The use of anesthesia in patients in shock is associated with many problems and considerable risk. This is particularly true when only little time is available for adequate pretreatment because surgical intervention is urgent. In choosing a method of anesthesia for patients in shock, knowledge of the pathophysiology and treatment is of utmost importance.

Le Dran first introduced the term “Shock” (French translation: “commotion”) to the medical nomenclature. The term has undergone alteration in later usage. In 1795, Latta defined shock as the condition arising from serious war injuries resulting from bullet wounds. He was the first to describe shock as “a short sojourn along the way to death.” During the First World War and the postwar period, the role of intra vascular volume deficiency in shock was clarified. Experience gained during the 1939-45 World War and the Korean War, together with the increased civilian accident rate, and research in the field of anesthesiology have led in recent years to considerble clarification of both pathogenetic and the therapeutic aspects. Today, shock can be defined as an acute reduction in tissue perfusion with consequent tissue hypoxia and metabolic acidosis, regardless of the causative factor.

The organs are first functionally and then morphologically damaged. Four mechanisms can be involved in shock; 1) reduction of the volume of blood in circulation (hypovolemic shock); 2) disturbances of the vascular system (vascular shock, anaphylactic and toxic shock); 3) reduction in the functional capacity of the heart (cardiogenic shock); and 4) intrathoracic circulation impediment (shock emboli).

Major disasters, during which large numbers of injured must be hospitalized, require specific medical measures. To obtain the most efficient results, the simplest means must be used at the site of the disaster to provide: the prevention of pain and shock; the maintenance of vital metabolic functions; the administration of local and general anesthesia; and the medical supervision of the transport of critically injured and the post-operative care of the patients. It must be taken into account that the use of non-physicians to help anesthesiologists may be necessary. These individuals work under the direction of the physician.

Pain relief must be provided by sedatives and analgesics which cause minimal central respiratory depression, no increased stimulation to cardiac patients, and no increase in intracranial pressure in head injuries. An additional requirement is that no unwieldly apparatus is required. These criteria are met with the narcotic, sodium-4-hydroxybutyrate (SomsanitR).

In 1950, Roberts and Frankel (1) investigated the effects of gamma-aminobutyric acid (GABA) on the regulating system for the sleep rhythm of the mammalian cerebrum. Two years later, Roberts and his co-workers (2-4) showed that GABA is reduced in the brain by a specific transaminase to a semial-dehyde of succinic acid (succinylsemialdehyde) and this, in turn, is reduced to a dehydrogenase, which is probably identical with lactate dehydrogenase, to gamma- or 4-hydroxybutyric acid. Since parenterally administered amino butyric acid is unable to pass through the blood-brain barrier, Laborit and his team (5,6) searched for derivatives which could reach the central nervous system via the cardiovascular system and found that 4-hydroxy-butyric acid has this property.

Traffic, industrial or natural disasters and wars frequently threaten the lives of a large number of victims. Often the patients suffer a combination of injuries to the head, extremities, thorax, lung and abdomen. Immediate anesthetic measures at the site of the accident are required and essential to the survival of the patients with multiple injuries. During transport, further surgical and anesthetic treatment may also be needed. Occasionally, the number of people involved in a disaster exceeds the treatment capacity of the nearby medical institutions. Urgent and improvised decisions are required with a clear picture of the treatment resources at the site of the accident or during transport.

Special attention must be focused on necessary surgical measures and intensive care, as well as resuscitation and advanced anesthetic expertise — essential pillars of support. In many cases, the anesthetic treatment of patients with multiple injuries is the decisive therapeutic measure. The anesthetic technique must be guided by the pathophysiological requirements. The medications used should have a controllable and pronounced hypnotic-sedative and analgesic effect, without having a depressant influence on respiration or circulation, and they should improve organ perfusion. Furthermore, they should provide a means for cerebral protection. The anesthetic apparatus should be simple and compact and it should be possible to apply the technique over several hours, using room air, with or without the addition of oxygen. The agents and apparatus should be compatible with the use of every type of muscle relaxant and narcotic. New intravenous anesthetic agents meet these criteria.

The use of oxygen in emergency situations outside hospitals is limited by difficulties in supply. Low capacity cylinders (100-120 1) weigh 3-4 kg, and have cumbersome mechanisms for pressure and flow reduction. Disposable cylinders of oxygen from a chemical source create the possibility of the contents running out, and are fragile. Particularly when exposed to high pressures or temperature.

Mouth-to-mouth remains most rational and effective. Problems include aesthetic concern and exhaustion in rescuer. It is possible, however, to adapt a Brooke or a Safar airway for use with oxygen, by attaching a tube with tape near the proximal outlet of the airway. This apparatus has been tried on 4 patients during general anesthesia with thiopentone-succinylcholine-neuroleptics—for appendectomies using controlled ventilation with expired air with oxygen added. Tidal volumes of 350-500 ml of air/oxygen were delivered at a frequency of 6-8 breaths per minute. The nose was closed by a clip. Sellik's maneuver could prevent gastric inflation. The color of blood was normal, arterial pressure and pulse did not change, and skin was dry. No fatigue or other effects were reported by the anesthesiologist-“rescuer”. In outdoor use, where oxygen from a chemical source is used, the problems associated with the exothermic reaction can be limited by cylinder lagging with openings to disperse heat. A flow of O2 6-7 1/min is sufficient to support a critical situation. It allows O2 enrichment for mouth-to-mouth, mouth-to-mask, mouth-to-airway, or bag valve ventilation. Modest cost, and low weight allow large numbers to be stored for airport disasters, when resuscitation is performed on a large scale for many victims.

The protective effect of an artificial tanning scab seems to be greater than that of the physiologic eschar, in controlling the invasion by micro-organisms and the loss of water, electrolytes and plasma. Allgöwer, et al. confirmed a reduced toxicity in burns, using experimental tanning procedures. Applying mercurochrome 2%, tannic acid 5% and silver nitrate 10% is a simple and most effective local treatment, especially when large numbers of patients are involved. No further topical agents are necessary for days, and infusion therapy may consist simply of water and electrolytes for the first 2k h, and the patients are stabilized for transport. A most important advantage of this procedure, which was obvious in all our patients, is the reduction of pain. Resorption of the applied substances must be considered. Toxic side-effects have not been seen with the use of tannic acid 5% nor with silver nitrate 10%. Increased blood levels of mercury have been found, however, but they have not caused toxic complications in more than 200 monitored patients. Betadine may be used instead of mercurochrome as a local antiseptic. The antiseptic effect of betadine was found to be greatly prolonged after tanning, as compared to 100 patients with comparable burns without tanning—with septic complications having been reduced in the tannic acid group.

Although decisive changes have been made in the past ten years by re-organizing and improving pre-hospital care, emergency measures at the scene of the accident still require special emphasis in accident victims with head injuries concerning the recognition and treatment of vital complications. The success of these measures depends on the time interval for their initiation, on the practical skill and expertise of the person administering life support, and the availability of equipment.

An emergency examination at the scene of the accident is absolutely essential for correct assessment and should reveal imminent failure of arrest of vital functions. This can be achieved by using the rescuer's five senses and does not require special diagnostic equipment. An initial sign that cerebral trauma has occurred can often be recognized by a superficial injury to the skull during an initial orientation examination, although some of the most severe closed craniocerebral injuries can occur without the slightest superficial sign of trauma.

Airplanes and airports are in potential danger during transport of highly toxic chemicals, and accidents can occur if the wrapping material is damaged. The chemicals are listed and classified by the International Civil Aviation Authority ICAO) (7). They are subdivided into nine classes, each marked by a special symbol. The classification is derived from the most important properties of the chemicals in relation to the air transport (Table 1). Special positions are listed in class 6. This does not mean, however, that the chemicals of all other classes are non-toxic. On the contrary, highly toxic substances also exist in each other class. For example, class 2 “compressed gas” includes dangerous toxic substances such as hydrochloric acid, fluorine, carbon monoxide or sulphur dioxide. Class 3 (“flammable liquids”) includes benzene, methanol, acrylonitrile and ethyl methyl ketone, for example. In class 6 (“poisons”), special poisons are listed such as tetraethyl lead, dimethyl mercury, organophosphates and aniline. Class 8 (“corrosives”) consists of poisons like bromide, dimethyl sulphate, phorphorous trichloride and hydrofloric acid.

There is no record in the history of medicine of a group of drugs which has gained such a reputation as the benzodiazepines, mainly among psychiatrists and physicians, who augmented their therapeutic arsenal with these drugs which have a safe and effective action. The benzodiazepines have many indications, with special emphasis in the treatment of anxiety, sleep disturbances, muscular spasms, convulsions, etc. There is, however, a difference between therapeutic and abusive usage and there is a danger of exposing an important drug to the risk of being transformed into a psychological crutch.

Airports are complex cosmopolitan units which receive millions of human beings, many of them suffering from tension which they try to hide. Many an air passenger takes, as a precaution, about 10 mg of diazepam (ValiumR). Depending upon the weather conditions and check-in problems, they may take another pill before boarding the plane. After take-off, either because they have forgotten the warning or because they choose to ignore the risks, they have a few drinks, which are served by the airline personnel to help ease tensions and sedate the group. A few moments later, the crew have one or more serious problems. Initially, the passenger becomes excited and aggressive. After being controlled, he reveals a concomitant anxiety. At the end of his trip, he is taken to the airport doctor. Following the routine examination, and familiar with the situation, the doctor knows that his patient is suffering from potentiation of alcohol by diazepam.

The terrors of flying are as old as the dreams of it. The first flight of man, reported in Greek mythology, ended with the crashing down of Icarus. Today, planes have become indispensable. Air transport companies boast the fact that travel by air is the safest, despite the fact that fear is ever present. There is little knowledge about fears and passenger behavior. Accident statistics turn terrifying events into “cases”. Tribute is paid to “technical progress” and to “more quality of life.” Measures must be taken to reduce the reasons for apprehension to achieve some kind of rationally based safety to relate to behavior. One should, however, not aim to abolish fear to an irrational and unrealistic degree. Such induced behavior cannot be firm in a real crisis. Fears are founded upon social and personal reasons: (1) Predominantly sociological aspects: the fact of airplane disasters; obscurity of the causes and effects of such disasters; inadequate knowledge of technical facts; doubts about disaster prevention; and “technology trauma.” (2) Predominantly socio-psychological aspects: alien surroundings; isolation; don't know what to do; inescapability; and “Mogadishou-effect.” Anthropological and socio-cultural factors also have an impact.

Fear of flying of pilot and crew: Their reasons for fear are related to the exact knowledge of dangers and risks, which are involved in economic and job efficiency oriented requirements and obligations. We recommend: improving information and explanation of risks and the related behavioral safety; improving technical means and management of disaster prevention along with appropriate mediation; courses to decrease fears of flying, including safety training; and decreasing potential conflict with airline personnel.

There are different social actors (or “collective social actors”) in a disaster who may have differing ideas on the “ideal passenger in a disaster”.

This is an euphemism; it includes a gang of hijackers. Any suggested human failure in a complicated technical environment might be threatened or committed deliberately. Some attitudes of the ideal passenger, as seen from the point of view of the pirate, show that: i) the passenger ought to keep quiet, should not panic and should readily obey orders of the hijackers and must be easily persuaded by bullying tactics; and ii) the passenger must be selective in observing his situation —neither apparently looking at anybody nor recognizing anything, except to obey the commands he might receive from the hijackers.

This one did not want the disaster to happen, e.g., a rescue team. It also has an “ideal passenger” in mind: i) he should not panic, and should keep quiet, after having given a signal that he is alive and needs help; ii) he should follow orders and should place his trust in personnel; and iii) he should do his best to help himself and identify emergency situations in his co-passengers and help them. The moment rescuers arrive he has to change his role and follow orders.

This is the company operating the flight, as presented by the pilot and his crew: i) this party is interested in a quiet and non-panicking passenger; ii) expect him to follow their advice on trust; and iii) require him to take precautions seriously; i.e., reading the emergency regulations put in front of his seat, without unduly worrying about them, but remembering them when disaster strikes.

With the development and deployment of commercial jet aircraft in the mid 1950's, airline travel has become commonplace throughout the world. A rapid increase in the numbers of aircraft, airline routes, and flying time has occurred. New technology has added sophisticated and complicated gear to aircraft and their support systems. Every new system has the potential for failure and to some extent additional components increase the risk of technological breakdown. The increased chance of technological breakdown favors an increase in aircraft accidents. Fortunately, development and utilization of sophisticated redundant electronic and mechanical improvements aimed specifically at improving safety have also occurred. The results of these changes over the past twenty-five years has been a decreasing rate of accidents per mile flown. Due to the tremendous increase in flying, however, the absolute numbers of accidents associated passenger morbidity and mortality have risen (1). For the health care system, the major impact has resulted from the absolute increase in aircrash victims.

Aircraft accidents have regularly produced mass casualty incidents with the number of victims ranging from a few to several hundred. Aircraft accidents can be divided into essentially four types: mid-air crashes (so called “hard impact”); crashes on takeoff; crashes on landing; and on-ground accidents (“soft impact”). Mid-air accidents are frequently away from population centers and usually there are no survivors. The medical impact therefore is minimal. Accidents occurring on takeoff, landing, and on the ground, occur at or close to airports, and the nature of the accident is such that there may be many victims (1).

A Boeing 747 took off from Nairobi International Airport on the morning of November 20, 1974. Its leading edge flaps failed to operate for technical reasons and barely a minute later the aircraft crashed, the tail separating from the fuselage. The wreck caught fire.

Since the aircraft's home base was Frankfurt, a Crisis Management Staff (CMS) was immediately constituted there. As an airline physician, I was requested to evaluate the medical information received from Nairobi and act as medical advisor to the CMS. According to the first rough estimate received, approximately 160 persons were believed to be on board at the time of take-off. By the same estimate, about 100 of these had escaped with their lives, of whom about 60 had been injured. Since there was no accurate information about the availability of adequate medical supplies in Nairobi, I advised the CMS that I should go with a medical staff and equipment to Nairobi. In 1974, the Lufthansa Medical Service in Frankfurt was manned by only three physicians as compared with six at present. Of these three, one was on vacation, one was required to maintain the Medical Service in Frankfurt and only one could be spared to go to the site of the crash.

On arrival in Nairobi, my colleague and I contacted and registered 44 passengers who had been on board: those who had been seriously injured were discovered in local hospitals, others were in hotels and lodgings in the locality.

At 15:15 hrs on 17 October 1977, the Lufthansa Medical Service in Frankfurt was notified about the hijacking of a 737 Boeing aircraft. At 15:30 hrs the Crisis Management Staff (CMS) asked me if I would accompany a stand-by crew on the rescue mission. The intention of the CMS was to come to an agreement with the hijackers to exchange the crew of the hijacked plane for a stand-by crew accompanied by an airline physician. I agreed. Medicines and medical equipment for the treatment of injured and sick passengers were packed by medical assistants. At 16:30 hrs highly confidential information was received from CMS—GSG 9 that the Border Patrol Special Commando led by Commander Wegner would accompany the rescue mission which would henceforth be termed “Special Mission”. The hijacked plane was to be followed and seized. It was likely that in the course of this operation an unpredictable number of burns, gunshot wounds and other serious injuries could occur. In a very short time, medical assistants packed further huge crates full of first-aid packs, Macrodex infusions, analgesics, and so forth. I asked Dr. Straub, a medical colleague, and Mr. Reiser, a nursing assistant, both employees of the Lufthansa Medical Service, to accompany me as volunteers, and they agreed. At 16:45 hrs the CMS approved the medical team and the medical equipment.

This report refers to interviews with 53 of the passengers of the Lufthansa aircraft “Landshut,” liberated in 1977 in Mogadishu, Somalia and to information acquired during group-psychotherapy with 16 of these passengers. The psychological care during hijacking depends on the aim and situation of: a) the hijackers; b) the hostages; and c) the extorted.

a) The hijackers are usually motivated by political aims. They feel that their crime is mitigated by their ideology. They are aware of the high risk of their undertaking and the violent counter-actions of the authorities, but they are highly motivated personally and socially. Hence, they are continually in a state of extreme expectant tension with most intensive perception and alert awareness. This activates the high intelligence they may have, but it is combined with a disturbance of their perception of reality. Usually there are several hijackers. Their communication with each other is characterized by a strong hierarchy structure, where the giving and acceptance of command is strictly defined. Their social situation is that of a “group”. The group interactions give them some relief of anxiety.

b) Unlike the hijackers, the social situation of the hostages is that of a “crowd”. They have arrived at this situation by chance and usually without knowing each other personally. Since the formation of a group among the passengers would be an additional danger for the hijackers and would disturb their orientation and weaken their power, any verbal or non-verbal communication and any moving among the passengers is prohibited.

Every airport large and small should have a disaster plan to involve all rescue and medical services. (Jessen, Reich, Rørmark, Fahey, Bergot)

Communications between participants at a disaster must be of the highest caliber if patients are to receive optimal care. Communications between fixed operational bases should be by dedicated telephone (intercom lines) and radio on an appropriate frequency. Redundancy must be incorporated into the system. Education for personnel must be reinforced by regular drills. (Baker)

Disaster planning must take into account the fact that in many cases there will be survivors even from “hard impact” crashes taking place away from the airport. (Domres, Baker)

Regular disaster drills using actual aircraft and involving all agencies for disaster management, including physicians, must occur. (Fahey, Jessen, Star)

The principles of triage, field stabilization, and rational evacuation through an ambulance dispatch area must be incorporated into all plans. (Baker, Bergot, Fisher, Oyen)

In a major disaster triage is essential in order for medical help to be most effective. (DeSinnger, Oyen, Matthews.) Triage should be carried out by the most experienced person available. Casualties should be categorized into the following groups: 1) those dead or about to die; 2) those who will benefit from immediate resuscitation and treatment; 3) those who will benefit from treatment at any early stage; and 4) those who have trivial or no injuries.