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.

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.

Since oil was found under the North Sea in the mid 1960's, oil production now plays an important part in Norwegian economy. A major oil field is Ekofisk, between Norway and Britain (Figure 1). The Alexander Kielland, one of the rigs at Ekofisk, was a mobile platform of the pentagon type, floating on 5 columns, 150 nautical miles of f the Norwegian coast. It was developed and built as a drilling rig, but was used as an accommodation platform since delivery in July 1976. OnMarch27,1980, the Alexander Kielland rig lay at anchor on the Ekofisk field, close to the production platform EDDA.

On the 28th of November 1979, the fourth largest air disaster in the world occurred on the icy slopes of Mount Erebus, deep in Antarctica and 50 km from Scott Base. The 237 passengers and 20 crew were all killed instantly on impact, and their bodies and the wreckage were spread over an area 500 m long and 100 m wide. It had started out as a scenic flight, the 14th to Antarctica, and it had ended in tragedy. It was suffered, too, by an airline company which had maintained the highest standards of aviation safety.

In an account of Scott's last Antartic expedition in 1910, Cherry Garrard wrote of the “worst journey in the world,” and he said, “I have seen Fuji, the most dainty and graceful of mountains—and also Kanchenjunga; only Mechelangelo among men could have conceived such grandeur.

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 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.

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.

The Solent is that stretch of seaway separating the Hampshire Dorset coast from the Isle of Wight. It is one of the busiest sea routes in the United Kingdom. Approximately 134 shipping movements take place weekly into the Docks and Naval Base at Portsmouth, the Docks and Ocean Terminal in Southampton and the nearby Esso Oil Refinery. During the height of the summer season there are numerous local Ferry Services to and from the mainland and the Isle of Wight, which is a popular summer resort, and at weekends as many as 35,000 pleasure craft may be afloat. Major collision is rare and reflects the high standard of seamanship, local pilotage and strict port control, but the possibility of disaster is ever present in such a congested seaway.

To meet this eventuality the Solent and Southampton Water Marine Emergency Plan was developed from preexisting Southampton and Portsmouth schemes in the early 1960's. Since that time it has been put into action on three occasions for episodes of fire at sea, with good effect.

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.

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.

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.

Disaster plans in response to a nuclear crisis involve extended forays into uncertainty. Controversy arises over whether or not a nuclear disaster or war might ever occur. Estimates of destructive parameters vary widely. Planning must take into account a wide range of issues, from the nature of radiation injury to the survival capacity of social systems. From the standpoint of analyzing possibilities for emergency response, we will discuss: l) medical effects of radiation; 2) severe core meltdown at a nuclear power plant; and 3) a scenario for a nuclear bomb explosion over one city in the USA, in the setting of a strategic nuclear exchange.

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.

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).

An understanding of combined injuries caused by both whole-body irradiation and wounds or burns is still at the present, in a clinical sense, largely lacking. This is, in part, due to the fact that Japanese and American scientists paid attention mainly to the individual injuries, especially those of subjects with acute radiation diseases, which had not been observed until then. Under the threat of a global nuclear confrontation, an intensive radiation biological investigation was initiated, especially in the military laboratories in the USA, the European countries, and the Soviet Union. The study of combined injuries, however, was relatively neglected. This may be because many investigators have considered combined injuries to be just modified radiation injuries, for which the same treatment principles are valid, that apply to radiation diseases.

On March 28,1979, a near nuclear catastrophe occurred at Three Mile Island (TMI) near Harrisburgh, Pennsylvania, USA. I was at that time Pennsylvania's Secretary of Health. It was an accident that just “could not happen.” After all, nuclear power plants were built so safely that they could not possibly affect public health.

As a physician, lam compelled to say that I am unalterably opposed to nuclear warfare. I am sure that most physicians would agree that there can be no adequate preparedness for the devastating medical consequences of nuclear war. Prevention of nuclear war is the only reasonable medical response to the hazards posed by nuclear weapons.

By contrast, many of you may not share my position on nuclear power. Nuclear power can be made relatively safe if we do not ignore the public health lessons of the past. I belive that physicians need to increase and update their understandings of the medical consequences of radiation accidents and be trained to triage and to treat blast, radiation, and burn injuries.

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.

Disaster preparedness as developed by civil authorities and hospitals has not adequately addressed the special characteristics of mass casualties from nuclear accidents, as demonstrated during the accident at the Three Mile Island (TMI) Nuclear Power Generating Plant. Experiences gained by the Radiation Emergency Task Force of the Milton S. Hershey Medical Center, established during the TMI incident, have resulted in reexamination of emregency medical services (EMS) systems response, population and hospital evacuation, decontamination procedures, communications, triage and psychologic impact during such an event. From these investigations, it is now possible to restructure disaster protocols to accommodate accidents involving toxic contamination. Although this report primarily deals with nuclear accidents, it is also useful in planning for large-scale biologic or chemical accidents.

The growing number of nuclear power, research, and industrial facilities places increasing numbers of people and places at risk from an accident involving radioactive material. Fortunately, such accidents are infrequent. Unfortunately, this rarity often results in very limited hospital and physician interest and awareness. The incident at the nuclear facility at Three Mile Island (TMI) in Pennsylvania, USA, has demonstrated that despite its rarity, a radiation accident may not only occur, but occur on a scale large enough to require more than the radiation accident protocol which each hospital is required to have. There is a need, therefore, for the incorporation of radiation accidents into disaster planning and triage systems. We address the considerations to be made in planning an emergency medical system's response to a large radiation accident. We describe the application of a triage team in such a plan.

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).