Although there may be international differences in some aspects of CPCR course content, we hope material presented will catalyze research in education with CPCR self-training systems. Historically, self-training in CPCR was first introduced to the University of Pittsburgh medical students in 1971 through a pilot program in a CPR learning laboratory. This training was enhanced by the development of a mobile prototype recording manikin (by Laerdall with immediate feedback via lights indicating correct and incorrect actions in breathing and external chest compressions.

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.

The impromptu and unforseeable problems, which the physician faced who was called upon to help a boy who had fallen into a deep well, are illustrated. Inability to recover the boy rapidly required oxygen and fluids to be provided in the well for over 2 days. The reasons why heroic efforts failed to save him will be presented in this rescue case report.

In reoccurring types of disasters, such as earthquakes and fires, the type of aid required can be predicted from previous experiences and results. Sometimes in cases involving one individual, who due to special circumstances is in danger of losing his life, rescue organizations have difficulty in organizing and providing the special aid required, which touches public sympathy, creating a state of general anxiety and interest. An unusual and dramatic case, the accidental fall of a boy into a deep well, had these characteristics. The intensive care unit (ICU) of our hospital had to deal with this extraordinary event. National and worldwide news media gave extensive coverage and direct transmission, with emotional details, ending with the drama of human life and the attempted rescue.

In the afternoon of 3une 10, 1981, in Vermicino, on the rural outskirts of Rome, a 6 year old boy did not return home. After carrying out an anxious and fruitless search, the parents informed the local authorities. The police continued the search, until they finally heard from the tunnel opening of an unmarked well the tearful wail of the boy.

Data from many rescue missions can be made more comprehensible by computer processing. Exact and systematic processing of data is needed to evaluate the effectiveness of treatments. We put into practice a computer assisted recording system for the rescue helicopter Christoph 5 in Ludwigshafen-Oggersheim, dealing specifically with medical performance.

For over 100 years, Innsbruck, Austria had been a center for Alpine and winter sports. In 1896, it became necessary to found an Alpine rescue service to come to the help of mountain climbers and skiers who were injured or stranded in our mountains. The reason for today's accidents are the same as they were 50 years ago. On the one hand, Alpine accidents are a consequence of preventable dangers, such as inadequate equipment, carelessness, and too little Alpine experience. On the other hand, they are caused by objective dangers, e.g., falling rocks, weather, lightning and avalanches. The rescue methods, however, have undergone a fundamental change over the last 3 years.

In 1964, the medical team at motor car races consisted of 2 physicians, including the author, several first aid workers, and 2 nurses. Only one physician stood at the trackside and sophisticated equipment was non-existant. Nevertheless, it was possible to resuscitate drivers who had suffered a cardiac arrest at the moment of impact, by simple cardiopulmonary resuscitation (CPR). In 1965, the Grand Prix mobile hospital was added. This was a Juggernaut container lorry containing a well-equipped operating room and scrub up area. It was found to be of little use in the UK, although the idea behind it was well intentioned. The problem with the unit was one of mobility. It was certainly true that the hospital could be taken from London to Paris, but it was far too big to be driven from the car park to the injured driver at the side of the track. In 1968, theBritish Racing and Sports Car Club (BRSCC) introduced the first rescue unit. This short wheel base vehicle was presented to the club by Ford as a service to motor sport. It contained all necessary fire-fighting, cutting and medical equipment. It was to reach the scene of any accident within 3 minutes. In that way a driver whose heart had stopped at the moment of impact could be resuscitated before his brain suffered irreparable damage. Apart from firemen, the rescue unit carried a physician, usually an anaesthetist skilled in resuscitation. As a result, the standard of care around the circuit became standardized after the first few minutes.

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).

Emergency medicine is, to a great extent, based on the progress made in clinical anesthesiology and resuscitation. It is only natural for these clinically approved measures, which are routinely used for surgery and anesthesia in recovery rooms and intensive care stations, to be applied outside the hospital, where first aid is required, be this at the scene of an accident or at bedside.

An emergency exists when “immediate danger to life or danger of serious lasting injury is present, cannot be excluded or has to be expected.” This is particularly the case with disturbances of the vital functions, respiration and circulation in polytraumatized patients, for example, with injuries of body cavities, head and cervical spine, hemorrhagic shock, coma or somnolence; or in patients with acute heart insufficiency.

In summer, mountain accidents may include falls, causing contusions and open wounds; fractures and torn ligaments; external bleeding;internal bleeding in the head, thorax and abdomen; injuries to the spinal column and extremities; falling rocks causing skull injuries; and falls into crevasses causing additional hypothermia, frostbite and drowning. In winter, there are skiing accidents with fractures and torn ligaments; and avalanches resulting in asphyxia, hypothermia and frostbite. In addition, there are mountain sickness; pulmonary edema of high altitude; snow blindness; heatstroke; sunstroke; heart attack; diarrhea and vomiting; pneumonia; snakebite; drowning in torrents or lakes; and burns, explosions and cuts acquired in huts. First aid, medical support and transport to hospital may vary widely.

The authors describe Italian public health intervention planning for civil nuclear emergencies. With the exception of a few special aspects of prophylaxis and therapy, public health intervention in the case of nuclear emergencies are basically the same as those planned for “conventional emergencies,” however, a key role in nuclear emergencies could be played by the psychological aspect. Two different situations must be considered: 1) nuclear accidents involving workers only; and 2) nuclear accidents involving population as well. Differences in public health intervention required to address these two situations are discussed, both in terms of public health personnel involved, and of public health means and structures that should be available.

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.

The staff of accident and emergency departments in the United Kingdom are realizing their increasing role in teaching the elements of emergency care. This paper highlights some recent developments which have influenced the way in which emergency medicine is taught.

First Aid instruction aims to impart the universally agreed and accepted principles to a wide ranging audience. Traditionally these principles have been embodied in the combined manual of the St. John Ambulance Service, St.

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.

In contrast to other European countries, Italy lacks a Civil Defense Organization. Air Rescue is a task for the Italian Air Force Search and Rescue (S.A.R.) organization. It may also draw, if necessary, on the cooperation of the other Armed Forces and State Corps, the Merchant Navy, civilian organizations, the Italian Red Cross (C.R.I.), and the Mountain Rescue Service of the Italian Alpine Club (C.A.I.). The S.A.R. units intervene at the request of civil, state, public and private, national and international organizations. The tasks currently performed by the S.A.R. in Italy include search and rescue of civilian and military air crews lost at sea or over land and of shipwrecked survivors; emergency transport of doctors and supplies to the seriously sick or injured patients from ships at sea; inaccessible localities, earthquakes, floods, and other disasters.

Norway has fairly well developed primary health care. It is developed around general practitioners who, in their local regions, are responsible for total health care, including emergency medical care. During the last few years, there has been an increasing buildup of resources in the hospitals in the area. Modern technical equipment, increasing knowledge and practical training among the house physicians have greatly improved standards of CPR and emergency health service inside hospitals. Unfortunately, there has not been a proportional build up of resources, knowledge and practical skills in the districts and rural areas. An increasing gap between the treatment offered inside and outside hospitals has developed.

In Third World countries there are many priorities that take precedence over cardiopulmonary resuscitation (CPR). Some more common concerns are malnutrition, infectious diseases (malaria, tuberculosis, measles and polio) and children's diseases such as diarrhea and dehydration. Other priorities such as sanitation, housing, primary and professional education, jobs and birth control, inflation (118% for Brazil in 1980), energy crises and balance of payments are important government priorities. Accident prevention in civil construction and traffic education should be of paramount importance in a country that holds world records of accidents in both sectors. After we consider the above priorities, first aid education and CPR are to be taken into account. This does not mean that CPR training is not to be undertaken until all of the other priorities are satisfied, but it does mean that the availability of funds and motivation will be relegated to a lower priority in countries that are developing and have similar problems.

The rescue of victims of accidents during underwater activities, and the treatment of the pathology provoked by too rapid ascent in diving, are unfortunately problems which still remain relevant today. The concept of rapid artificial recompression is at the basis of the fundamental therapeutic techniques for the early treatment of all those involved in accidents of this type. Though numerous advances have been achieved in this field, many practical limitations still prevent their complete utilization.

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.