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I would like to talk about the changing forms of warfare, terrorism in particular, and try to relate to you where you may have some involvement with the problem. First of all, let me tell you that terrorism, and I'm not going to seek to define it fully because no one has ever succeeded in doing so, is political extortion. It is the warfare of the weak. The terrorists generally use very low technology weapons, by this I mean, hand grenades, bombs, automatic weapons, pistols; but their logistical support is of the highest magnitude in terms of technology, things such as jet aircraft and instant global satellite communications. The most fundamental observation to make about terrorism is that it's theatre and very highly choreographed. Its purpose is to make large governments, particularly democracies which both enjoy and insist upon human dignity and human rights, look impotent. And we have been made to look impotent in my mind.
Your program discussion this morning about the Mexico City earthquake brings back some recent and actual vivid memories. I was in Mexico City last fall. I went there within two weeks of the earth tremor that hit. I was there in my capacity as the Director in the Office of Foreign Disaster Assistance (OFDA) and AID. Several weeks later, I joined FEMA, the Federal Emergency Management Agency, with its full load of domestic emergencies and various systems and plans to meet those crises. Some of you may ask, well, is there any major difference, basic difference, between coping with a disaster overseas and disasters that occur here in the United States? And, of course, you also, I suspect, would be interested to find out how I connect those disasters with the purpose of this conference, which is how to deal with the mass casualty incidents. Obviously, there are differences in all nations.
The Oxfordshire Area Ambulance Service in common with all civilized ambulance services in the western world, has made extensive plans for dealing with major disasters. These plans include the use of specialized vehicles which attend the scene of a disaster in an effort to provide medical expertise and equipment together with some hospital type facilities to commence treatment for the severely injured casualties. In the late '70s, the ambulance service in Oxfordshire purchased a caravan, at ridiculously low cost, from the local regional blood transfusion service which was no longer required. This caravan was converted for use as a three-bedded medical aid unit to be towed and parked near to the scene of the disaster. The unit was superbly equipped, but suffered severely from its size, and also from the need to tow it to its destination. It was a slow and ponderous vehicle but nevertheless it performed a useful service at static displays and exhibitions where the possibility of a major incident was anticipated. It was regularly to be found as a part of the medical presence at the local Royal Air Force establishments during their open days and flying displays. It had many advantages, such as good lighting and ventilation, and was well equipped, but it was very slow to mobilize and move and also because of its size and weight, it was unstable unless properly and carefully parked on a firm surface.
In a field of medicine where precise procedure and clear-cut decision making should be the rule, it is perhaps depressing to address a subject where too little is certain and possibilities are almost endless. I regret that this should be so in respect to medicolegal problems in air transport, but such are the facts which have to be reported.
A clear-cut authoritative guide to each and every situation is not only impossible in the air, it is also impossible on the ground. Were it not so, there would be no need for lawyers—and herein as we may see could lie an important clue.
Coming from the city in the world which has made the least political progress in the past decade, I hope you will excuse me for starting with a distinction often made in Northern Ireland, and for all I know in other places in relation to the sphere of political activity. We say that such and such a matter is politics with a small p, and such and such is politics with a large P. Let me give you two examples. If I were to say that the contribution of nurses to disaster medicine is ten times as important as the contribution of paramedics, this would not only demonstrate that my death wish is alive and well, it would also be an example of politics with a small p. On the other hand if I were to say that Maggie Thatcher is destroying the National Health Service and somehow we must persuade all non Conservative parties to form a single coalition to get rid of her, that would be an example of politics with a very big P. If you wish to understand the entire scope of political activity, then it is very important that you recognize both politics with a small p and politics with a large P. Politics with a large P is really a subset of politics with a small p, which in its broadest sense embraces the totality of the subject.
In defining our terms we must ask ourselves—how many aircraft accidents occur and where do the majority of them happen?
Figure 1 shows the total number of losses to be 318 over a 25 year period, the average being around 12 per year. While 1984 was a better than average year when only 7 losses occurred.
The disaster committee is a mechanism for educating health care workers for the unpredictable consequences of serious natural and manmade calamities. Planning is the key, and the disaster committee must strive toward this challenging objective.
A persistent and positive attitude can make the difference between the disaster committee's success of failure. By using some very old principles of good management and organization, and adding some new concepts, a disaster committee can be an effective and worthwhile venture.
Trauma kills more people in the USA under 14 years of age than die of heart disease, cancer, pneumonia and intestinal disease combined. It is the leading cause of death in those under 38 years of age and it is the fourth commonest cause of death for the entire population. Advances in trauma emergency care are important from both the medical and economic standpoint since fatalities cost over twice the amount of non fatalities.
Mental health professionals are increasingly becoming aware of the number and variety of catastrophic events affecting the lives of individuals. These sources of Stressors are being generally categorized into man-made (radiation leaks, chemical pollution, terrorism) and natural disasters (earthquakes, tornadoes, volcanoes). The need to plan, develop and offer assistance to the victims of these injurious events is prompting further study into the human health and mental health consequences and sequelae.
We believe the National Disaster Medical System is of benefit to each participant, to his community, and to the nation. The National Disaster Medical System will enhance local, State, and national ability to respond to emergencies. The system is now under development with the support of the health care professions and institutions of the country.
India is one of the most populous nations in the world with over 900 million people living in 21 States. One of these States is Tamil Nadu situated in the Southern tip of India. Madras is the Capital City of Tamil Nadu which has a population of 4 million people. India as a whole is advancing rapidly in the industrial, agricultural and scientific field but rapid modernization also has its disadvantages. An average of 5,000 to 6,000 road trafile accidents occur every year in Madras City alone with at least one fatality per day. About 40% of the accidents involve pedestrians and cyclists who are unprotected by the vehicle shell or by crash helmet.
In 1967 an apparently new viral hemorrhagic disease appeared in research workers in the cities of Marburg and Frankfurt in West Germany, and in Belgrade in Yugoslavia. In all, 35 workers became ill, of whom 9 died. The only common factor between the three centers was a batch of green monkeys, imported from Uganda. These animals had been used throughout the world to provide tissue cultures with up to 12,000 being imported annually into the USA, with no previous disease noted. Eventually a virus was isolated and called the Marburg virus, but as yet it has not been detected to give any symptoms in the monkeys.
Underground medical care is required in certain instances where patients sustain life or limb threatening injuries or illness while in the underground environment. This most often occurs during deep mining operations, both coal and non-coal, and during recreational caving activities. Additional situations such as industrial tunneling, underground repositories and storage areas and building collapses, such as might occur in a natural disaster or in terroristic activities might also occasion the need for such care. The U.S. mining industry suffered 102 fatal accidents with 250 total permanent disabilities during 1980. In 1983 there were 70 fatalities and in 1984, 124 miners died because of mining accidents. Analysis of accident reports indicate that 25–50% of these injuries may have been ameliorated by timely delivery of physician and paramedic based care in the underground environment. From 1967–1975, 187 recorded caving accidents resulted in 33 deaths among 311 victims. It is unclear how many of these fatalities or injuries could have been prevented or ameliorated by rapid delivery of physician and paramedic based underground medical care.
I will present a general view of the events that took place in Mexico City on September 19th, 1985.
I will make reference, in the first place, to certain facts related with the subject, then I will describe the general damage to health and to the health services, and finally I will give information about the action taken in the area of epidemiological surveillance.
The information in this work was generated through a committee formed by different health institutions and in which I participated. This organization was responsible for the health services and the epidemiological surveillance during the events of September 1985.
The Incident Command System is a personnel and resource management scheme which has several interactive components which make it an effective plan.
This system is being used effectively in the State of California for the control of large scale incidents on a daily basis. Dr. Rodney Herbert of London advised us not long ago, during his presentation of the “Moorgate Incident”, an event in which he participated, that a valuable lesson was learned as that catastrophe unfolded and was managed by local emergency services agencies. The lesson learned was that “special plans” for disaster management which sit on a shelf to collect dust while awaiting the event soon become of little use through inactivity. His message was that the protocols used by emergency services agencies for disaster management should merely be an extension of the day-to-day activities of that agency.
A bachelor's degree in EMS management was the initial course of studies in an academic program designed to prepare people to work in a variety of occupations in EMS.
This paper includes a brief history of that program, its purposes, goals and curriculum and the first data on follow up of its graduates.
In the United States of America, the Emergency Medical Systems (EMS) act of 1973 stimulated people from a variety of fields and backgrounds to work together to develop and manage emergency systems of care; it also raised the question of how to prepare people to meet the future needs of the system. At that time, and with few exceptions, there was little or no academic involvement directed to the concept of the system of EMS and there was a dearth of persons with predictable knowledge and skills in this area. The apparent need for preparing leadership personnel for EMS became the focus of thinking by the Maryland Institute of Emergency Medical Services Systems (MIEMSS) and the University of Maryland, Baltimore County (UMBC).
There is a rich mythology surrounding disasters and our response to them, which has built up over decades and hampers a scientific and objective response to the salvage of life and property. That mythology supports rationales for not dealing prospectively with the very real, but unpredictable, quirks of mankind, nature, and technology. Our response to disaster planning is all too often characterized by ignorance, with a fair share of parochialism, misinformation and unrealistic expectations.
The constant increase of accidental and selfpoisoning has become one of the most important problems of clinical practice and the institution of specialized centers for the care and prevention of these cases has become necessary.
The problems of providing information for clinical, diagnostic, and therapeutic uses are several:
— the number of data required to identify a poison
— the synonyms of generic products and commercial preparations
— the need for a data bank with continuous updating
— the need to provide the information in real time
The use of a computer in an anti-poison center has been potentially rewarding for solving these problems.