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Italian physicians who, from Oct. 1979 to April 1981 directed an emergency medical team in the Ogaden refugee camps of the Qorioley district of Somalia, report on location, general set-up, vital statistics, health aspects, water and food supply, sanitation, disposal of waste matter, health hazards, spread and control of diseases, health education, and planning of health services and health teams.
Invited by the Caritas of Somalia and the United Nations High Commissioner for Refugees (UNHCR) office in Mogadishu, Somalia, from October 15, 1979 to December 31, 1980, two Italian medical teams of the Associazione Universitaria per la Cooperazione Internazionale (AUCI) worked among the Ogaden Refugees in 3 camps of the Qorioley District, lower Shabelli Region of Somalia. Each team consisted of one physician and 2 registered nurses. The Qorioley district, about 140 km SW of Mogadishu, has high day-time temperatures and high humidity throughout the year. The day to night temperature gradients are high. Strong winds are blowing to and from the Indian Ocean.
The 3 camps had been set up in the bush, on the right bank of the Shabelli river, about 8 km NW of Qorioley Town. The refugees in these camps were of Somali extraction and of Muslin culture and religion. They were housed in large military tents, aqal (round roofed skin covered hut of nomads), “mundul” (circular grass-thatched hut built around a central pole) and “arysh” (rectangular hut, corrugated iron tile roofs), aggregated at a very high density. More than 5000 people lived on one hectar. It was so crowded lhat there was no more space than 1.5 m2 of shelter per person. They lacked all hygienic services.
Each camp had a food storage hut (mud walled with corrugated iron roof) and 2-3 water collection ponds, fed from the river. At the time of our arrival, two “arysh” with a total of 20 beds were in use for non-ambulatory patients. Scattered in the camps there were 6 “medical posts.”
There has recently been a steady increase in the number of patients treated in intensive care units (ICUs) and requiring resuscitation. This number has risen from 1 to 3% in patients after cardiac arrest (19) and from 7 to 13% in those with severe injuries (18). The immune system investigations, introduced more and more widely in intensive care medicine for prophylactic, therapeutic and prognostic reasons, did not, in principle, concern the cases of post-resuscitation disease after cardiac arrest. Only a few reports have been published on this subject (11).
The aims of our investigations were the analysis of selected humoral and cellular factors in patients after cardiac arrest in comparison to those with multiple injuries, evaluation of the host resisctance against infection and of prognostic values of some immunological indices.
Examinations were carried out in 50 patients, treated in an ICU of 15 beds, from 1981 to 1982, and in 20 healthy volunteers. The patients were divided into two main groups (Fig. 1): The first group consisted of 25 patients after cardiac arrest, age 47±12. The second group consisted of 25 patients after severe multiple injuries, age 42±18 y; they corresponded to an abbreviated injury scale (AIS) of 4–6 (8). 56% of the patients with cardiac arrest could not be resuscitated. In 64% of the trauma patients treatment was unsuccessful. Infection complications, influencing recovery were observed in 10 (40%) after cardiac arrest and in 12 (48%) after trauma. The cardiopulmonary-cerebral resuscitation methods used were standard (16).
In discussions of the pathogenesis of posttraumatic respiratory distress syndrome (adult respiratory distress syndrome, ARDS), thromboembolism or microembolism (6) is the most frequently suggested mechanism. Embolic material released from the site of injury and/or intravascularly formed aggregates of platelets and fibrin are thought to plug the pulmonary capillaries, giving rise to diffuse pulmonary damage. Pulmonary trapping of platelets and fibrin has been studied in various animal models in which intravascular aggregation was induced pharmacologically, without trauma (2). Studies in patients with ARDS are difficult to standardize, and the results therefore are often inconclusive. We have evolved an experimental model (5) by means of which changes identical to ARDS can be induced from reproducible musculoskeletal trauma in anesthetized pigs. The pigs are observed under anesthesia for three days after the trauma under standardized and carefully controlled conditions. The aim of the present study was to use this model for registration and monitoring of pulmonary trapping of platelets and fibrin in animals with ARDS following standardized trauma, without adding any pharmacologic substance that could influence platelet aggregation or fibrinolysis. Pulmonary trapping was determined by external detection of 51Cr-labeled homologous platelets and 125I-labeled human fibrinogen, intravenously administered before anesthesia and trauma.
On June 22, 1982, the main power transformer at a local high school (St. Paul, Minnesota) overheated, causing the pressure relief valve to operate and release smoke and mist throughout the building. The transformer contained thermal-dielectric fluid with the tradename “Pyranol,” consisting of polychlorinated biphenyls (PCB's) in the form of “Aroclor” and chlorinated benzenes. The transformer did not explode or flame. The emmission characterized by a “white mist” occurred over an approximately 4-hour period with resultant contamination of basement and first floor areas. The temperature of the emission was estimated to be approximately 250-300°F.
“Pyranol” contains PCB aroclor 1260 (45%) and chlorinated benzenes (40% trichloro and 15% tetrachlorobenzenes). Commercial PCB preparations manufactured in the United States have been marketed under the trade name “Aroclor.” Several grades of Aroclor have been designated by numbers such as 1260. The first two digits represent the type of molecule (12 = chlorinated biphenyl). The last wo digits give the weight percent of chlorine.
The fire was discovered by the school janitor and the firefighters arrived at 5:40 a.m. As the firefighters walked near the transformer, several men began complaining of nausea, sore throat and burning of exposed skin. Firefighters having symptoms were asked to go out in the open and were immediately hosed down with water. Initially, 14 firefighters were taken to the emergency room of St. Paul-Ramsey Medical Center, where they were evaluated, treated and released. When inquiry was begun to find out what kind of substance was burning, it was discovered that the transformer which contained “Pyranol” (installed in the school in 1958) had overheated.
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).
In aircraft and airport disasters help must reach the site of the accident in a very short time. In addition to the ground rescue service, rescue helicopters can also offer help. The rescue helicopter as a mobile intensive care unit contains a medical crew with a flying physician and a paramedic. The following are required basic equipment for rescue helicopters: resuscitation apparatus with and without oxygen; endotracheal intubation set; suction unit; apparatus for measuring blood pressure; infusion sets and solutions with intravenous cannulas; syringes and needles; bandages; special burn dressings; fixation and splinting material; vacuum mattress; surgical pocket kit; stomach tube; ECG monitor; defibrillator with pacemaker; drugs; and otoscope. This medical equipment has to be portable so that it can be used outside the rescue helicopter.
The medical crew must be trained in emergency medical treatment and in aeromedical problems. Patients who are fit to fly can be transported by rescue helicopters after triage and support of their vital functions. This method is of most value if rapid transport to a distant specialized medical department, for example, to a burn or neurosurgery center, is required.
The German Air Rescue operates seven rescue helicopters at five rescue helicopter centers for primary rescue with the helicopter types BO 105 CBS, BO 105, Bell 206 Long Ranger and 3et Ranger. Another important function of the service are long distance flights with patients to medical centers after aircraft and airport disasters. Specially equipped ambulance aircraft are used in these cases.
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.
One of the most important aspects of disaster planning is providing for early availability of medical equipment, partly stored at the airport and partly brought from outside. The first priority is obviously to evaluate what is required.
Correct Medical Strategy. This is based on the concept that the first priority is to care for the injured whose life is in immediate danger. The activity on site will include: triage, simple at the beginning, based on first aid concepts, but more sophisticated as more experienced personnel become available; on site care, ranging from first aid to resuscitation; and a rational dispatching of patients to hospitals, using resuscitation ambulances, specially equipped helicopters, or standard ambulances.
Classification of Victims. Priority I or red tag. Priority II or yellow tag. Priority III or green tag. Priority IV or black tag (dead).
The Disaster Planning for Stansted Airport, which' it is proposed will become London's third airport, with expansion to handle up to 50 million passengers per annum by the end of the decade, poses a unique problem because, unlike most other major airports, it is relatively isolated and some distance from the medical facilities required to handle a major disaster. The airport is situated about halfway between London and Cambridge, each 30 miles away, in the heart of the countryside in North Western Essex, close to its border with Hertfordshire.
In the past, the number of survivors from aircraft accidents involving narrow-bodied jets has been very small but, with the advent of the wide-bodied jets such as the Boeing 7k7, this has changed and survival rates in excess of 50% have been found. This gives a potential of more than 250 survivors from an aircraft with 500 seats, many of whom might be expected to have major injuries.
The nearest hospital is k miles away which, in the event of a major disaster, could take up to 6 seriously injured and 12 walking wounded within the first 4 h. Twelve miles away is another hospital which could take the same number, and 20 miles away is a further hospital which could handle up to 8 seriously injured and 20 walking wounded. The nearest hospitals with major accident departments are in North East London and Cambridge, each of which could take up to 10 seriously injured and 50 walking wounded initially.
Irreversible brain damage may occur when cessation of circulation (cardiac arrest) lasts longer than a few minutes. Resuscitative measures, however, can be initiated anywhere without use of equipment, by trained individuals, ranging from the lay public to the physician specialist. The history of modern cardiopulmonary resuscitation (CPR) includes the following steps during the past 30 years:
1. Proof that ventilation with the operator's exhaled air is physiologically sound and superior to manual chestpressure arm-lift maneuvers (Elam, Safar, Gordon).
2. Re-discovery and development of external cardiac compression (Kouwenhoven).
3. Demonstration of the need to combine positive pressure ventilation with external cardiac compression (Safar).
4. Intrathoracic and external electric defibrillation of the heart (Prevost, Zoll, Beck).
For didactic purposes, Safar has divided cardiopulmonary - cerebral resuscitation (CPCR) into three phases and nine steps, using the letters of the alphabet from A to I.
Basic Life Support is for emergency tissue oxygenation and consists of: A) airway control; B) breathing support, artificial ventilation of the lungs; and C) circulation support, recognition of pulselessness and establishment of an artificial circulation by cardiac compressions.
Advanced Life Support addresses restarting spontaneous circulation and stabilizing the cardiopulmonary system. Phase II consists of steps: D) drugs and fluids by intravenous infusion; E) electrocardiography; and F) fibrillation treatment by electric countershock.
Prolonged Life Support represents brainoriented intensive care for multiple organ failure in the post-resuscitative period. Phase III should be continued until the patient regains consciousness, brain death has been certified, or his underlying disease makes further resuscitation efforts useless.
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.
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.
There remains a challenge to improve worldwide, the medical response, and the ground safety response to the disaster of an aircraft crash. Statistically more survive all crashes than perish, and if an aircraft crashes with survivors, in most cases there will be more survivors than dead.
The challenge of survival is to ensure that if an aircraft does crash, the medical and rescue response to this disaster must be immediate, competent, technically skilled and adequately equipped to save the maximum number of lives possible, and to help preserve the quality of life for all who survive. Improving safety standards has been stimulated by the excellent work of the Flight Safety Foundation, the International Civil Aviation Organization (ICAO), the United States Air Line Pilots Association — in particular by Captain John Stefanski and by the World Association for Emergency and Disaster Medicine.
Many will recall that at the meeting of the Club of Mainz Association held in Monaco in 1979, a committee was appointed to investigate aircraft crash management at 100 international airports. The task of the Airport Disaster Workshop was to develop a model of emergency care for large and smaller airports, in order to produce a standard for the various groups of airports. The Club of Mainz Association has been concerned with the poor standard of medical response that has been shown at recent flight disasters. As a member of this consultant committee, it was obvious even from very early days of my research that the medical response to aircraft crash in some countries with high air traffic flows is incompetent, inadequate, and demonstrates little awareness of advances in resuscitation and on-site care of aircraft crash survivors.
During peak hours at Frankfurt Airport, approximately 10,000 employees of 300 different firms, organizations and services simultaneously handle more than 10,000 passengers and accompanying people. Most of them are not familiar with the airport facilities and speak several different languages.
Disaster management is the act of solving an organization problem under pressure of time. The leading role during the immediate action concerning major accidents or disasters is played by the Safety and Security Control Center of the airport operator, which alerts and controls all emergency services of the airport. Included in this organization are the fire-fighting, rescue and medical services of the airport operator, the U.S. Rhein Main Air Base and the emergency services of the City of Frankfurt. The immediate actions are exclusively based on the operation of professional task forces (without volunteer helpers). As far as possible, the emergency procedures, including personnel operations, are the same at all hours (working/holidays, day/night).
The basis for the emergency operation is the “Emergency Orders” manual. The manual consists of an alarm plan in the form of alarm checklists for the different emergency services and of emergency procedures which are activated through the alarm plan.
Command and control through the staff and communication system of the Safety and Security Operation Center, the on-scene Mobil Command Post and the operation centers of the airport services guarantee that the immediate response of the airport's and external task forces is fully coordinated without delay.
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 organization of medical facilities in the USSR is able to provide adequate and rapid care, including intensive therapy in prehospital conditions for the whole population of a very big country. The principles of organization are very simple: the country is divided into regions and these into districts. Each district has to have a fixed number of hospital beds, stations for first aid and urgent care, and a determined number of physicians, and medical assistants (feldshers, nurses and others). The only difference between the emergency care in Moscow and Northern Siberia or Pamir is the distance to be travelled and the means of transport, i.e., modern first-aid cars, helicopters, planes or boats; or reindeer or dog teams when the weather makes aviation impossible. As a rule, all medical teams working in emergency medicine include physicians and medical assistants. Only in places where the population is very sparse are some emergencies still managed by only medical assistants at the pre-hospital stage.
In cases of severe trauma we prefer, when possible, to have teams especially trained in shock treatment. These are already available in the emergency ambulance systems of the bigger towns. These so-called “shock-teams” are experienced and well equipped for intensive therapy at the accident site and with problems occurring during transport. When necessary, we are now able to transport critically ill or traumatized patients not only inside the hospital, but also from one hospital to another, when better intensive therapy can be obtained.
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.
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.