Last updated 10th July 2024: Online ordering is currently unavailable due to technical issues. We apologise for any delays responding to customers while we resolve this. For further updates please visit our website https://www.cambridge.org/news-and-insights/technical-incident
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.
The Search and Rescue Co-ordination Center Goch called me, some years ago, to the Stuttgart airport with the rescue helicopter of the Federal Armed Forces Rescue Center at Ulm. A single-engine sports plane, whose pilot was a student on his first solo flight, had tried a belly landing. Next to the runway, there were several fire-trucks, two ambulances and one emergency physician's car waiting. Our rescue helicopter stayed hovering for nearly one hour until the student pilot finally managed a belly landing. Safe on the ground, he was surrounded by firemen, paramedics and physicians, while we flew back to Ulm. We had not landed promptly I was told because of the landing taxes an army helicopter has to pay at a civilian airport! This episode prompted me to look for more information.
The Federal Republic of Germany is obliged by international agreements to search for planes in distress—no matter what nationality—to save the passengers and, if possible, the equipment and to provide medical treatment for the survivors if necessary. This Search and Rescue (SAR) Service is executed according to the instructions given by the International Civil Aeronautical Organization (ICAO). In the Federal Republic, the SAR service is provided jointly by the Ministry of Defense and the Ministry of Transport. The Ministry of defense provides the means and the Rescue Co-ordination Center. The Ministry of Transport provides the alarm services through the air traffic control offices.
If the best intervention is to be achieved at any incident, be it an aircraft disaster or not, there must be the utmost co-operation between all the intervention services attending or connected with the disaster. Such co-operation cannot be guaranteed to happen overnight or on the day of the disaster, but must be the result of lengthy pre-planning. It is necessary for all involved organizations to decide their area of responsibility on the occasion of a disaster, and contingency plans must clearly set out such responsibilities in order to avoid confusion and duplication of effort on the day of the event. Chaos will surely result if the various responsible officers of each organization do not personally meet during the planning stages, if only so as to be able to readily identify those in charge of each service at an incident. More importantly, each leader can learn of the mannerisms, shortcomings and attributes of his colleagues in other services and thus, when the incident occurs, be in a position to readily appreciate what is likely to be the approach of his fellow officers and services.
Disaster conditions can be characterized as rare, extraordinary and unpredictable events which threaten, injure or kill many people at the same time. The prime examples are earthquakes, floods, traffic or train accidents with hundreds of victims.
While emergency pain relief measures in a few injured victims can be managed individually and really effectively, the requirement for effective pain relief under disaster conditions is still a problem which is largely unsolved. The primary goal of immediate pain relief is the elimination of pain and anxiety which, in themselves, additionally threaten the elementary body functions.
The ideal analgesic drug for adequate pain relief under disaster conditions: 1) should provide the patient with effective analgesia under severe or moderate pain conditions; 2) should ideally sedate the emergency patient to a certain extent; 3) must be effective within a few minutes after intra-muscular, subcutaneous or intravenous administration; 4) should be sufficiently long-acting to avoid the necessity for re-administration several times; 5) should be applicable by paramedical as well as medical personnel; 6) should not have any depressant side effects on respiration and circulation, particularly under conditions of shock and trauma; and 7) should not require intensive monitoring of the patient. This drug has still to be discovered.
The intramuscular or subcutaneous administration of most drugs cannot be considered as methods of immediate effectiveness because most drugs are slowly absorbed, particularly under conditions of shock and trauma. Although the opiate drugs such as morphine, pethidine, and so forth, are obviously effective analgesics, particularly under conditions of severe pain, they cause respiratory and circulation depression, especially if the patient is suffering from hemorrhagic shock, dyspnea and hypoventilation due to thoracic trauma, and so forth.
This report refers to interviews with 53 of the passengers of the Lufthansa aircraft “Landshut,” liberated in 1977 in Mogadishu, Somalia and to information acquired during group-psychotherapy with 16 of these passengers. The psychological care during hijacking depends on the aim and situation of: a) the hijackers; b) the hostages; and c) the extorted.
a) The hijackers are usually motivated by political aims. They feel that their crime is mitigated by their ideology. They are aware of the high risk of their undertaking and the violent counter-actions of the authorities, but they are highly motivated personally and socially. Hence, they are continually in a state of extreme expectant tension with most intensive perception and alert awareness. This activates the high intelligence they may have, but it is combined with a disturbance of their perception of reality. Usually there are several hijackers. Their communication with each other is characterized by a strong hierarchy structure, where the giving and acceptance of command is strictly defined. Their social situation is that of a “group”. The group interactions give them some relief of anxiety.
b) Unlike the hijackers, the social situation of the hostages is that of a “crowd”. They have arrived at this situation by chance and usually without knowing each other personally. Since the formation of a group among the passengers would be an additional danger for the hijackers and would disturb their orientation and weaken their power, any verbal or non-verbal communication and any moving among the passengers is prohibited.
Experiences from accidents show that the majority of critical injuries die within the first 1-4 h if they do not receive some appropriate medical treatment. The problems of an accident with many casualties is dealt with by: (a) maximum utilization of resources; and (b) sorting the tasks.
By rapid and skillful evaluation, we may sort out the critical injuries and give priority for treatment and transport. Through experience we have learned the few and very simple principles of dealing with critical injuries: (a) rapid and sufficient first-aid at the scene, (b) rapid evacuation to a hospital, (c) efficient final treatment, and (d) the need for an effective system of communication between the scene, the ambulances and the hospital.
The principle objective of medical first-aid on the scene of an accident is to stabilize the patient and to make him fit for transportation. Only thereafter is the most necessary temporary treatment carried out. The resuscitation must be continued during transportation. Qualified personnel with equipment must accompany critical injuries. During the last decades there has been a considerable development in the first-aid on the site. Each wounded individual must get the maximum benefit. This requires a high degree of field administration and co-ordination of medical activity on site. This may differ from country to country, but in general the principles will be the same.
Endeavors to expand the flight safety programs into the ground safety response to an aircraft disaster have over the last decade involved many flight safety foundations, aviation organizations, pilot associations, and emergency medical societies. Much work has been done to upgrade airport emergency planning and many data from reports concerning airport disaster drills and crashes have been collected.
The goals of an airport disaster plan include the care, treatment and transportation of the wounded with a quality and quantity of care that minimizes the mortality and morbidity of the survivors of the crash. This simple but ambitious challenge is only accomplished by proper pre-planning and management which depends on the quality of the overall plan, the communication systems, the initial life support and resuscitation, the medical equipment, the patient handling and transportation, and the hospital system. According to a variety of reports from many parts of the world, this concept has, however, been difficult to teach, mainly because of insufficient co-ordination in planning, as well as at the scene of the accident.
At Copenhagen Airport — one of the major airports in the northern part of Europe — it was recently decided to have an airport disaster drill. But instead of a “push-button” test it was decided that an executive committee with members from the police, fire brigade, local airport authorities, flight safety council, pilots association, and the medical field should begin the drill by analyzing the topics which are known and expected to be at risk in the overall efficiency.
In recent years a number of disasters have been handled less than perfectly. Large numbers of patients are sent to the medical facility with little or no warning. Hysterical relatives and friends also arrive, plus the media and curiosity seekers. Well-meaning volunteers and off-duty medical people begin to fill in where each individual thinks he or she fits in best. Soon the rooms and the corridors of the hospital are filled with people lying, standing and sitting. All sorts of treatments are attempted, orders for assistance go unanswered and general confusion reigns.
For many years the military have claimed leading roles in disaster care, giving and taking orders more readily than do most groups of medical civilians. It is the nature of their business to plan for disaster. They take the time to practice and may even be able to test their concepts during wartime.
Primary to all these plans is triage or sorting with “the object being to provide preferential treatment for those who could be attended readily and returned to battle, leaving aside those with more complex injuries until either they could be transported or time became available” (1).
Watt writes that in 1863 a Doctor Moyle tried to convince military sugeons to adopt a triage system to save lives: “Death, wounds, … limbs lacerated and torn off, wounds from muskets or splinters, bayonet wounds, all these appalling and horrible injuries have to be coped with in a few minutes…” He suggested a system of dividing casualties into three groups: slight, serious and fatal and argued that immediate live-saving surgery be done on the severely injured only if the slightly injured were deferred and the fatally injured put aside (2).
Hong Kong is situated at the center of the air traffic axis for Asia, and has, at Kai Tak, one of the busiest airports in the world. The areahas experienced a ten-fold increase in population over 25 years and now has the highest urban density in Asia. Hong Kong is in the monsoon belt and is subjected to the very severe weather conditions of typhoons.
Kai Tak airport is unique. The main 7,000 foot runway is substantially reclaimed from the harbor which in turn lies within a spectacular mountain bowl. The 310° flight path traverses the north end of the Kowloon peninsula with equally spectacular urban development.
Overall disaster contingency planning within this broad spectrum is the responsibility of a joint Police/Military Command. An Aircraft Accident Committee coordinates joint emergency service planning, command and communications training and exercises.
Response to an aircraft disaster is initated by Air Traffic Control through the joint Fire Service/Police/Military Command which sets up a discretionary response for intervention, search and rescue by land, sea and air.
Although the problems are universal, the Maximum Credible Incident scale is extraordinary to Hong Kong. Unique means of dealing with this problem have been specially evolved here, particularly in the field of fire fighting and marine rescue which involve a Catamaran Rescue and Immediate Care Vessel.
Some two years ago the Club of Mainz Executive Committee endorsed a proposal to investigate the rescue and medical facilities at a selection of the world's airports. A number of members of the Club agreed to take part in a survey of a sample of airports in their own regions and some of these reports will be presented in this article. Three airports were studied in the United Kingdom — London Heathrow and Stansted — both civilian airports, and one military airport, Brize Norton, in Oxfordshire.
London Heathrow is one of the biggest international airports in the world, handling more airlines than any other. More than 25 million passengers a year pass through Heathrow and at peak periods there are up to 78 aircraft arrivals and departures per hour. More than 60,000 people are employed at Heathrow. A wide variety of planes are handled from Concorde and wide-bodied jets to small executive aircraft.
Stansted Airport is situated some 30 miles north of London and is also a standby airport for both Heathrow and London's second airport, Gatwick. At present only 500,000 passengers use the airport each year, but it has a capacity for four times this number and there are facilities for further expansion. Stansted is also the fourth biggest air cargo handler in Britain and caters to a complete range of aircraft.
At 15:15 hrs on 17 October 1977, the Lufthansa Medical Service in Frankfurt was notified about the hijacking of a 737 Boeing aircraft. At 15:30 hrs the Crisis Management Staff (CMS) asked me if I would accompany a stand-by crew on the rescue mission. The intention of the CMS was to come to an agreement with the hijackers to exchange the crew of the hijacked plane for a stand-by crew accompanied by an airline physician. I agreed. Medicines and medical equipment for the treatment of injured and sick passengers were packed by medical assistants. At 16:30 hrs highly confidential information was received from CMS—GSG 9 that the Border Patrol Special Commando led by Commander Wegner would accompany the rescue mission which would henceforth be termed “Special Mission”. The hijacked plane was to be followed and seized. It was likely that in the course of this operation an unpredictable number of burns, gunshot wounds and other serious injuries could occur. In a very short time, medical assistants packed further huge crates full of first-aid packs, Macrodex infusions, analgesics, and so forth. I asked Dr. Straub, a medical colleague, and Mr. Reiser, a nursing assistant, both employees of the Lufthansa Medical Service, to accompany me as volunteers, and they agreed. At 16:45 hrs the CMS approved the medical team and the medical equipment.
Coping with an airport disaster is difficult. It is enough to have once been the witness of such an event to understand the enormity of the problem. Instantaneously, the routine atmosphere becomes a nightmare. There are smoke, flames, vehicles, useful people and useless people and above all, the dead, the injured, and the uninjured survivors, some of whom are running about.
An airport disaster plan should be carefully set up and applied as strictly as possible. Many features exist in our favor: (a) we know the place; (b) we can roughly evaluate in advance the magnitude of the problem as far as the number of victims is concerned, thanks to the International Civil Aviation Organization (ICAO) studies; (c) we can keep in mind the classification of the injured and the medical policy with which now all seem to agree, that is to give on-site immediate care and control evacuation; and (d) we can utilize the medical resources of the surrounding community in a co-ordinated way. This paper summarizes the basic principles for disaster control.
Air traffic into Malta is heavy for such a small island', especially during the busy summer tourist season. Almost every type of aircraft flies in, including jumbos with up to 450 passengers. Since the airport has been the sole responsibility of the Maltese authorities, there have been two minor incidents; one in which a small private plane made a crash landing, resulting in minor injuries; and another when a commercial aircraft engine caught fire on take-off. Both incidents were efficiently dealt with. The island is only 10 km in width at the widest point and Luqa airport is 3-4 km distant from each coast. The flight path along the main runway passes over the Grand Harbor on the east and over high cliffs on the west. At landing speeds, this is approximately 1 minute of flying time, so there is considerable likelihood that a disaster could be at sea.
All those persons involved in the aircraft industry whom we consulted have indicated that, forewarned of an aircraft fault, they would always prefer to come down on land, rather than in the sea. An emergency landing at sea compounds the difficulties in rescuing the passengers and salvaging the aircraft, which would be almost impossible. Luqa airport has emergency equipment immediately available, and has procedures selected according to the likely extent of the disaster. These are normally designated as “Priorities” numbered 1-3, following the practices of the International Civil Aviation Organization (ICAO). In addition to procedures for a crash on land, preparations are in hand for rescue at sea.
The use of anesthesia in patients in shock is associated with many problems and considerable risk. This is particularly true when only little time is available for adequate pretreatment because surgical intervention is urgent. In choosing a method of anesthesia for patients in shock, knowledge of the pathophysiology and treatment is of utmost importance.
Le Dran first introduced the term “Shock” (French translation: “commotion”) to the medical nomenclature. The term has undergone alteration in later usage. In 1795, Latta defined shock as the condition arising from serious war injuries resulting from bullet wounds. He was the first to describe shock as “a short sojourn along the way to death.” During the First World War and the postwar period, the role of intra vascular volume deficiency in shock was clarified. Experience gained during the 1939-45 World War and the Korean War, together with the increased civilian accident rate, and research in the field of anesthesiology have led in recent years to considerble clarification of both pathogenetic and the therapeutic aspects. Today, shock can be defined as an acute reduction in tissue perfusion with consequent tissue hypoxia and metabolic acidosis, regardless of the causative factor.
The organs are first functionally and then morphologically damaged. Four mechanisms can be involved in shock; 1) reduction of the volume of blood in circulation (hypovolemic shock); 2) disturbances of the vascular system (vascular shock, anaphylactic and toxic shock); 3) reduction in the functional capacity of the heart (cardiogenic shock); and 4) intrathoracic circulation impediment (shock emboli).
The use of oxygen in emergency situations outside hospitals is limited by difficulties in supply. Low capacity cylinders (100-120 1) weigh 3-4 kg, and have cumbersome mechanisms for pressure and flow reduction. Disposable cylinders of oxygen from a chemical source create the possibility of the contents running out, and are fragile. Particularly when exposed to high pressures or temperature.
Mouth-to-mouth remains most rational and effective. Problems include aesthetic concern and exhaustion in rescuer. It is possible, however, to adapt a Brooke or a Safar airway for use with oxygen, by attaching a tube with tape near the proximal outlet of the airway. This apparatus has been tried on 4 patients during general anesthesia with thiopentone-succinylcholine-neuroleptics—for appendectomies using controlled ventilation with expired air with oxygen added. Tidal volumes of 350-500 ml of air/oxygen were delivered at a frequency of 6-8 breaths per minute. The nose was closed by a clip. Sellik's maneuver could prevent gastric inflation. The color of blood was normal, arterial pressure and pulse did not change, and skin was dry. No fatigue or other effects were reported by the anesthesiologist-“rescuer”. In outdoor use, where oxygen from a chemical source is used, the problems associated with the exothermic reaction can be limited by cylinder lagging with openings to disperse heat. A flow of O2 6-7 1/min is sufficient to support a critical situation. It allows O2 enrichment for mouth-to-mouth, mouth-to-mask, mouth-to-airway, or bag valve ventilation. Modest cost, and low weight allow large numbers to be stored for airport disasters, when resuscitation is performed on a large scale for many victims.
The introduction of wide-bodied aircraft in air transport has required airports to be equipped to keep pace with the advanced aviation technology and the potential for dealing with a really major disaster. Most airports now have their Emergency Plan that defines with details everything which should be done, when, how and where to do it. Communications, Leadership and Coordination are frequently tested through simulated crashes. These tests are considered as an important factor in performance evaluation. When the alert is given at the airport, the Emergency Plan is put into action to face each aspect of the event.
The basic medical service at the airport works around the clock for routine cases and its team, although small, is enough for these duties. In an emergency, the Plan calls for external medical help. When a crash involved a large number of victims, who will help them?
In most instances, the Airport's Emergency Plan foresees a scheme to cater to many serious cases, in accordance with their urgency. The various means of communications alert the hospitals of the neighborhood, rescue bases equipped with helicopters, civilian auxiliary corps, and so forth. Theoretically, most of these systems have been put into action during the practice drills. Following a serious analysis, it would be optimistic, however, to expect a perfect reaction. Communications problems, holidays, cold mornings, congested traffic, bad weather, and so forth, might on the day lead to disappointment for those experienced with disaster drills which are usually performed in favorable conditions.
What exactly comprises a “disaster?” The American College of Emergency Physicians has defined the term as “a sudden massive disproportion between hostile elements of any kind and survival resources that are available to counterbalance these hostile elements in the shortest period of time” (1).
In a small airport supporting a town of 10,000 an aircraft accident involving 4 or 5 casualties can constitute a disaster by this definition, whereas at Kennedy Airport (JKF) with its large depots of medical support, and where our experience in this area has been considerable, it would take many more casualties to qualify as a disaster. “Black Sunday” at Tenerife, with 500 casualties in a single incident (2), focused world attention on the need for more adequate casualty care of air crashes at airports, particularly at airports that handle wide-bodied jets. In our efforts to improve the methods of “bringing the hospital to the emergency rather than the emergency to the hospital,” the “workshop” at Kennedy Airport has evolved over the years from a cumbersome inflatable unit with limited mobility, to a Mobile Emergency Hospital with a capacity of 100 beds and an operating room (3).
In the past year, we have developed an even more practicable Mobile Emergency Hospital, the size of a standard cargo container, 40 feet long by 8 feet wide and 8 feet high with 4-wheel drive and self-propelled at 55 miles per hour, capable of being lifted by helicopter, flown in a Lockheed C130 or cargo 747, placed on a railroad flat-bed or transported as a container on the deck of a ship (4,5).
The protective effect of an artificial tanning scab seems to be greater than that of the physiologic eschar, in controlling the invasion by micro-organisms and the loss of water, electrolytes and plasma. Allgöwer, et al. confirmed a reduced toxicity in burns, using experimental tanning procedures. Applying mercurochrome 2%, tannic acid 5% and silver nitrate 10% is a simple and most effective local treatment, especially when large numbers of patients are involved. No further topical agents are necessary for days, and infusion therapy may consist simply of water and electrolytes for the first 2k h, and the patients are stabilized for transport. A most important advantage of this procedure, which was obvious in all our patients, is the reduction of pain. Resorption of the applied substances must be considered. Toxic side-effects have not been seen with the use of tannic acid 5% nor with silver nitrate 10%. Increased blood levels of mercury have been found, however, but they have not caused toxic complications in more than 200 monitored patients. Betadine may be used instead of mercurochrome as a local antiseptic. The antiseptic effect of betadine was found to be greatly prolonged after tanning, as compared to 100 patients with comparable burns without tanning—with septic complications having been reduced in the tannic acid group.
Triage or sorting means recognition and selection of the injured for treatment and transport. It is a very important and difficult task and has the aim of saving as many lives as possible, ensuring the best possible treatment, leading to the best possible recovery. Triage requires judgment, courage to assume responsibility and determination to act rapidly. The examination of a patient to assess his priority includes his vital functions, his specific injuries and his environment. Triage leads to the following priorities:
(1) immediate, compulsory treatment;
(2) early treatment, within hours;
(3) delayed treatments; and
(4) slightly injured and hopeless cases.
Although triage is primarily a physician's job, trained paramedical personnel or firstaiders may be the first to arrive at the scene and should to able to recognize and treat casualties requiring immediate care on the spot.
The first physician at the disaster site may not be well qualified in emergency medicine, and indeed may have little or no experience in handling casualties. He may be a passenger involved in the emergency landing of an airplane. Let us therefore examine three possible situations:
Most of us are aware of the medical airlifts that were practiced by the United States Air Force during the Korean and Viet Nam conflicts. Likewise, we read regularly of the air transport of one or more severely burned patients from the scene of an accident to the Burn Center at Brooke Army Medical Center in San Antonio, Texas. But what is not generally known is the daily movement of patients who are armed forces members, or their dependents, throughout the world for the purpose of receiving sophisticated medical care, regardless of where they may be stationed.
The reasons for this service are two: first, quite obviously, it is humanitarian; second, it is a way for the Air Force to maintain medical readiness for their wartime mission by exercising this system on a daily basis during peacetime. We are talking about a worldwide network whose major and minor branches sweep around the globe.
Patients are air transported according to three levels of need: routine, high priority, and urgent. This article will be limited to a general description of the necessary hardware and current practices used for the urgent mission.
We use three types of aircraft: the Huey helicopter for short distances; the C-9, a two-engined jet, for medium range; and the C-141, a four-engined jet, for intercontinental transport. The medical modifications to the C-9 include a built-in ramp; a nurses' station similar to that found on a hospital ward, complete with built-in drug and equipment cabinets; multiple sources for oxygen and suction; and ready communication fore and aft. Seats can be quickly removed, leaving space for litters in tiers, infant isolettes and Stryker frames.
In a mass casualty situation after airplane accidents, it is not unusual that physicians with only limited experience in emergency medicine need to perform initial triage. In their day to day work, they may not usually be confronted with the problems of hypovolemic shock. The same holds true for a proportion of the paramedical personnel employed.
Speedy assessment and immediate, purposeful therapy is of the utmost importance in a mass casualty situation to increase the survival prospects of the victims. Timeconsuming and elaborate examinations are naturally precluded.
The estimation of blood loss from profusely bleeding open wounds should not be too difficult. The extent, however, of the total blood loss associated with the insidious development of fracture hematomas is more frequently underestimated. This error can be avoided during triage at a mass casualty situation by means of a quick approximate calculation of the probably internal bleeding volumes:
More difficulty is presented by internal hemorrhage in individuals appearing uninjured or only slightly injured. In such cases, the personnel employed in the early phase after an airplane accident should use simple and proven rules as criteria for their evaluation.
The quotient of the pulse frequency and the systolic blood pressure has been called the shock index (Allgöwer and Burryi) (1). Disregarding the later and more complicated pathophysiological processes such as cardiogenic shock or septic shock, this index has been suggested as a method of assessment of the seveity of the hypovolemic shock in an injured person (Figure 1).