The airport clinic at Flughafen Frankfurt Main AG (FAG) is a 24 hour manned casualty ward. It employs three surgeons and approximately 40 paramedics. This clinic is supported by external physicians during the night and weekends that guarantees, on a 24 hour basis, a minimum of one physician and four paramedics available for immediate response.

In addition, the airport operator provides an industrial medical service which employs (during normal working hours) six physicians and approximately 10 paramedics.

Finally, there is support from the clinic of the US Rhein Main Air Base, at the military part of the airport, which employs approximately 12 physicians and flight surgeons, 10 dentists and another 100 paramedics. The emergency staff of the clinic of the US Rhein Main Air Base is also manned on a 24 hour basis. The airport clinic and the clinic of the US Forces and their respective fire departments collaborate together in cases of emergency or disaster.

For immediate medical care the airport clinic has available an emergency surgery unit, one emergency surgery ambulance vehicle, and three ambulances with first-aid equipment. In addition, the airport clinic provides two trucks with medical equipment for 100 severely injured persons and two inflatable air-conditioned emergency tents.

Comparable medical equipment is also available at the clinic of the US Rhein Main Air Base, according to US military standards. The US Rhein Main Air Base also operates three DC-9 Nightingale medical aircraft which are responsible for all types of emergencies in the area of the US Forces in Europe.

The introduction of wide-bodied aircraft in air transport has required airports to be equipped to keep pace with the advanced aviation technology and the potential for dealing with a really major disaster. Most airports now have their Emergency Plan that defines with details everything which should be done, when, how and where to do it. Communications, Leadership and Coordination are frequently tested through simulated crashes. These tests are considered as an important factor in performance evaluation. When the alert is given at the airport, the Emergency Plan is put into action to face each aspect of the event.

The basic medical service at the airport works around the clock for routine cases and its team, although small, is enough for these duties. In an emergency, the Plan calls for external medical help. When a crash involved a large number of victims, who will help them?

In most instances, the Airport's Emergency Plan foresees a scheme to cater to many serious cases, in accordance with their urgency. The various means of communications alert the hospitals of the neighborhood, rescue bases equipped with helicopters, civilian auxiliary corps, and so forth. Theoretically, most of these systems have been put into action during the practice drills. Following a serious analysis, it would be optimistic, however, to expect a perfect reaction. Communications problems, holidays, cold mornings, congested traffic, bad weather, and so forth, might on the day lead to disappointment for those experienced with disaster drills which are usually performed in favorable conditions.

In the event of a disaster, all personnel present in the airport area must modify their own everyday rules to ensure the best response to the emergency situation. For medical aid there are two main objectives: (a) organization of rescue operation; and (b) mustering medical resources. The initiators of the rescue operation must be the control tower staff and each Italian airport is provided with emergency plans which have been carefully studied.

Information systems between the accident site and the centers of available medical resources, however, are less well organized. These can be simplified by the use of a video terminal, connected with a data system elaborator. The Lombardy region plans to install a video-terminal in every Regional Hospital in order to be able to present the airport with the up-to-date situation of vacant beds and of medical staff present in the hospital for emergency tasks.

It is proposed that the alert from the accident site should be in two phases. Initially, a general alert must be given, followed after a short time by a more detailed specific alert. The first phase must be addressed to those departments that, independently of the type of the disaster, will always be involved in any critical situation, e.g., Ambulance Headquarters, ICUs, Blood Centers, Emergency Departments. The second phase will be used to inform hospital departments specializing in treating the pathology prevailing in the particular disaater. In airport disasters, the pathology which prevails will include major and multiple injuries with blood loss and burns.

In the history of aviation there has never been a period when so much effort has been demonstrated to improve the safety standards of international and national airports. This has come about through the knowledge that aircraft crashes in recent years at some airports have been mismanaged because of bad or non-existent planning for such a disaster, and by poor emergency medical response.

We share today a faith in the safety of the aircraft. We share, too, the awareness that more people have survived aircraft crashes than have perished, and that if there are survivors on board, in most cases there will be more survivors than dead (1).

The encouragement to improve airport safety and crash management has come largely from the International Civil Aviation Organization (ICAO); from the Club of Mainz Association, who in 1979 set up a consultant committee to investigate and improve international airports; from the Flight Safety Foundation and from the US Airline Pilots Association. All these organizations have rightly questioned the quality of existing emergency medical response to an aircraft crash, and have offered expert advice to improve disaster preparedness and management. This article will report our response to this challenge, particularly in New Zealand, but will also concern our neighboring continent of Australia.

New Zealand, set in the Pacific Ocean with its two long islands, has international flight contacts through its three major airports with North America, South East Asia, Japan and the South West Pacific. It has its own national aviation hazards of mountain chains, difficult landing approaches from the sea, made more hazardous with strong winds which are a feature of our capital city airport. Despite this, the safety record of New Zealand airports is extremely high.

Hong Kong is situated at the center of the air traffic axis for Asia, and has, at Kai Tak, one of the busiest airports in the world. The areahas experienced a ten-fold increase in population over 25 years and now has the highest urban density in Asia. Hong Kong is in the monsoon belt and is subjected to the very severe weather conditions of typhoons.

Kai Tak airport is unique. The main 7,000 foot runway is substantially reclaimed from the harbor which in turn lies within a spectacular mountain bowl. The 310° flight path traverses the north end of the Kowloon peninsula with equally spectacular urban development.

Overall disaster contingency planning within this broad spectrum is the responsibility of a joint Police/Military Command. An Aircraft Accident Committee coordinates joint emergency service planning, command and communications training and exercises.

Response to an aircraft disaster is initated by Air Traffic Control through the joint Fire Service/Police/Military Command which sets up a discretionary response for intervention, search and rescue by land, sea and air.

Although the problems are universal, the Maximum Credible Incident scale is extraordinary to Hong Kong. Unique means of dealing with this problem have been specially evolved here, particularly in the field of fire fighting and marine rescue which involve a Catamaran Rescue and Immediate Care Vessel.

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.

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.

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).

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.

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.

Irreversible brain damage may occur when cessation of circulation (cardiac arrest) lasts longer than a few minutes. Resuscitative measures, however, can be initiated anywhere without use of equipment, by trained individuals, ranging from the lay public to the physician specialist. The history of modern cardiopulmonary resuscitation (CPR) includes the following steps during the past 30 years:

1. Proof that ventilation with the operator's exhaled air is physiologically sound and superior to manual chestpressure arm-lift maneuvers (Elam, Safar, Gordon).

2. Re-discovery and development of external cardiac compression (Kouwenhoven).

3. Demonstration of the need to combine positive pressure ventilation with external cardiac compression (Safar).

4. Intrathoracic and external electric defibrillation of the heart (Prevost, Zoll, Beck).

For didactic purposes, Safar has divided cardiopulmonary - cerebral resuscitation (CPCR) into three phases and nine steps, using the letters of the alphabet from A to I.

Basic Life Support is for emergency tissue oxygenation and consists of: A) airway control; B) breathing support, artificial ventilation of the lungs; and C) circulation support, recognition of pulselessness and establishment of an artificial circulation by cardiac compressions.

Advanced Life Support addresses restarting spontaneous circulation and stabilizing the cardiopulmonary system. Phase II consists of steps: D) drugs and fluids by intravenous infusion; E) electrocardiography; and F) fibrillation treatment by electric countershock.

Prolonged Life Support represents brainoriented intensive care for multiple organ failure in the post-resuscitative period. Phase III should be continued until the patient regains consciousness, brain death has been certified, or his underlying disease makes further resuscitation efforts useless.

Triage or sorting means recognition and selection of the injured for treatment and transport. It is a very important and difficult task and has the aim of saving as many lives as possible, ensuring the best possible treatment, leading to the best possible recovery. Triage requires judgment, courage to assume responsibility and determination to act rapidly. The examination of a patient to assess his priority includes his vital functions, his specific injuries and his environment. Triage leads to the following priorities:

(1) immediate, compulsory treatment;

(2) early treatment, within hours;

(3) delayed treatments; and

(4) slightly injured and hopeless cases.

Although triage is primarily a physician's job, trained paramedical personnel or firstaiders may be the first to arrive at the scene and should to able to recognize and treat casualties requiring immediate care on the spot.

The first physician at the disaster site may not be well qualified in emergency medicine, and indeed may have little or no experience in handling casualties. He may be a passenger involved in the emergency landing of an airplane. Let us therefore examine three possible situations:

In recent years a number of disasters have been handled less than perfectly. Large numbers of patients are sent to the medical facility with little or no warning. Hysterical relatives and friends also arrive, plus the media and curiosity seekers. Well-meaning volunteers and off-duty medical people begin to fill in where each individual thinks he or she fits in best. Soon the rooms and the corridors of the hospital are filled with people lying, standing and sitting. All sorts of treatments are attempted, orders for assistance go unanswered and general confusion reigns.

For many years the military have claimed leading roles in disaster care, giving and taking orders more readily than do most groups of medical civilians. It is the nature of their business to plan for disaster. They take the time to practice and may even be able to test their concepts during wartime.

Primary to all these plans is triage or sorting with “the object being to provide preferential treatment for those who could be attended readily and returned to battle, leaving aside those with more complex injuries until either they could be transported or time became available” (1).

Watt writes that in 1863 a Doctor Moyle tried to convince military sugeons to adopt a triage system to save lives: “Death, wounds, … limbs lacerated and torn off, wounds from muskets or splinters, bayonet wounds, all these appalling and horrible injuries have to be coped with in a few minutes…” He suggested a system of dividing casualties into three groups: slight, serious and fatal and argued that immediate live-saving surgery be done on the severely injured only if the slightly injured were deferred and the fatally injured put aside (2).

Most of us are aware of the medical airlifts that were practiced by the United States Air Force during the Korean and Viet Nam conflicts. Likewise, we read regularly of the air transport of one or more severely burned patients from the scene of an accident to the Burn Center at Brooke Army Medical Center in San Antonio, Texas. But what is not generally known is the daily movement of patients who are armed forces members, or their dependents, throughout the world for the purpose of receiving sophisticated medical care, regardless of where they may be stationed.

The reasons for this service are two: first, quite obviously, it is humanitarian; second, it is a way for the Air Force to maintain medical readiness for their wartime mission by exercising this system on a daily basis during peacetime. We are talking about a worldwide network whose major and minor branches sweep around the globe.

Patients are air transported according to three levels of need: routine, high priority, and urgent. This article will be limited to a general description of the necessary hardware and current practices used for the urgent mission.

We use three types of aircraft: the Huey helicopter for short distances; the C-9, a two-engined jet, for medium range; and the C-141, a four-engined jet, for intercontinental transport. The medical modifications to the C-9 include a built-in ramp; a nurses' station similar to that found on a hospital ward, complete with built-in drug and equipment cabinets; multiple sources for oxygen and suction; and ready communication fore and aft. Seats can be quickly removed, leaving space for litters in tiers, infant isolettes and Stryker frames.

The organization of medical facilities in the USSR is able to provide adequate and rapid care, including intensive therapy in prehospital conditions for the whole population of a very big country. The principles of organization are very simple: the country is divided into regions and these into districts. Each district has to have a fixed number of hospital beds, stations for first aid and urgent care, and a determined number of physicians, and medical assistants (feldshers, nurses and others). The only difference between the emergency care in Moscow and Northern Siberia or Pamir is the distance to be travelled and the means of transport, i.e., modern first-aid cars, helicopters, planes or boats; or reindeer or dog teams when the weather makes aviation impossible. As a rule, all medical teams working in emergency medicine include physicians and medical assistants. Only in places where the population is very sparse are some emergencies still managed by only medical assistants at the pre-hospital stage.

In cases of severe trauma we prefer, when possible, to have teams especially trained in shock treatment. These are already available in the emergency ambulance systems of the bigger towns. These so-called “shock-teams” are experienced and well equipped for intensive therapy at the accident site and with problems occurring during transport. When necessary, we are now able to transport critically ill or traumatized patients not only inside the hospital, but also from one hospital to another, when better intensive therapy can be obtained.

We must be prepared for a survivorship of about 600 to 700 injured passengers in case of an accident involving two jumbo jets as these planes are able to absorb more impact forces than earlier types, and 40%-50% of the passengers may survive.

A triage post, an anteroom for resuscitation and anesthesia, and an operating room with 3 tables must be installed within the airport. Mobile operation units are necessary in addition for urgent surgical care on the spot. The optimum time of the operational readiness is approximately half an hour, if “on the spot surgical care” is to be effective.

At the triage post several tables are available, each with an experienced surgeon for the rapid medical examination. The time of examination and triage for each victim of the earthquake disaster in El Asnam was three minutes.

In an airport disaster, about 10% of survivors might belong to the first category of triage, i.e., have life-threatening injuries. They will require resuscitation and urgent surgical care. Twenty percent might be seriously wounded passengers of the second category, who should be conveyed to hospital as soon as possible. Seventy percent might have minor injuries of the third category and can wait for care and transportation.

Many victims may require neurosurgical operations, but this should be carried out by trained experts and not at the airport. Open depressed skull fractures should be treated at the airport by shaving the scalp, irrigating the wound, applying a sterile dressing and instituting antibiotic therapy. Foreign bodies should be left in place until definitive surgery can be undertaken.

In a mass casualty situation after airplane accidents, it is not unusual that physicians with only limited experience in emergency medicine need to perform initial triage. In their day to day work, they may not usually be confronted with the problems of hypovolemic shock. The same holds true for a proportion of the paramedical personnel employed.

Speedy assessment and immediate, purposeful therapy is of the utmost importance in a mass casualty situation to increase the survival prospects of the victims. Timeconsuming and elaborate examinations are naturally precluded.

The estimation of blood loss from profusely bleeding open wounds should not be too difficult. The extent, however, of the total blood loss associated with the insidious development of fracture hematomas is more frequently underestimated. This error can be avoided during triage at a mass casualty situation by means of a quick approximate calculation of the probably internal bleeding volumes:

More difficulty is presented by internal hemorrhage in individuals appearing uninjured or only slightly injured. In such cases, the personnel employed in the early phase after an airplane accident should use simple and proven rules as criteria for their evaluation.

The quotient of the pulse frequency and the systolic blood pressure has been called the shock index (Allgöwer and Burryi) (1). Disregarding the later and more complicated pathophysiological processes such as cardiogenic shock or septic shock, this index has been suggested as a method of assessment of the seveity of the hypovolemic shock in an injured person (Figure 1).

As with many manmade and natural disasters, those involving airports and aircraft give rise to a number of emergency medical situations that require prompt and sometimes drastic responses. The number of casualties can be very large and adequate hospital facilities can be quite distant from the disaster site, even when the latter is at an airport. Obviously, the situation is compounded when the accident has occurred at a remote place or involves a landing on water. Emergency measures are therefore of great importance to minimize loss of life and reduce exacerbations of initial injuries. Fortunately, major disasters are infrequent. This very fact, however, makes it even more impractical at most airports to have on hand at all times a large supply of blood and the facilities for typing and cross-matching rapidly and accurately. No supply of blood, of course, exists on any ordinary aircraft. There are therefore good reasons why artificial preparations capable of carrying oxygen and carbon dixoide and maintaining blood volume have potential usefulness in airport and airplane disasters.

These disasters can involve one or more forms of bodily injury including physical trauma, burns, and asphyxiation (Table 1). All can lead to shock, and some form of emergency treatment is often required to restore blood volume and oxygenation levels. Since any delay in initiating treatment must be avoided, the required materials should be on hand and in a form which allows their being used without delay. Artifical blood replacement preparations (1-4) based on liquid perfluorochemicals have a number of desirable attributes in this regard.

Disaster conditions can be characterized as rare, extraordinary and unpredictable events which threaten, injure or kill many people at the same time. The prime examples are earthquakes, floods, traffic or train accidents with hundreds of victims.

While emergency pain relief measures in a few injured victims can be managed individually and really effectively, the requirement for effective pain relief under disaster conditions is still a problem which is largely unsolved. The primary goal of immediate pain relief is the elimination of pain and anxiety which, in themselves, additionally threaten the elementary body functions.

The ideal analgesic drug for adequate pain relief under disaster conditions: 1) should provide the patient with effective analgesia under severe or moderate pain conditions; 2) should ideally sedate the emergency patient to a certain extent; 3) must be effective within a few minutes after intra-muscular, subcutaneous or intravenous administration; 4) should be sufficiently long-acting to avoid the necessity for re-administration several times; 5) should be applicable by paramedical as well as medical personnel; 6) should not have any depressant side effects on respiration and circulation, particularly under conditions of shock and trauma; and 7) should not require intensive monitoring of the patient. This drug has still to be discovered.

The intramuscular or subcutaneous administration of most drugs cannot be considered as methods of immediate effectiveness because most drugs are slowly absorbed, particularly under conditions of shock and trauma. Although the opiate drugs such as morphine, pethidine, and so forth, are obviously effective analgesics, particularly under conditions of severe pain, they cause respiratory and circulation depression, especially if the patient is suffering from hemorrhagic shock, dyspnea and hypoventilation due to thoracic trauma, and so forth.

Pain relief is important — not only for humane reasons — but also for protection of the circulation and tissue perfusion which suffer as a result of the enormous secretion of catecholamines which occur. In the operating room during anesthesia we take care to combat this trend by giving adequate analgesics, and it is logical that we should attempt to take similar steps in the prehospital care phase.

One of the reasons why the provision of analgesia is so poor in practice is that the usual parenteral agents — the opiates — are accompanied by side effects which are particularly dangerous in the seriously ill or injured patient. The introduction of low dose ketamine, however, has altered this position somewhat, offering, as it does, good analgesia without significant depression of respiration or the circulation.

A major practical difficulty in providing analgesia outside hospital lies in the fact that the majority of the patients are being cared for by personnel who are not physicians. We, therefore, need an agent which can be administered by an ambulance attendant or trained rescuer. In many countries the opiates and ketamine may only be administered by a physician and therefore they are effectively ruled out for the majority of patients.

Let us look at the properties of an ideal analgesic for use outside hospital. It should be: 1) effective but safe; 2) have no undesirable side effects; 3) have a rapid onset and short duration of action; 4) be easy to administer; and 5) be capable of being used by paramedical personnel.