The speedy development of disaster medicine has made intensive care on accident sites possible for everyday use. This prehospital care Has proved to be an indispensable, life-preserving work. It does, however, require having qualified medical and technical help brought to the site of disasters in reasonable time, and the ability to bring patients back in properly equipped units, supervised by paramedic staff, to ready and well run hospitals which are able to carry on the treatment and secure the results already obtained.

Rescue work associated with air crashes must be of high interest to all nations, as air traffic is global and a European traveller may easily get into trouble in a wilderness in another part of the world. Through the International Civil Aviation Organization (ICAO) membership, nations are bound by means of international regulations, to contribute to security in the air and supervision of planes in their own area, and to co-operate with the FIR-system in adjoining areas. This system contributes to a better chance of detection of an aeroplane in difficulties, but the rescue problem will have to be solved by the existing and available national military and civil rescue service, its organization, material, education, medical preparedness and disaster plans.

Statistics reveals that about 50% of all crashes take place in landing procedures, some of them occurring just outside the airport. To these must be added collisions en route and cases of sabotage. Most crashes at take-off happen so near the airport that there will be no problems of detection, and help in fire-fighting will be available from the airport, if necessary.

Asmund Laerdal, a patron, catalyst and leader for resuscitation developments worldwide, died from cancer at his home in Stavanger, Norway on November 19, 1981. At the funeral services on America's Thanksgiving Day, we said thanks for what he has given the world. He was a great man, whose quiet, but determined, manners and eagerness to help whenever he perceived a need, earned him much respect and love.

Asmund Laerdal was born in Norway on October 11, 1913. He went to business school, traveled throughout Europe by bicycle during his youth, married Margit in 1939, and started a small printing business in 1940. Nazi occupation between 1941 and 1945 threatened his life, but did not wreck his little company. Throughout the 1940s and 1950s he printed childrens' books and calendars and made inexpensive wooden and plastic toys. The latter included “Anne Doll,” the “toy of the year,” made of soft plastic, with sleeping eyes and natural hair.

There has recently been a steady increase in the number of patients treated in intensive care units (ICUs) and requiring resuscitation. This number has risen from 1 to 3% in patients after cardiac arrest (19) and from 7 to 13% in those with severe injuries (18). The immune system investigations, introduced more and more widely in intensive care medicine for prophylactic, therapeutic and prognostic reasons, did not, in principle, concern the cases of post-resuscitation disease after cardiac arrest. Only a few reports have been published on this subject (11).

The aims of our investigations were the analysis of selected humoral and cellular factors in patients after cardiac arrest in comparison to those with multiple injuries, evaluation of the host resisctance against infection and of prognostic values of some immunological indices.

Examinations were carried out in 50 patients, treated in an ICU of 15 beds, from 1981 to 1982, and in 20 healthy volunteers. The patients were divided into two main groups (Fig. 1): The first group consisted of 25 patients after cardiac arrest, age 47±12. The second group consisted of 25 patients after severe multiple injuries, age 42±18 y; they corresponded to an abbreviated injury scale (AIS) of 4–6 (8). 56% of the patients with cardiac arrest could not be resuscitated. In 64% of the trauma patients treatment was unsuccessful. Infection complications, influencing recovery were observed in 10 (40%) after cardiac arrest and in 12 (48%) after trauma. The cardiopulmonary-cerebral resuscitation methods used were standard (16).

This is an age of unprecedented uncertainty. Life is now perilously posed at the precipice of history. Never before has man possessed the destructive resources to make this planet uninhabitable. Having unlocked the Pandora's box of the atom, a new dimension has been provided to our potential for self-annihilation.

An objective assessment indicates no vital national interest that would justify nuclear war. Nonetheless, the nuclear arms race is ever accelerating.

If the best intervention is to be achieved at any incident, be it an aircraft disaster or not, there must be the utmost co-operation between all the intervention services attending or connected with the disaster. Such co-operation cannot be guaranteed to happen overnight or on the day of the disaster, but must be the result of lengthy pre-planning. It is necessary for all involved organizations to decide their area of responsibility on the occasion of a disaster, and contingency plans must clearly set out such responsibilities in order to avoid confusion and duplication of effort on the day of the event. Chaos will surely result if the various responsible officers of each organization do not personally meet during the planning stages, if only so as to be able to readily identify those in charge of each service at an incident. More importantly, each leader can learn of the mannerisms, shortcomings and attributes of his colleagues in other services and thus, when the incident occurs, be in a position to readily appreciate what is likely to be the approach of his fellow officers and services.

Drugs for CPR need reinvestigation; at the present time their use is as much an art as a science (14). American Heart Associations standards and guidelines and other recommendations for CPR call for the administration of 500 mg CaC12 i.v. routinely, in attempts to resuscitate patients with asystole or electromechanical dissociation (1). However, calcium's popularity for use in restarting the arrested heart has fallen (3,6,14).

There is a lack of evidence in the literature for calcium's supposed beneficial role in cardiac resuscitation. Calcium in combination with epinephrine — the traditional drug of choice in CPR — was not experimentally investigated before. On the other hand, the effects of calcium antagonists were never examined in CPR, but several theoretical considerations seemed to favor their use. However, a proposed use of calcium antagonists during CPR would lead to the withdrawal of current recommendations for the use of calcium.

The Swiss Civil Defense system forms part of the national defense, has no combat tasks, and aims at the protection, rescue of, and care for the entire population of Switzerland. Horizontal evacuation is considered impractical and unrealistic. Vertical evacuation into special shelters in homes, public buildings, factories, etc., is the focus of CD. planning efforts. Shelters have increased air pressure, are artificially ventilated, are equipped with gas filters and are strong enough to give a relative protection against outside pressure, irradiation, chemical contamination and missile fragments of conventional weapons. The Swiss CD. system is to ameliorate the direct or indirect effects on the population of conventional, chemical, or nuclear war.

The relatively young scientific field of health services research, whose practitioners are still struggling to establish legitimacy within the vast domain of health care, owes much to Michael Pozen. Indeed, Michael must be counted as one of the founders of this new speciality in that his brief but incredibly productive career began as the field of health services research took form and emerged as a distinct career specialty. His very significant contributions to health care can be assessed from two perspectives.

The most visible perspective upon Michael Pozen's professional work can be obtained from a review of his research as reported in his published articles and presented papers. Michael clearly established himself as a creative and resourceful scholar and researcher who had a particular interest in improving the design and delivery of emergency medical services as well as the clinical aspects of emergency medical care.

In serious emergency situations such as the aircraft crash, the medical staff can also be in danger. The risk for the medical and paramedical staff has two sources: (a) factors related to the cause of the accident; and (b) dangers occurring during rescue operations. It is necessary that the emergency staff look to their own security, and avoid exposing themselves to the risks associated with the panicking movements of frightened people (herd effect). The first aid station should be established in a position down-wind, to avoid the toxic smoke from fire. An essential condition is that the medical emergency staff is composed of people physically and psychologically suitable to the sudden effort and the acute stress.

To reduce the risks associated with rescue operations training is essential, conducted under the supervision of experts from the Fire Brigade. A minimum program of training must be arranged between the physician in charge and the airport authorities, so as to reconcile the activities of the two parties and achieve co-ordination. The medical and paramedical staff must be trained to operate with a gas-mask or oxygen auto-respirator, necessary to prevent intoxication with compounds such as tri-o-cresyl phosphate, fire extinguisher compounds such as dibromodil-fluoromethane and bromocloromethane. Metabolites of air contaminants found in airport disasters are not well known. We summarize in the table some toxicologic data of interest.

The German Association for Disaster Medicine published the following declaration for physicians, citizens and governments (J. German Physicians, June 24, 1983, pg. 39): “Disaster medicine defines as the limit of its applicability situations in which violence and the dimension of destruction will make every systematic and organized aid impossible; this would be the case in a nuclear war.” This explanation would show the right way to act for those who reject disaster medicine, as they consider it an alleged preparation for nuclear war — i.e., some members of the peace movement. This declaration also addresses authorities, so that they will not cherish false expectations. Some of these allegations culminate in the statement that the physicians supporting disaster medicine would suggest to the political and military leaders that nuclear warfare could be risked. This is obvious nonsense.

Rapid and repeated administration of concentrated NaHCO3 solutions during cardiopulmonary resuscitation (CPR) has become routine since the advent of modern resuscitation techniques (1), although it has been pointed out since the early 1960s that acidemia results from prolonged arrest time and that brief arrests may not require NaHCO3 administration (6,8,13). In spite of the widespread use of large amounts of NaHCO3 there is no convincing evidence that the routine use of this drug offers a clear benefit. Only a few studies have been undertaken to ascertain the role of acidosis and acidemia in survival from cardiac arrest, and the possibility of overcorrecting with NaHCO3 in CPR cases (3,4,8,11). Therefore, the intention of this study was: 1) to clarify the role of acidemia in CPR; 2) to investigate the effects of overcorrection of acidemia (leading to metabolic alkalemia; 3) to test the accurate doses of NaHCO3; 4) to examine the optimal sequence of drug administration in CPR, i.e., whether NaHCO3 or epinephrine should be administered as the first drug.

During attempts at restoring spontaneous circulation (CPCR Phase II, advanced life support) (12), and during post-CPR prolonged life support (CPCR Phase III) (12), measurements were made in dogs following resuscitation from asphyxial cardiac arrest. The model and methods used have been described in the preceding paper of this Journal. Asphyxial cardiac arrest (mechanical asystole, electromechanical dissociation) was reversed with open-chest CPR and defibrillation as necessary to 20 min max.

The time has come when it may be asserted quite categorically that a new medical science, the theoretical foundation of reanimation, has emerged on the medical scene. At the International Congress of Traumatology held in Budapest in 1961, I proposed to call this new science reanimatology. My suggestion was based on the medical tradition of using the Latin roots of words. I am pleased that not only this term but also its notion are being increasingly used by experts in the field.

The members of the World Association for Emergency and Disaster Medicine (WAEDM) (The Club of Mainz) have considered the medical consequences of a major nuclear war and would like to make the following recommendations to all relevant governments and powers, and their medical professions:

1. That disaster medical preparedness should be continued and developed for conventional wars, nuclear accidents and the single small nuclear bomb explosion (e.g., by accident or terrorism).

Profound hypothermia has a high mortality if not treated with active rewarming. Most successful is central core rewarming. Many methods have been designed for this purpose: mediastinal irrigation, colon irrigation, peritoneal dialysis, and warm water via a Sengstaken-Blakemore esophageal tube.

A new esophageal tube was constructed for this study. The tube consists of a small, stiff and narrow inner tube, placed inside a larger thinwalled outer tube. Warm water (41-42°C) is circulated from a waterbath via the inner tube to the outer tube and then back to the waterbath. Five healthy mongrel dogs were anesthetized, intubated and made hypothermic. All dogs were paralyzed with pancuronium to eliminate shivering. The only fluid given was isotonic saline to compensate urine loss (50-75 ml/hour). At a core temperature below 30°C the esophageal tube was inserted, and rewarming started when temperatures had reached 27.1-24.7°C. Rectal and peripheral temperatures were monitored, and in 3 dogs blood temperature was also followed.

Up to the cardiac safety temperature (31°C) the blood temperature increased 4.6°C ± 0.79 (SD) (Fig. 1, whereas the rectal temperature rose 3.74°C ± 0.76 (SD) (Fig. 2). The peripheral temperature showed only a minor increase below a central core temperature of 30°C. This means that a secondary temperature decrease is eliminated with this method. No cardiac arrhythmias or other complications were noted. these results correspond to those with peritoneal dialysis (1), and show a greater temperature rise than with use of a modified Sengstaken-Blakemore tube (2). (Supported by the Danish Medical Research Council.)

Major disasters require extensive activity by the fire-fighting, technical and emergency services. Simultaneously, victims have to be rescued, fires have to be fought and other technical aspects of assistance have to be employed. Ill and injured patients have to be removed from danger, prepared for transport, and taken by ambulance, under the care of skilled personnel, to hospitals. The responsibility for these actions lies in West Germany in the hands of the Fire Brigades.

The Alert. Emergency calls arriving at Fire Brigade communication centers or emergency service control centers are often inaccurate. It is necessary for professional emergency personnel to give detailed information from the incident site. This should include the nature and gravity of the damage, the number of injured and their severity, and the best possible access.

Exploration of the Site. In major medical incidents it is highly important to gain a full overview of the scale of the danger and damage. Often incident sites with a great number of injured are difficult to reach and to survey.

Searching for the Injured. It is a matter of high priority to search all over the site for injured persons and those suffering from shock. In large areas, which are difficult to survey, this must still remain a priority. Additional personnel may have to be called in.

Research on acute dying processes, emergency resuscitation (cardiopulmonary-cerebral resuscitation, CPCR) and long-term resuscitation (intensive therapy) have the potential of leading to so far unimagined restoration of total body function, including human mentation, after sudden cardiac death from ventricular fibrillation, asphyxia or exsanguination; and also after prolonged terminal states from trauma or other insults—conditions which have so far been considered irreversible. Since the 1950's, an increasing number of investigators have embarked on resuscitation-related research.

The Critical Care Medicine department, St. Jans hospital, Brugge, has a prehospital emergency medicine service (EMS) staffed by experienced intensive care specialists. We have been involved in clinical research for the improvement of cerebral outcome after circulatory arrest (CA) and cardiopulmonary resuscitation (CPR) since 1977. In 1982, 250 patients in CA were resuscitated from an area of about 150,000 people. There were 70 short-term survivals, 30 longtime survivals. Although the success rate of CPR is highly influenced by important EMS related factors, including response time, a substantial proportion of hearts are restarted also after prolonged CA, but the patients die later in brain failure. There is evidence that the brain is not only damaged by the CA itself, but that lesions after restoration of spontaneous circulation (ROSC) progress and are amenable to therapy. We can illustrate the progressivity of brain lesions by two phenomena: 1) Animal experiments in other centers (P. Safar, J. Michenfelder) and our research at Janssen Pharmaceutics, Beerse, Belgium. Cerebral venous blood was sampled from the sagittal sinus after a prolonged CA (10 min); cerebral venous PO2 of 40-60 mmHg before CA, rose to 80-100 mmHg immediately after ROSC and about 1-2 h after ROSC decreased to 20-30 mmHg — indicating progressive failure of oxygen transport. 2) Cerebrospinal fluid (CSF) enzyme activity was studied after CA in humans. We correlated final neurological outcome with the early appearance (at 2k h) of lytic enzymes in the CSF. In some patients who later recover neurologically only partially, CSF enzymes are still low at 2k h, as if the cells are still viable at this stage.

Experiences from accidents show that the majority of critical injuries die within the first 1-4 h if they do not receive some appropriate medical treatment. The problems of an accident with many casualties is dealt with by: (a) maximum utilization of resources; and (b) sorting the tasks.

By rapid and skillful evaluation, we may sort out the critical injuries and give priority for treatment and transport. Through experience we have learned the few and very simple principles of dealing with critical injuries: (a) rapid and sufficient first-aid at the scene, (b) rapid evacuation to a hospital, (c) efficient final treatment, and (d) the need for an effective system of communication between the scene, the ambulances and the hospital.

The principle objective of medical first-aid on the scene of an accident is to stabilize the patient and to make him fit for transportation. Only thereafter is the most necessary temporary treatment carried out. The resuscitation must be continued during transportation. Qualified personnel with equipment must accompany critical injuries. During the last decades there has been a considerable development in the first-aid on the site. Each wounded individual must get the maximum benefit. This requires a high degree of field administration and co-ordination of medical activity on site. This may differ from country to country, but in general the principles will be the same.