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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).
Major disasters require extensive activity by the fire-fighting, technical and emergency services. Simultaneously, victims have to be rescued, fires have to be fought and other technical aspects of assistance have to be employed. Ill and injured patients have to be removed from danger, prepared for transport, and taken by ambulance, under the care of skilled personnel, to hospitals. The responsibility for these actions lies in West Germany in the hands of the Fire Brigades.
The Alert. Emergency calls arriving at Fire Brigade communication centers or emergency service control centers are often inaccurate. It is necessary for professional emergency personnel to give detailed information from the incident site. This should include the nature and gravity of the damage, the number of injured and their severity, and the best possible access.
Exploration of the Site. In major medical incidents it is highly important to gain a full overview of the scale of the danger and damage. Often incident sites with a great number of injured are difficult to reach and to survey.
Searching for the Injured. It is a matter of high priority to search all over the site for injured persons and those suffering from shock. In large areas, which are difficult to survey, this must still remain a priority. Additional personnel may have to be called in.
Approximately 200,000 emergency patients die annually in the Federal Republic of Germany (FRG) after a sudden illness or a serious accident. According to estimates, more than 20,000 die because effective first aid was not rendered soon enough. We know that two-thirds of all victims of fatal traffic accidents die within 25 minutes after the accident has occurred. In order to improve chances of survival, the therapy-free interval must be as brief as possible.
Data from many rescue missions can be made more comprehensible by computer processing. Exact and systematic processing of data is needed to evaluate the effectiveness of treatments. We put into practice a computer assisted recording system for the rescue helicopter Christoph 5 in Ludwigshafen-Oggersheim, dealing specifically with medical performance.
The members of the World Association for Emergency and Disaster Medicine (WAEDM) (The Club of Mainz) have considered the medical consequences of a major nuclear war and would like to make the following recommendations to all relevant governments and powers, and their medical professions:
1. That disaster medical preparedness should be continued and developed for conventional wars, nuclear accidents and the single small nuclear bomb explosion (e.g., by accident or terrorism).
Latin American and Caribbean countries have been affected by many natural disasters in past decades. Earthquakes caused in Peru (1970) approximately 70,000 deaths, in Nicaragua (1972) 5,000 deaths while destroying the capital, Managua, and in Guatemala (1976) 22,000. Hurricanes also wreak havoc: hurricane Fifi in Honduras (1974) with 10,000 deaths, hurricane David (1979), and hurricane Allen in Saint Lucia, Haiti and Jamaica (1980), have amply demonstrated the high vulnerability of these countries to emergency situations. These catastrophes and many other smaller ones required that all resources of the nation, governmental or private, military or civilian, be mobilized in a coordinated manner to meet the emergency needs of the population.
At the beginning of many of its armed conflicts, the United States has found itself unprepared for large numbers of casualties. The Vietnam War was no exception. In August 1965, Marines landed at Chu Lai, just south of Danang in South Vietnam, for their first major unit combat effort. They suffered more casualties than anticipated. They were cared for by Navy physicians and corpsmen in the combat area and then flown by helicopter to the Danang airbase. There, they were further triaged in a small field hospital, which quickly became saturated with those casualties which could not be moved. Those less seriously wounded and those who could be made transportable were flown directly to Clark Airforce Base in the Philippines by C130 combat aircraft, a flight of approximately 3 hours. They arrived unwashed, in their combat gear, with weapons on the litters. A C130 aircraft carries 72 litter casualties when fully loaded. At Clark AFB, after word had been received of the combat action, all patients, who could be discharged, were sent out. All personnel at the base, including wives and dependents, were mobilized to help at the hospital. They washed and moved the casualties as they arrived.
For over 100 years, Innsbruck, Austria had been a center for Alpine and winter sports. In 1896, it became necessary to found an Alpine rescue service to come to the help of mountain climbers and skiers who were injured or stranded in our mountains. The reason for today's accidents are the same as they were 50 years ago. On the one hand, Alpine accidents are a consequence of preventable dangers, such as inadequate equipment, carelessness, and too little Alpine experience. On the other hand, they are caused by objective dangers, e.g., falling rocks, weather, lightning and avalanches. The rescue methods, however, have undergone a fundamental change over the last 3 years.
In contrast to other European countries, Italy lacks a Civil Defense Organization. Air Rescue is a task for the Italian Air Force Search and Rescue (S.A.R.) organization. It may also draw, if necessary, on the cooperation of the other Armed Forces and State Corps, the Merchant Navy, civilian organizations, the Italian Red Cross (C.R.I.), and the Mountain Rescue Service of the Italian Alpine Club (C.A.I.). The S.A.R. units intervene at the request of civil, state, public and private, national and international organizations. The tasks currently performed by the S.A.R. in Italy include search and rescue of civilian and military air crews lost at sea or over land and of shipwrecked survivors; emergency transport of doctors and supplies to the seriously sick or injured patients from ships at sea; inaccessible localities, earthquakes, floods, and other disasters.
This is an editorial comment for Volume 1, Number 1. Medical disasters are “events in which the number of acutely ill or injured persons exceeds the capacity of the local emergency medical services (EMS) system to provide basic and advanced medical care according to prevalent regional standards.” There are multi-casualty incidents, such as transportation accidents, in which the local EMS system is overwhelmed; mass disasters, such as major earthquakes and wars, in which the local EMS system is severely damaged; and endemic disasters, such as combinations of famine, epidemics and revolutions which often occur in world regions without EMS systems. Nuclear war has become recognized as the “ultimate disaster” which is beyond disaster medicine systems' capacities to save lives. Military medicine, however, which is organized for “conventional” war, offers the maximal life-saving potential for mass disasters in peace time.
Magnitude and Configuration of Disasters. The increasing number of disasters and consequent casualties in an era of growing sophistication of care for the emergency patient mandates a systematized disaster response utilizing all of a nation's resources in optimum fashion. Life in the second half of this century has grown more complicated and in so doing has laid the basis for more complex disasters. Larger groups of people are vulnerable to individual catastrophic events. Population increases and sociopolitical alterations have accelerated the trend toward the establishment of residential and industrial centers in areas subject to natural disasters. Societal and political pressures are increasing tensions, producing ever more disasters along a broad spectrum, ranging from isolated terrorist events through low intensity conflict to limited conventional warfare. Perhaps most important, our increasingly technological society has not only contributed significantly to the menu of conflicts but has brought a variety of new transportation and industrial hazards to the ordinary course of life.
The Swiss Civil Defense system forms part of the national defense, has no combat tasks, and aims at the protection, rescue of, and care for the entire population of Switzerland. Horizontal evacuation is considered impractical and unrealistic. Vertical evacuation into special shelters in homes, public buildings, factories, etc., is the focus of CD. planning efforts. Shelters have increased air pressure, are artificially ventilated, are equipped with gas filters and are strong enough to give a relative protection against outside pressure, irradiation, chemical contamination and missile fragments of conventional weapons. The Swiss CD. system is to ameliorate the direct or indirect effects on the population of conventional, chemical, or nuclear war.
The subject of disaster medicine may seem suspect to those who say that it means to prepare for war. Others maintain that in the FRG we need not concern ourselves with disaster medicine because “disasters in this country seem unlikely.” I consider those claims absurd. I will try to point out possibilities for medical support by the West German Bundeswehr (Federal Armed Forces) in the event of natural disasters (e.g., earthquakes, floods, forest fires) or in severe accidents (e.g., traffic, aircraft, railway) where suitable civilian helpers or equipment are unavailable or are available only in insufficient numbers or too late. The Federal Armed Forces' Medical Service, according to legislation, is part of the Armed Forces, organized for defense. The medical service has to provide free medical care for military personnel, and protect, maintain or restore as far as possible the health of military personnel. Moreover, it is a matter of course in our country to employ the medical service of the Bundeswehr for aid in natural disasters or major accidents. For this purpose, the Surgeon General, Federal Armed Forces, in March 1982, issued guidelines on which I will primarily base my remarks.
The United States Military Health Care System exists primarily to ensure the ready availability of medical support to U.S. Armed Forces at any level of conflict anywhere in the world. Many military medical units are therefore organized and equipped to permit their rapid deployment on short warning to relatively remote areas. They can provide life-saving services within hours and can operate almost independently in any climate, provided they have the means to evacuate patients and to receive supplies. The military mission demands that the medical personnel assigned to these units be trained in peacetime to do their jobs in wartime.