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The exercise held at Brussels Airport was carried out by inexperienced personnel to highlight the most common errors and shortcomings of an existing disaster plan.
INCIDENT COMMUNICATION
Once an aircraft is known to be in trouble, all the nearby fire brigades are alerted by means of the unique call number 900 and move to take up their stand-by position close to the landing point. The Military Hospital is also alerted and sends out a liaison car, with a doctor among its occupants. This car joins the stand-by position. Once the aircraft has crashed, the fire engines rush to the site and all the major university hospitals and the Military Hospital are notified by the same 900-code number. Disaster teams arrive by road.
This report is almost exclusively limited to aspects of rescue, triage, on-site stabilization, and evacuation of the casualties.
Individual cultures, as shown in folklore, have practiced some form of resuscitation. For instance the Celts traditionally carried a large cauldron or cooking pot with them into battle. This was not, as might be supposed, to cook their enemies but in which to throw the heroes slain in battle, who then re-emerged whole to continue fighting. The well known practice of the inhabitants of the West Indies in blowing tobacco smoke per rectum as a means of revival may well have had its origins in distant mythology. In addition to the observed, better preservation of the lower intestines after death, and the obvious irritant and stimulative effects of the apparatus and fumes towards an involuntary breath, there may well have been a more philosophical concept of the reintroduction of the spirit—the anima.
Extensive coastlines, varied weather conditions, scattered industrial centers and a large rural population create special problems with regard to the delivery of health care services in the Great Lakes area, which are further complicated by the discrepancies in the level and type of care available within the region. Hospital based helicopter emergency medical services (HEMS) providing very specialized life support (VSLS) provides safe and rapid transport for patients needing a higher level of care than is available at the accident scene or local hospitals. This service assists local efforts to meet the medical needs of the population. Air transport systems are an integral part of an EMS system. Even though they are costly, they help avoid duplication of more expensive resources, such as hospitals and personnel.
I won't pretend that I can summarize everything that has been said here in the past 2½ days or that I can capsulize the most important things that have been said. What I will do is comment on three areas, underlining those that have had an impact on me and, I suggest, are things that we should think about.
I'll divide my comments into three areas: first, a few aphorisms; second, a few issues that have been raised; and third, some recommendations.
In the United States, pre-hospital immediate care generally is practiced by paramedical personnel. These individuals are either firemen or civilians who have specific training in the assessment and management of acutely ill or injured patients outside the hospital. In most systems, once the initial evaluation of the patient is made, radio or telephone communication occurs between the pre-hospital team and a hospital-based physician or specially trained nurse. These hospital-based personnel are the responsible medical authority for the care delivered by the paramedical staff. Based on data reported by the field unit, the hospital team gives medical direction and specific therapeutic orders to the paramedics. This style of immediate care seems to work well for us in America although it is different in many ways from immediate care schemes elsewhere in the world, in that the physician or nurse is rarely on the scene, able to assess firsthand and provide medical care to the victims.
The Republic of Colombia is situated in the northern part of South America, with coasts to both the Atlantic and the Pacific Oceans. It has a long history of natural disasters: hurricanes from the Caribbean sea have lashed the eastern seaboard more than once, while the western part of the country belongs to the so called “Pacific Fire Belt.” Being in the zone of contact between the Nazca and the South American Techtonic Plates, where the former gets under the latter, it suffers from volcanic eruptions and earthquakes (Figures 1 and 2). The more recent major earthquakes were those in Tumaco in 1979 and Popayan in 1983. In Tumaco, the combined action of the earth movement (magnitude 7.9 in the Richter scale) and the subsequent Tsunami caused an estimated 500 deaths (Gueri et al). Popayan was almost totally destroyed by an earthquake of 5.3 magnitude in which over 100 people died (Gueri and Alzate).
Prediction of natural phenomena which have the potential for causing disasters is an extremely difficult proposition both from a scientific and socio-political perspective. Experience has shown repeatedly our inability to predict events leading to disasters. Geophysical predictions, in order to have maximum utility, must specify the date, time, place and magnitude of physical events. In order to meet the minimum criteria for effectiveness and credibility, predictions must be stated within limits which are useful to the public and can be practically applied. Perhaps the best way to deal with the inevitable conflicts and uncertainties associated with the problem of disaster prediction is to either not make such pronouncements or issue forecasts based on the likelihood or probability of event occurrence. In the latter case it is best to provide simplified thresholds for various threat levels and suggest appropriate actions necessary to avert the impacts of an event.
The famine presently ravaging the population of the Sahel belt in Central Africa is not a new occurrence. In the last 15 years, hundreds of thousands of people have died because of malnutrition and disease, caused by the successive failure of crops. In addition to the lack of adequate rainfalls, many other factors have contributed to the present situation:
• Overgrazing of available land by increasing numbers of livestock.
• Failure of the governments involved to modernize their agriculture by irrigation programs, fertilization, etc.
• Consummation of grains for seeding and livestock by the famine stricken population—preventing rehabilitation.
It has been said that never are two disasters alike. Indeed the effects of floods on health are considerably different from the effects of earthquakes. But even two earthquakes may bring different results depending on a number of circumstances, which basically involve the characteristics of the event itself (e.g., magnitude, depth of the hypocenter, distance from the epicenter, etc.), of the striken population (its “disaster culture,” knowledge of disasters and preparedness, level of immunity against certain diseases, endemicity, etc.) and the physical and sociological environment (e.g., type of housing, high mountains vs. pantanous jungles, etc.). However, we are getting to know more and more about disasters and about populations at risk to be able to anticipate some of the effects the disaster may have on the health of the community, as long as we keep in mind the three factors mentioned above.
There are over 25 active insurgencies in progress worldwide today. Terrorism is often part of these actions. But terrorism is also found worldwide in areas where no active insurgency exists. There has been a sharp rise in terrorist activities in the last five years, and there will continue to be an increase in such activities in the future.
Bombs, in various assortments, are the favorite weapons of terrorists. When guns are utilized, they are often of the military type and produce subsequent high velocity missile injuries which have entirely different characteristics than the normal type of handgun injury encountered in the civilian practice of medicine. The type of wounds produced by bombings include blast injuries, burns, multiple fragment injuries, blunt trauma, and major mutilation to include amputation. High velocity missile injuries produced by the use of various military rifles and submachine guns require treatment by a surgeon knowledgeable in the care of such wounds. Surgical lessons learned by military surgeons dating back to the time of Napoleon's surgeon Larrey are discussed in some detail in the article. Special considerations attending to medical care associated with terrorist activities are highlighted. Such consequences include multi-system trauma to an individual, trauma to large numbers of individuals at one time, massive trauma to individuals, and the difficulty in treating and evacuating victims who are trapped in rubble.
In introducing this session on Military Medical Methods, I wish to set the scene. While the principles of First Aid and the methods of management of the injured are broadly the same in most scenarios, i.e. accidents and disasters do not occur in convenient places or at convenient times, there is one enormous difference with respect to Military affairs-casualties must be managed in the circumstances of war.
Aircraft Disaster Readiness is traditionally considered as a preparation for a prompt reaction to an aircraft disaster situation with the purpose of saving lives.
As all emergency or disaster readiness requires planning and preparatory actions before an emergency occurs, the planning process should include attempts at prevention of the accident as well as a proper rescue plan for any airport, small or large. Further, a rehabilitation program should be included for those who subsequent to the event may suffer from physical or psychological lesions.
The Hospital Emergency Response Team concept, as outlined here and in the Multi-Casualty Incident Operational Procedures of the California Fire Chiefs Association, is the result of a consensus effort by all EMS interest groups in Los Angeles. It is an effective way to utilize the skills of emergency medical personnel at the scene of a disaster. The role of the physician is an important one, and this concept was specifically designed to maximize the benefit to be derived from having a physician at the scene. It is important, however, that physicians recognize their limitations; a medical degree does not automatically confer “mystic abilities”in the area of disaster management. The role of the physician should include pre-disaster planning and at-scene patient management responsibilities as a member or leader of a pre-designated hospital-based emergency medical response team.
Each year in the United States 700,000 people die from the sudden onset of heart attack symptoms. Of these deaths over 350,000 occur in the prehospital setting. Many of these deaths are felt to be avoidable if a greater number of the lay public were trained in Cardiopulmonary Resuscitation.
In the twenty-five years since Kouwenhoven, et al, suggested that closed chest cardiac compression and mouth-to-mouth artificial ventilation may artificially produce a satisfactory oxygenated systemic blood flow, there have been thousands of published research reports and articles focused upon a broad spectrum of subtopics ranging from the improvement of these techniques to the training of the lay rescuer. Knopp has suggested some parameters within which new CPR techniques must fall. First, any new skill should be applicable to the field setting. Second, the techniques should be simple to apply. And thirdly, any new techniques must be statistically linked with a significant increase in survival rates. Citizen Cardiopulmonary Resuscitation (CPR) has taken on almost religious connotations. A national strategy has been adopted by the American Heart Association and American Red Cross to train the lay public using a variety of training techniques of varying lengths.
Of all the natural disasters, none has a greater potential to cause widespread casualties and destruction of property than a large earthquake centered in an urban area. This scenario was tragically illustrated in 1976 when two large earthquakes occurred in heavily populated areas. In February, an earthquake measuring 7.6 on the Richter Scale struck Guatemala and left 30,000 dead and 100,000 people injured. In July ofthat same year, a Richter 7.8 earthquake devastated the city of Tangshan, China. The earthquake destroyed over 90% of the buildings in that city and caused the deaths of over 240,000 people. Since earthquakes strike without warning, preparation and disaster planning are mandatory in order to reduce injury and mortality.