Functional and structural disturbances of the brain produced by sudden impact to the skull represent a fundamental problem in neurosurgical treatment of head trauma. A proper experimental approach to brain trauma requires the development of an adequate animal model useful in defining both the biomechanical and physiological variables relevant to mechanical injury to the human central nervous system (CNS). The development of appropriate animal models has proved essential to progress in other clinically related research and is a prerequisite for the development of rational modes of diagnosis and treatment of head injury.

Coping with an airport disaster is difficult. It is enough to have once been the witness of such an event to understand the enormity of the problem. Instantaneously, the routine atmosphere becomes a nightmare. There are smoke, flames, vehicles, useful people and useless people and above all, the dead, the injured, and the uninjured survivors, some of whom are running about.

An airport disaster plan should be carefully set up and applied as strictly as possible. Many features exist in our favor: (a) we know the place; (b) we can roughly evaluate in advance the magnitude of the problem as far as the number of victims is concerned, thanks to the International Civil Aviation Organization (ICAO) studies; (c) we can keep in mind the classification of the injured and the medical policy with which now all seem to agree, that is to give on-site immediate care and control evacuation; and (d) we can utilize the medical resources of the surrounding community in a co-ordinated way. This paper summarizes the basic principles for disaster control.

Present national and international guidelines for resuscitation call for open-chest cardiopulmonary resuscitation (CPR) instead of standard external CPR under the following circumstances associated with pulselessness:

1) chest already open;

2) penetrating thoracic trauma;

3) suspected intrathoracic hemorrhage;

4) suspected pulmonary embolism (thoracotomy permits disruption or removal of emboli);

5) deep hypothermia (open chest allows direct warming of the heart for defibrillation); and

6) no palpable artificial pulse during standard external CPR basic life support, as is sometimes encountered in cases of barrel chest or spine deformities.

We will present evidence in support of a 7th indication, that is when standard external CPR advanced life support efforts do not result in the prompt restoration of spontaneous circulation, as may be the case after prolonged unwitnessed cardiac arrest or in patients with severe myocardial disease.

Historically, open-chest CPR has been used effectively to reverse cardiac arrest in laboratory animals since the 1980s and in patients since 1900. We conducted interviews with Drs. DelGuercio, Johnson, Stephenson and Leighninger (for Beck), who have had extensive experience with open-chest CPR. All confirmed personal experience of one of us (PS) with open-chest CPR in the 1950s, and anecdotal reports, that during direct cardiac massage, the heart usually regained color, spontaneous breathing returned, survivors had a very low incidence of neurologic deficit, and complications were almost non-existent. Stephenson's review of 1200 cases of open-chest CPR hospital-wide between 1900 and 1950 (1) report an overall recovery rate of 30%. However, after Kouwenhoven's report on closed-chest CPR in 1960 (2), open-chest CPR became a forgotten art.

In disasters, the success of medical action in the hospital will only be measured according to the number of survivors and not to the number of major operations executed. Thus, for the clinician his usual standards may have to be modified and he must keep in mind the principle of helping the largest possible number of patients in the given circumstances.

According to previous experience it can be expected that 20% of the survivors in a disaster need surgical treatment. Even in well organized and fully equipped surgical clinics, the proportion of immediate treatment capacity to the total number of beds is no more than 5% to 8% under normal conditions. This means that every hospital should make plans to organize facilities to cope with a major disaster. The individual hospital plans should be co-ordinated with other hospitals in the neighborhood and be integrated into the disaster plans for the entire area. Communication between hospital and the central headquarters is of the utmost importance.

Since standard cardiopulmonary resuscitation (SCPR) cannot reliably preserve the brain during resuscitation, a “New” CPR has been proposed, which seeks to augment blood flow by increasing peak intrathoracic pressure (ITP) during chest compression. This “New” CPR (NCPR) consists of a) high pressure ventilation (70-110 cmH2O) simultaneous with chest compression, b) compression rate of 40/min, c) compression duration of 60% of the compression relaxation cycle, and d) abdominal binding. Although laboratory evidence suggests that NCPR may be capable of augmenting cerebral blood flow (1), the effect on cerebral outcome remains to be demonstrated.

Although the hemodynamic superiority of open-chest CPR has long been recognized, its advantages with respect to the brain have only recently been recognized. It can reliably sustain EEC activity and pupillary light reflexes during CPR (2) as well as providing better cerebral blood flow (3,4). The objective of this two phase study was to establish the relative efficacy of standard, “new,” and open-chest CPR with respect to preserving the brain during CPR.

The objective of phase I of this study was to compare standard and “New” CPR with respect to maintenance of hemodynamic, respiratory, and cerebral variables during prolonged resuscitation. Methods: Ten 10-15 kg dogs were anesthetized with halothane and 50% N2O/O2. Catheters were placed in the carotid artery, aortic arch, right atrium, external jugular vein and the sagittal sinus. An electromagnetic flowprobe was placed on the common carotid artery. Intracranial pressure was monitored with a subdural catheter. EEG electrodes were secured to the skull.

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.

The above contributions by Professors Chazov and Lown, the comments by Dr. Rebentisch, and the Resolutions by the WAEDM, the Red Cross and the WHO indicate that disaster medicine planning for a response to and civil defense protection in case of nuclear war is senseless, wasteful of resources (which are needed for current vital social programs worldwide), and also dangerous, by giving national leaders the impression that some individuals' medical protection in a nuclear war is possible. Most people, including some national leaders and military experts, believe that limited use of nuclear weapons would escalate to a global nuclear holocaust, and that any medical planning for nuclear war might encourage the irrational belief that nuclear was is winnable. Even if it were “winnable” the resulting death and torture of millions of innocent people and the damage of our planet's ecologic balance, make any consideration of the military use of nuclear explosions morally and medically unacceptable.

Preservation of the brain is the obvious goal of every cardiopulmonary resuscitation, but resumption of heart and lung function is the only chance to achieve that goal. In the field, basic life support without equipment remains the mainstem of resuscitation. But what should we do if we are not successful, if even advanced life support does not restart the heart? Should we give up or should we add to the advanced life support a new concept: extended cardiopulmonary resuscitation by mechanical support? This would allow more time for the heart to recover or to begin definitive therapy. Prolonged mechanical support could support weak function of the failing heart or lungs until they return to full performance.

Throughout the world, experience is growing in the development of plans for military-civilian collaboration in disaster preparedness. This involves the complex problems associated with the coordination of various components of military and civilian Emergency Medical Services (EMS) systems and organizational differences between countries.

EMS are dependent on relationships between hospitals, police-fire-ambulance services, and municipal, county and state governments. In an emergency, their integration is accomplished in: (1) detection and assessment; (2) call for ambulance and hospital; (3) organization; and (4) emergency medical treatments.

Air traffic into Malta is heavy for such a small island', especially during the busy summer tourist season. Almost every type of aircraft flies in, including jumbos with up to 450 passengers. Since the airport has been the sole responsibility of the Maltese authorities, there have been two minor incidents; one in which a small private plane made a crash landing, resulting in minor injuries; and another when a commercial aircraft engine caught fire on take-off. Both incidents were efficiently dealt with. The island is only 10 km in width at the widest point and Luqa airport is 3-4 km distant from each coast. The flight path along the main runway passes over the Grand Harbor on the east and over high cliffs on the west. At landing speeds, this is approximately 1 minute of flying time, so there is considerable likelihood that a disaster could be at sea.

All those persons involved in the aircraft industry whom we consulted have indicated that, forewarned of an aircraft fault, they would always prefer to come down on land, rather than in the sea. An emergency landing at sea compounds the difficulties in rescuing the passengers and salvaging the aircraft, which would be almost impossible. Luqa airport has emergency equipment immediately available, and has procedures selected according to the likely extent of the disaster. These are normally designated as “Priorities” numbered 1-3, following the practices of the International Civil Aviation Organization (ICAO). In addition to procedures for a crash on land, preparations are in hand for rescue at sea.

Reduced glytathione (GSH) is the tripeptide of glycine, cysteine and glutamic acid and is widely distributed in the body. FSH has been reported to comprise at least 90% of the nonprotein sulfhydryl (NPSH). Although the role of GSH in the tissue has not been clearly established, it is known to be a cofactor for enzymes, a substrate in detoxifications, and a free radical scavenger.

Several investigators have reported that the level of NPSH, mainly GSH, in the tissue was decreased in several types of shock and that exogenous administration of GSH has beneficial effects on shock (1,2). This study was designed to evaluate the effects of GSH on the survival rate in mice and the hepatic energy metabolism in rats after administration of endotoxin. These results were compared with those of methylprednisolone sodium succinate (MP), since many investigators have reported that the large doses of glucocorticoid have beneficial effects in several types of shock in experimental animals and in man (3,4).

To emphasize the importance of pathologic studies to physicians and biomedical scientists should be “preaching to the converted.” Unfortunately there are disturbing signs that this is not so, particularly in clinical medicine. The autopsy rate is declining globally and some authors have even unwisely implied in print that modern diagnostic techniques render the autopsy and other pathologic studies superfluous. Fortunately, pathologists continue to expose and resist such attitudes by means of analytical discussion of the problem. The role of pathologic study remains an essential one in both clinical and experimental studies of therapy of all types.

The term pathologic studies includes: pathologic anatomy (the autopsy and surgical biopsy); clinical pathology (hematology, chemistry, microbiology, immunologyl and experimental pathology.

The Search and Rescue Co-ordination Center Goch called me, some years ago, to the Stuttgart airport with the rescue helicopter of the Federal Armed Forces Rescue Center at Ulm. A single-engine sports plane, whose pilot was a student on his first solo flight, had tried a belly landing. Next to the runway, there were several fire-trucks, two ambulances and one emergency physician's car waiting. Our rescue helicopter stayed hovering for nearly one hour until the student pilot finally managed a belly landing. Safe on the ground, he was surrounded by firemen, paramedics and physicians, while we flew back to Ulm. We had not landed promptly I was told because of the landing taxes an army helicopter has to pay at a civilian airport! This episode prompted me to look for more information.

The Federal Republic of Germany is obliged by international agreements to search for planes in distress—no matter what nationality—to save the passengers and, if possible, the equipment and to provide medical treatment for the survivors if necessary. This Search and Rescue (SAR) Service is executed according to the instructions given by the International Civil Aeronautical Organization (ICAO). In the Federal Republic, the SAR service is provided jointly by the Ministry of Defense and the Ministry of Transport. The Ministry of defense provides the means and the Rescue Co-ordination Center. The Ministry of Transport provides the alarm services through the air traffic control offices.

The United States Military Health Care System exists primarily to ensure the ready availability of medical support to U.S. Armed Forces at any level of conflict anywhere in the world. Many military medical units are therefore organized and equipped to permit their rapid deployment on short warning to relatively remote areas. They can provide life-saving services within hours and can operate almost independently in any climate, provided they have the means to evacuate patients and to receive supplies. The military mission demands that the medical personnel assigned to these units be trained in peacetime to do their jobs in wartime.

The aim of primary air rescue is to assist the ground-level rescue services by bringing emergency physicians and rescue assistants more quickly to the scene of the accident, and, if necessary, to carry but the swiftest possible and most careful transport of emergency patients to the nearest suitable hospital. Furthermore, the rescue helicopter can substitute for the ambulance car in case of unsuitable terrain, or in certain climatic conditions.

Limitations of helicopter services include night, certain weather conditions, cost and distance. Helicopters are centered in Air Rescue Centres which have an operational radius of 30-50 km. Expense permits only one helicopter to be stationed in each center, but if the helicopter is not able to fly, a replacement machine must be available immediately. Secondary rescue operations should be taken over by neighboring centers.

In 1983, the Federal Republic of Germany had 36 officially recognized helicopter centers concerned with primary air rescue. They are supported by the Federal Home Office (emergency control) (18 centers), the Army (6), the German Air Rescue (5), the ADAC (German Automobile Club) (4), and other organizations (3). The Swiss Air Rescue in Basel, Switzerland covers Germany's area of South Baden, and the French Air Rescue in Strasbourg covers middle Baden.

To even pose the question, “Can you do worthwhile pathophysiological research on critically injured patients?” practically suggests that we give up and surrender a field of medical science that is both challenging and laden with potential. Rather we should be posing the question, “Can we really afford not to be doing this research?” The purists of science must shudder when they think of trying to make sense out of the apparent chaos which surrounds a victim of multiple trauma. Sometimes we do as well, but perhaps we cannot afford to turn our backs because our egos perk at the recognized challenge. Perhaps we look at the heart-rending deterioration of a previously healthy 20–year old and say to ourselves, “What can I do differently the next time?” For these reasons and more, we all continue in our endeavors.

Latin American and Caribbean countries have been affected by many natural disasters in past decades. Earthquakes caused in Peru (1970) approximately 70,000 deaths, in Nicaragua (1972) 5,000 deaths while destroying the capital, Managua, and in Guatemala (1976) 22,000. Hurricanes also wreak havoc: hurricane Fifi in Honduras (1974) with 10,000 deaths, hurricane David (1979), and hurricane Allen in Saint Lucia, Haiti and Jamaica (1980), have amply demonstrated the high vulnerability of these countries to emergency situations. These catastrophes and many other smaller ones required that all resources of the nation, governmental or private, military or civilian, be mobilized in a coordinated manner to meet the emergency needs of the population.

In aircraft and airport disasters help must reach the site of the accident in a very short time. In addition to the ground rescue service, rescue helicopters can also offer help. The rescue helicopter as a mobile intensive care unit contains a medical crew with a flying physician and a paramedic. The following are required basic equipment for rescue helicopters: resuscitation apparatus with and without oxygen; endotracheal intubation set; suction unit; apparatus for measuring blood pressure; infusion sets and solutions with intravenous cannulas; syringes and needles; bandages; special burn dressings; fixation and splinting material; vacuum mattress; surgical pocket kit; stomach tube; ECG monitor; defibrillator with pacemaker; drugs; and otoscope. This medical equipment has to be portable so that it can be used outside the rescue helicopter.

The medical crew must be trained in emergency medical treatment and in aeromedical problems. Patients who are fit to fly can be transported by rescue helicopters after triage and support of their vital functions. This method is of most value if rapid transport to a distant specialized medical department, for example, to a burn or neurosurgery center, is required.

The German Air Rescue operates seven rescue helicopters at five rescue helicopter centers for primary rescue with the helicopter types BO 105 CBS, BO 105, Bell 206 Long Ranger and 3et Ranger. Another important function of the service are long distance flights with patients to medical centers after aircraft and airport disasters. Specially equipped ambulance aircraft are used in these cases.

Eugene Ionesco once remarked that an excess of politics and an exaggeration of sports are characteristics of our contemporary civilization. The excess of politization affects all parts of our public life, including medicine and its specialty Disaster Medicine. Political ideologies try to usurp a field that has solely humanitarian objectives, that depends on providing for and applying relief to many people in acute distress. There are already many relief organizations and ambulance services, physician staffed emergency medical services systems and first aid trained laymen. There are state and federal disaster relief authorities. Why then was it necessary to add another organization to this sometimes confusing manifold, the German Society on Disaster Medicine?

Emergency medicine is for the individual. It must provide optimal care for each single injured or sick person — except for the shortterm management of multiple casualties. Emergency medical missions are limited by time and locality. These missions are hospital services extended to the scene of the accident and work in connection with hospitals. Disaster medicine is for the masses. Its task is to do the best possible for the largest number of people at the right time and at the right place. This implies that in a disaster situation, optimal care for every single individual can and should not be the goal, but rather the best possible care for the largest number. Disaster medicine has to work in large areas, supraregional and long-term. It needs numerous treatment facilities and several steps or levels of treatment. Therefore it requires a firm medical coordination of lay help, primary professional help, transportation, and specialized hospital treatment with maximal efficiency.