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All requests for medical assistance need to be answered. In France, the public “Service d'Aide Medicale d'Urgence” (SAMU) receives the calls and can send, if necessary, mobile physician-staffed ambulances. SAMU works in coordination with the police, the fire brigade and general practitioners.
Response to the request for medical assistance from the public has been solved in different ways, such as agreement on a single call number for certain countries, and whether or not to use a physician-staffed system. In France, the first mobile emergency and resuscitation units (SMUR) were created in 1967. This initiative was taken by anesthesiologists, some surgeons, and military physicians belonging especially to the fire brigade of Paris, and to the seafaring-men of Marseille. The necessity of centralizing coordinating calls and radio controlling the public means of assistance has led to the creation of the Emergency Aid Services or SAMU.
Emergency medicine is, to a great extent, based on the progress made in clinical anesthesiology and resuscitation. It is only natural for these clinically approved measures, which are routinely used for surgery and anesthesia in recovery rooms and intensive care stations, to be applied outside the hospital, where first aid is required, be this at the scene of an accident or at bedside.
An emergency exists when “immediate danger to life or danger of serious lasting injury is present, cannot be excluded or has to be expected.” This is particularly the case with disturbances of the vital functions, respiration and circulation in polytraumatized patients, for example, with injuries of body cavities, head and cervical spine, hemorrhagic shock, coma or somnolence; or in patients with acute heart insufficiency.
Preservation of the brain is the obvious goal of every cardiopulmonary resuscitation, but resumption of heart and lung function is the only chance to achieve that goal. In the field, basic life support without equipment remains the mainstem of resuscitation. But what should we do if we are not successful, if even advanced life support does not restart the heart? Should we give up or should we add to the advanced life support a new concept: extended cardiopulmonary resuscitation by mechanical support? This would allow more time for the heart to recover or to begin definitive therapy. Prolonged mechanical support could support weak function of the failing heart or lungs until they return to full performance.
To even pose the question, “Can you do worthwhile pathophysiological research on critically injured patients?” practically suggests that we give up and surrender a field of medical science that is both challenging and laden with potential. Rather we should be posing the question, “Can we really afford not to be doing this research?” The purists of science must shudder when they think of trying to make sense out of the apparent chaos which surrounds a victim of multiple trauma. Sometimes we do as well, but perhaps we cannot afford to turn our backs because our egos perk at the recognized challenge. Perhaps we look at the heart-rending deterioration of a previously healthy 20–year old and say to ourselves, “What can I do differently the next time?” For these reasons and more, we all continue in our endeavors.
The problems of improving care of life-threatened victims of accidents influence the organization, equipment and training of hospitals, staff and physicians. Our review of the helicopter rescue program at Frankfurt/Main, introduced in 1972, clarifies the following: Nearly 200 annual daylight sorties underline a strong demand for helicopter activities in the densely populated Rhein-Main area. Unnecessary dispatches were made only in 16% of calls. The helicopter is stationed near the city of Frankfurt/Main at the BG Unfallklinik, a department specializing chiefly in traumatic and orthopedic surgery. The surgeons of this department are well trained in emergency interventions. They are competent to make triage decisions. When necessary, endotracheal intubation, resuscitation, and infusion therapy are performed immediately.
Once an earthquake or similar disaster has occurred, and the salvage operation begins, it must be viewed as something that can do further damage to the victims as well as help them. The more ambitious the rescue and salvage effort—the effort to minimize the human casualties—the more serious the problem becomes of preventing the salvage operation from doing more harm than good after the obvious and easy cases have been located and treated. The key engineering elements can be reviewed from the position of the rescuer or of the victim and his ability to participate actively or passively in his own rescue and treatment. In either case, the main improvement would appear to result from, first, improved sensors and receptors; second, improved methods for timely debris removal; third, improved aids to active self-indicated survival efforts, including rescue and treatment; and fourth, improved methods of restoring vital services (water, sewage, heat, light, food, transportation and communication).
A survey conducted among Indochinese refugees in Thailand in 1979, revealed significant levels of Vitamin A deficiency blindness (xerophthalmia). A Vitamin A supplementation program for children was implemented. Recent events in South East Asia have resulted in the mass movements of thousands of Kampucheans. These people underwent extreme deprivation for several years before migrating in large numbers to the Thai-Kampuchean border and later into Thailand. This massive influx of starving and ill men, women and children stimulated a large international relief effort aimed at providing food, shelter and health care. Under the supervision of the United Nations High Commission for Refugees, several holding centers or camps were established within Thailand.
Early reports indicated severe problems with malnutrition among the children reaching these areas. Since these malnourished children were susceptible to a blinding affliction, xerophthalmia, Helen Keller International, a voluntary agency long interested in the disease, became alarmed. I was dispatched as a consultant public health ophthalmologist to the holding center for an on-site investigation.
Sudden illnesses, accidents, fire catastrophes, explosions, gas leakages and war damage constitute serious threats to industry and other production enterprises all over the world.
To counteract the hazards resulting from such emergencies the Federation of Norwegian Industries in 1948 decided to establish an industrial civil defense organization. The Federation also decided that the industry itself should cover the cost both for operation of a central staff and for organizing and running an industrial civil defense at each individual plant or facility.
In 1953, the organization was legalized through the Norwegian Civil Defense Act and a Royal Decree of 1965 decided that the Industrial Civil Defense central staff should organize and supervise self protection in all enterprises employing 40 or more persons engaged in industrial activity, manufacturing and skilled trades, etc. This applies irrespective of where the facility is situated or where the operation takes place.
At the Second World Congress on Emergency and Disaster Medicine there were many presentations of drama and disaster from all over the world. This article is unusual in that no major disasters are discussed.
Australia is a huge island continent with many of its cities separated by over 3000 kilometres. The dense settlement is in the southeast, but the greatest disaster potential is in the sparsely populated northwest.
This country is fortunate to have been spared from calamities during the documented history of the 200 years of European settlement. Previous Aboriginal history is sketchy, due to the absence of a written language. A history of the disasters includes earthquakes, cyclone, floods and bushfires. There are no volcanoes in Australia. Earthquake fault lines do exist, but there have been no incidents accompanied by great loss of life and property. Cyclones are frequent, but they usually wear themselves out on sparsely populated northern coastlines.
In view of public concern about health impairment from accidental radiation exposure, the record of forty years experience in the utilization of nuclear energy was reviewed. All reported exposure incidents producing health effects from external radiation sources and internal radionuclide contamination in the United States and some in other countries have been included. Preparations for the management of such accidents will be considered briefly. The relationship of this actual accident experience to the unresolved problems in management planning and professional and public education for future accidents like that at the Three Mile Island nuclear power station in Middletown, Pennsylvania, March 1979, but with potential associated health impairment, was discussed. The complete paper is published in the Proceedings of the 3rd World Congress for Emergency and Disaster Medicine, organized by the “Club of Mainz” in Rome, Italy, 1983 (see Manni, C and Magalini, S, Springer Publ, Heidelberg, 1984).
The Maryland Institute for Emergency Medical Services Systems (MIEMSS) is the smoke and carbon monoxide (CO) inhalation referral center for Maryland, particularly Baltimore City and the five surrounding counties. The majority of our patients are from the Baltimore/Washington corridor.
The use of a short screening battery of psychometric tests is an important method for improving the clinical approach to the diagnosis of CO poisoning. Our own experience and a literature survey have shown how poorly the CO level correlates with clinical signs and symptoms. We have reported on six patients who were unconscious from CO poisoning but had a carboxyhemoglobin (HbCO) level of under 1%, and we have seen apparently well oriented patients with HbCO levels of 45%. From these experiences, we have concluded that the HbCO level is only an indicator of exposure to CO, not necessarily of the severity of poisoning. These large discrepancies have necessitated the development of a supplemental test, such as the psychometric battery, to determine generalized cerebral dysfunction.
Although none of us likes to think of nuclear war as a possibility, a truly prepared society evaluates the unthinkable. This paper specifically addresses a model for evaluating the medical situation of an area after a nuclear attack.
Consider the situation shown in Table 1 [all Tables and Figures follow the text], which shows an estimation of casualties resulting from a nuclear attack on an area with a preattack population of 9.5 million. The table indicates over half of the population survives and more than half of the survivors (about 3.4 million people) have injuries. This large number of injuries requires medical attention, and, if the area is unable to get outside help (as would be the case for nuclear war), only resources already available within the area could be used.
Accidental or intentional carbon monoxide poisoning is common throughout the year. In the Midwest, however, accidental exposures are more common during the winter months when the furnaces are overworked or malfunction. Consequently, enmasse exposures to the poisonous gas are frequently encountered during this season. Adding to the problem are the energy conservation efforts. Doors, windows and other ventilation avenues are tightly sealed, and solid fuel might be substituted to save other expensive conventional fuels. Other causes of carbon monoxide poisoning are blocked exhaust systems, automobiles with inadequate mufflers, fires and solvent (methylene chloride, etc.) usage in poorly ventilated areas, e.g., basements. The exact incidence of nonfatal subacute carbon monoxide poisoning is not available. National Clearinghouse Bulletin reported that in 1978, out of 376 reported exposures, there were eight fatalities. A figure which has been frequently quoted in the literature is that each year in the United States, approximately 3,500 deaths are caused by carbon monoxide poisoning.
The triage (i.e., sorting) of casualties is the most important task of a physician in a disaster. This function is so extensive that only an experienced doctor can fulfill it satisfactorily. To do so, he needs comprehensive information. This article will demonstrate a time-saving method of receiving and giving information for triage in connection with the registration of casualties.
The immediate situation determines classification. A rigid pattern cannot be applied. The doctor must know the number of casualties and helpers, transportation facilities, hospital capacities, and medical supplies. To help him assemble these data, the doctor has at his disposal an assistant registrar. This assistant is equipped with a walkietalkie to communicate with ambulance control. He also has a registration list and can enter important data concerning the patients clearly thereon (Figures 1 A, B).
This study focused upon one critical condition, acute respiratory insufficiency (ARI), and the treatment patterns used before and after a training program designed to teach hospital personnel the most current methods of treating acute respiratory insufficiency. The study was a methodological investigation in which a means for collecting and analyzing data concerning the treatment of an acute health problem was developed, implemented, and assessed. It was also an attempt to evaluate the quality of treatment of ARI in a set of hospitals and to assess the extent to which a training program was able to affect the quality of treatment. Thirdly, the study was an epidemiological investigation of the extent to which ARI exists in hospital critical care units.
In order to analyze the cause, effect and relief efforts of the Johnstown floods of 1889,1936, and 1977, existing literature, journalistic accounts, and official documents concerning the floods were investigated.
At 4:00 PM on May 31, 1889, the South Fork Dam burst, releasing 60 million tons of water into the Conemaugh Valley. The flood destroyed Johnstown and the surrounding communities within a few minutes. The official totals were 2209 persons killed, 30,000 homeless, and 17.2 million dollars property damage. From Sang Hollow, a community four miles from Johnstown, the first description of the disastrous flood was sent to Pittsburgh by telegraph about two hours after the catastrophe. Several journalists set out by train for Johnstown immediately. A fire started in the flood debris and burned throughout the night. By morning rescue squads of survivors were trying to get through to those still marooned and to identify the dead.
This is an introduction for a one-day CPCR course for intended instructors-coordinators. The course is a pilot project using a new manual. Its goal is to explore the feasibility of instructors using semi-self-training modes to acquire the necessary knowledge and skills for the organization of basic and advanced life support courses in CPR for all types of personnel, ranging from the lay public via ambulance personnel and nurses to physician generalists and physician specialists. The American Heart Association (AHA) CPR courses for instructors-to-be were originated in Pittsburgh in the early 1960s; this present course, sponsored by the World Federation of Societies of Anesthesiologists (WFSA) CPR Committee was given in 1981. The traditional 2 to 3 days CPR instructors' courses for physicians have spread knowledge and skills slowly. We believe that the dissemination and uniformity of resuscitation training could be enhanced by wider use of self-training systems, not only for doers but also instructors-to-be.
A study conducted by the Massachusetts Institute of Technology concluded that in a large city, a minimum of eight ambulances per 500,000 population was desirable to assure a reasonable response time.
How does a large city with less than this suggested minimum make best use of its available ambulance units ?
A three week study was conducted in New York City to examine the impact of various dispatching procedures on response time, “backlog”, availability of “back-up” units and patient care.
Following the founding of the Society of Critical Care Medicine (SCCM) in the USA in 1970, and of other national Critical Care Medicine (CCM) societies in Europe, Australia and New Zealand, Japan, Israel, South Africa and Central and South America, a World Congress on Intensive Care Medicine (ICM) was held in London in 1973. This first World Congress was organized by Drs. Alan Gilston of the National Herat Hospital in London and Iain McA. Ledingham of Western Infirmary in Glasgow. During the Congress, Dr, Gilston initiated formation of The World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) which sponsored the second World Congress on Intensive and Critical Care Medicine (ICCM) in Paris in 1977 and the Third World Congress on ICCM in Washington, D. C. in 1981. The Fourth World Congress will be held in Jerusalem, June 23–28, 1985.
In view of the increasing importance of the transportation of newborn and premature infants in distress, we have felt the need to create a mobile unit for pediatric reanimation. Therefore, it was important to build a very well-defined and specially adapted mobile unit for these kinds of particularly delicate transportations.
For this purpose, and with the agreement of the pediatricians, we have adopted a solution that seems compatible with this kind of work.