22 August 2024: Due to technical disruption, we are experiencing some delays to publication. We are working to restore services and apologise for the inconvenience. For further updates please visit our website: https://www.cambridge.org/universitypress/about-us/news-and-blogs/cambridge-university-press-publishing-update-following-technical-disruption
We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
This journal utilises an Online Peer Review Service (OPRS) for submissions. By clicking "Continue" you will be taken to our partner site
https://mc.manuscriptcentral.com/pdm.
Please be aware that your Cambridge account is not valid for this OPRS and registration is required. We strongly advise you to read all "Author instructions" in the "Journal information" area prior to submitting.
To save this undefined to your undefined account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your undefined account.
Find out more about saving content to .
To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
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.
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.
The speedy development of disaster medicine has made intensive care on accident sites possible for everyday use. This prehospital care Has proved to be an indispensable, life-preserving work. It does, however, require having qualified medical and technical help brought to the site of disasters in reasonable time, and the ability to bring patients back in properly equipped units, supervised by paramedic staff, to ready and well run hospitals which are able to carry on the treatment and secure the results already obtained.
Rescue work associated with air crashes must be of high interest to all nations, as air traffic is global and a European traveller may easily get into trouble in a wilderness in another part of the world. Through the International Civil Aviation Organization (ICAO) membership, nations are bound by means of international regulations, to contribute to security in the air and supervision of planes in their own area, and to co-operate with the FIR-system in adjoining areas. This system contributes to a better chance of detection of an aeroplane in difficulties, but the rescue problem will have to be solved by the existing and available national military and civil rescue service, its organization, material, education, medical preparedness and disaster plans.
Statistics reveals that about 50% of all crashes take place in landing procedures, some of them occurring just outside the airport. To these must be added collisions en route and cases of sabotage. Most crashes at take-off happen so near the airport that there will be no problems of detection, and help in fire-fighting will be available from the airport, if necessary.
In disasters, the success of medical action in the hospital will only be measured according to the number of survivors and not to the number of major operations executed. Thus, for the clinician his usual standards may have to be modified and he must keep in mind the principle of helping the largest possible number of patients in the given circumstances.
According to previous experience it can be expected that 20% of the survivors in a disaster need surgical treatment. Even in well organized and fully equipped surgical clinics, the proportion of immediate treatment capacity to the total number of beds is no more than 5% to 8% under normal conditions. This means that every hospital should make plans to organize facilities to cope with a major disaster. The individual hospital plans should be co-ordinated with other hospitals in the neighborhood and be integrated into the disaster plans for the entire area. Communication between hospital and the central headquarters is of the utmost importance.
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.
Private aviation being popular, there are many light planes in regular use. Several of these are operated by pilots in training through local flying clubs. There is naturally a risk every time a plane takes to the air, but the statistics show that the risk is actually quite small. Most insurance companies do not increase their premiums for private pilots flying for pleasure. The most common emergencies which arise in light aircraft are caused by deteriorating weather conditions, fuel shortage, engine failure or pilot error.
Accidents caused by the inept pilot usually occur during take-off or landing. Gusting wind conditions can produce an unexpectd stall position when there is inadequate height to recover. The strong vortices generated in the wake of high powered jet engines can turn over a light plane which is following too closely at take-off or landing in the circuit. Accidents may also occur during flight because of the pilot's failure to fly at the correct height on the correct course and communicate properly to the local air traffic control. Fear of being made to look incompetent often results in the inexperienced pilot failing to ask for help when he is in doubt or in trouble.
If problems such as engine failure or fuel starvation occur, however, all is not lost since, unlike their enormous commercial counterparts, light planes have excellent gliding characteristics and can usually make an emergency landing. Requiring only a relatively short landing run if full flaps are used, they can often find a suitable site free from buildings and people.
In the history of aviation there has never been a period when so much effort has been demonstrated to improve the safety standards of international and national airports. This has come about through the knowledge that aircraft crashes in recent years at some airports have been mismanaged because of bad or non-existent planning for such a disaster, and by poor emergency medical response.
We share today a faith in the safety of the aircraft. We share, too, the awareness that more people have survived aircraft crashes than have perished, and that if there are survivors on board, in most cases there will be more survivors than dead (1).
The encouragement to improve airport safety and crash management has come largely from the International Civil Aviation Organization (ICAO); from the Club of Mainz Association, who in 1979 set up a consultant committee to investigate and improve international airports; from the Flight Safety Foundation and from the US Airline Pilots Association. All these organizations have rightly questioned the quality of existing emergency medical response to an aircraft crash, and have offered expert advice to improve disaster preparedness and management. This article will report our response to this challenge, particularly in New Zealand, but will also concern our neighboring continent of Australia.
New Zealand, set in the Pacific Ocean with its two long islands, has international flight contacts through its three major airports with North America, South East Asia, Japan and the South West Pacific. It has its own national aviation hazards of mountain chains, difficult landing approaches from the sea, made more hazardous with strong winds which are a feature of our capital city airport. Despite this, the safety record of New Zealand airports is extremely high.
In serious emergency situations such as the aircraft crash, the medical staff can also be in danger. The risk for the medical and paramedical staff has two sources: (a) factors related to the cause of the accident; and (b) dangers occurring during rescue operations. It is necessary that the emergency staff look to their own security, and avoid exposing themselves to the risks associated with the panicking movements of frightened people (herd effect). The first aid station should be established in a position down-wind, to avoid the toxic smoke from fire. An essential condition is that the medical emergency staff is composed of people physically and psychologically suitable to the sudden effort and the acute stress.
To reduce the risks associated with rescue operations training is essential, conducted under the supervision of experts from the Fire Brigade. A minimum program of training must be arranged between the physician in charge and the airport authorities, so as to reconcile the activities of the two parties and achieve co-ordination. The medical and paramedical staff must be trained to operate with a gas-mask or oxygen auto-respirator, necessary to prevent intoxication with compounds such as tri-o-cresyl phosphate, fire extinguisher compounds such as dibromodil-fluoromethane and bromocloromethane. Metabolites of air contaminants found in airport disasters are not well known. We summarize in the table some toxicologic data of interest.
The airport clinic at Flughafen Frankfurt Main AG (FAG) is a 24 hour manned casualty ward. It employs three surgeons and approximately 40 paramedics. This clinic is supported by external physicians during the night and weekends that guarantees, on a 24 hour basis, a minimum of one physician and four paramedics available for immediate response.
In addition, the airport operator provides an industrial medical service which employs (during normal working hours) six physicians and approximately 10 paramedics.
Finally, there is support from the clinic of the US Rhein Main Air Base, at the military part of the airport, which employs approximately 12 physicians and flight surgeons, 10 dentists and another 100 paramedics. The emergency staff of the clinic of the US Rhein Main Air Base is also manned on a 24 hour basis. The airport clinic and the clinic of the US Forces and their respective fire departments collaborate together in cases of emergency or disaster.
For immediate medical care the airport clinic has available an emergency surgery unit, one emergency surgery ambulance vehicle, and three ambulances with first-aid equipment. In addition, the airport clinic provides two trucks with medical equipment for 100 severely injured persons and two inflatable air-conditioned emergency tents.
Comparable medical equipment is also available at the clinic of the US Rhein Main Air Base, according to US military standards. The US Rhein Main Air Base also operates three DC-9 Nightingale medical aircraft which are responsible for all types of emergencies in the area of the US Forces in Europe.
At large airports, the principal problem is coordination of resources. These resources consist of airport medical resources and outside medical resources. At small airports, the problem is often more complex because the surrounding community's small medical and non-medical resources often may be inadequate. The danger of crash is about the same, however, as that of a large airport, if this small airport serves aircraft of categories 4 or 5. The following recommendations are relevant to small airports:
1. The guidelines contained in “Airport Emergency Planning,” recently published by the International Civil Aviation Organization (ICAO) should be followed.
2. An inventory of all the private and public resources available in the surrounding communities should be completed and their development and expansion actively supported.
3. A flexible medical policy should be adopted stressing first aid as a first priority. Air evacuation of victims should be arranged by helicopter or medevac aircraft to other better equipped communities. Rescue teams and medical equipment, including mobile shelters, should be brought by air from other communities.
4. An International Medical Task Force should be considered which could be capable of being rapidly mobilized. This could be useful not only for airport disaster, but also in case of natural disasters or any other mass accident.
The concept of treating mass casualties in major disasters, particularly at or near airports, has gained considerable momentum in recent years (1). Major urban airports are almost without exception, plagued by access road traffic problems even under normal circumstances. Given a disaster within the confines of an airport, emergency equipment and medical support are found to be mired in a morass of sightseer and emergency service vehicles, compounding the congestion already present immeasurably (2).
Evolving from experiences gained over the past 30 years in handling masses of casualties resulting from aircraft disasters, we at Kennedy Airport have developed a Mobile Emergency Hospital which now serves as the “workshop” for stabilizing large numbers of injuries prior to subsequent transfer to definitive hospitals. The keys to this plan are the Trauma Team support used in conjunction with the mobile hospitals.
The ideal trauma team consists of 2 surgeons or trauma-trained physicians, one surgical nurse and one medical or 2 surgical technicians. These teams can be varied according to the immediate situation, time of day, available physicians, nurses and technicians. Anesthesiologists respond either individually or as members of some of the teams reporting directly to the operating units on arrival.
For an efficient response plan to function, previous liaison must be established primarily with teaching hospitals with a surgical staff that includes surgery and trauma residents. The Kennedy plan has a working arrangement with the New York Medical College and 8 of its affiliated major teaching hospitals in Manhattan, as well as in the main campus at Valhalla, which maintains an associated Burn Center.
Pain relief is important — not only for humane reasons — but also for protection of the circulation and tissue perfusion which suffer as a result of the enormous secretion of catecholamines which occur. In the operating room during anesthesia we take care to combat this trend by giving adequate analgesics, and it is logical that we should attempt to take similar steps in the prehospital care phase.
One of the reasons why the provision of analgesia is so poor in practice is that the usual parenteral agents — the opiates — are accompanied by side effects which are particularly dangerous in the seriously ill or injured patient. The introduction of low dose ketamine, however, has altered this position somewhat, offering, as it does, good analgesia without significant depression of respiration or the circulation.
A major practical difficulty in providing analgesia outside hospital lies in the fact that the majority of the patients are being cared for by personnel who are not physicians. We, therefore, need an agent which can be administered by an ambulance attendant or trained rescuer. In many countries the opiates and ketamine may only be administered by a physician and therefore they are effectively ruled out for the majority of patients.
Let us look at the properties of an ideal analgesic for use outside hospital. It should be: 1) effective but safe; 2) have no undesirable side effects; 3) have a rapid onset and short duration of action; 4) be easy to administer; and 5) be capable of being used by paramedical personnel.
Up to 1980, the important European airports and European airlines increased the number of their flights and passengers. As a result, it has been necessary to develop and launch airplanes with a high passenger capacity (e.g., Boeing 747, Jumbo, with 270 seats; Douglas DC 10 with 265 seats; and the Airbus A 300 with 249 seats). Simultaneously, the airports had to be enlarged or even rebuilt. After this substantial investment, the number of passengers began to decrease. In 1981, the French airline “Air France” expected a deficit of about 65 million DM (29.5 million US dollars), excluding the deficit by Concord. For the first time in 18 years, the Scandinavian airline “SAS” in 1980 had a deficit. The German airline “Lufthansa” expects no profits in 1981. This situation has been caused by rising oil prices, decreasing numbers of passengers, and a general recession. Many airlines have been reducing prices to attract more passengers. In spite of the high investments in new airplanes and modernizing airports, there has been little improvement in the necessary air- and ground-control-systems.
In April 1981, the International Associates of Pilots (IFALPA) graded the security of air- and ground-control-systems of German airports as follows: deficient — Frankfurt and Bremen; seriously deficient — Hamburg, Stuttgart and Saarbrücken. According to the security scale of the IFALPA, the most important airports in the Mediterranean area were surveyed and estimated in 1977/78 as follows: deficient — Los Rodeos (Canary Islands), Las Palmas (Canary Islands), Lisbon, Faro, Malaga, Alicante, Madrid, Gerona, Ibiza, Palma de Mallorca, Venice and Roma; and critically deficient — Alghero, Rimini, Naples.
We must be prepared for a survivorship of about 600 to 700 injured passengers in case of an accident involving two jumbo jets as these planes are able to absorb more impact forces than earlier types, and 40%-50% of the passengers may survive.
A triage post, an anteroom for resuscitation and anesthesia, and an operating room with 3 tables must be installed within the airport. Mobile operation units are necessary in addition for urgent surgical care on the spot. The optimum time of the operational readiness is approximately half an hour, if “on the spot surgical care” is to be effective.
At the triage post several tables are available, each with an experienced surgeon for the rapid medical examination. The time of examination and triage for each victim of the earthquake disaster in El Asnam was three minutes.
In an airport disaster, about 10% of survivors might belong to the first category of triage, i.e., have life-threatening injuries. They will require resuscitation and urgent surgical care. Twenty percent might be seriously wounded passengers of the second category, who should be conveyed to hospital as soon as possible. Seventy percent might have minor injuries of the third category and can wait for care and transportation.
Many victims may require neurosurgical operations, but this should be carried out by trained experts and not at the airport. Open depressed skull fractures should be treated at the airport by shaving the scalp, irrigating the wound, applying a sterile dressing and instituting antibiotic therapy. Foreign bodies should be left in place until definitive surgery can be undertaken.
At the John F. Kennedy International Airport in New York City, disaster planning has been an integral part of the airport operations for the past 28 years. Through the Medical Office, emergency medical teams have been recruited from all ranks of airport personnel and trained in rescue and resuscitation. Following the crash of a commercial B 727 aircraft in 1976 and the resulting crippling traffic jams in the vicinity of the airport, a new concept was added to the disaster plan. This concept involves bringing the hospital, its facilities and its personnel to the scene.
A new piece of equipment, known as a Mobile Emergency Hospital was designed from existing airport equipment, with the cooperation of the airlines, the operating authority of the airport, and other interested parties. Two such vehicles are now in constant readiness at the airport and together provide 12 monitored ICU beds, a 16-bed burn unit, 2 operating rooms and 72 other stretcher-beds to be used for the stabilization of critically ill patients prior to their transfer to an appropriate definitive care facility. A newer modularized version which incorporates these features, for use in any type disaster, is currently being developed. These mobile hospitals, together with two inflatable structures maintained at the airport, are supplemented by Mobile Emergency Rescue Vehicles (MERV vans) maintained at local hospitals by the Emergency Medical Service Systems (EMSS) of New York City. Together they provide the on-site Resuscitation and Stabilization Center in the event of a disaster.
In the event of a disaster, all personnel present in the airport area must modify their own everyday rules to ensure the best response to the emergency situation. For medical aid there are two main objectives: (a) organization of rescue operation; and (b) mustering medical resources. The initiators of the rescue operation must be the control tower staff and each Italian airport is provided with emergency plans which have been carefully studied.
Information systems between the accident site and the centers of available medical resources, however, are less well organized. These can be simplified by the use of a video terminal, connected with a data system elaborator. The Lombardy region plans to install a video-terminal in every Regional Hospital in order to be able to present the airport with the up-to-date situation of vacant beds and of medical staff present in the hospital for emergency tasks.
It is proposed that the alert from the accident site should be in two phases. Initially, a general alert must be given, followed after a short time by a more detailed specific alert. The first phase must be addressed to those departments that, independently of the type of the disaster, will always be involved in any critical situation, e.g., Ambulance Headquarters, ICUs, Blood Centers, Emergency Departments. The second phase will be used to inform hospital departments specializing in treating the pathology prevailing in the particular disaater. In airport disasters, the pathology which prevails will include major and multiple injuries with blood loss and burns.
As with many manmade and natural disasters, those involving airports and aircraft give rise to a number of emergency medical situations that require prompt and sometimes drastic responses. The number of casualties can be very large and adequate hospital facilities can be quite distant from the disaster site, even when the latter is at an airport. Obviously, the situation is compounded when the accident has occurred at a remote place or involves a landing on water. Emergency measures are therefore of great importance to minimize loss of life and reduce exacerbations of initial injuries. Fortunately, major disasters are infrequent. This very fact, however, makes it even more impractical at most airports to have on hand at all times a large supply of blood and the facilities for typing and cross-matching rapidly and accurately. No supply of blood, of course, exists on any ordinary aircraft. There are therefore good reasons why artificial preparations capable of carrying oxygen and carbon dixoide and maintaining blood volume have potential usefulness in airport and airplane disasters.
These disasters can involve one or more forms of bodily injury including physical trauma, burns, and asphyxiation (Table 1). All can lead to shock, and some form of emergency treatment is often required to restore blood volume and oxygenation levels. Since any delay in initiating treatment must be avoided, the required materials should be on hand and in a form which allows their being used without delay. Artifical blood replacement preparations (1-4) based on liquid perfluorochemicals have a number of desirable attributes in this regard.