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 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.

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.

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.

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.

Investigations describing the utilization pattern and comparing the outcome from emergency and mass casualty situations are limited by the lack of a reliable and valid patient classification system. In this study we briefly describe the use of APACHE (Acute Physiology and Chronic Health Evaluation), a physiologically based classification system for measuring severity of illness in groups of critically ill patients, as a tool in comparing outcomes of 1437 ICU admissions from eight European and five American hospitals. Because of the successful results from this pilot effort, we believe that APACHE could be used to compare the performance of hospitals in an emergency or mass casualty situation.

This study focused upon one critical condition, acute respiratory insufficiency (ARI), and the treatment patterns used before and after a training program designed to teach hospital personnel the most current methods of treating acute respiratory insufficiency. The study was a methodological investigation in which a means for collecting and analyzing data concerning the treatment of an acute health problem was developed, implemented, and assessed. It was also an attempt to evaluate the quality of treatment of ARI in a set of hospitals and to assess the extent to which a training program was able to affect the quality of treatment. Thirdly, the study was an epidemiological investigation of the extent to which ARI exists in hospital critical care units.

Medicine has made great advances in the past decade, and is now opening the frontiers of brain resuscitation. Coinciding with the advances in medicine, society has witnessed great changes. There is an increasing awareness of patients' rights, an increasing desire for self determination, a rejection of the once-accepted paternal role of the physician, and an increasing willingness to challenge physicians in the courts. At the same time, government regulation of biomedical research has been expanding rapidly. The origin of this regulation dates back to the post-World War II Nuremburg trials. In 1974, the National Research Act established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The evolving concern about human experimentation has led to the current Department of Health and Human Services (DHHS) and the Federal Drug Administration (FDA) regulations which became effective July 27,1981. All biomedical research supported by federal funds must conform to these legal requirements. One aspect of these regulations is that all research protocols be approved by an institutional review board (IRB) established at the institution where the research is conducted.

In preparation for the visit of Pope John Paul II on Oct. 5, 1979 to Chicago, Illinois, a multi-departmental committee met for a number of months prior to the Pope's visit to prepare for possible mass casualties at the outdoor papal mass held in Grant Park. Data taken into consideration in preparation for this mass gathering included predictions of the number of people to attend the event, calculations by the National Safety Council of the possible number of victims and type of casualties, a review of the literature and the experience of others at outdoor events of the same scale.

On this basis, it was predicted that aproximately 3,000 to 3,500 casualties would occur simply as a result of a mass gathering of one million individuals. The actual total number of casualties was 400, with twenty being transported to the hospital and no deaths. On the basis of this experience a formula was described to predict the number of casualties based on total attendance figures.

A study conducted by the Massachusetts Institute of Technology concluded that in a large city, a minimum of eight ambulances per 500,000 population was desirable to assure a reasonable response time.

How does a large city with less than this suggested minimum make best use of its available ambulance units ?

A three week study was conducted in New York City to examine the impact of various dispatching procedures on response time, “backlog”, availability of “back-up” units and patient care.

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.

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.

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.

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?

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.

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.

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.

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.

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.