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The Prague Emergency Service brought help in many cases of mass accidents with 30 to 120 injured persons (explosions, train crashes, plane crashes, tram crashes, etc.) during the years 1955–1979. We have discovered facts from our own experience and by comparison with disasters in other parts of our country. Prague's mobile ICU-type ambulance service has provided advanced resuscitation and life-support by physicians, since the early 1960s, also for multicasualty incidents.
It is necessary to reduce the consequences of mass injuries to a minimum. Some principal questions are: who is to be treated immediately, who can wait, where is help unnecessary?
The dangers of mass emergencies are greater today than ever before in the history of man. The reasons are:
1) The exponential growth of the world population from 2 billion in 1925 to 4 billion today and to an expected 8 billion in the year 2025. This growing population is badly in need of more and more food and energy to sustain itself.
2) The increasingly severe competition world-wide for the available supplies of food and energy will precipitate mass emergencies and even mass disasters. Some of these mass disasters, such as nuclear war, have the potential to destroy entire countries…or even the human race itself.
No matter how gloomy the outlook is, however, it is still the task of the medical profession to recognize this growing danger and to do everything possible to be prepared for and treat not only individual emergencies, but mass disasters as well.
Volume substitutes for restoring circulating blood volume are eminently important for emergency care. In addition to side effects, the intravascular volume effect immediately after infusion and the duration of this volume effect are determining factors for the selection of volume replacement solutions available on the market today. Therefore, we controlled the intravascular volume effect of 16 test solutions, immediately as well as 90 and 240 min after the end of infusion.
Planning for emergency medical services (EMS) in a large state with a sparse population like Alaska poses unique challenges that EMS planners in urbanized areas never have to consider. Alaska is the largest state in the USA in land area, covering 586,000 square miles, or an area more than twice the size of the state of Texas. Alaska also has more miles of coastline than the rest of the USA. Despite its large size, Alaska continues to have the smallest year-round population of any state in the nation (400,481–1980 census). Many of Alaska's villages and towns are not accessible by road, including Juneau, the state capital, which can only be accessed by air or water. This means that, with Alaska's often harsh climate, many communities have no available ingress or egress for several hours, or even several days at a time. In these conditions, response times can not be measured in minutes, as they often are in some urbanized areas in other states. For example, Unalaska in the Aleutian Islands, one of Alaska's major fishing ports, is over 900 miles from the nearest hospital in Anchorage.
In Third World countries there are many priorities that take precedence over cardiopulmonary resuscitation (CPR). Some more common concerns are malnutrition, infectious diseases (malaria, tuberculosis, measles and polio) and children's diseases such as diarrhea and dehydration. Other priorities such as sanitation, housing, primary and professional education, jobs and birth control, inflation (118% for Brazil in 1980), energy crises and balance of payments are important government priorities. Accident prevention in civil construction and traffic education should be of paramount importance in a country that holds world records of accidents in both sectors. After we consider the above priorities, first aid education and CPR are to be taken into account. This does not mean that CPR training is not to be undertaken until all of the other priorities are satisfied, but it does mean that the availability of funds and motivation will be relegated to a lower priority in countries that are developing and have similar problems.
A major man-made disaster, like a nuclear attack, may suddenly reduce a highly developed country to very primitive conditions. The choice of anesthetics for the field depends on medical suitability, but, primarily upon a country's production possibilities in disaster conditions. Simple anesthesiological procedures must be preferred. Provisions are to be made for ketamine, atropine, narcotics (pethidine, morphine), in order to make possible intravenous/intramuscular anesthesia. For inhalation anesthesia, diethylether with a simple inhalation anesthesia apparatus is needed. Ether remains important for disaster conditions, because of its relative safety in less experienced hands and because its production is both cheap and simple. When possible, self-administered inhalation analgesia with methoxyflurane would greatly help to alleviate the suffering of the seriously wounded. In Czechoslovakia inhalation of methoxyflurane (AnecotanSPofA) from a simple “Analgizer” (vaporizer) proved to be of greatest help in mine casualties and in traffic accidents, before extrication of the casualties. As long as ether is considered as the “anesthetic for the field” it remains necessary to keep young anesthetists informed and skilled in ether anesthesia.
Sudden cardiac death is the number one killer in the western world. In the USA alone, CPR attempts are justified in 200,000 cases per year. Recovery of brain function requires immediate initiation and uninterrupted maintenance of artificial ventilation and circulation by basic life support (BLS) until restoration of spontaneous circulation (ROSC) is possible with advanced life support (ALS). Presently recommended standard CPR (SCPR) produces only 6–30% of normal common carotid blood flow. For this reason, a more effective method of prolonged CPR-BLS is necessary in the absence of ALS ambulance services, which is common in rural areas.
Augmentation of blood flow during CPR can be accomplished by intravenous fluid load and epinephrine, which are unavailable to BLS personnel. Sustained abdominal compression in dogs during CPR increases blood flow but produces a high incidence of hepatic trauma. The use of military anti-shock trousers (MAST) during short-term SCPR has been shown to increase common carotid blood flow (CCABF); this, however, has not been evaluated with a long-term model.
In the Federal Republic of Germany, 1.2 million people per year get into a life-threatening situation from which they can be saved only by immediate medical assistance. Progress in intensive care therapy and the improved organization of rescue services have led to a greater number of doctors being available for first aid at the scene of the accident. The creation of an emergency medical service was designed to ensure medical treatment of emergency patients by medically qualified personnel. The Emergency Medical Service is defined as an organization within the framework of rescue services providing care for emergency patients. The emergency physician is trained and equipped particularly to recognize and treat life-threatening conditions. Through the rescue service, the physician can be taken to the scene of the accident by the quickest and shortest way. For this need, two systems have become established in the Federal Republic of Germany.
It has previously been demonstrated that high frequency jet ventilation, via transtracheal cricothyroid membrane puncture, can maintain good gas exchange even during cardiopulmonary resuscitation. When the upper airways were filled with fluid, aspiration could be prevented without a cuffed endotracheal tube when respiratory rates of 100/min or higher and an inspiratory time of at least 50% were used. We have also shown that cricothyroid membrane puncture is relatively easy to perform and produces less tracheal damage than a cuffed endotracheal tube.
In one of our studies, cardio-green dye was mixed into the jet using a Y-connector on the proximal end of the angiocath cannula (Figure 1). In two dogs, the distribution of the dye in the lungs was investigated. It was found that nebulized dye was transported by the jet stream to the most distant bronchi which could be observed. On subsequent autopsy, the dye was found in the most peripheral airways.
The Pan American Health Organization (PAHO) has two components: (1) The Pan American Sanitary Bureau (PASB), founded in 1902, serves as the health agency affiliated with the Organization of the American States (OAS); in 1947, the PASB became the Regional office of the World Health Organization for the Americas. (2) The Emergency Preparedness and Disaster Relief Coordination office.
In October 1976, the Directing Council of PAHO, “anxious that the international assistance given to countries affected by natural disasters should be better coordinated, rational, and more effective”, requested that the Director set up a “disaster unit with instructions to define the policy of the Organization, to formulate a plan of action for the various types of disasters, to make an inventory of the human and other resources available, to train the necessary personnel, to prepare and disseminate the appropriate guidelines and manuals, and to promote operational research.” In March 1977, a permanent office for Emergency Preparedness and Disaster Relief Coordination was established at PAHO Headquarters in Washington, D.C.
Major trauma in disasters leading to open wounds is frequently followed by infection with a variety of microorganisms. Usually, antibiotics are administered systemically to prevent the onset of sepsis. In thermal burns, topical therapy with 1% silver sulfadiazine (AgSD) cream has proven effective and now supersedes systemic therapy. Experimentally standardized traumatic wounds in animals have been difficult to obtain. Standardized burn wounds in mice subsequently infected with pseudomonas facilitated demonstration of the efficacy of silver or zinc sulfadiazine (ZnSD) which has also shown an advantage in improved wound closure. (Fox CL, fr: Burns 1978;4:223). In a limited series of 18 patients with a variety of surgical trauma and infected wounds, topical silver sulfadiazine was utilized after prolonged systemic antibiotics had failed to eradicate the infection.
Since early recorded use of the endotracheal catheter for controlled ventilation of the lung and protection of the airway from aspiration, the protection of airway integrity has been inconsistently obtained and not without significant morbidity.
Trauma is the leading cause of death between the ages of 1 and 40. The three most common causes of trauma related death are inadequate ventilation, inadequate circulation and massive hemorrhage. Thus high priority must be given to airway management, breathing and circulation. The efficiency of the former is essential to optimal circulatory adjustment. No presently available instrument fulfills these needs within a single system.
History of “Disaster Resuscitology.” The late Rudolf Frey, Professor of Anesthesiology at the Johannes Gutenberg University of Mainz, West Germany (see pages VIII-X), founded the “Club of Mainz” in September 1976, following initiating discussions with Peter Safar at the “International Symposium on Mobile Intensive Care and Advanced Emergency Medical Services (EMS) Delivery Systems” in September 1973 in Mainz (1), and the drafting of objectives and plans with the founding members in 1976 in Geneva and Mainz. Throughout the initiating discussions, Safar stressed the following: Presently active national and international disaster relief organizations are public health oriented. In mass disasters, such as major earthquakes, these organizations have been rendering effective aid to uninjured survivors, usually starting one day or later after the disaster event.
Standard CPR, consisting of 60 chest compressions per min with a ventilation interposed after every fifth compression, often allows restoration of spontaneous circulation but cannot be relied upon to preserve the brain during resuscitation attempts. In experimental models, it produces only one-third to one-half of normal cerebral blood flow and cannot sustain EEG activity. Many attempts have been made to augment overall cardiac output during CPR and presumably thereby increase cerebral blood flow. Crile used a pneumatic pressure suit to bind the abdomen and legs, but subsequent investigations found a high risk of hepatic trauma with abdominal binding. Both Wilder and Harris showed in dogs that simultaneous ventilation and compression augment carotid flow. Birch showed in an animal model that prolonged compression increased mean arterial pressure during CPR. Weisfeldt and colleagues of Baltimore have recently extended these findings to man, and combined them into a so-called “New” CPR, which consists of:
a) high pressure ventilation simultaneous with sternal compression;
Clinical management is exceedingly difficult to evaluate in emergency patients because resuscitation is often chaotic, disorderly, and frantic. Resuscitation depends upon many factors: the primary illness or injury, the amount of blood and fluid losses, the patient's age, the prior state of health, the associated medical conditions, the time delay in instituting therapy, the volume and rate of fluids administered, and, finally, the choice of fluids given. Although it is difficult to control the effects of these complex interrelated factors, their influence may be evaluated by stratifying patients and then comparing the direct effects and outcome measures within each stratum.
There has been persistent controversy over the relative merits of crystalloids and colloids in fluid resuscitation. We studied reviews of fluid management of all hypotensive patients seen in the adult surgical section of the Emergency Department (ED) during a 2½ year period, to compare the conventional crystalloid resuscitation which had been standard for this busy university-run county hospital with a fluid management protocol consisting of about 1/4 A colloids depending on age, cardiac history, and CVP.
How can the results of computer modeling be used most effectively to serve the public policy decision-making process? In considering that question, I find it useful to keep two factors very clearly in mind:
First, simulation models never provide any final answers; they simply offer an accurate, rapid, and mathematically precise means of analyzing a number of complex variables and tracing their dynamic interactions over time.
Second, the use of computer modeling therefore presupposes—even demands—an ultimate higher level of decision —political, medical, or what have you—among the policy alternatives analyzed and compared in the model.
During the latter part of 1979, hundreds of thousands Kampuchean refugees fled from all parts of their war- and hunger-ridden country to the Thai-Cambodian border, thousands perishing from hunger, disease and stepping on mine fields on the way. The majority of those who survived settled in several large villages straddling the border in relative security from the advancing Vietnamese army, receiving food and medical supplies from many international welfare organizations.
Widespread public interest in the plight of these refugees arose in Israel after a television program late in October 1979, and a public campaign initiated by Mr. Abie Nathan, an Israeli citizen. The ensuing fund-raising efforts resulted in 1.2 million dollars, most of which originated from private donations. These contributions enabled the Israeli government to equip 5 medical teams and send them to Thailand, covering the last two months of 1979 and the first 4 months of 1980.
Our emergency medical services (EMS) system is called SAMU (“Service d'Aide Medicale d'Urgence”). It was initiated in Paris in 1956. Since that date, it has developed a new concept of emergency transportation, which excludes speed as the best way for saving life threatened by danger. Indeed, this EMS System is based upon the same principles that are used everywhere, but there are some practical differences which are characteristic of the service in France. One example is the medicalization (physician-staffing), which permits excluding speed in transportation.
Everywhere, the fundamental EMS principle is to struggle against time to give efficient care as soon as possible. In emergency situations, all things are simpler and all treatment is more efficient if you can do it within the limit of time available for resuscitation. If this limit is surpassed, success is dubious. The means to reach it are more sophisticated and cost increases tremendously; however, the mortality goes up inexorably to death in all severe cases.
Each year 4,000–9,000 people die in the USA from hyperthermia-related crises, such as heat stroke and febrile convulsions. In most of these cases, variable combinations of hot environment, physical exercise, dehydration, and infection can be identified. Heat stroke is a complex clinical picture with poorly understood pathophysiology and unexplored resuscitation potentials. Protection of vital organs against hyperthermia is also important for cancer therapy.
This study (1978–1980) was aimed exclusively at the effects of controlled hyperthermia. In pilot experiments on lightly anesthetized dogs and rhesus monkeys, brain temperature was raised to 42°C for 1/2–1 hour by immersion heating. This was followed by cooling to normothermia. Partial recovery with a lucid period of 1 hour or longer was followed by diffuse gastrointestinal bleeding and irreversible shock in spite of standard life support measures.