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A Controlled Clinical Trial is the formal experimental approach to treatment evaluation. In such a trial, the investigator controls the assignment of treatments—ideally by randomization— to experimental groups. When well executed, such a trial provides the strongest evidence for the relative effectiveness of the different therapeutic interventions. Some people, myself among them, believe that the clinical trial approach should be used early when a new therapeutic modality is first introduced.
The purpose of a controlled clinical trial is to answer the question of whether the new therapy is preferable to standard therapies. If no standard therapy exists, then new therapy has to compete either with no treatment or placebo.
Prehospital emergency medicine in the USSR is one of the most widespread aspects of our medical system. The structure is extremely simple. The country is divided into regions, which in turn are divided into districts. Each district has a definite population and a fixed number of physicians, hospital beds and stations for first aid and urgent care. The system has to provide adequate medical attention without delay for every severely ill or injured patient.
In the prehospital emergency system, there are standard and specialized intensive therapy teams and equipment. For all emergency calls we have teams, which include a physician, a medical assistant (feldsher) and attendants. Specialized intensive therapy teams usually include two physicians, two feldshers and laboratory assistants.
Investigations describing the utilization pattern and comparing the outcome from emergency and mass casualty situations are limited by the lack of a reliable and valid patient classification system. In this study we briefly describe the use of APACHE (Acute Physiology and Chronic Health Evaluation), a physiologically based classification system for measuring severity of illness in groups of critically ill patients, as a tool in comparing outcomes of 1437 ICU admissions from eight European and five American hospitals. Because of the successful results from this pilot effort, we believe that APACHE could be used to compare the performance of hospitals in an emergency or mass casualty situation.
A few minutes before 9:00 a.m. on Friday 28th February 1975, a call was made to London Ambulance from Moorgate Station, stating nothing more than a train driver had been injured. Some three minutes later, a second call came which indicated that there had in fact, been a major disaster with many casualties. The extent of the casualties and difficulties to be encountered were still not realized, and only when the first of the rescue services and a medical team entered the wreckage was, what was before them was apparent. Three cars containing commuters had been compressed and “concertinaed” into a a blind ending tunnel. Three cars having a combined total length of 150 feet, with a possible total capacity of 440 persons, had been crushed in a tunnel with a maximum length of some 67 feet. Fortunately, despite the time, the cars were not full to capacity, and the total number of injured was only 113.
On November 23, 1980, an earthquake equivalent to 10 degrees on the Mercalli scale struck two regions of Southern Italy: Campania and Basilicata. Its epicenter was identified in the area of Colliano. The destruction caused by the earthquake extended to 7 provinces and affected 685 communities distributed over an area of 23,570 Km with a population of approximately 4 million. The material damages ascertained —not counting the consequences to industrial, agricultural and commercial activity—amount to approximately 17,000 billion Italian lire. In terms of the medical sector, 3 regional hospitals (722 beds) and 20 smaller hospitals were totally destroyed; another 16 hospitals (for a total of 9,495 bedsl suffered varying degrees of serious damage. In economic terms, the damage sustained by the medical structures amounted to 88 billion lire.
Spinal injuries associated with aquatic sports account for about 30 admissions per year to spinal injury units in Australia. These injuries are considered not only for their significance to the victim, to his family and to the community, but to ensure that voluntary organizations are teaching first-aid measures which help to reduce morbidity and mortality—for on those first-aid measures depend the quality of the victim's life.
Clinical experiences on perfluorochemical emulsion as an artificial blood has confirmed that perfluorochemical could transport oxygen indefinitely in circulating blood. We felt that an adequate cardiac output could be maintained no longer due to concomitant hypovolemia after the replacement with perfluorochemical emulsion for massive hemorrhage. Few studies have been reported on changes in the blood volume after replacement of circulating blood volume with fluorochemical.
The question of whether colloids are better than crystalloid solutions for resuscitation of hypovolemic patients remains to be answered.
The purpose of this study was to investigate how the closing lung volume is affected by a reduction of colloid oncotic pressure.
We measured closing lung volumes of anesthetized dogs in the presence of undisturbed serum proteins (COP= 18.9–22.1 mmHg). Following these determinations, we reduced the colloid oncotic pressure to 10.9–12.9 mmHg by administration of 50 ml/kg of 5% dextrose solution. Closing lung volumes were evaluated repeatedly from 10 to 90 minutes following the completion of infusion.
The objectives of the Second World Congress on Emergency and Disaster Medicine are closely aligned with those of the International Academy of Astronautics' Studies Committee. The fundamental concern that we share is that of reducing human suffering in the wake of life-threatening natural forces, man-made disasters, or emergencies experienced in the course of daily life. The overarching objective is to reduce to a minimum a population's vulnerability to disasterous occurrences by anticipating exposures accurately and setting in place wise precautionary systems.
The contribution made by space-borne systems is essentially that they can provide accurate information rapidly, clearly and dependably over wide areas.
Multiple trauma is the leading cause of death of all Americans below the age of 37. The estimated cost to American society is between 70 and 80 billion dollars per year. In our present day society, one person in four will require the use of a trauma facility during his or her lifetime. Several studies have now been performed to demonstrate that the management of trauma is woefully inadequate. Stemming from the classical studies of Trunkey, Lim and West comparing San Francisco with Orange County, California; it was demonstrated that approximately 30% of fatalities resulting from traumatic injury were preventable in Orange County as compared to an extremely small percentage in San Francisco which does have a designated trauma center. Recent advances in the management of head injury may further increase this salvageable percentage.
The Agency for International Development (AID) of the U.S. Department of State administers most U.S. bilateral foreign aid for development. The AID Administrator is the President's Special Coordinator for International Disaster Assistance. The office of U.S. Foreign Disaster Assistance (ofDA) coordinates all U.S. Government assistance to help alleviate suffering of people affected or threatened by natural or manmade disasters that occur abroad. Persons in developing countries are the main beneficiaries of the program. In addition to providing emergency relief, AID's disaster assistance program aims to strengthen the capabilities of other governments to respond to disasters. It is hoped that such efforts will help decrease dependence on the donor community.
OFDA response to disasters takes place only at the request of a foreign government to the U.S. Ambassador in the affected area. The Ambassador must then declare the existence of a situation warranting U.S. Government assistance. Once that disaster declaration has been made, he/she has the use of up to $25,000 which may be used as a donation or as a vehicle to purchase locally-available supplies to aid in relief efforts. Any amount above $25,000 must be approved by the OFDA.
The problem of forecasting the number of injured in need of treatment as a consequence of earthquake damage, and the percentage of those in need of diversified forms of therapy, still remains unresolved. Past experience provides us with partial and variable figures. It may thus be useful to propose as a working hypothesis some degree of comparability between the effects caused by the energy released by earthquakes and those resulting from nuclear explosions, especially as regards some of their predominant aspects (collapse of buildings).
During 4½ years, 24 terrorist explosions occurred in Jerusalem. of 511 casualties, 340 were evacuated to the Emergency Department of our hospital. of a total of 272 admissions graded by the Injury Severity Score (ISS), 87% were light injuries, 2.9% medium and 10% severe. The high proportion of light injuries may be explained by the evacuation of all casualties to the nearest hospital by the public. The distribution of injuries to body areas is discussed. Head and neck injuries comprised 19.3% and extremity injuries 39%. The most common primary blast effect was acoustic trauma encountered in 16.3%. Solutions to the most commonly encountered problems in the Emergency Department are discussed.
First of all, I would like to express gratitude on behalf of academician Eugeni I. Chazov, who was kindly invited by Professor Safar to attend this Congress. Unfortunately, some circumstances connected with work prevented Dr. Chazov's attending. Most of you are probably informed about his attitude toward the movement known as Physicians for Nuclear Disarmament. In 1981, Dr. Chazov delivered his paper at the First Congress of International Physicians for the Prevention of Nuclear War (IPPNW), held in Airlie, Virginia, USA. The Academy of Medical Sciences of the USSR has established a special Council to help guide this disaster prevention movement among Soviet physicians. Academician Chazov is the chairman of this Council.
In May 1981, our central newspaper, Pravda, published an appeal to the scientists of the world, signed by many prominent Soviet scientists, Lenin and State Prize winners of the USSR, and Nobel Prize winners, calling upon their colleagues and urging all scientific workers to do everything possible to avert the danger of nuclear war. Professor Chazov was among those who signed.
A widely attended, well-publicized annual event in San Antonio, Texas each spring is Fiesta Week. Fiesta Week begins with the Battle of Flowers parade. In April 1979, a deranged gunman began to fire upon parade participants and bystanders. The area-wide disaster plan was activated in order to deal with the many casualties resulting from his actions. This paper provides a description of the disaster situation and describes the implementation of the mass casualty plan.
Over 300,000 people lined the parade route as the parade began. Gunfire erupted shortly after the start of the parade in an area where approximately 4,000 people had moved to observe the festivities. The first casualties included police and several parade spectators. Instinctively, onlookers sought cover behind cars, barrels and other parade barricades. Authorities estimated that about 500 people were pinned down by the gunfire.
During the last ten years, both in Western Europe and in the USA, the attitude towards medical transport activities has radically changed. From being a purely transportation vehicle the ambulance is now increasingly regarded as an extended arm of medical care. At the same time as ambulance crews have received more qualified medical training, the equipment of the ambulances themselves has been improved. In several countries such as the USA, France and West Germany, a differentiated ambulance organization has been built up, with specially equipped emergency ambulances manned by paramedics, and standard ambulances with emergency technicians for planned transports. During this time helicopters have been put into increasing use as a supplement to ambulances for emergency long distance transport to units such as trauma and burn centers.
A 28-month study was made of the delivery of emergency medical services (EMS) in disasters and large casualty-producing situations. Focus was on the organizational and human aspects of EMS in such situations rather than technical medical matters. Intensive interview, observational, documentary and statistical data were obtained in field work in 29 actual natural and technological disasters, and five potentially high mass casualty pre-planned events (e.g., the Mardi Gras celebration); additionally, in-depth studies were made of hospital and medical sector EMS preparedness in six disaster prone communities. Quantitative and qualitative analyses were made of the data by using a model which linked the pre-impact conditions of the established EMS local community system to the characteristics of the emergent EMS system.
Improvements of results in emergency care of critically ill patients can be realized if EMS organizations are properly based on local conditions. The Emergency Medical Unit is the first of three parts of the Integrated Health Service in Poland. The second part is in-hospital treatment. The third part is outpatient care. In most hospitals, the head of the department of anesthesiology and intensive therapy coordinates each emergency medical unit. Each unit consists of ambulances (mobile intensive care units), admission (emergency) rooms, and an intensive medical care unit (ICU). A specialization program was created and physicians who complete this type of training obtain the title “specialist in anesthesiology and intensive therapy.”
This four year specialization program contains the educational elements necessary to administer all types of modern anesthesia, and provides full preparation for work in mobile and stationary intensive medical care units as well. Such training has also given these specialists the chance to initiate treatment methods for chronic pain. An examination consisting of practical tests, multiple choice written knowledge tests, and oral tests completes the program. The latter is a conversation with a commission, consisting of full professors and associate professors in anesthesiology and intensive therapy.
In order to introduce EMS problems in large urban communities, I will first tell you the parable of the County of Smog. It covers an area of about 4,000 square miles and includes areas of mountain wilderness, dense urban population, coastal ocean communities and a peculiar blend of heat, foul air, and residential and industrial communities known simply as “The Valley.” About ten years ago, Smog County health officials established a pilot program to train a handful of firemen in reading electrocardiograms, the pharmacology of emergency cardiac drugs, intravenous infusions, and defibrillation. The firemen responded in a station wagon from a hospital. It was readily learned that these paramedical personnel could impact positively on the outcome of patients with cardiac conditions.