one Resource Trauma Center, utilizing a central communications center, was responsible for the medical component. Hospital categorization on-scene triage, patient staging, patient transportation and regionalization of resources have changed the City's plan to reflect new EMS developments.

On January 23, 1982, Boston experienced the final stages of a winter storm that began with snow followed by freezing rain. A plane with 198 passengers and 12 crew members was the last plane scheduled to land before the runway was closed for plowing and sanding. The DC-10 landed and slid off the runway into Boston Harbor. The plowing and sanding crew that was scheduled to service the runway was in position, and therefore witnessed the incident and confirmed the crash.

Airline companies, the Director of the International Paris Airport, and sanitary and administrative authorities of the Seine-Saint-Denis Dpt of SAMU were asked to organize a simulation of an aircraft crash on the site of the Charles-de-Gaulle airport. The two main purposes of this simulation were to check the efficiency of the rescue means from a technical point of view, the delays in the organization, and the coordination of services.

The scenario was an accident during take-off of a big jet. The fuselage of the plane was in three parts. There was an intense fire in the middle one. The crash happened at the end of the runway, on soft ground which was normally unapproachable for ordinary vehicles. The casualties were distributed according to aircraft accidents statistics; 200 military personnel and 30 volunteers of Civil Security participated. The victims were classified into 5 groups: 1) uninjured (30 in front and 40 in rear); 2) slightly injured (15 in frontand 15 in rear); 3) severely wounded (8 in front 4 in center, and 8 in rear); 4) critically injured (5 in front, 6 in center, and 4 in rear)); and 5) dead (95 in center).

The injured were simulated by first aid workers who had been trained and made up so as to be seen by the rescuers. Besides, they were given a tag on which was indicated the group, the types of injuries, the delay of survival without care, the necessary time for the diagnosis, and the appreciation of the victims.

On June 22, 1982, the main power transformer at a local high school (St. Paul, Minnesota) overheated, causing the pressure relief valve to operate and release smoke and mist throughout the building. The transformer contained thermal-dielectric fluid with the tradename “Pyranol,” consisting of polychlorinated biphenyls (PCB's) in the form of “Aroclor” and chlorinated benzenes. The transformer did not explode or flame. The emmission characterized by a “white mist” occurred over an approximately 4-hour period with resultant contamination of basement and first floor areas. The temperature of the emission was estimated to be approximately 250-300°F.

“Pyranol” contains PCB aroclor 1260 (45%) and chlorinated benzenes (40% trichloro and 15% tetrachlorobenzenes). Commercial PCB preparations manufactured in the United States have been marketed under the trade name “Aroclor.” Several grades of Aroclor have been designated by numbers such as 1260. The first two digits represent the type of molecule (12 = chlorinated biphenyl). The last wo digits give the weight percent of chlorine.

The fire was discovered by the school janitor and the firefighters arrived at 5:40 a.m. As the firefighters walked near the transformer, several men began complaining of nausea, sore throat and burning of exposed skin. Firefighters having symptoms were asked to go out in the open and were immediately hosed down with water. Initially, 14 firefighters were taken to the emergency room of St. Paul-Ramsey Medical Center, where they were evaluated, treated and released. When inquiry was begun to find out what kind of substance was burning, it was discovered that the transformer which contained “Pyranol” (installed in the school in 1958) had overheated.

The impromptu and unforseeable problems, which the physician faced who was called upon to help a boy who had fallen into a deep well, are illustrated. Inability to recover the boy rapidly required oxygen and fluids to be provided in the well for over 2 days. The reasons why heroic efforts failed to save him will be presented in this rescue case report.

In reoccurring types of disasters, such as earthquakes and fires, the type of aid required can be predicted from previous experiences and results. Sometimes in cases involving one individual, who due to special circumstances is in danger of losing his life, rescue organizations have difficulty in organizing and providing the special aid required, which touches public sympathy, creating a state of general anxiety and interest. An unusual and dramatic case, the accidental fall of a boy into a deep well, had these characteristics. The intensive care unit (ICU) of our hospital had to deal with this extraordinary event. National and worldwide news media gave extensive coverage and direct transmission, with emotional details, ending with the drama of human life and the attempted rescue.

In the afternoon of 3une 10, 1981, in Vermicino, on the rural outskirts of Rome, a 6 year old boy did not return home. After carrying out an anxious and fruitless search, the parents informed the local authorities. The police continued the search, until they finally heard from the tunnel opening of an unmarked well the tearful wail of the boy.

In 1964, the medical team at motor car races consisted of 2 physicians, including the author, several first aid workers, and 2 nurses. Only one physician stood at the trackside and sophisticated equipment was non-existant. Nevertheless, it was possible to resuscitate drivers who had suffered a cardiac arrest at the moment of impact, by simple cardiopulmonary resuscitation (CPR). In 1965, the Grand Prix mobile hospital was added. This was a Juggernaut container lorry containing a well-equipped operating room and scrub up area. It was found to be of little use in the UK, although the idea behind it was well intentioned. The problem with the unit was one of mobility. It was certainly true that the hospital could be taken from London to Paris, but it was far too big to be driven from the car park to the injured driver at the side of the track. In 1968, theBritish Racing and Sports Car Club (BRSCC) introduced the first rescue unit. This short wheel base vehicle was presented to the club by Ford as a service to motor sport. It contained all necessary fire-fighting, cutting and medical equipment. It was to reach the scene of any accident within 3 minutes. In that way a driver whose heart had stopped at the moment of impact could be resuscitated before his brain suffered irreparable damage. Apart from firemen, the rescue unit carried a physician, usually an anaesthetist skilled in resuscitation. As a result, the standard of care around the circuit became standardized after the first few minutes.

The authors describe Italian public health intervention planning for civil nuclear emergencies. With the exception of a few special aspects of prophylaxis and therapy, public health intervention in the case of nuclear emergencies are basically the same as those planned for “conventional emergencies,” however, a key role in nuclear emergencies could be played by the psychological aspect. Two different situations must be considered: 1) nuclear accidents involving workers only; and 2) nuclear accidents involving population as well. Differences in public health intervention required to address these two situations are discussed, both in terms of public health personnel involved, and of public health means and structures that should be available.