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 overall goal of the emergency medical services (EMS) system is to reduce overall mortality and morbidity at nominal or reduced costs. To accomplish this goal an EMS system uses many subcomponents, each with specialized skills, integrated so as to insure a competent continuum of care. Questions inevitably arise about the ability of EMS systems to deliver the intended results. While discussions of mortality and morbidity tendencies are meaningful measures of outcomes and, perhaps, the “bottom line,” these two criteria are a total system measurement. They are not subsystem measures, and, therefore, offer little insight into the reasons for success or failure of the EMS system.

As a field commander attacks an emergency medical incident, his thought processes depend upon information gathered during the incident and information about the effect of resources and competencies upon past incidents. The decisions which determine treatment and patient survival, as well as rescuer safety, are a direct function of this tactical thought process. This paper examines how this thought process is formed and how it may be improved through the use of a mechanistic system evaluation model.

In 1966, the first major step toward a systematic delivery system for EMS was taken when a U.S. government report recommended that a nationwide program be established that would form non-traditional “EMS regions.” These regions would be the foundation for a comprehensive systematic approach to the problem of unnecessary death and disability in the prehospital setting (1).

The EMS delivery system in Japan is divided into three levels of medical care. One can request the first aid ambulance by dialing the emergency number 119. The ambulance service takes the patient to the first aid clinic (hospital), i.e., emergency department. Physicians and nurses of a city, town or village are being rotated for the first aid clinic once every month or two. A physician has to decide whether or not a certain patient needs further evaluation. When the physician of the first aid clinic (hospital) decides the patient needs hospital admission, he sends the patient to the second aid hospital. When a physician of the second aid hospital judges the patient needs special examinations or surgical treatment which requires the patient's admission to a more advanced facility, he sends the patient to the third aid hospital. At the present time, the third aid hospitals are medical school hospitals and national hospitals.

The efficiency of EMS, especially resuscitation of the severely wounded, depends upon speed and skills. This requires well-organized military-civilian collaboration, as shown during recent earthquakes in Ashkhabad and Tashkent. Reasons include the great mobility of military medical units, including field hospitals; communication facilities; specialized means of transportation; readiness of equipment and supplies; as well as skillled military medical personnel.

The quick re-establishment of communications is vital to all disaster relief operations, but simple effective means of doing so are usually lacking. The unpredictability of the type, time, and location of catastrophic or disaster events requires a communications capability which is mobile, versatile, and dependable under all conditions of weather and terrain. Similar needs are essential for emergency medical services and search and rescue operations. These are problems without national boundaries.

In the last few years various departments of the University Hospital “A. Gemelli” have been engaged in dealing with disasters of different kinds: the earthquakes of Belice, Friuli and Irpinia, the fire of the Todi antique exhibition, and various terrorist attacks. In these events the organization of the care of the survivors took the following four aspects into account: 1) Type and kind of lesions related to the nature of the event. 2) Criteria and collection areas of the injured, casualty clearing and treatments. 3) Distance of the disaster from the treatment center. 4) New structures to be set up for improving efficiency in the future.

1) The most frequent clinical problems encountered burns and crushing injuries, and those affecting the musculoskeletal, cardiorespiratory and neuro-muscular systems. In a second phase, together with the possible lack of water, food, clothing, shelter and toilet facilities, infectious diseases of the respiratory and gastro-intestinal tract appear, particularly in old people and children. The treatment of the injured in the emergency phase requires a series of interventions at a very high technological level. In the subsequent phase, which may last for months, the treatment needed comes under normal preventive and clinical care.

2) In the emergency period, which in our experience does not generally last longer than ten days, the medical and surgical departments of our hospital mostly concerned were the intensive care units (18 beds), the orthopedics and traumatology sections (122 beds), the surgical wards (309 beds), the transfusion center and the hemodialysis service.

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.

The only organization presently capable of responding immediately to a mass casualty situation in peacetime in Israel would be the Israeli Defense Forces. They have available the necessary means, organization, trained manpower and equipment. If a state of emergency would be proclaimed in the state of Israel in case of a major earthquake or similar disaster, in any part of the country, the chief military commander would be in charge. His army would take command over that area. All the other civilian institutions concerned with the care of casualties, including fire fighting forces, police and hospitals, would come under his command. With the military in charge, the response would be much shorter. The chief military commander would proclaim a state of emergency if he feels that it is warranted.

A 28-month study was made of the delivery of emergency medical services (EMS) in disasters and large casualty-producing situations. Focus was on the organizational and human aspects of EMS in such situations rather than technical medical matters. Intensive interview, observational, documentary and statistical data were obtained in field work in 29 actual natural and technological disasters, and five potentially high mass casualty pre-planned events (e.g., the Mardi Gras celebration); additionally, in-depth studies were made of hospital and medical sector EMS preparedness in six disaster prone communities. Quantitative and qualitative analyses were made of the data by using a model which linked the pre-impact conditions of the established EMS local community system to the characteristics of the emergent EMS system.

The need to arrange the assistance beforehand and therefore prepare for the prevention of damage to people and property that may result from accidents or events of considerable magnitude occurring inside the University Hospital, “A. Gemelli,” has led to several laws of the Constitution of the Italian Republic (Article 35), the Criminal Code (Articles 437 and 451), and the Civil Code (Article 2087): The law of Feb 12, 1955, #51 (Official Gazette 54, March 7, 1955); Decree 547 of April 27, 1955 “Regulations for the prevention of industrial accidents” and Decree 302 of March 19, 1956.

The study of these assistance procedures has led to the formulation of an emergency plan divided into two basic parts: prevention of accidents, and rescue operations.

By prevention we mean: a) The training of all staff and Managing Bodies of our Faculty/Staff to take effective action in the case of an intra-hospital accident, b) The need for detailed information on the various procedures to be used depending on the gravity of the event, c) Awareness of the civil and criminal responsibilities relating to the various management and non-management levels in case of emergency.

The training plan for the whole staff, approved by the management administrative, technical and medical bodies, consists of theoretical and practical courses. These courses, which started in June 1983 are “modular.” The staff will take part in them as homogeneous groups, for a period of time which will vary, in regard to the number of hours and kind of instruction, and in relation to what each group has to learn about work safety, fire prevention and emergency measures.

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.

Besides defense, a military organization can protect a country in two ways: (1) Ensure the integrity of a country despite internal disasters and disturbances; military aid can have a humanitarian role. (2) International responsibilities.

The Canadian Forces participate in peacekeeping and disaster relief all over the globe. This international military job results in increased prestige for Canada and security for Canadians.

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.

RURALSIM is a sophisticated computer simulation model designed as an aid in planning and evaluating rural emergency medical services (EMS) systems. Written in SIMULA, it has been successfully used in Indiana County, Pennsylvania, to study the potential effects of changes in existing vehicle placement and relocation strategies, vehicle dispatching policies and alternative forms of prehospital care, including the ability of the system to respond to a disaster.

RURALSIM is a stochastic, dynamic, event-oriented computer model. Stochastic means that all random events, such as the occurrence of an incident, are generated according to appropriate probability distributions obtained from empirical data. Dynamic means that events occur over time and that the model selects the appropriate incident rates and response strategies for the particular time and day simulated.

The subject of disaster medicine may seem suspect to those who say that it means to prepare for war. Others maintain that in the FRG we need not concern ourselves with disaster medicine because “disasters in this country seem unlikely.” I consider those claims absurd. I will try to point out possibilities for medical support by the West German Bundeswehr (Federal Armed Forces) in the event of natural disasters (e.g., earthquakes, floods, forest fires) or in severe accidents (e.g., traffic, aircraft, railway) where suitable civilian helpers or equipment are unavailable or are available only in insufficient numbers or too late. The Federal Armed Forces' Medical Service, according to legislation, is part of the Armed Forces, organized for defense. The medical service has to provide free medical care for military personnel, and protect, maintain or restore as far as possible the health of military personnel. Moreover, it is a matter of course in our country to employ the medical service of the Bundeswehr for aid in natural disasters or major accidents. For this purpose, the Surgeon General, Federal Armed Forces, in March 1982, issued guidelines on which I will primarily base my remarks.

The topic of this paper is not only of concern to people interested in transplantation. The organization described stemmed from the experience of the earthquake in southern Italy in 1980, in which physicians of our transplant center participated only as surgeons. We feel that a tranaplant team could be useful in a mass casualty situation with the intent to help in the triage of the seriously injured, select patients with brain death, and transport selected donors to transplant centers.

The problem of triage in mass casualties is by itself a difficult and complex ethical and practical issue (1). The first hours after any disaster has occurred are crucial in dividing patients into different categories and in putting them into the care of specialized physicians, according to their primary lesions. Often severely traumatized people are discovered late and do not get the primary intensive assistance which will allow them to stabilize their clinical condition (2).

According to the type of disaster, the percentage of head trauma patients varies greatly, reaching its peak in case of earthquakes (approximately 4% of victims died of head trauma), air crashes and building destructions (3). It is reasonable to think that often head trauma is associated with multiple traumas and that in some cases (direct trauma of the most important organs, crush lesions, etc.) this may represent a contraindication to considering the patient as a donor. Generally, however, head trauma with brain death, even associated with different lesions but without metabolic, septic or cardiovascular alterations, must at least be considered for organ donation (4).

The Department of Defense (DOD) must be prepared to deal with the most likely contingency situations. In developing plans, certain medical factors must be considered. One of these is mobilization time. In prior conflicts, we had sufficient time to expand the military medical system to meet the needs of military operations. We did this by organizing medical units, building hospitals, and training personnel. But, given the high state of readiness and mobility of current combat forces, a future conventional conflict could begin with very little warning. If the USA were to be involved in this kind of a situation, our military forces would have to be supported with our present medical capabilities.

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.

DePauw University operates yearly mission projects in disaster areas of Central and South America. Since 1976, 26 missions in 8 countries have been conducted. With the guidance of international health and engineering professionals, over 500 undergraduate student volunteers have managed the planning, execution, and outcome review aspects of the projects. This paper examines and summarizes the work to date, emphasizing the vital interactions between volunteers and the local health communities. We conclude that ongoing disaster relief projects such as ours serve a useful purpose in the delivery of disaster relief services.

Paramedic units have awakened a new concept in prehospital care in the USA. New emergency medical services (EMS) administrations, better educated personnel, and mass public awareness through media events have all contributed to the change.

Operational changes designed to tighten control of the emergency medical technician (EMT) and paramedic came about through deployment of ambulances and categorization and designation of emergency hospitals. Clinical changes have given the EMS responder, particularly the paramedic, a great deal of freedom in the care given to patients. The paramedic, who uses subjective criteria, can administer care ranging from Standard First Aid to advanced cardiology. Subjective control should be rigid for the EMT or paramedic, when cognitive abilities include only knowledge, comprehension and application, but not for those who have had a chance to exercise analytic and synthetic skills in pre-hospital training programs.