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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 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).
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 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.
The aim of primary air rescue is to assist the ground-level rescue services by bringing emergency physicians and rescue assistants more quickly to the scene of the accident, and, if necessary, to carry but the swiftest possible and most careful transport of emergency patients to the nearest suitable hospital. Furthermore, the rescue helicopter can substitute for the ambulance car in case of unsuitable terrain, or in certain climatic conditions.
Limitations of helicopter services include night, certain weather conditions, cost and distance. Helicopters are centered in Air Rescue Centres which have an operational radius of 30-50 km. Expense permits only one helicopter to be stationed in each center, but if the helicopter is not able to fly, a replacement machine must be available immediately. Secondary rescue operations should be taken over by neighboring centers.
In 1983, the Federal Republic of Germany had 36 officially recognized helicopter centers concerned with primary air rescue. They are supported by the Federal Home Office (emergency control) (18 centers), the Army (6), the German Air Rescue (5), the ADAC (German Automobile Club) (4), and other organizations (3). The Swiss Air Rescue in Basel, Switzerland covers Germany's area of South Baden, and the French Air Rescue in Strasbourg covers middle Baden.
Eugene Ionesco once remarked that an excess of politics and an exaggeration of sports are characteristics of our contemporary civilization. The excess of politization affects all parts of our public life, including medicine and its specialty Disaster Medicine. Political ideologies try to usurp a field that has solely humanitarian objectives, that depends on providing for and applying relief to many people in acute distress. There are already many relief organizations and ambulance services, physician staffed emergency medical services systems and first aid trained laymen. There are state and federal disaster relief authorities. Why then was it necessary to add another organization to this sometimes confusing manifold, the German Society on Disaster Medicine?
Emergency medicine is for the individual. It must provide optimal care for each single injured or sick person — except for the shortterm management of multiple casualties. Emergency medical missions are limited by time and locality. These missions are hospital services extended to the scene of the accident and work in connection with hospitals. Disaster medicine is for the masses. Its task is to do the best possible for the largest number of people at the right time and at the right place. This implies that in a disaster situation, optimal care for every single individual can and should not be the goal, but rather the best possible care for the largest number. Disaster medicine has to work in large areas, supraregional and long-term. It needs numerous treatment facilities and several steps or levels of treatment. Therefore it requires a firm medical coordination of lay help, primary professional help, transportation, and specialized hospital treatment with maximal efficiency.
Profound hypothermia has a high mortality if not treated with active rewarming. Most successful is central core rewarming. Many methods have been designed for this purpose: mediastinal irrigation, colon irrigation, peritoneal dialysis, and warm water via a Sengstaken-Blakemore esophageal tube.
A new esophageal tube was constructed for this study. The tube consists of a small, stiff and narrow inner tube, placed inside a larger thinwalled outer tube. Warm water (41-42°C) is circulated from a waterbath via the inner tube to the outer tube and then back to the waterbath. Five healthy mongrel dogs were anesthetized, intubated and made hypothermic. All dogs were paralyzed with pancuronium to eliminate shivering. The only fluid given was isotonic saline to compensate urine loss (50-75 ml/hour). At a core temperature below 30°C the esophageal tube was inserted, and rewarming started when temperatures had reached 27.1-24.7°C. Rectal and peripheral temperatures were monitored, and in 3 dogs blood temperature was also followed.
Up to the cardiac safety temperature (31°C) the blood temperature increased 4.6°C ± 0.79 (SD) (Fig. 1, whereas the rectal temperature rose 3.74°C ± 0.76 (SD) (Fig. 2). The peripheral temperature showed only a minor increase below a central core temperature of 30°C. This means that a secondary temperature decrease is eliminated with this method. No cardiac arrhythmias or other complications were noted. these results correspond to those with peritoneal dialysis (1), and show a greater temperature rise than with use of a modified Sengstaken-Blakemore tube (2). (Supported by the Danish Medical Research Council.)
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.
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.
The Critical Care Medicine department, St. Jans hospital, Brugge, has a prehospital emergency medicine service (EMS) staffed by experienced intensive care specialists. We have been involved in clinical research for the improvement of cerebral outcome after circulatory arrest (CA) and cardiopulmonary resuscitation (CPR) since 1977. In 1982, 250 patients in CA were resuscitated from an area of about 150,000 people. There were 70 short-term survivals, 30 longtime survivals. Although the success rate of CPR is highly influenced by important EMS related factors, including response time, a substantial proportion of hearts are restarted also after prolonged CA, but the patients die later in brain failure. There is evidence that the brain is not only damaged by the CA itself, but that lesions after restoration of spontaneous circulation (ROSC) progress and are amenable to therapy. We can illustrate the progressivity of brain lesions by two phenomena: 1) Animal experiments in other centers (P. Safar, J. Michenfelder) and our research at Janssen Pharmaceutics, Beerse, Belgium. Cerebral venous blood was sampled from the sagittal sinus after a prolonged CA (10 min); cerebral venous PO2 of 40-60 mmHg before CA, rose to 80-100 mmHg immediately after ROSC and about 1-2 h after ROSC decreased to 20-30 mmHg — indicating progressive failure of oxygen transport. 2) Cerebrospinal fluid (CSF) enzyme activity was studied after CA in humans. We correlated final neurological outcome with the early appearance (at 2k h) of lytic enzymes in the CSF. In some patients who later recover neurologically only partially, CSF enzymes are still low at 2k h, as if the cells are still viable at this stage.
Our belief that there is a superagency that goes to work when a disaster occurs is unfounded. What does exist is a network of integrating expertise and resources that are escalated from different routine activities to cooperatively respond to one event. This paper concerns the governmental approach in one area, New York City.
In the United States, federal and state laws exist to minimize the effects of disasters, by identifying measures to prevent or mitigate them, developing mechanisms to coordinate the use of resource and manpower during disasters, and by providing recovery and redevelopment following a disaster. These functions and services are coordinated to the maximum extent with comparable activities of local state and federal governments, and many voluntary private agencies. Organizational responsibility follows a bi-directional flow from federal to state to county-, city-, town- and village level, and in the reverse (Fig. 1). The roles and responsibilities depend on the type of disaster (Fig. 2) and hence the response and activity needed. Response activities include need for clothing, crisis counseling, debris removal and disposal, disease and pest control, equipment and supplies, evacuation, food provisions, fuel provisions, housing and shelter, identification and disposition of the dead, labor pools, law and order, medical care and treatment, power provision, protective measures, search and rescue, sewage control, transportation, the need to waiver codes, water provisions, and weather forecasting.
Adult respiratory distress syndrome (ARDS) is the most fatal complication after severe trauma (1,3). ARDS is seen in multiple injured patients with fractures and the risk for ARDS increases with the number of fractures (9). One of the theories concerning the etiology in ARDS is, that tissue thromboplastine from the site of the fracture and surrounding soft tissue activates the coagulation system resulting in pulmonary microembolism (6). Riska (8) has noticed by clinical experience that increased frequency of early fracture stabilization by internal fixation in multiply injured patients has dramatically reduced the frequency of post-traumatic respiratory insufficiency. The aim of the present study was to investigate the effect of primary fracture immobilization on post-traumatic pulmonary changes in pigs. We used a model in which anesthetized pigs can be subjected to trauma and then observed for several days, while still under anesthesia, under careful respiratory and circulatory control, by means of repeated chest x-rays and postmortem macroscopic and microscopic examination of lung tissue.
Twenty-six pigs (Swedish Landrace), weight 17–23 kg were used. Chest x-rays were done in all animals before the experiment excluding those pigs with any pulmonary changes. The pigs were anesthetized with pentobarbital and pethidine, and tracheostomy, carotid artery cateterization and cystostomy were performed.
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.
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 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).
Drugs for CPR need reinvestigation; at the present time their use is as much an art as a science (14). American Heart Associations standards and guidelines and other recommendations for CPR call for the administration of 500 mg CaC12 i.v. routinely, in attempts to resuscitate patients with asystole or electromechanical dissociation (1). However, calcium's popularity for use in restarting the arrested heart has fallen (3,6,14).
There is a lack of evidence in the literature for calcium's supposed beneficial role in cardiac resuscitation. Calcium in combination with epinephrine — the traditional drug of choice in CPR — was not experimentally investigated before. On the other hand, the effects of calcium antagonists were never examined in CPR, but several theoretical considerations seemed to favor their use. However, a proposed use of calcium antagonists during CPR would lead to the withdrawal of current recommendations for the use of calcium.
Reduced glytathione (GSH) is the tripeptide of glycine, cysteine and glutamic acid and is widely distributed in the body. FSH has been reported to comprise at least 90% of the nonprotein sulfhydryl (NPSH). Although the role of GSH in the tissue has not been clearly established, it is known to be a cofactor for enzymes, a substrate in detoxifications, and a free radical scavenger.
Several investigators have reported that the level of NPSH, mainly GSH, in the tissue was decreased in several types of shock and that exogenous administration of GSH has beneficial effects on shock (1,2). This study was designed to evaluate the effects of GSH on the survival rate in mice and the hepatic energy metabolism in rats after administration of endotoxin. These results were compared with those of methylprednisolone sodium succinate (MP), since many investigators have reported that the large doses of glucocorticoid have beneficial effects in several types of shock in experimental animals and in man (3,4).