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Coughing is a vital reflex consisting of two steps: firstly, the simultaneous closure of the glottis and the rise of the intrathoracic pressure to 150–180 torr by maximum contraction of the abdominal muscles; and secondly, the quick opening of the glottis valve within 0.03 seconds. Consequently a small amount of air is pushed out of the lungs with a velocity as high as 5–8 liters/sec, carrying with it secretions or foreign materials. Under pathological conditions or in special medical situations such as general anesthesia with muscle relaxation—this physiological reflex mechanism is blocked or interrupted, possibly resulting in more or less severe pulmonary complications or even deadly asphyxia.
Paramedic units have awakened a new concept in prehospital care in the USA. New emergency medical services (EMS) administrations, better educated personnel, and mass public awareness through media events have all contributed to the change.
Operational changes designed to tighten control of the emergency medical technician (EMT) and paramedic came about through deployment of ambulances and categorization and designation of emergency hospitals. Clinical changes have given the EMS responder, particularly the paramedic, a great deal of freedom in the care given to patients. The paramedic, who uses subjective criteria, can administer care ranging from Standard First Aid to advanced cardiology. Subjective control should be rigid for the EMT or paramedic, when cognitive abilities include only knowledge, comprehension and application, but not for those who have had a chance to exercise analytic and synthetic skills in pre-hospital training programs.
Norway has fairly well developed primary health care. It is developed around general practitioners who, in their local regions, are responsible for total health care, including emergency medical care. During the last few years, there has been an increasing buildup of resources in the hospitals in the area. Modern technical equipment, increasing knowledge and practical training among the house physicians have greatly improved standards of CPR and emergency health service inside hospitals. Unfortunately, there has not been a proportional build up of resources, knowledge and practical skills in the districts and rural areas. An increasing gap between the treatment offered inside and outside hospitals has developed.
In disasters, every available physician and lay person alike is called upon to render help. Disaster medicine is a most demanding field because of its multidisciplinary nature. Specialties like anesthesia, general surgery, internal medicine, pediatrics, opthalmology, orthopedics, otorhinolaryngology, bacteriology, thoracic and vascular surgery, toxicology, radiology, and others are each separately and directly involved. Without specialized knowledge, no one physician is able to cope with all problems that may arise. Therefore, disaster management planning calls for adequate training and organizational preparations, with plans for the whole spectrum of possible catastrophes from man-made and natural disasters (e.g., floods, avalanches, fire, war, terrorism attacks; air, rail and high-way accidents; chemical catastrophes, irradiation, and radioactive fallout).
On the 28th of November 1979, the fourth largest air disaster in the world occurred on the icy slopes of Mount Erebus, deep in Antarctica and 50 km from Scott Base. The 237 passengers and 20 crew were all killed instantly on impact, and their bodies and the wreckage were spread over an area 500 m long and 100 m wide. It had started out as a scenic flight, the 14th to Antarctica, and it had ended in tragedy. It was suffered, too, by an airline company which had maintained the highest standards of aviation safety.
In an account of Scott's last Antartic expedition in 1910, Cherry Garrard wrote of the “worst journey in the world,” and he said, “I have seen Fuji, the most dainty and graceful of mountains—and also Kanchenjunga; only Mechelangelo among men could have conceived such grandeur.
The medical and nursing staff of the Niguarda-Ca' Granda Hospital of Milano has been involved in three major disasters that occurred in Italy in the years 1976 and 1980: (1) the earthquake of May 6, 1976 in a northeastern region (Friuli); (2) the ICMESA plant explosion of July 10, 1976 in Seveso (Milano) and (3) the earthquake of November 23, 1980 in the region of Irpinia (Southern Italy).
Friuli Earthquake 1976
On May 7, 1976, about 12 hours after the earthquake struck, the Udine Hospital, located at about 15 km from the border of the disaster area, contacted by phone the director of the Ca' Granda Hospital in Milano, requesting a relief staff of operating room and ICU nurses. The Udine Hospital was undamaged and was overburdened by work for the surgical, orthopedic and medical treatment of the rescue victims. The staff requested was needed to relieve the exhausted local nursing staff. Extra staff was needed also to accompany ambulances with patients that, after initial triage and treatment, were evacuated to other hospitals outside the seismic area.
Ischemic and traumatic brain insults may be followed by pulmonary failure, which is a frequent cause of death in cases of multi-trauma, cardiac arrest and stroke. Pulmonary edema (PE) can occur secondary to events in the central venous nervous system (CNS). This is generally termed neurogenic pulmonary edema (NPE). It is not known which of the following 4 factors of the modified Starling equation of pulmonary edema development are involved in the development of NPE: a) filtration coefficient, that is, increased membrane permeability; b) abnormal hydrostatic pressure gradient; c) abnormal oncotic pressure gradient; and d) blockage or overwhelming of lymphatic drainage (Fig. 1).
Asmund Laerdal, a patron, catalyst and leader for resuscitation developments worldwide, died from cancer at his home in Stavanger, Norway on November 19, 1981. At the funeral services on America's Thanksgiving Day, we said thanks for what he has given the world. He was a great man, whose quiet, but determined, manners and eagerness to help whenever he perceived a need, earned him much respect and love.
Asmund Laerdal was born in Norway on October 11, 1913. He went to business school, traveled throughout Europe by bicycle during his youth, married Margit in 1939, and started a small printing business in 1940. Nazi occupation between 1941 and 1945 threatened his life, but did not wreck his little company. Throughout the 1940s and 1950s he printed childrens' books and calendars and made inexpensive wooden and plastic toys. The latter included “Anne Doll,” the “toy of the year,” made of soft plastic, with sleeping eyes and natural hair.
Appreciation of reliable commuications might seem universal; yet when natural disasters strike, few communities are equipped to handle these essential needs. In many instances their ability to notify the rest of the world about their disaster is seriously impaired. Why this is so and why Amateur Radio Operators, or “hams”, always seem to play such a vital part in community survival is the topic of this article.
The best communication systems can fail from traffic overload. As an example, there may be little if any loss of telephone lines or commerical radio links; yet the local population can totally paralyze a system simply by picking up the phone and calling someone. An analogy to this stoppage of communications traffic is seen daily on our expressways as too many cars enter and exceed some critical density at which all traffic must stop.
The American Red Cross is an independent, voluntary body dedicated to performing the relief obligations entrusted to it by the Congress of the United States. The American Red Cross is required by congressional charter (Act of Congress of January 5, 1905, as amended, 36 U.S. Code 3, Fifth) to undertake relief activities for the purpose of mitigating the suffering caused by disasters. A disaster is an occurrence such as a hurricane, tornado, storm, flood, highwater, wind-driven water, tidal wave, earthquake, drought, blizzard, pestilence, famine, fire, explosion, building collapse, transportation wreck, or other situation that causes human suffering or creates human needs that victims cannot alleviate without assistance.
Through internal planning, policy setting, and implementation, and cooperation with private and governmental bodies, the American Red Cross at all levels gives priority to preparing for and providing assistance in disasters of any size.
In an emergency medical services (EMS) system, a certain number of events come to the attention of the pre-hospital subsystem that are subsequently characterized as having required “life-supportive” care. Such cases represent an undetermined portion of the persons, in the population served, who actually require such care. Generally, the life-support units that are available in a community are dispatched on the basis of information received at a medical emergency dispatching center. Very often, the information obtained from the caller is too ambiguous for a clear decision and, inevitably, there is a significant portion of “false-positive” or inappropriate runs. In systems in which little or no attempt is made to screen calls, the dispatching procedure inevitably becomes a “first come, first served” phenomenon and the inappropriateness of the responses is bound to be even greater.
Previous work of our group and data from the literature show that in the polytraumatic patient the metabolic status is characterized by a severe and persistent catabolic situation involving carbohydrate, protein, lipid, mineral metabolism and hormonal and chemical mediators. This situation is clinically expressed by the so-called “post stress syndrome.”
Total parenteral nutrition has assumed a major role in the treatment of polytrauma patients and its application has produced a significant modification of the physiopathological evolution and improvement of the clinical outcome.
Functional and structural disturbances of the brain produced by sudden impact to the skull represent a fundamental problem in neurosurgical treatment of head trauma. A proper experimental approach to brain trauma requires the development of an adequate animal model useful in defining both the biomechanical and physiological variables relevant to mechanical injury to the human central nervous system (CNS). The development of appropriate animal models has proved essential to progress in other clinically related research and is a prerequisite for the development of rational modes of diagnosis and treatment of head injury.
I should like in these remarks to try to place the discussions of this Congress in a larger perspective and perhaps to broaden somewhat our concept of what constitutes a medical emergency, and what should be labelled as a disaster. I should also like to ask whether emergency care and disaster planning as we usually think of these activities are either affordable or useful when viewed in a global context. What are the day-to-day emergencies and major disasters of this planet, and are we addressing them properly with the emergency medical services systems as now constituted?
Disaster preparedness as developed by civil authorities and hospitals has not adequately addressed the special characteristics of mass casualties from nuclear accidents, as demonstrated during the accident at the Three Mile Island (TMI) Nuclear Power Generating Plant. Experiences gained by the Radiation Emergency Task Force of the Milton S. Hershey Medical Center, established during the TMI incident, have resulted in reexamination of emregency medical services (EMS) systems response, population and hospital evacuation, decontamination procedures, communications, triage and psychologic impact during such an event. From these investigations, it is now possible to restructure disaster protocols to accommodate accidents involving toxic contamination. Although this report primarily deals with nuclear accidents, it is also useful in planning for large-scale biologic or chemical accidents.
The physiological range of respiratory rates and heart rates in neonates is approximately 40 per min and 120 per min, respectively, which yields a theoretical ventilation-compression ratio of 1:3ratherthan 1:5.
Thirty-six anesthetized pigs with an average body weight of 4–5 kg were used in the study. After establishing a steady state by artificial ventilation with 100% oxygen, a cardiac arrest was induced by an intravenous injection of potassium chloride. Following the cardiac arrest, the animals were resuscitated with ventilation rates of 30 and 40 per min, respectively, while external cardiac compression was performed at rates between 60 and 160 per min. Randomly selected animals were resuscitated with ventilation-compression ratios of 1:2, 1:3 and 1:4 for 10 min each, 6 animals each were ventilated using a ventilation rate of 30 per min, 40 per min, or positive end-expiratory pressure.
The automatic implantable defibrillator is an electronic device designed to continuously monitor cardiac rhythm, identify ventricular fibrillation and deliver corrective defibrillatory discharges, when indicated. Physically similar to early pacemakers, it weights 250 grams and has a volume of 145 cc (Figure 1). All materials in contact with body tissue are biocompatible. The defibrillating electrodes are made from titanium and silicone rubber. One electrode, designed for placement in the superior vena cava near the right atrial junction, is located on the distal end of an intravascular catheter. The second electrode, in the form of a flexible rectangular patch, is placed extrapericardially over the apex of the heart. The outside surface of the apical electrode is insulated to achieve optimal current distribution.
The device is powered by lithium batteries having a projected monitoring life of approximately 3 years or a discharge capability of approximately 100 shocks. The sensing system detects ventricular fibrillation by monitoring a sampled probability density function of ventricular electrical activity.
The setting up of anesthesia units and any future planning in this field has to be considered in the context of the social and economic development of the country. The situation requires a different attitude towards the handling of anesthesia, where malnutrition, kwashiorkor and parasites are the dominant diseases. One sixth of the world's population is permanently undernourished, and the figure might even be higher in many “developing countries.” Problems of an esthesia in most areas in Africa include: (1) insufficient supply of drugs; (2) inadequate equipment; (3) lack of anesthetic manpower; and (4) underestimation of the importance of anesthesia.
Sweden has not been at war since 1809–1810, when we fought against Russia in Finland. Lyrics by Runeberg are among the few documentations about the wounded in that war. Life-saving first aid was not very good at that time, and most of the wounded died. Modern Sweden is a technically advanced community. We have had some mass casualty situations, such as fires in restaurants and airplane accidents. Six months ago a train crashed just outside the fire brigade station, only five minutes running distance from the hospital. The result was one person dead, two severely injured and about 40 slightly injured. The same crash could have occurred elsewhere in Sweden where the situation might have been much worse, for much of Sweden is very deserted with large woods, and roads are scarce.