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Extensive experiments in animals and humans, as well as clinical experience in disaster areas, have shown that expensive devices and complicated inhalation narcotics are not suited for anesthesia under disaster conditions. Today, the most important drugs are intravenous and, in emergencies, also intramuscular preparations which do not cause any significant central respiratory depression:
1. Ketamine, suited for routine anesthesia under disaster conditions; and
2. Gamma-Hydroxy-Butyric-Acid (Somsanit), suited for poor risk patients with hypoxic injuries and/or shock.
The newspapers present almost daily reports on great accidents some place on earth. However, on a national basis, catastrophes occur at rare intervals. There is hardly anywhere a professional rescue personnel which is ready for major accidents with mass casualties because of underutilization and for financial reasons.
That means that at major accidents with mass casualties, the need for rescue personnel and equipment usually exceeds the daily professional readiness for rescue services, and the required manpower and equipment in sufficient numbers are seldom available to handle such big accidents. Voluntary lief organizations will then lend a hand, but they mostly consist of helpers who are neither educated nor trained for such difficult rescue work.
Perhaps the greatest operational problem faced by the New York City Emergency Medical Service (EMS) today is the sheer volume of calls entering the system, and the fact that many of those requests for medical aid are not life-threatening emergencies requiring ambulance transport. This creates two situations that New York City is all too familiar with: (l) ambulances are not available for true emergencies; and (2) response times for ambulances to arrive at the scene of an emergency are extended.
A four-month pilot “on-scene triage” program was initiated by EMS as a possible solution to these problems. The program ran from May to August of 1980. A marked EMS car was designated as the “Triage Car” and was in operation during those hours when ambulance requests were at their peak (usually two to ten PM).
In order to better understand the conditions permitting a fire disaster to occur and to better postulate methods of fire prevention, an historic analysis of three fire disasters was performed. Journalistic accounts, official investigative studies and documents were examined concerning 3 fire disasters: (1) The General Slocum Ship Fire of 1904; (2) the Triangle Shirtwaist Factory Fire of 1911; and (3) the Coconut Grove Nightclub Fire in Boston of 1942. Although the fires occurred on a ship, in a factory, and in a nightclub, several striking similarities were found.
(1) On June 15, 1904, the ship General Slocum embarked on a voyage up New York's East River, that ended in death for 1031 people. The ship, which was constructed entirely of wood, had recently passed inspection. The ship's crew, mostly longshoremen with little sea experience, had never fought a fire at sea. The hatches and bulkheads were flammable, the fire hoses were old and rotten, the fire buckets were out of reach and empty.
There is controversy concerning the best method for rapid fluid administration in shock secondary to severe or continuing blood loss. Some authors recommend immediate cutdown, while others support percutaneous central intravenous lines. In addition, the data available on maximum flow rates for various catheters is limited and does not compare different solutions. To gain more insight into these problems we have studied the flow rates for different lengths and gauges of catheters utilizing various physiologic solutions.
In the late 1960's and early 1970's, several major disasters occurred in rapid succession. The most devastating of them was no doubt the earthquake in Peru in 1970, which claimed some 50,000 lives and caused untold damage and destruction in that country.
Experience in these, and indeed in other disasters, made it clear that much of the generous aid provided by the international community in the wake of these disasters was, in the absence of co-ordination, often wasted or did not correspond to the real needs of victims. Enormous quantities of goods, some of them quite unsuitable, would pour in, together with countless well-meaning individuals wishing to help. Unfortunately, many of them were more hindrance than help. Obviously, some order had to be created to rectify this haphazard approach, and to ensure that relief supplies of the right kind and in appropriate quantities would reach the survivors rapidly to cover their basic and most urgent requirements during the emergency period.
Successful management of a mass casualty situation involving 45 injured marines following a fire in Japan demonstrates the important principles of triage, patient movement, quality patient care, logistics, communication and medical direction.
Following the accident, the US Army Institute of Surgical Research assembled a burn team consisting of three surgeons, three nurses, one microbiologist and eleven clinical specialists (three of whom were inhalation therapy technicians) and the equipment and supplies necessary to treat and transport these patients. The US Air Force Military Airlift Command transported the team and equipment to Japan in a C–141 Starlifter Medevac plane and pre-positioned a second C–141 in Japan for the return flight. Additional ventilators and supplies were mobilized from Japan, Okinawa, the Philippines and Alaska.
There have been 81 patients brought to Treliske Hospital, Truro, UK in the last 6 years, having been rescued from near-drowning. Only 5 have been declared dead on arrival and not treated. We consider that hypothermia is a major factor in patients who have apparently drowned, particularly when it has been known that they were strong swimmers. In 1980, 45% of all drownings had rectal temperatures less than 35°C. The sea temperature around our shores varies between 5°C in January and 15.5°C in September. Hypothermia causes little problem until a central temperature of 35°C or less is reached. Between 35°C and approximately 32°C there is disorientation and incoordination, which may make swimming difficult to maintain efficiently. Below 32°C there is loss of consciousness; when this occurs, the victim's head drops below the water level and drowning occurs just as quickly as in a victim who is unconscious on entering the water.
We could obtain good results similar to other groups with a device for cardiac compression and automatic ventilation during CPR. The following paper will not discuss the experience with such a device, but the further development and improvement of a device already used and found to be useful.
The further development seemed to be necessary since we tried to utilize new hemodynamic results important for external cardiac compression and ventilation. Other reasons were problems occurring with its practical use.
At 0400 hours on Wednesday, March 28, 1979, an extremely small and initially thought unimportant malfunction occurred at the nuclear power plant at Three Mile Island (TMI). Within a short period of time, that malfunction would turn into an event of momentous impact with repercussions felt over most of the world. The events of that malfunction would cause TMI to be labelled as the worst commercial nuclear incident in history and transform it into the nuclear test tube of the universe. What really happened at Three Mile Island? Thirty-six seconds after 0400 hours, several water pumps stopped functioning in the unit 2 nuclear power plant. In the minutes, hours and days that followed, a series of events—compounded by equipment failure, inappropriate procedures and human errors—escalated into the worst crisis yet experienced by the nation's nuclear power industry. This resulted in the loss of reactor coolant, overheating of the core, damage to the fuel (but probably no melting) and release outside the plant of radioactive gases. Hydrogen has was formed, primarily by the reaction between the zirconium casing that holds the radioactive fuel and steam. There, however, was no danger of the bubble inside the reactor vessel exploding, because of the absence of oxygen within the reactor.
There are two principal aspects of disaster preparedness. First the daily around the clock routine already existing in ambulance services, hospitals, police forces, firebrigade, voluntary humanitarian organizations, etc. These organizations are occupied daily with accidents, each within their own areas of responsibility, and often in cooperation with each other.
Where people are hurt, medical care will have priority over damage of materials and property. So resuscitation and transport are basic factors in most accidents.
Second, according to the definition of disaster, the problems created by accidents of various types will exceed these daily operating resources. The community must take extraordinary steps to provide rescue and first aid to the victims, and provide fire control, police control, transportation, etc.
Experience and history have taught us that much can be done for the sick and injured before such patients reach the hospital. From the legacy of the Good Samaritan to the modern day organization of emergency medical services, the immediate care of those stricken has undergone significant change in both philosophy and practice. While many prehospital care organizations with roots established deeply in the past still flourish, modern emergency care, in the new world at least, has developed rapidly only over the past ten years.
In the United States, a concerted effort to improve the care of the wounded during the Civil War led to the introduction of the “flying ambulances” used earlier by Napoleon's Chief Surgeon, Larrey. Americans made significant contributions to acute care with the work of such noted men as Crile, with his form of external pneumatic counterpressure; Kouwenhoven, Knickerbocker and Jude at lohns Hopkins; Beck and the first reported defibrillation in a patient; Safar and his co-workers with the rediscovery of mouth-to-mouth; and many others.
RURALSIM is a sophisticated computer simulation model designed as an aid in planning and evaluating rural emergency medical services (EMS) systems. Written in SIMULA, it has been successfully used in Indiana County, Pennsylvania, to study the potential effects of changes in existing vehicle placement and relocation strategies, vehicle dispatching policies and alternative forms of prehospital care, including the ability of the system to respond to a disaster.
RURALSIM is a stochastic, dynamic, event-oriented computer model. Stochastic means that all random events, such as the occurrence of an incident, are generated according to appropriate probability distributions obtained from empirical data. Dynamic means that events occur over time and that the model selects the appropriate incident rates and response strategies for the particular time and day simulated.
Resuscitation of the brain after ischemic-anoxic brain injury remains a controversial topic. There is, however, presently a certain therapeutic optimism in this field. Ours is partly based on the recognition of a post-resuscitation disease, that is, treatable pathologic processes in all organs after restoration of adequate perfusion pressure and arterial oxygenation. Also, Hossmann has shown that neurons can survive longer periods of anoxia than previously assumed.
There have been reports on experimental focal ischemia indicating beneficial effects of barbiturates and moderate hemodilution before and after initiation of focal ischemia. After complete temporary global brain ischemia (GBI), as in cardiac arrest, however, results so far have been conflicting and controversial.
A status report of CCM in different countries varies considerably. In the USA, resuscitation and intensive care were pioneered by anesthesiologists in the 1950s, but CCM evolved later as a multidisciplinary movement through the initiative of the Society of Critical Care Medicine (SCCM) starting in 1970. Recently, CCM has been introduced as a subspecialty of anesthesiology, internal medicine, pediatrics, and surgery. Australia has already, for a couple of years, had a primary specialty of intensive therapy, but there are two tracks, one in medicine and one in anesthesiology. In the Scandinavian countries, as well as in Italy, CCM is an integral part of anesthesiology, since intensive care was initiated there in the early 1950s by anesthesiologists. In several Ibero-Latin American nations, we find a primary specialty in intensive therapy.
In spite of extensive research, the question of fluid therapy for hemorrhagic shock is still controversial. Certain drawbacks in the experimental models are among the reasons for this controversy. These drawbacks are mainly related to the animal species used, to the way the shock insult is initiated and to the effects of deep anesthesia on the response to shock.
Dogs were used in more than 90% of shock studies—although their response to bleeding is different from the human response. The dog has a large, contractile spleen, which can modify its cardiovascular response to bleeding.
Many of the world leaders in emergency medicine and in disaster medicine systems have made advances in these fields, and I compliment them on the accomplishments that I have seen over the years. Dr. Safar charged me to look ahead, if that is possible, and offer some perspective—obviously my own—on the next five to ten years. Hopefully, our future can be controlled in certain limits. Toynbee philosophized that when new and unanticipated challenges are presented, they represent great opportunity for response. If we fail to respond or if we respond in an inappropriate way, we may become a fossil in history—in this case, in the history of medicine. I have attempted to look at important challenges that I see in emergency medicine, and to predict from these a course that I think represents a proper response.
The first challenge, one that you have heard of before, clearly is the most important one. It is the challenge of limited or relative resources. The term “relative” means that fraction of a country's or region's output or wherewithall that is available in a logical or rational way for emergency medicine.
On July 11, 1978, a truck with a tank loaded with liquid propylene crashed into a camping ground, Los Alfaques, on the Eastern coast of Spain, giving rise to a Boiling Liquid Expanding Vapour Explosion (BLEVE) with a large number of casualties. The Swedish Organizing Committee for Disaster Medicine initiated a study of the events by sending the authors to Spain to make all possible observations at the scene. We were in the camp 48 hours after the explosion.
The Camp
The camping ground Los Alfaques is situated about 190 kilometers south of Barcelona and 165 kilometers north of Valenica. There are hospitals of varying sizes on the route to these big cities, both of which have large hospitals equipped with burn units of high standards, Francisco Franco Hospital in Barcelona and La Fe Hospital in Valencia.
The main aim of the primary treatment of polytraumatized patients at the accident site is the stabilization and maintenance of vital functions, especially the cardiocirculatory and the respiratory systems. The next step in the rescue chain is rapid transport to the nearest hospital with the ability to manage critically injured patients. Because of the difficulty in carrying out measurements in such critical situations, very little reliable data concerning trauma induced changes in respiratory function and metabolism is available. Clinical experience has shown that even after successfully recovering from the acute stress phase, a trauma related progressive respiratory distress syndrome can nevertheless develop during the first few days following injury.
Recent studies led to the conclusion that the late development of respiratory distress syndrome is already induced during the early shock phase. Early discovery and adequate treatment of trauma related metabolic and respiratory dysfunctions have a decisive influence on current status and outcome.
Although there may be international differences in some aspects of CPCR course content, we hope material presented will catalyze research in education with CPCR self-training systems. Historically, self-training in CPCR was first introduced to the University of Pittsburgh medical students in 1971 through a pilot program in a CPR learning laboratory. This training was enhanced by the development of a mobile prototype recording manikin (by Laerdall with immediate feedback via lights indicating correct and incorrect actions in breathing and external chest compressions.