The goal of critical care medicine is to provide specific care to the patient in whom one or more vital systems are threatened or deficient. The methods of critical care medicine are monitoring, support or temporary substitution of vital systems, and the application of titrated therapy. The specific objective of each link in the chain of medical facilities involved with the critical patient deserves to provide the same expertise and should act according to the same protocol.

The different links of the chain are these: (l)recognition of the critical condition; (2) emergency call; (3) care on the spot of the emergency; (4) care during transport; (5) further diagnostic and therapeutic work in the emergency department; and finally (6) if indicated, continued intensive care.

During the last ten years, both in Western Europe and in the USA, the attitude towards medical transport activities has radically changed. From being a purely transportation vehicle the ambulance is now increasingly regarded as an extended arm of medical care. At the same time as ambulance crews have received more qualified medical training, the equipment of the ambulances themselves has been improved. In several countries such as the USA, France and West Germany, a differentiated ambulance organization has been built up, with specially equipped emergency ambulances manned by paramedics, and standard ambulances with emergency technicians for planned transports. During this time helicopters have been put into increasing use as a supplement to ambulances for emergency long distance transport to units such as trauma and burn centers.

Planning for emergency medical services (EMS) in a large state with a sparse population like Alaska poses unique challenges that EMS planners in urbanized areas never have to consider. Alaska is the largest state in the USA in land area, covering 586,000 square miles, or an area more than twice the size of the state of Texas. Alaska also has more miles of coastline than the rest of the USA. Despite its large size, Alaska continues to have the smallest year-round population of any state in the nation (400,481–1980 census). Many of Alaska's villages and towns are not accessible by road, including Juneau, the state capital, which can only be accessed by air or water. This means that, with Alaska's often harsh climate, many communities have no available ingress or egress for several hours, or even several days at a time. In these conditions, response times can not be measured in minutes, as they often are in some urbanized areas in other states. For example, Unalaska in the Aleutian Islands, one of Alaska's major fishing ports, is over 900 miles from the nearest hospital in Anchorage.

Due to the development of modern resuscitation during anesthesia and surgical operations, methods of intensive therapy have been introduced in clinical medicine. Efforts, through cardiopulmonary resuscitation (CPR), to give any patient in need the chance to survive resulted in systems of emergency medical services (EMS). A short account of the present state of CCM in the CSSR is given here. The principle of “differentiated patient care” is outlined, with accepted definitions of resuscitative and intensive care. The terminology of different steps in CCM is offered for discussion.

In Czechoslovakia, the Constitution of 1960 proclaims the right to health care for every citizen. Medical care is provided to all citizens free of charge by the State. The State took over the responsibility for planning, organizing and providing medical care on the highest attainable contemporary level. In the last ten years, special programs have been launched in order to cover most actual health areas such as neonatal and maternal health care, cardiovascular disease programs, oncology, geriatric care, and, last but not least, the care of patients with acute organ systems' failure.

Improvements of results in emergency care of critically ill patients can be realized if EMS organizations are properly based on local conditions. The Emergency Medical Unit is the first of three parts of the Integrated Health Service in Poland. The second part is in-hospital treatment. The third part is outpatient care. In most hospitals, the head of the department of anesthesiology and intensive therapy coordinates each emergency medical unit. Each unit consists of ambulances (mobile intensive care units), admission (emergency) rooms, and an intensive medical care unit (ICU). A specialization program was created and physicians who complete this type of training obtain the title “specialist in anesthesiology and intensive therapy.”

This four year specialization program contains the educational elements necessary to administer all types of modern anesthesia, and provides full preparation for work in mobile and stationary intensive medical care units as well. Such training has also given these specialists the chance to initiate treatment methods for chronic pain. An examination consisting of practical tests, multiple choice written knowledge tests, and oral tests completes the program. The latter is a conversation with a commission, consisting of full professors and associate professors in anesthesiology and intensive therapy.

Mobile intensive care units (MICU) will take care of all real emergency patients with presumed or proven disturbances of vital functions. These vehicles are equipped according to standardized criteria, and usually stationed at emergency hospitals. MICU's are accompanied by one rescue assistant, one emergency medical technician (EMT) and one physician.

Eighty-five to 90% of the total number of emergency calls were primary emergency calls, where the emergency patient had to be treated at the scene; 10% to possibly 20% were emergency patients who had already received treatment by medical or paramedical personnel.

Our emergency medical services (EMS) system is called SAMU (“Service d'Aide Medicale d'Urgence”). It was initiated in Paris in 1956. Since that date, it has developed a new concept of emergency transportation, which excludes speed as the best way for saving life threatened by danger. Indeed, this EMS System is based upon the same principles that are used everywhere, but there are some practical differences which are characteristic of the service in France. One example is the medicalization (physician-staffing), which permits excluding speed in transportation.

Everywhere, the fundamental EMS principle is to struggle against time to give efficient care as soon as possible. In emergency situations, all things are simpler and all treatment is more efficient if you can do it within the limit of time available for resuscitation. If this limit is surpassed, success is dubious. The means to reach it are more sophisticated and cost increases tremendously; however, the mortality goes up inexorably to death in all severe cases.

All requests for medical assistance need to be answered. In France, the public “Service d'Aide Medicale d'Urgence” (SAMU) receives the calls and can send, if necessary, mobile physician-staffed ambulances. SAMU works in coordination with the police, the fire brigade and general practitioners.

Response to the request for medical assistance from the public has been solved in different ways, such as agreement on a single call number for certain countries, and whether or not to use a physician-staffed system. In France, the first mobile emergency and resuscitation units (SMUR) were created in 1967. This initiative was taken by anesthesiologists, some surgeons, and military physicians belonging especially to the fire brigade of Paris, and to the seafaring-men of Marseille. The necessity of centralizing coordinating calls and radio controlling the public means of assistance has led to the creation of the Emergency Aid Services or SAMU.

Perhaps the greatest operational problem faced by the New York City Emergency Medical Service (EMS) today is the sheer volume of calls entering the system, and the fact that many of those requests for medical aid are not life-threatening emergencies requiring ambulance transport. This creates two situations that New York City is all too familiar with: (l) ambulances are not available for true emergencies; and (2) response times for ambulances to arrive at the scene of an emergency are extended.

A four-month pilot “on-scene triage” program was initiated by EMS as a possible solution to these problems. The program ran from May to August of 1980. A marked EMS car was designated as the “Triage Car” and was in operation during those hours when ambulance requests were at their peak (usually two to ten PM).

In the Federal Republic of Germany, 1.2 million people per year get into a life-threatening situation from which they can be saved only by immediate medical assistance. Progress in intensive care therapy and the improved organization of rescue services have led to a greater number of doctors being available for first aid at the scene of the accident. The creation of an emergency medical service was designed to ensure medical treatment of emergency patients by medically qualified personnel. The Emergency Medical Service is defined as an organization within the framework of rescue services providing care for emergency patients. The emergency physician is trained and equipped particularly to recognize and treat life-threatening conditions. Through the rescue service, the physician can be taken to the scene of the accident by the quickest and shortest way. For this need, two systems have become established in the Federal Republic of Germany.

The Netherlands, due to its density of population (415 residents per square kilometer) has ambulance services organized under municipal and district health departments (emergency services) or private services (routine transportation). The law requires that each patient be reached by an ambulance within 15 minutes everywhere in the country.

Emergency services are generally performed by the health departments, whereas more routine patient transport is carried out by private firms. In the Netherlands, it is usual that emergency complaints are first directed to the family physician who makes further decisions concerning the use of ambulance services. All ambulance services are coordinated from central district ambulance posts.

Multiple trauma is the leading cause of death of all Americans below the age of 37. The estimated cost to American society is between 70 and 80 billion dollars per year. In our present day society, one person in four will require the use of a trauma facility during his or her lifetime. Several studies have now been performed to demonstrate that the management of trauma is woefully inadequate. Stemming from the classical studies of Trunkey, Lim and West comparing San Francisco with Orange County, California; it was demonstrated that approximately 30% of fatalities resulting from traumatic injury were preventable in Orange County as compared to an extremely small percentage in San Francisco which does have a designated trauma center. Recent advances in the management of head injury may further increase this salvageable percentage.

The problems of improving care of life-threatened victims of accidents influence the organization, equipment and training of hospitals, staff and physicians. Our review of the helicopter rescue program at Frankfurt/Main, introduced in 1972, clarifies the following: Nearly 200 annual daylight sorties underline a strong demand for helicopter activities in the densely populated Rhein-Main area. Unnecessary dispatches were made only in 16% of calls. The helicopter is stationed near the city of Frankfurt/Main at the BG Unfallklinik, a department specializing chiefly in traumatic and orthopedic surgery. The surgeons of this department are well trained in emergency interventions. They are competent to make triage decisions. When necessary, endotracheal intubation, resuscitation, and infusion therapy are performed immediately.

Successful management of a mass casualty situation involving 45 injured marines following a fire in Japan demonstrates the important principles of triage, patient movement, quality patient care, logistics, communication and medical direction.

Following the accident, the US Army Institute of Surgical Research assembled a burn team consisting of three surgeons, three nurses, one microbiologist and eleven clinical specialists (three of whom were inhalation therapy technicians) and the equipment and supplies necessary to treat and transport these patients. The US Air Force Military Airlift Command transported the team and equipment to Japan in a C–141 Starlifter Medevac plane and pre-positioned a second C–141 in Japan for the return flight. Additional ventilators and supplies were mobilized from Japan, Okinawa, the Philippines and Alaska.

In view of the increasing importance of the transportation of newborn and premature infants in distress, we have felt the need to create a mobile unit for pediatric reanimation. Therefore, it was important to build a very well-defined and specially adapted mobile unit for these kinds of particularly delicate transportations.

For this purpose, and with the agreement of the pediatricians, we have adopted a solution that seems compatible with this kind of work.

Tertiary care for critically ill children requires a safe, efficient transport modality designed for the pediatric patient. This system should be capable of delivering mobile intensive care en route after resuscitation and stabilization at the sending hospital.

In July 1979, a Pediatric Emergency Transport Service (PETS) was organized at The Children's Hospital, Denver, to provide physicians of the Rocky Mountain-Plains Region with the capability of triaging pediatric nonneonatal patients to three Denver Pediatric Intensive Care Units (PICU's). The components of the system included: (1) a transport team comprising of a medical attending-director, twelve transport physicians including nine pediatricians, two anesthesiologists and one surgeon, six pediatric transport nurses, six pediatric transport respiratory therapists, and four emergency medical technicians; (2) a communication dispatch system; (3) an answering service with Wide Area Telecommunications Service capability; (4) an equipment depot within the PICU at The Children's Hospital; (5) a complete dispatch log; (6) a continuing education and information system for the team, providers, consumers and health planners; (7) a cost and administrative center with established billing procedures and support services; (8| management, drug and equipment protocols, and (9) specifically designed air and ground ambulances which are owned and/or leased by The Children's Hospital.

The following papers, submitted in Spanish, may be obtained directly from the author (Telephone: 258458):

1. Manejo de Emergencias y Accidentes en el nino. Reanimacion Cardiopulmonar Cerebral en un Sistema de Cuidado Progressivo.

2. Programma Asistencial Docente de Medicina Urgencia-Primeros Auxilios y Cuidado Intensivo.

3. Proyecio Chileno-Panamericano Sobre Prevencion y Manejo de Emergencias y Accidentes en la Infancia. Sistema de Atencion Progresiva.

Prehospital emergency medicine in the USSR is one of the most widespread aspects of our medical system. The structure is extremely simple. The country is divided into regions, which in turn are divided into districts. Each district has a definite population and a fixed number of physicians, hospital beds and stations for first aid and urgent care. The system has to provide adequate medical attention without delay for every severely ill or injured patient.

In the prehospital emergency system, there are standard and specialized intensive therapy teams and equipment. For all emergency calls we have teams, which include a physician, a medical assistant (feldsher) and attendants. Specialized intensive therapy teams usually include two physicians, two feldshers and laboratory assistants.

An Approach to First Aid Programming: The Yugoslavian Red Cross Society has had the unique opportunity to design, develop and commence implementation of a full National First Aid Service. The program is divided into four areas: (1) first aid skill components of existing programs; (2) student training courses; (3) leadership courses; and (4) public education. The movement toward a National First Aid Service has been rapid. The radical change in delivery systems, principles upon which the program is built, and the overall philosophy are recognized as potential risks but ones well worth taking.

The Second World Congress on Emergency and Disaster Medicine was held on May 31–June 3,1981, in Pittsburgh, Pennsylvania, USA, under the auspices of the “Club of Mainz for Emergency and Disaster Medicine Worldwide.” The First World Congress organized by the Club of Mainz was held in Mainz, West Germany on September 30–October 3, 1977 (Chairman, Rudolf Frey), and the Third World Congress will be held in Rome, Italy on May 23–27, 1983 (Chairman, Corrado Manni). It is appropriate to report here on the World Congress in Pittsburgh, since the first four issues of this new Journal consist of edited papers and abstracts presented at that Congress.