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.

Several thousand distinct medical devices exist and for each one the user usually has a choice from among a number of manufacturers. The process whereby a clinician or hospital purchasing agent makes a selection from a number of competing brands may be based on anything from, on the one extreme, little more than an emotional attraction to a particular brand name to, at the other end of the spectrum, a fully enlightened choice after an inhouse evaluation together with extensive additional information. This paper will describe, with concrete examples drawn from the ensemble of equipment used in the fields of resuscitation and critical care, how Emergency Care Research Institute evaluates such devices, investigates hazards associated with these instruments, and communicates this information to users.

One of the worst hotel fires in the USA occurred at the MGM Grand Hotel in Las Vegas, Nevada, on November 21, 1980. This tragedy claimed 84 lives and injured 300 others. The toll might have been higher were it not for Air Force assistance.

Nine U.S. Air Force helicopters responded swiftly to the scene in answer to the city of Las Vegas plea for help. The call came from the Metropolitan Police Department at 7:38 a.m. and got an immediate response from the Nellis Air Force Base (AFB) Consolidated Command Post. By 7:55 a.m., the first Huey helicopter was airborne. Less than 20 minutes later it was hovering over the MGM Grand Hotel. Evacuation of survivors began immediately, according to Major Larry B. Doege, commander of Detachment 1, 57th Fighter Weapons Wing.

The nutritional status of children in the 3 refugee camps at Qorioley, Somalia, was studied in Dec, 1979-3an 1980. Out of the 13,000 children under 5 in a total camp population of 49,000, a sample of 1700 was selected for measurements. Food and water supplies and environmental hygiene were also evaluated. Growth in weight was near normal from birth to 7 mo. age, slowed sharply during 7-24 mo. (as compared with reference curves), and picked up during 24-60 mo., to become nearly parallel to, although lower than, the normal curve. The arm circumference curve was similar. Growth curve for height, on the other hand, was closer to the reference curve. The curve for head circumference was normal. These data clearly point to malnutrition one of the major indices of poor health. Food supply for 3000 cal daily per child was theoretically available (not counting medically ordered supplements), but in many cases did not reach the children because of cultural food taboos and it having been sold to obtain other goods.

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 the county of Stockholm with 2 million inhabitants and an area of 6,500 km2 , a trial project with a helicopter ambulance, staffed by physicians, was carried out during the summer seasons of 1978 to 1980. A total of 507 missions were accomplished.

The Trial Project. During the summer a large number of tourists visit the Stockholm archipelago. For these people there is a problem in the event of acute illness or accident to get qualified medical care without delay. A Bell 206 Long Ranger was based at Barkarby airport just outside the city of Stockholm. This was manned by doctors, ambulance personnel and a pilot, and was supplied with an emergency kit, intubation equipment, a portable ECG apparatus and a defibrillator.

Since the Cambodian refugee emergency of 1979, refugee emergencies continue to be a global problem. Health care workers returning from the Cambodian emergency relief presented the need for improved predeparture training and orientation to the Second World Congress on Emergency and Disaster Medicine in Pittsburgh and elsewhere (1,2). The special training needs of health professionals working in such emergencies have come to the attention of the National Council for International Health in the US (NCIH) whose role is to increase US effectiveness in international health in developing countries (3,4,5). NCIH, established in 1971, is a private non-profit organization. Membership includes individuals, private and voluntary organizations, health and medical associations, universities, governmental agencies, foundations, corporations and consulting firms.

Worldwide today, more than 10 mill. refugees have been forced to leave their homelands because of political and civil disturbances, war, famine, earthquakes, floods and other disasters. Host governments are often unable to deal with these situations and rely on international relief to provide for the various physical, humanitarian and other needs of these victims.

Providing health care is a complex process that takes place in phases within political, economic, social and cultural constraints that are unfamiliar to health care workers without prior experience or special training. Unfortunately training to meet these emergencies is either non-existent or consists of brief predeparture sessions. Only a fraction of those with prior experience are available at short notice. In Thailand, for example, organizations were forced to recruit medical professionals who were inexperienced in refugee relief.

The purpose of first aid remains the same through the ages: to prevent pain, disease and death. But the need is different in different places and at different times.

It should not be forgotten that in large parts of the world the most immediate threat to human life is starvation and malnutrition, together with lack of hygiene and basic medical care. The kind of first aid most needed under such circumstances is food and medicine. The key to a long-term solution is education in self-help. The prosperity and experience of the Western world must, in the future, be used more systematically to booster development towards self-sufficiency in the less developed countries. These are most important aspects that should be dealt with more often. The time frame of this article forces me to concentrate on conditions in the industrial world.

The Emergency Medical Services (EMS) system response to a multiple victim disaster can be preplanned to identify various components, such as scene authority, communications, triage, vehicular staging, and point-of-entry of patients to area hospitals. On 1/23/82, a DC-10 airplane carrying 210 people, slid off the runway while landing at night on ice at Boston's Logan airport. The plane broke into two pieces after it slid into Boston Harbor; 33 patients required definitive medical management and were transported to 7 area hospitals. The Boston EMS system, coordinated through one Resource Trauma Center, utilizing a central communications center, was responsible for the medical component. Hospital categorization on-scene triage, patient staging, patient transportation and regionalization of resources have changed the City's plan to reflect new EMS developments.

On January 23, 1982, Boston experienced the final stages of a winter storm that began with snow followed by freezing rain. A plane with 198 passengers and 12 crew members was the last plane scheduled to land before the runway was closed for plowing and sanding. The DC-10 landed and slid off the runway into Boston Harbor. The plowing and sanding crew that was scheduled to service the runway was in position, and therefore witnessed the incident and confirmed the crash.

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).

For more than 20 years, our company has had the pleasure of working closely with medical authorities and active first aid organizations in many countries for the teaching and practice of life-support. The access thus gained by experience in the field permits me to present the following status report of CPR teaching of the populations in North America and Western Europe.

History

Before 1960, little or no life-supporting treatment was given to the seriously injured or acutely ill prior to arrival at the hospital. First aid was largely limited to dressing wounds and splinting broken limbs. The ambulance at that time merely served as a means of fast transportation.

There are high mountains around Oslo, which is located at the foot of the Oslo Fjord. The winter is rough, with snowstorms and secondary roads often closed, and people often ski long distances. Avalanches have buried many people. We started a physician-staffed ambulance helicopter service on June 1, 1978 out of the Central Hospital of Akershus, Oslo, primarily to get a physician to the scene as soon as possible. The helicopter is on alert 24 h a day and can take off in 2 min in the daytime and 15 min at night. In 86% of the cases, the helicopter can land within 50 m of the patient. At night, the landing places have to be more secure. The helicopter is a Bolkow BO 105, which can carry 2 patients, 1 pilot, 1 rescuer or paramedic, and 1 physician. In case of an accident on a lake, the paramedic is a frogman and in case of an avalanche we take a specially trained dog along. The pilot has vase experience with helicopter duty, and the paramedic has good medical and rescue experience. The physician has to be a specialist in emergency medicine and is usually an anesthesiologist. The team is always on duty at the hospital where the helicopter is stationed, only 100 m from the emergency entrance of the hospital.

Airline companies, the Director of the International Paris Airport, and sanitary and administrative authorities of the Seine-Saint-Denis Dpt of SAMU were asked to organize a simulation of an aircraft crash on the site of the Charles-de-Gaulle airport. The two main purposes of this simulation were to check the efficiency of the rescue means from a technical point of view, the delays in the organization, and the coordination of services.

The scenario was an accident during take-off of a big jet. The fuselage of the plane was in three parts. There was an intense fire in the middle one. The crash happened at the end of the runway, on soft ground which was normally unapproachable for ordinary vehicles. The casualties were distributed according to aircraft accidents statistics; 200 military personnel and 30 volunteers of Civil Security participated. The victims were classified into 5 groups: 1) uninjured (30 in front and 40 in rear); 2) slightly injured (15 in frontand 15 in rear); 3) severely wounded (8 in front 4 in center, and 8 in rear); 4) critically injured (5 in front, 6 in center, and 4 in rear)); and 5) dead (95 in center).

The injured were simulated by first aid workers who had been trained and made up so as to be seen by the rescuers. Besides, they were given a tag on which was indicated the group, the types of injuries, the delay of survival without care, the necessary time for the diagnosis, and the appreciation of the victims.

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.

I should like in these remarks to try to place the discussions of this Congress in a larger perspective and perhaps to broaden somewhat our concept of what constitutes a medical emergency, and what should be labelled as a disaster. I should also like to ask whether emergency care and disaster planning as we usually think of these activities are either affordable or useful when viewed in a global context. What are the day-to-day emergencies and major disasters of this planet, and are we addressing them properly with the emergency medical services systems as now constituted?

Air transportation missions of seriously ill or injured patients are subdivided into rescue missions and medical evacuation missions. In 1981, for rescue missions, 29 stationed rescue helicopters were available with an operation radius of 50 km. Their task consisted of securing the primary care for vital risk patients as soon as possible. Medical evacuation missions were realized by helicopter, ambulance aircraft, and airliner. Before take-off a medical briefing was held to diminish the transport-trauma. Patients with cardiopulmonary insufficiency are at risk as simultaneous appearance of acceleration, climbing rate, falling cabin pressure and emotional stress may produce serious complications. Additional education of the medical crew is required.

This is an introduction for a one-day CPCR course for intended instructors-coordinators. The course is a pilot project using a new manual. Its goal is to explore the feasibility of instructors using semi-self-training modes to acquire the necessary knowledge and skills for the organization of basic and advanced life support courses in CPR for all types of personnel, ranging from the lay public via ambulance personnel and nurses to physician generalists and physician specialists. The American Heart Association (AHA) CPR courses for instructors-to-be were originated in Pittsburgh in the early 1960s; this present course, sponsored by the World Federation of Societies of Anesthesiologists (WFSA) CPR Committee was given in 1981. The traditional 2 to 3 days CPR instructors' courses for physicians have spread knowledge and skills slowly. We believe that the dissemination and uniformity of resuscitation training could be enhanced by wider use of self-training systems, not only for doers but also instructors-to-be.

On June 22, 1982, the main power transformer at a local high school (St. Paul, Minnesota) overheated, causing the pressure relief valve to operate and release smoke and mist throughout the building. The transformer contained thermal-dielectric fluid with the tradename “Pyranol,” consisting of polychlorinated biphenyls (PCB's) in the form of “Aroclor” and chlorinated benzenes. The transformer did not explode or flame. The emmission characterized by a “white mist” occurred over an approximately 4-hour period with resultant contamination of basement and first floor areas. The temperature of the emission was estimated to be approximately 250-300°F.

“Pyranol” contains PCB aroclor 1260 (45%) and chlorinated benzenes (40% trichloro and 15% tetrachlorobenzenes). Commercial PCB preparations manufactured in the United States have been marketed under the trade name “Aroclor.” Several grades of Aroclor have been designated by numbers such as 1260. The first two digits represent the type of molecule (12 = chlorinated biphenyl). The last wo digits give the weight percent of chlorine.

The fire was discovered by the school janitor and the firefighters arrived at 5:40 a.m. As the firefighters walked near the transformer, several men began complaining of nausea, sore throat and burning of exposed skin. Firefighters having symptoms were asked to go out in the open and were immediately hosed down with water. Initially, 14 firefighters were taken to the emergency room of St. Paul-Ramsey Medical Center, where they were evaluated, treated and released. When inquiry was begun to find out what kind of substance was burning, it was discovered that the transformer which contained “Pyranol” (installed in the school in 1958) had overheated.

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.

Approximately 200,000 emergency patients die annually in the Federal Republic of Germany (FRG) after a sudden illness or a serious accident. According to estimates, more than 20,000 die because effective first aid was not rendered soon enough. We know that two-thirds of all victims of fatal traffic accidents die within 25 minutes after the accident has occurred. In order to improve chances of survival, the therapy-free interval must be as brief as possible.