Of the 110 million people in Brazil, only 4% to 6% read regularly; nevertheless, 50% have access to a television set. Instructors, audio-visual training aids, and manikins are virtually non-existent. The objective of this study is to test the feasibility of teaching cardiopulmonary resuscitation (CPR) through television (TV). Two representative groups were taught in this study: 1) high school students; and 2) regular army recruits. The first group because 50% of the population is under age 18; the second group of 18 to 19 years because they better represent the general population.

Lay persons can learn cardiopulmonary resuscitation (CPR) with the instructors' method, and by self-training with the use of manikins. LSFA includes airway control (head-tilt, jaw thrust), mouth-to-mouth ventilation, control of external bleeding by direct compression and elevation, positioning for coma (stable side position) and shock (horizontal, legs up), and extrication from a wreck (rescue pull). LSFA so far has not included chest compressions for cardiac arrest. LSFA capability by bystanders who would treat injured victims in mass disasters might be the most important component to consider for disaster response. A LSFA self-training system, including a manual which coaches skill practice on one another, and an attractive first aid kit (A. Laerdal) was found effective in a study carried out in Norway. The present controlled study was to compare two self-training systems (designed by A. Laerdal et al), one with and one without the use of manikins, with the presently prevalent instructors' method and an untrained control group. The trainees were high school students in a typical community in Indiana PA, USA. The study was carried out in 1978–1979.

Cardiopulmonary Resuscitation (CPR) lessens mortality and morbidity following cardiac arrest and has gained widespread acceptance. However, the cognitive and psychomotor skills achieved at the initial training sessions tend to deteriorate fairly quickly. Experience or retraining can help to preserve these skills. The authors felt that repetitive exposure to the principal facts might achieve the same purpose. Furthermore they viewed the time spent in the bathroom (lavatory) as an untapped educational resource for instructing a group of individuals; a suitable poster taped on a bathroom wall would repeatedly present the key information to a captive audience. Judging by the graffiti already present, the audience is presumably accustomed to reading in this environment. This paper reports two trials: in the first, posters were displayed in an undergraduate dormitory followed by a test of theoretical knowledge; in the second, the posters were displayed in hospital bathrooms used by nurses followed by a test of theoretical and practical ability.

The objective of this study was to evaluate a school Trauma Awareness (TA) program conducted by the Health Education Center (HEC) of Pittsburgh, Pennsylvania under contract with the Emergency Medical Services (EMS) Institutes. A total of 44 presentations were made before 3545 persons dealing with school children in seven counties of western Pennsylvania. The TA program was undertaken because: l) the leading cause of death among school-age children in the USA during the 1970s was accidents, 60% of which occurred on school premises or going to and from school; and 2) there was a need for improvement of EMS in the local schools.

Resuscitation and acute respiratory care must be taught to all personnel involved in the management of everyday emergencies and mass casualties. Personnel range from the lay public to physician specialists. In deciding who should be taught what and how one must consider the limitations of learning ability of trainees and of resources. Mouth-to-mouth ventilation can be learned by laymen merely from viewing pictures, but better with manikin practice to perfection. CPR steps A-B-C can be effectively taught to non-physicians including laymen with instructor-coached manikin practice to perfection. but also with self-practice coached by audiotape, and to some extent even by frequent film viewing only without manikin practice. In 1972, A. Laerdal invented a CPR steps A-B-C self-training system consisting of a recording manikin, flipcharts and the coaching audiotape. We added a demonstration film to be shown before manikin practice.

A standardized approach to advanced cardiac life support (ACLS) improves the morbidity and mortality from cardiac arrest. Physicians should receive formal training, certification, and periodic recertification in ACLS. This paper describes the system we have developed to provide all the medical graduates of our university with training and American Heart Association (AHA) certification in ACLS.

Method

The course takes place during the third year of medical school in four afternoons during the students' medical clerkship. The students are required to take this course and are freed from all other commitments during these afternoons. Several weeks before the course, the students are given a brief introductory lecture, registered, and strongly encouraged to read the AHA manual for providers of advanced cardiac life support.

The effectiveness even of the best organized emergency medical services (EMS) system depends on the level of knowledge and the abilities of those persons who are the first at the scene. Only on few occasions will that be a physician specialist in resuscitology. So it seems necessary to educate and train laymen, medical students, and physicians in life saving methods. This should be done in a uniform way concerning organization and contents. In the German Democratic Republic (GDR), we try to perform this task on a nationwide basis.

Recent advances in the resuscitation and stabilization skills of prehospital emergency care providers have done much to improve the quality of immediate care provided to suddenly ill or injured patients. Although much of the innovation and leadership in this area has been provided by emergency department physicians, most of them still lack an adequate appreciation of the circumstances under which these skills are executed. While many physicians participate in prehospital care teaching and evaluation of the system, most have not gained personal experience in those aspects of care foreign to hospital environment. They are particularly unacquainted with the intricacies of rescuing patients from automobile accidents and similar entrapments. It is not unusual, however, for an accident victim to spend half of the time required for the prehospital phase of emergency medical care undergoing extrication, and in many cases this must be done before full advanced life support measures may be initiated.

The discipline of emergency medicine includes the field of disaster medicine. Unfortunately, little actual emphasis is placed upon this vital area of training in emergency medical residency programs aside from nominal involvement in mock hospital-community disaster drills and triage exercises. In addition to these important areas of disaster medicine, physicians must be knowledgeable in field medical sanitation, environmental illnesses, ground and aero-medical evacuation, epidemiology and logistics in addition to hands on emergency medical casualty care. To better serve this important neglected area of the emergency medicine residency curriculum, we developed a one-month block of instruction.

The operational medicine course is composed of separate instructional modules. The emphasis of the field medical training is obviously a military one; however, that emphasis is easily translated into a field medical environment, one that is commonly employed in military disaster relief operations. The American armed forces, particularly the US Army, frequently come to the aid of victims of both civil and natural disasters. This humanitarian assistance also serves the readiness training goals of the Army Medical Department during peacetime.

In disasters, every available physician and lay person alike is called upon to render help. Disaster medicine is a most demanding field because of its multidisciplinary nature. Specialties like anesthesia, general surgery, internal medicine, pediatrics, opthalmology, orthopedics, otorhinolaryngology, bacteriology, thoracic and vascular surgery, toxicology, radiology, and others are each separately and directly involved. Without specialized knowledge, no one physician is able to cope with all problems that may arise. Therefore, disaster management planning calls for adequate training and organizational preparations, with plans for the whole spectrum of possible catastrophes from man-made and natural disasters (e.g., floods, avalanches, fire, war, terrorism attacks; air, rail and high-way accidents; chemical catastrophes, irradiation, and radioactive fallout).

Sweden has not been at war since 1809–1810, when we fought against Russia in Finland. Lyrics by Runeberg are among the few documentations about the wounded in that war. Life-saving first aid was not very good at that time, and most of the wounded died. Modern Sweden is a technically advanced community. We have had some mass casualty situations, such as fires in restaurants and airplane accidents. Six months ago a train crashed just outside the fire brigade station, only five minutes running distance from the hospital. The result was one person dead, two severely injured and about 40 slightly injured. The same crash could have occurred elsewhere in Sweden where the situation might have been much worse, for much of Sweden is very deserted with large woods, and roads are scarce.

Experience and history have taught us that much can be done for the sick and injured before such patients reach the hospital. From the legacy of the Good Samaritan to the modern day organization of emergency medical services, the immediate care of those stricken has undergone significant change in both philosophy and practice. While many prehospital care organizations with roots established deeply in the past still flourish, modern emergency care, in the new world at least, has developed rapidly only over the past ten years.

In the United States, a concerted effort to improve the care of the wounded during the Civil War led to the introduction of the “flying ambulances” used earlier by Napoleon's Chief Surgeon, Larrey. Americans made significant contributions to acute care with the work of such noted men as Crile, with his form of external pneumatic counterpressure; Kouwenhoven, Knickerbocker and Jude at lohns Hopkins; Beck and the first reported defibrillation in a patient; Safar and his co-workers with the rediscovery of mouth-to-mouth; and many others.

Many of the world leaders in emergency medicine and in disaster medicine systems have made advances in these fields, and I compliment them on the accomplishments that I have seen over the years. Dr. Safar charged me to look ahead, if that is possible, and offer some perspective—obviously my own—on the next five to ten years. Hopefully, our future can be controlled in certain limits. Toynbee philosophized that when new and unanticipated challenges are presented, they represent great opportunity for response. If we fail to respond or if we respond in an inappropriate way, we may become a fossil in history—in this case, in the history of medicine. I have attempted to look at important challenges that I see in emergency medicine, and to predict from these a course that I think represents a proper response.

The first challenge, one that you have heard of before, clearly is the most important one. It is the challenge of limited or relative resources. The term “relative” means that fraction of a country's or region's output or wherewithall that is available in a logical or rational way for emergency medicine.

I would hope that there is no question regarding the need for physician leadership in an EMS system; and that the question, if there is any, concerns the amount required, where it is to be applied, and its quality. EMS, I would remind you, stands for emergency medical services. Medical delivery systems, in my opinion, require physicians for their design and implementation. That does not mean that all the services have to be delivered by physicians, but they need physician leadership.

If this outlines the area of physician authority, then there is by definition a concomitant responsibility—authority without responsibility would be tyranny. The responsibility should provide an appropriate level of medical care that is current in concept, appropriate to the needs, considerate of the resources available, and coherent with the overall health care system. It must not be just an isolated EMS system.

A status report of CCM in different countries varies considerably. In the USA, resuscitation and intensive care were pioneered by anesthesiologists in the 1950s, but CCM evolved later as a multidisciplinary movement through the initiative of the Society of Critical Care Medicine (SCCM) starting in 1970. Recently, CCM has been introduced as a subspecialty of anesthesiology, internal medicine, pediatrics, and surgery. Australia has already, for a couple of years, had a primary specialty of intensive therapy, but there are two tracks, one in medicine and one in anesthesiology. In the Scandinavian countries, as well as in Italy, CCM is an integral part of anesthesiology, since intensive care was initiated there in the early 1950s by anesthesiologists. In several Ibero-Latin American nations, we find a primary specialty in intensive therapy.

The 1973 Emergency Medical Services System Act in the United States mandates that one of the 15 functions to be performed by every EMS system is coordinated disaster planning. Implicit in the legislation is the assumption that everyday emergency medical service (EMS) systems will be the basis for the provisions of EMS in extraordinary mass emergencies, or in the language of the act, during “mass casualties, natural disasters or national emergencies.” Policy interpretations of the Act specified that the EMS system must have links to local, regional and state disaster plans and must participate in biannual disaster plan exercises. Thus, the newly established EMS systems have been faced with both planning for, as well as providing services in large-scale disasters.

The Royal Victoria Hospital, Belfast, over a four-year period, used its disaster plan more than 100 times due to the civil disturbances in Northern Ireland. The concept of classifying these patients into three or four triage categories made me critical of assumed methods and articles dealing with triage. None of it measured up to my own experience. What is triage? Triage is the French word for “sorting.” I, therefore, addressed myself to the kind of sorting I had seen, where it was done and what categories were used.

The triage (i.e., sorting) of casualties is the most important task of a physician in a disaster. This function is so extensive that only an experienced doctor can fulfill it satisfactorily. To do so, he needs comprehensive information. This article will demonstrate a time-saving method of receiving and giving information for triage in connection with the registration of casualties.

The immediate situation determines classification. A rigid pattern cannot be applied. The doctor must know the number of casualties and helpers, transportation facilities, hospital capacities, and medical supplies. To help him assemble these data, the doctor has at his disposal an assistant registrar. This assistant is equipped with a walkietalkie to communicate with ambulance control. He also has a registration list and can enter important data concerning the patients clearly thereon (Figures 1 A, B).

In order to introduce EMS problems in large urban communities, I will first tell you the parable of the County of Smog. It covers an area of about 4,000 square miles and includes areas of mountain wilderness, dense urban population, coastal ocean communities and a peculiar blend of heat, foul air, and residential and industrial communities known simply as “The Valley.” About ten years ago, Smog County health officials established a pilot program to train a handful of firemen in reading electrocardiograms, the pharmacology of emergency cardiac drugs, intravenous infusions, and defibrillation. The firemen responded in a station wagon from a hospital. It was readily learned that these paramedical personnel could impact positively on the outcome of patients with cardiac conditions.

Resuscitation in the prehospital phase is feasible. As intensivists, however, we know that many cases could reach our intensive care units (ICU's) in far better condition if prehospital care were improved. We have learned from feedback on our cases in the unit that we physicians are indeed the best prepared specialists for fast and efficient intervention outside the hospital. Diagnosis and, hence, titrated therapy are more and more transportable and, under acute conditions, it is often safer to transport medicine to the patient, rather than the patient to medicine. Technological problems are no longer an excuse for the doctor to refuse to go to the scene.