Although decisive changes have been made in the past ten years by re-organizing and improving pre-hospital care, emergency measures at the scene of the accident still require special emphasis in accident victims with head injuries concerning the recognition and treatment of vital complications. The success of these measures depends on the time interval for their initiation, on the practical skill and expertise of the person administering life support, and the availability of equipment.

An emergency examination at the scene of the accident is absolutely essential for correct assessment and should reveal imminent failure of arrest of vital functions. This can be achieved by using the rescuer's five senses and does not require special diagnostic equipment. An initial sign that cerebral trauma has occurred can often be recognized by a superficial injury to the skull during an initial orientation examination, although some of the most severe closed craniocerebral injuries can occur without the slightest superficial sign of trauma.

A standardized approach to advanced cardiac life support (ACLS) improves the morbidity and mortality from cardiac arrest. Physicians should receive formal training, certification, and periodic recertification in ACLS. This paper describes the system we have developed to provide all the medical graduates of our university with training and American Heart Association (AHA) certification in ACLS.

Method

The course takes place during the third year of medical school in four afternoons during the students' medical clerkship. The students are required to take this course and are freed from all other commitments during these afternoons. Several weeks before the course, the students are given a brief introductory lecture, registered, and strongly encouraged to read the AHA manual for providers of advanced cardiac life support.

The effectiveness even of the best organized emergency medical services (EMS) system depends on the level of knowledge and the abilities of those persons who are the first at the scene. Only on few occasions will that be a physician specialist in resuscitology. So it seems necessary to educate and train laymen, medical students, and physicians in life saving methods. This should be done in a uniform way concerning organization and contents. In the German Democratic Republic (GDR), we try to perform this task on a nationwide basis.

Airplanes and airports are in potential danger during transport of highly toxic chemicals, and accidents can occur if the wrapping material is damaged. The chemicals are listed and classified by the International Civil Aviation Authority ICAO) (7). They are subdivided into nine classes, each marked by a special symbol. The classification is derived from the most important properties of the chemicals in relation to the air transport (Table 1). Special positions are listed in class 6. This does not mean, however, that the chemicals of all other classes are non-toxic. On the contrary, highly toxic substances also exist in each other class. For example, class 2 “compressed gas” includes dangerous toxic substances such as hydrochloric acid, fluorine, carbon monoxide or sulphur dioxide. Class 3 (“flammable liquids”) includes benzene, methanol, acrylonitrile and ethyl methyl ketone, for example. In class 6 (“poisons”), special poisons are listed such as tetraethyl lead, dimethyl mercury, organophosphates and aniline. Class 8 (“corrosives”) consists of poisons like bromide, dimethyl sulphate, phorphorous trichloride and hydrofloric acid.

Recent advances in the resuscitation and stabilization skills of prehospital emergency care providers have done much to improve the quality of immediate care provided to suddenly ill or injured patients. Although much of the innovation and leadership in this area has been provided by emergency department physicians, most of them still lack an adequate appreciation of the circumstances under which these skills are executed. While many physicians participate in prehospital care teaching and evaluation of the system, most have not gained personal experience in those aspects of care foreign to hospital environment. They are particularly unacquainted with the intricacies of rescuing patients from automobile accidents and similar entrapments. It is not unusual, however, for an accident victim to spend half of the time required for the prehospital phase of emergency medical care undergoing extrication, and in many cases this must be done before full advanced life support measures may be initiated.

There is no record in the history of medicine of a group of drugs which has gained such a reputation as the benzodiazepines, mainly among psychiatrists and physicians, who augmented their therapeutic arsenal with these drugs which have a safe and effective action. The benzodiazepines have many indications, with special emphasis in the treatment of anxiety, sleep disturbances, muscular spasms, convulsions, etc. There is, however, a difference between therapeutic and abusive usage and there is a danger of exposing an important drug to the risk of being transformed into a psychological crutch.

Airports are complex cosmopolitan units which receive millions of human beings, many of them suffering from tension which they try to hide. Many an air passenger takes, as a precaution, about 10 mg of diazepam (ValiumR). Depending upon the weather conditions and check-in problems, they may take another pill before boarding the plane. After take-off, either because they have forgotten the warning or because they choose to ignore the risks, they have a few drinks, which are served by the airline personnel to help ease tensions and sedate the group. A few moments later, the crew have one or more serious problems. Initially, the passenger becomes excited and aggressive. After being controlled, he reveals a concomitant anxiety. At the end of his trip, he is taken to the airport doctor. Following the routine examination, and familiar with the situation, the doctor knows that his patient is suffering from potentiation of alcohol by diazepam.

The discipline of emergency medicine includes the field of disaster medicine. Unfortunately, little actual emphasis is placed upon this vital area of training in emergency medical residency programs aside from nominal involvement in mock hospital-community disaster drills and triage exercises. In addition to these important areas of disaster medicine, physicians must be knowledgeable in field medical sanitation, environmental illnesses, ground and aero-medical evacuation, epidemiology and logistics in addition to hands on emergency medical casualty care. To better serve this important neglected area of the emergency medicine residency curriculum, we developed a one-month block of instruction.

The operational medicine course is composed of separate instructional modules. The emphasis of the field medical training is obviously a military one; however, that emphasis is easily translated into a field medical environment, one that is commonly employed in military disaster relief operations. The American armed forces, particularly the US Army, frequently come to the aid of victims of both civil and natural disasters. This humanitarian assistance also serves the readiness training goals of the Army Medical Department during peacetime.

The terrors of flying are as old as the dreams of it. The first flight of man, reported in Greek mythology, ended with the crashing down of Icarus. Today, planes have become indispensable. Air transport companies boast the fact that travel by air is the safest, despite the fact that fear is ever present. There is little knowledge about fears and passenger behavior. Accident statistics turn terrifying events into “cases”. Tribute is paid to “technical progress” and to “more quality of life.” Measures must be taken to reduce the reasons for apprehension to achieve some kind of rationally based safety to relate to behavior. One should, however, not aim to abolish fear to an irrational and unrealistic degree. Such induced behavior cannot be firm in a real crisis. Fears are founded upon social and personal reasons: (1) Predominantly sociological aspects: the fact of airplane disasters; obscurity of the causes and effects of such disasters; inadequate knowledge of technical facts; doubts about disaster prevention; and “technology trauma.” (2) Predominantly socio-psychological aspects: alien surroundings; isolation; don't know what to do; inescapability; and “Mogadishou-effect.” Anthropological and socio-cultural factors also have an impact.

Fear of flying of pilot and crew: Their reasons for fear are related to the exact knowledge of dangers and risks, which are involved in economic and job efficiency oriented requirements and obligations. We recommend: improving information and explanation of risks and the related behavioral safety; improving technical means and management of disaster prevention along with appropriate mediation; courses to decrease fears of flying, including safety training; and decreasing potential conflict with airline personnel.

There are different social actors (or “collective social actors”) in a disaster who may have differing ideas on the “ideal passenger in a disaster”.

This is an euphemism; it includes a gang of hijackers. Any suggested human failure in a complicated technical environment might be threatened or committed deliberately. Some attitudes of the ideal passenger, as seen from the point of view of the pirate, show that: i) the passenger ought to keep quiet, should not panic and should readily obey orders of the hijackers and must be easily persuaded by bullying tactics; and ii) the passenger must be selective in observing his situation —neither apparently looking at anybody nor recognizing anything, except to obey the commands he might receive from the hijackers.

This one did not want the disaster to happen, e.g., a rescue team. It also has an “ideal passenger” in mind: i) he should not panic, and should keep quiet, after having given a signal that he is alive and needs help; ii) he should follow orders and should place his trust in personnel; and iii) he should do his best to help himself and identify emergency situations in his co-passengers and help them. The moment rescuers arrive he has to change his role and follow orders.

This is the company operating the flight, as presented by the pilot and his crew: i) this party is interested in a quiet and non-panicking passenger; ii) expect him to follow their advice on trust; and iii) require him to take precautions seriously; i.e., reading the emergency regulations put in front of his seat, without unduly worrying about them, but remembering them when disaster strikes.

In disasters, every available physician and lay person alike is called upon to render help. Disaster medicine is a most demanding field because of its multidisciplinary nature. Specialties like anesthesia, general surgery, internal medicine, pediatrics, opthalmology, orthopedics, otorhinolaryngology, bacteriology, thoracic and vascular surgery, toxicology, radiology, and others are each separately and directly involved. Without specialized knowledge, no one physician is able to cope with all problems that may arise. Therefore, disaster management planning calls for adequate training and organizational preparations, with plans for the whole spectrum of possible catastrophes from man-made and natural disasters (e.g., floods, avalanches, fire, war, terrorism attacks; air, rail and high-way accidents; chemical catastrophes, irradiation, and radioactive fallout).

Sweden has not been at war since 1809–1810, when we fought against Russia in Finland. Lyrics by Runeberg are among the few documentations about the wounded in that war. Life-saving first aid was not very good at that time, and most of the wounded died. Modern Sweden is a technically advanced community. We have had some mass casualty situations, such as fires in restaurants and airplane accidents. Six months ago a train crashed just outside the fire brigade station, only five minutes running distance from the hospital. The result was one person dead, two severely injured and about 40 slightly injured. The same crash could have occurred elsewhere in Sweden where the situation might have been much worse, for much of Sweden is very deserted with large woods, and roads are scarce.

With the development and deployment of commercial jet aircraft in the mid 1950's, airline travel has become commonplace throughout the world. A rapid increase in the numbers of aircraft, airline routes, and flying time has occurred. New technology has added sophisticated and complicated gear to aircraft and their support systems. Every new system has the potential for failure and to some extent additional components increase the risk of technological breakdown. The increased chance of technological breakdown favors an increase in aircraft accidents. Fortunately, development and utilization of sophisticated redundant electronic and mechanical improvements aimed specifically at improving safety have also occurred. The results of these changes over the past twenty-five years has been a decreasing rate of accidents per mile flown. Due to the tremendous increase in flying, however, the absolute numbers of accidents associated passenger morbidity and mortality have risen (1). For the health care system, the major impact has resulted from the absolute increase in aircrash victims.

Aircraft accidents have regularly produced mass casualty incidents with the number of victims ranging from a few to several hundred. Aircraft accidents can be divided into essentially four types: mid-air crashes (so called “hard impact”); crashes on takeoff; crashes on landing; and on-ground accidents (“soft impact”). Mid-air accidents are frequently away from population centers and usually there are no survivors. The medical impact therefore is minimal. Accidents occurring on takeoff, landing, and on the ground, occur at or close to airports, and the nature of the accident is such that there may be many victims (1).

Experience and history have taught us that much can be done for the sick and injured before such patients reach the hospital. From the legacy of the Good Samaritan to the modern day organization of emergency medical services, the immediate care of those stricken has undergone significant change in both philosophy and practice. While many prehospital care organizations with roots established deeply in the past still flourish, modern emergency care, in the new world at least, has developed rapidly only over the past ten years.

In the United States, a concerted effort to improve the care of the wounded during the Civil War led to the introduction of the “flying ambulances” used earlier by Napoleon's Chief Surgeon, Larrey. Americans made significant contributions to acute care with the work of such noted men as Crile, with his form of external pneumatic counterpressure; Kouwenhoven, Knickerbocker and Jude at lohns Hopkins; Beck and the first reported defibrillation in a patient; Safar and his co-workers with the rediscovery of mouth-to-mouth; and many others.

A Boeing 747 took off from Nairobi International Airport on the morning of November 20, 1974. Its leading edge flaps failed to operate for technical reasons and barely a minute later the aircraft crashed, the tail separating from the fuselage. The wreck caught fire.

Since the aircraft's home base was Frankfurt, a Crisis Management Staff (CMS) was immediately constituted there. As an airline physician, I was requested to evaluate the medical information received from Nairobi and act as medical advisor to the CMS. According to the first rough estimate received, approximately 160 persons were believed to be on board at the time of take-off. By the same estimate, about 100 of these had escaped with their lives, of whom about 60 had been injured. Since there was no accurate information about the availability of adequate medical supplies in Nairobi, I advised the CMS that I should go with a medical staff and equipment to Nairobi. In 1974, the Lufthansa Medical Service in Frankfurt was manned by only three physicians as compared with six at present. Of these three, one was on vacation, one was required to maintain the Medical Service in Frankfurt and only one could be spared to go to the site of the crash.

On arrival in Nairobi, my colleague and I contacted and registered 44 passengers who had been on board: those who had been seriously injured were discovered in local hospitals, others were in hotels and lodgings in the locality.