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.

The concept of treating mass casualties in major disasters, particularly at or near airports, has gained considerable momentum in recent years (1). Major urban airports are almost without exception, plagued by access road traffic problems even under normal circumstances. Given a disaster within the confines of an airport, emergency equipment and medical support are found to be mired in a morass of sightseer and emergency service vehicles, compounding the congestion already present immeasurably (2).

Evolving from experiences gained over the past 30 years in handling masses of casualties resulting from aircraft disasters, we at Kennedy Airport have developed a Mobile Emergency Hospital which now serves as the “workshop” for stabilizing large numbers of injuries prior to subsequent transfer to definitive hospitals. The keys to this plan are the Trauma Team support used in conjunction with the mobile hospitals.

The ideal trauma team consists of 2 surgeons or trauma-trained physicians, one surgical nurse and one medical or 2 surgical technicians. These teams can be varied according to the immediate situation, time of day, available physicians, nurses and technicians. Anesthesiologists respond either individually or as members of some of the teams reporting directly to the operating units on arrival.

For an efficient response plan to function, previous liaison must be established primarily with teaching hospitals with a surgical staff that includes surgery and trauma residents. The Kennedy plan has a working arrangement with the New York Medical College and 8 of its affiliated major teaching hospitals in Manhattan, as well as in the main campus at Valhalla, which maintains an associated Burn Center.

Magnitude and Configuration of Disasters. The increasing number of disasters and consequent casualties in an era of growing sophistication of care for the emergency patient mandates a systematized disaster response utilizing all of a nation's resources in optimum fashion. Life in the second half of this century has grown more complicated and in so doing has laid the basis for more complex disasters. Larger groups of people are vulnerable to individual catastrophic events. Population increases and sociopolitical alterations have accelerated the trend toward the establishment of residential and industrial centers in areas subject to natural disasters. Societal and political pressures are increasing tensions, producing ever more disasters along a broad spectrum, ranging from isolated terrorist events through low intensity conflict to limited conventional warfare. Perhaps most important, our increasingly technological society has not only contributed significantly to the menu of conflicts but has brought a variety of new transportation and industrial hazards to the ordinary course of life.

At the Second World Congress on Emergency and Disaster Medicine in Pittsburgh in 1981, Professor Negovsky talked about the Science of Resuscitation. Science is defined as systematic and formulated knowledge. Therefore, to be a science, resuscitation must be presented in accurate and concise terms. The introduction of Standards in the methodology of Resuscitation has achieved this. In 1977, the American Heart Association published Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care (1) and revised them in 1980 as Standards and Guidelines (2). Organizations in other countries have also introduced such standards: the Canadian Heart Foundation, the Heart Foundation of New Zealand, the Australian Resuscitation Council, and the Resuscitation Advisory Council in the United Kingdom; they all have systematic and formulated methodologies. The value of these standards and guidelines in Resuscitation methods can only be gauged by the results of various individual surveys. The definition of Resuscitation as a science runs into problems when one begins to examine these results. This paper will illustrate the difficulties of evaluating Resuscitation results.

Figure 1 shows a comparison of survival rates in5 centers (3-7) when Cardiopulmonary Resuscitation (CPR) was initiated by a rescue team or a bystander. It would appear that Seattle had the best overall survival rate, followed by Oslo. But Thompson and colleagues (5) from Seattle studied survival from cardiac arrest only when ventricular fibrillation was present when the paramedical personnel arrived. Lund and Skulberg (7) from Oslo did not state their type of victim, whereas Cobb and his colleagues (4) in suburban Seattle, with the lowest survival rates, looked at all forms of cardiac arrests.

At the John F. Kennedy International Airport in New York City, disaster planning has been an integral part of the airport operations for the past 28 years. Through the Medical Office, emergency medical teams have been recruited from all ranks of airport personnel and trained in rescue and resuscitation. Following the crash of a commercial B 727 aircraft in 1976 and the resulting crippling traffic jams in the vicinity of the airport, a new concept was added to the disaster plan. This concept involves bringing the hospital, its facilities and its personnel to the scene.

A new piece of equipment, known as a Mobile Emergency Hospital was designed from existing airport equipment, with the cooperation of the airlines, the operating authority of the airport, and other interested parties. Two such vehicles are now in constant readiness at the airport and together provide 12 monitored ICU beds, a 16-bed burn unit, 2 operating rooms and 72 other stretcher-beds to be used for the stabilization of critically ill patients prior to their transfer to an appropriate definitive care facility. A newer modularized version which incorporates these features, for use in any type disaster, is currently being developed. These mobile hospitals, together with two inflatable structures maintained at the airport, are supplemented by Mobile Emergency Rescue Vehicles (MERV vans) maintained at local hospitals by the Emergency Medical Service Systems (EMSS) of New York City. Together they provide the on-site Resuscitation and Stabilization Center in the event of a disaster.

The easy availability of small aircraft for charter, has been accompanied by increasing willingness on the part of insurance companies to pay the costs for the use of these air ambulances. Operators of aircraft in the United Kingdom and Europe were becoming increasingly worried about the moral, medical and legal implications of carrying seriously ill or injured passengers. In late 1980 the UK Air Taxi Operators Association (ATOA) began to formulate Guidelines for air ambulance operations, and in 1981 these were incorporated into the studies of the same subject by the International Business Aircraft Association (IBAA), Europe. This paper presents the Guidelines adopted by the ATOA and ratified by IBAA Europe. The Guidelines are designed not to hamper the development of aeormedical rescue, but to bring it within a proper medical aeronautical framework for the safety of the patients, and medical and aircraft crews.

During the last 30 years development of the international travel market in Europe has resulted in many patients becoming ill or suffering injuries many miles from their own home. In the past these people would have remained in a local hospital and received treatment by the locally available facilities. There has been a revolution in the technology of medical transport, providing skills and equipment which allows the most seriously injured people to be transported over long distances. The public demand has pressed insurance companies to offer as part of travel packages the possiblity of medical repatriation. The number of new serious medical cases abroad reported to Europ Assistance in London, rose from 736 in 1978 to a projected 3,500 in 1983.

During the early summer of 1982, Her Majesty's Armed Forces embarked upon an operation to repossess the Falkland Islands. The campaign was fought over a difficult terrain and under hostile climatic conditions, 8,000 miles from home shores. Resupply was difficult, sometimes unreliable and, during the initial battles, medical practitioners supporting combat troops had to practice ingenuity and improvisation. During the battles, 225 British Soldiers were killed and 777 wounded. Of the wounded who presented at the British Advanced Surgical Centers, only 7 subsequently died (1%). 658 battle casualties were dealt with at the various land-based surgical facilities. About 270 general anesthetics were given.

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.

Following the June 1982 war in South Lebanon, the Israel Ministry of Health sent a medical team to assess health conditions in the area, to assist in the restoration of local health services, and to provide additional medical assistance as needed in public health and specialized medical services. For the approximately 600,000 population of the area, public health sanitary conditions were restored by local authorities, with some external assistance. Sanitation and housing for the refugee camp populations were difficult to solve because of extensive damage in the camps; but United Nations activities, supported by international and Israeli sources, were effective. Epidemic conditions did not occur. Monitoring for specific infectious diseases showed increases not exceeding usual summer conditions. Child nutrition status was satisfactory. Medical needs for specialty services, not available in South Lebanon, were arranged through screening and referral to Israeli hospitals. Renal dialysis needs were met by establishing a dialysis unit using local personnel in a damaged and non-functioning government hospital. Private medical and hospital services, the bulk of health care in the area, functioned except for minor dislocations throughout the war and post-war period. Israeli medical aid, managed by a small multidisciplinary team, was designed to assist and, where necessary, augment rather than replace local health services.

What exactly comprises a “disaster?” The American College of Emergency Physicians has defined the term as “a sudden massive disproportion between hostile elements of any kind and survival resources that are available to counterbalance these hostile elements in the shortest period of time” (1).

In a small airport supporting a town of 10,000 an aircraft accident involving 4 or 5 casualties can constitute a disaster by this definition, whereas at Kennedy Airport (JKF) with its large depots of medical support, and where our experience in this area has been considerable, it would take many more casualties to qualify as a disaster. “Black Sunday” at Tenerife, with 500 casualties in a single incident (2), focused world attention on the need for more adequate casualty care of air crashes at airports, particularly at airports that handle wide-bodied jets. In our efforts to improve the methods of “bringing the hospital to the emergency rather than the emergency to the hospital,” the “workshop” at Kennedy Airport has evolved over the years from a cumbersome inflatable unit with limited mobility, to a Mobile Emergency Hospital with a capacity of 100 beds and an operating room (3).

In the past year, we have developed an even more practicable Mobile Emergency Hospital, the size of a standard cargo container, 40 feet long by 8 feet wide and 8 feet high with 4-wheel drive and self-propelled at 55 miles per hour, capable of being lifted by helicopter, flown in a Lockheed C130 or cargo 747, placed on a railroad flat-bed or transported as a container on the deck of a ship (4,5).

The Somali government has had to deal with serious health problems in the refugee population, especially malnutrition, tubercolosis, malaria, schistosomiasis, and parasitic diseases, arising from changes in environment and living patterns, the process of migration itself, lack of food, and the settlement in special camps. Emergency health plans have therefore been formulated by the Ministry of Health in concert with international agencies, foreign governments, and private aid organizations. An original contribution has been made by the Department of Community Health at the Faculty of Medicine at the National University, in the field of health education and health care. A number of problems were encountered, originating from varying philosophies of intervention and from the particular cultural characteristics of the population. The authors compare their experience with the period of mass resettlement during and after the 1974-75 drought in order to arrive at recommendations for the planning of health services in similar situations.

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.

In preparation for the visit of Pope John Paul II on Oct. 5, 1979 to Chicago, Illinois, a multi-departmental committee met for a number of months prior to the Pope's visit to prepare for possible mass casualties at the outdoor papal mass held in Grant Park. Data taken into consideration in preparation for this mass gathering included predictions of the number of people to attend the event, calculations by the National Safety Council of the possible number of victims and type of casualties, a review of the literature and the experience of others at outdoor events of the same scale.

On this basis, it was predicted that aproximately 3,000 to 3,500 casualties would occur simply as a result of a mass gathering of one million individuals. The actual total number of casualties was 400, with twenty being transported to the hospital and no deaths. On the basis of this experience a formula was described to predict the number of casualties based on total attendance figures.

At large airports, the principal problem is coordination of resources. These resources consist of airport medical resources and outside medical resources. At small airports, the problem is often more complex because the surrounding community's small medical and non-medical resources often may be inadequate. The danger of crash is about the same, however, as that of a large airport, if this small airport serves aircraft of categories 4 or 5. The following recommendations are relevant to small airports:

1. The guidelines contained in “Airport Emergency Planning,” recently published by the International Civil Aviation Organization (ICAO) should be followed.

2. An inventory of all the private and public resources available in the surrounding communities should be completed and their development and expansion actively supported.

3. A flexible medical policy should be adopted stressing first aid as a first priority. Air evacuation of victims should be arranged by helicopter or medevac aircraft to other better equipped communities. Rescue teams and medical equipment, including mobile shelters, should be brought by air from other communities.

4. An International Medical Task Force should be considered which could be capable of being rapidly mobilized. This could be useful not only for airport disaster, but also in case of natural disasters or any other mass accident.

Italian physicians who, from Oct. 1979 to April 1981 directed an emergency medical team in the Ogaden refugee camps of the Qorioley district of Somalia, report on location, general set-up, vital statistics, health aspects, water and food supply, sanitation, disposal of waste matter, health hazards, spread and control of diseases, health education, and planning of health services and health teams.

Invited by the Caritas of Somalia and the United Nations High Commissioner for Refugees (UNHCR) office in Mogadishu, Somalia, from October 15, 1979 to December 31, 1980, two Italian medical teams of the Associazione Universitaria per la Cooperazione Internazionale (AUCI) worked among the Ogaden Refugees in 3 camps of the Qorioley District, lower Shabelli Region of Somalia. Each team consisted of one physician and 2 registered nurses. The Qorioley district, about 140 km SW of Mogadishu, has high day-time temperatures and high humidity throughout the year. The day to night temperature gradients are high. Strong winds are blowing to and from the Indian Ocean.

The 3 camps had been set up in the bush, on the right bank of the Shabelli river, about 8 km NW of Qorioley Town. The refugees in these camps were of Somali extraction and of Muslin culture and religion. They were housed in large military tents, aqal (round roofed skin covered hut of nomads), “mundul” (circular grass-thatched hut built around a central pole) and “arysh” (rectangular hut, corrugated iron tile roofs), aggregated at a very high density. More than 5000 people lived on one hectar. It was so crowded lhat there was no more space than 1.5 m2 of shelter per person. They lacked all hygienic services.

Each camp had a food storage hut (mud walled with corrugated iron roof) and 2-3 water collection ponds, fed from the river. At the time of our arrival, two “arysh” with a total of 20 beds were in use for non-ambulatory patients. Scattered in the camps there were 6 “medical posts.”

The medical successes realized in Vietnam can be attributed to several factors: rapid evacuation of casualties by helicopter or ambulances; the availability of whole blood; well-equipped field hospitals; highly skilled and well-organized surgical teams; and improved medical management. Of these important factors, rapid evacuation by helicopter contributed the most to saving the lives of the wounded. Without effective helicopter evacuation, it would have been difficult to exploit the other factors and management of medical resources would have been less efficient.

Private aviation being popular, there are many light planes in regular use. Several of these are operated by pilots in training through local flying clubs. There is naturally a risk every time a plane takes to the air, but the statistics show that the risk is actually quite small. Most insurance companies do not increase their premiums for private pilots flying for pleasure. The most common emergencies which arise in light aircraft are caused by deteriorating weather conditions, fuel shortage, engine failure or pilot error.

Accidents caused by the inept pilot usually occur during take-off or landing. Gusting wind conditions can produce an unexpectd stall position when there is inadequate height to recover. The strong vortices generated in the wake of high powered jet engines can turn over a light plane which is following too closely at take-off or landing in the circuit. Accidents may also occur during flight because of the pilot's failure to fly at the correct height on the correct course and communicate properly to the local air traffic control. Fear of being made to look incompetent often results in the inexperienced pilot failing to ask for help when he is in doubt or in trouble.

If problems such as engine failure or fuel starvation occur, however, all is not lost since, unlike their enormous commercial counterparts, light planes have excellent gliding characteristics and can usually make an emergency landing. Requiring only a relatively short landing run if full flaps are used, they can often find a suitable site free from buildings and people.

Migration of whole populations, driven by natural calamities or war in search for safe territory, has come to the attention of International Organizations. The sanitary situation of refugee camps in Somalia which take care of the nomad populations arriving from the contested Ogaden territory, has been studied in Nov.-Dec. 1980 at the refugee camp of 3alalaksi. A study of the environment and organization of the camp was made to examine housing, water supply, sewage and alimentation. The nutritional state of refugees was recorded. The anthropometric data of 1185 children, including weight, height and arm circumference according to age and sex have provided interesting comparisons.

At the beginning of many of its armed conflicts, the United States has found itself unprepared for large numbers of casualties. The Vietnam War was no exception. In August 1965, Marines landed at Chu Lai, just south of Danang in South Vietnam, for their first major unit combat effort. They suffered more casualties than anticipated. They were cared for by Navy physicians and corpsmen in the combat area and then flown by helicopter to the Danang airbase. There, they were further triaged in a small field hospital, which quickly became saturated with those casualties which could not be moved. Those less seriously wounded and those who could be made transportable were flown directly to Clark Airforce Base in the Philippines by C130 combat aircraft, a flight of approximately 3 hours. They arrived unwashed, in their combat gear, with weapons on the litters. A C130 aircraft carries 72 litter casualties when fully loaded. At Clark AFB, after word had been received of the combat action, all patients, who could be discharged, were sent out. All personnel at the base, including wives and dependents, were mobilized to help at the hospital. They washed and moved the casualties as they arrived.

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.