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Medicine has made great advances in the past decade, and is now opening the frontiers of brain resuscitation. Coinciding with the advances in medicine, society has witnessed great changes. There is an increasing awareness of patients' rights, an increasing desire for self determination, a rejection of the once-accepted paternal role of the physician, and an increasing willingness to challenge physicians in the courts. At the same time, government regulation of biomedical research has been expanding rapidly. The origin of this regulation dates back to the post-World War II Nuremburg trials. In 1974, the National Research Act established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The evolving concern about human experimentation has led to the current Department of Health and Human Services (DHHS) and the Federal Drug Administration (FDA) regulations which became effective July 27,1981. All biomedical research supported by federal funds must conform to these legal requirements. One aspect of these regulations is that all research protocols be approved by an institutional review board (IRB) established at the institution where the research is conducted.
The Second World Congress on Emergency and Disaster Medicine was held on May 31–June 3,1981, in Pittsburgh, Pennsylvania, USA, under the auspices of the “Club of Mainz for Emergency and Disaster Medicine Worldwide.” The First World Congress organized by the Club of Mainz was held in Mainz, West Germany on September 30–October 3, 1977 (Chairman, Rudolf Frey), and the Third World Congress will be held in Rome, Italy on May 23–27, 1983 (Chairman, Corrado Manni). It is appropriate to report here on the World Congress in Pittsburgh, since the first four issues of this new Journal consist of edited papers and abstracts presented at that Congress.
Although in Sweden the risk of natural catastrophes is small, several have occurred in recent years. Two examples are a storm disaster in 1970 and a landslide in 1978—both causing extensive personal and material damage.
Other disasters can be caused by human activity in different forms, for instance, fires, explosions and accidents involving public transport, and also—a subject of much concern today—accidents at nuclear power plants. Terrorist actions have also led to serious disaster situations in recent years.
Common to the different types of disasters from the viewpoint of medical care is the fact that locally available resources are often inadequate. Even with very good access to ambulances and other forms of medical transport the waiting time at the scene of the accident can be so long that many patients suffer from acute respiratory distress, major hemorrhages and shock. Under such circumstances qualified first aid can be expected to reduce the morbidity and mortality considerably.
Of the 110 million people in Brazil, only 4% to 6% read regularly; nevertheless, 50% have access to a television set. Instructors, audio-visual training aids, and manikins are virtually non-existent. The objective of this study is to test the feasibility of teaching cardiopulmonary resuscitation (CPR) through television (TV). Two representative groups were taught in this study: 1) high school students; and 2) regular army recruits. The first group because 50% of the population is under age 18; the second group of 18 to 19 years because they better represent the general population.
Of the more than one million earthquakes which occur each year on our planet, very few involve areas of major population concentration. During the last decade, however, a significantly large number of earthquakes involved populations in cities or areas of large population density. The injuries, therefore, are multiplied by the collapse of large buildings or of walls of houses of poor design and construction of adobe brick. Crashing upon people asleep, they entrap, entomb or mutilate defenseless and often aged, ill, and diseased and helpless pediatric victims. The three earthquakes we witnessed recently have resulted in 70,000 deaths in Peru;, 12,000 in Managua, Nicaragua;, and 22,000 in Guatemala City and large suburban cities.
Most of the injuries are orthopedic fractures. Fatalities often occur from compression and permanent restriction of respiratory movement. These megaton disruptions of the environment cause the following types of respiratory challenge: (l) The unbelievably large and dense dust clouds from falling buildings, created by pulverization of the walls of mud, straw, and limestone, create suffocating chemical damage of some degree to the nasal mucosa, the bronchial tree and the respiratory bronchioles, immediately initiating endothelial edema, airway obstruction and collapse, and irritational bronchitis.
The CPR committee of the Dutch Heart Association currently recommends for the management of sudden cardiac arrest, the initiation of external cardiac compressions before airway control and ventilation, which may be termed the “CAB” sequence. This differs from the ABC sequence, recommended by the American Heart Association, in which the patient is ventilated first. Supporters of the CAB sequence reason that, since most sudden cardiac deaths are due to ventricular fibrillation, the blood in the arterial system should be well oxygenated at the onset of such an episode. We conducted these studies to characterize the decline in arterial blood gases during 5 min of cardiac arrest, followed by external cardiac compressions alone, vs followed by external cardiac compressions with ventilation. In addition, we studied the decline in arterial blood gases and ventricular fibrillation without therapy.
The 1973 Emergency Medical Services System Act in the United States mandates that one of the 15 functions to be performed by every EMS system is coordinated disaster planning. Implicit in the legislation is the assumption that everyday emergency medical service (EMS) systems will be the basis for the provisions of EMS in extraordinary mass emergencies, or in the language of the act, during “mass casualties, natural disasters or national emergencies.” Policy interpretations of the Act specified that the EMS system must have links to local, regional and state disaster plans and must participate in biannual disaster plan exercises. Thus, the newly established EMS systems have been faced with both planning for, as well as providing services in large-scale disasters.
The Club of Rome is limited to 100 persons around the world, representing more than 35 countries, and a very wide spectrum of experiences, professions, backgrounds, and views.
With such a small organization, it should be obvious that its power – if, indeed, it has any power – derives not from the size of its membership or the imposing structure of the institution supporting it, for there is none. To the extent that The Club of Rome exerts any power, it is the power of ideas to more individuals, societies, and governments. And that is precisely what The Club of Rome has styled itself as a catalyst of ideas. (See references.)
The members of The Club of Rome around the world represent no single social, political, economic, geographic, or ideological viewpoint. But they are united in the belief that the societies and governments can, and must, do a much better job of preparing themselves to deal effectively with the multiple crises that many agree are emerging on the global horizon.
Methodological considerations should be discussed within the context of emergency medical services (EMS) and disaster research. The fast pace and the information explosion of the society in which we live open new opportunities for epidemiological research and evaluation of care in disasters. The many methodological considerations necessary to generate useful and valid research is the topic of this article.
I would like to discuss four major issues which raise a series of questions and suggest a variety of alternatives. The four major areas are: (l) the taxonomy required to do this type of research; (2) the elements of care; (3) comparative samples; and (4) planned as opposed to unplanned disasters.
In a considerable number of cases, many polytraumatized patients in a state of hemorrhagic shock, who require immediate surgical treatment, there is craniocerebral trauma. Ketamine is viewed, on one hand, as an appropriate induction anesthetic, due to its circulatory stimulating effect in treating shock victims, and, on the other hand, it is rejected for treating patients with craniocerebral injuries, because of the danger of possible increase in intracranial pressure (ICP). Therefore, we examined the effects of ketamine on ICP and calculated the cerebral perfusion pressure, using test animals in a state of hemorrhagic shock and a space occupying intracranial process.
Recent case reports have shown that persistent hypoxia after the resuscitation of nearly-drowned patients is a major problem. PEEP ventilation could be successfully applied in such a condition. After PEEP valves for manually operated resuscitators became available, the question arose of how beneficial the immediate application of positive end expiratory pressure of 5 cm H2O would be for lungs damaged by either seawater or fresh water. This question was examined by means of standardized animal experiments.
Material and Methods
In four test groups comprising 34 randomly selected young pigs, either 25 ml fresh water/kg body weight, or else 12.5 ml salt water/kg body weight, were instilled by way of an endotracheal tube. This was followed by a period of apnea lasting 4 min and subsequent ventilation with 100% oxygen for a 2 hour period. The 32 animals which survived the first part of the experiment were then subjected to either PEEP or ZEEP ventilation therapy without further medication.
The Khao I Dang Holding Center for Kampucheans opened November 21, 1979 as part of an effort to bring relief to the thousands of Cambodian on the eastern frontier of Thailand. The camp population increased from 4800 that first day to 50,000 by December 1, 1979 and 110,000 by mid-January, 1980. Sixty-one percent (61%) of the population were 15 years of age and older; 12% of these over 44. Thirty-nine percent (39%) were children under 15.
Although each disaster is unique, the medical problems for a type of disaster in a stated area are considered predictable. This was not the case at Khao I Dang for hospital pysicians in providing patient care. It has been shown that relief efforts are amenable to study, yet such studies have been handicapped by a lack of data. Since major disasters involving international aid are reported several times a year, the problem is considerable.
An International Working Party on the Definition and Classification of Disasters, sponsored by the International Trauma Foundation, developed recommendations on the definition and classification of disasters. The party consisted of: WH Rutherford (Chairman), Royal Victoria Hospital, Belfast UK; Dr. Jacob Adler, Shaare Zedek Hospital, Jerusalem, Israel; Dr. Peter Baskett, Frenchay Hospital, Bristol UK; Dr. Jan De Boer, Het Nieve Spittal, Warnsveld, Netherlands; Professor Bo Brismar, Department of Surgery, Huddinge, Sweden; Dr. Rudolf Frey, Department of Anesthesiology, University of Mainz, West Germany; Dr. Olafur Jonson, Borgarspitalinn, Reykjavik, Iceland; Dr. Stanely Miles, International Trauma Foundation, Salsbury, UK; Dr. Ronald Stewart, University of Pittsburgh, USA; Dr. Henryk Zielinski, League of Red Cross Societies, Geneva, Switzerland.
Resuscitation in disasters must be effective, prompt, safe and uncomplicated. Clinical experience in severe, extensive thermal burns in numerous clinics has shown that balanced hypertonic sodium solution (BHSS) can achieve effective resuscitation with: administration of less volume of fluid; early onset of excretion of sodium-containing urine; less generalized edema and without pulmonary edema. This experience is now being transferred to patients after trauma and major surgical procedures often complicated by peritonitis. In an ongoing study of randomly selected adults following surgical trauma, either Ringer's lactate (RL) or the BHSS (0.9% NaCl plus 100ml of one molar sodium acetate, total 1100ml yielding Na230, Cl 140, acetate 90mEq/l) was administered. All patients received daily (or more frequent) electrolyte and osmotic analyses of plasma and urine, continuous ICU monitoring of pulmonary and cardiac function, and similar wound care.
We recognize that priorities in disasters are most often the supply of shelter, water and food, but to streamline this paper we have limited ourselves to aspects of Disaster Preparedness pertaining to medical intervention.
It is essential to understand that the overall responsibility in disaster preparedness and for coordination in case of disaster remains under all circumstances with public authorities. National Red Cross Societies, being auxiliary to their governments, are usually given a clearly defined role in disaster. In many cases the tasks assigned to the Red Cross include medical, paramedical and welfare assistance in varying degrees.
The activities described hereafter are therefore not necessarily to be seen as a standard applied to all National Red Cross Societies.
Lay persons can learn cardiopulmonary resuscitation (CPR) with the instructors' method, and by self-training with the use of manikins. LSFA includes airway control (head-tilt, jaw thrust), mouth-to-mouth ventilation, control of external bleeding by direct compression and elevation, positioning for coma (stable side position) and shock (horizontal, legs up), and extrication from a wreck (rescue pull). LSFA so far has not included chest compressions for cardiac arrest. LSFA capability by bystanders who would treat injured victims in mass disasters might be the most important component to consider for disaster response. A LSFA self-training system, including a manual which coaches skill practice on one another, and an attractive first aid kit (A. Laerdal) was found effective in a study carried out in Norway. The present controlled study was to compare two self-training systems (designed by A. Laerdal et al), one with and one without the use of manikins, with the presently prevalent instructors' method and an untrained control group. The trainees were high school students in a typical community in Indiana PA, USA. The study was carried out in 1978–1979.
Monitoring of the level of neurological response is an essential component of the diagnostic and therapeutic process in the management of craniocervical injury and neurological catastrophes. When Hippocrates reminded us that “No Head Injury is so mild that it can be neglected,” he cannot have been aware of the significance of the lethal factors of cerebral swelling and intracranial hematoma contributing to poor survival. Neither can he have known how these factors could be detected. Coma scales have evolved to indicate when deterioration is likely and intervention indicated.
Many hospitals use simple grades of responsiveness for their unconscious patients, but the widespread habit of recording the level of response in an abstract manner is as meaningless as measuring temperature in units of feverishness. There is a requirement for a device which can be expressed in numerical terms and, when necessary, related to an analogue or graphical mode.
Ventilation is an integral part of cardiopulmonary resuscitation (CPR). Early intubation is recommended not only for the sake of better ventilation but also to prevent aspiration since aspiration is a common occurrence during CPR. It probably not infrequently contributes to an unfavorable outcome. Endotracheal intubation is sometimes very difficult especially under field conditions. Cricothyroid membrane puncture or transtracheal puncture with a 14g or 16g catheter needle enables high frequency jet ventilation (HFJV) and can often be performed more easily than intubation.
The World Federation of Societies of Anesthesioologists (WFSA) is a federation of some 76 anesthesia societies throughout the world. Our role in the management of disasters is very minimal; in fact, we have no specific service role. It does have a role to play in education and research aspects of acute medicine. The World Federation's aims are those of education of anesthesiologists of our member societies. This educational role is fulfilled by the staging of meetings, by the foundation of training centers in anesthesiology, by the production of special manuals and by meeting some of the expenses of visiting educational teams that travel to various parts of the world as visiting professors. These are all educational functions. Included in this function, of course, would be education in emergency medicine and disaster medicine.