Each year 4,000–9,000 people die in the USA from hyperthermia-related crises, such as heat stroke and febrile convulsions. In most of these cases, variable combinations of hot environment, physical exercise, dehydration, and infection can be identified. Heat stroke is a complex clinical picture with poorly understood pathophysiology and unexplored resuscitation potentials. Protection of vital organs against hyperthermia is also important for cancer therapy.

This study (1978–1980) was aimed exclusively at the effects of controlled hyperthermia. In pilot experiments on lightly anesthetized dogs and rhesus monkeys, brain temperature was raised to 42°C for 1/2–1 hour by immersion heating. This was followed by cooling to normothermia. Partial recovery with a lucid period of 1 hour or longer was followed by diffuse gastrointestinal bleeding and irreversible shock in spite of standard life support measures.

Accidental or intentional carbon monoxide poisoning is common throughout the year. In the Midwest, however, accidental exposures are more common during the winter months when the furnaces are overworked or malfunction. Consequently, enmasse exposures to the poisonous gas are frequently encountered during this season. Adding to the problem are the energy conservation efforts. Doors, windows and other ventilation avenues are tightly sealed, and solid fuel might be substituted to save other expensive conventional fuels. Other causes of carbon monoxide poisoning are blocked exhaust systems, automobiles with inadequate mufflers, fires and solvent (methylene chloride, etc.) usage in poorly ventilated areas, e.g., basements. The exact incidence of nonfatal subacute carbon monoxide poisoning is not available. National Clearinghouse Bulletin reported that in 1978, out of 376 reported exposures, there were eight fatalities. A figure which has been frequently quoted in the literature is that each year in the United States, approximately 3,500 deaths are caused by carbon monoxide poisoning.

The Maryland Institute for Emergency Medical Services Systems (MIEMSS) is the smoke and carbon monoxide (CO) inhalation referral center for Maryland, particularly Baltimore City and the five surrounding counties. The majority of our patients are from the Baltimore/Washington corridor.

The use of a short screening battery of psychometric tests is an important method for improving the clinical approach to the diagnosis of CO poisoning. Our own experience and a literature survey have shown how poorly the CO level correlates with clinical signs and symptoms. We have reported on six patients who were unconscious from CO poisoning but had a carboxyhemoglobin (HbCO) level of under 1%, and we have seen apparently well oriented patients with HbCO levels of 45%. From these experiences, we have concluded that the HbCO level is only an indicator of exposure to CO, not necessarily of the severity of poisoning. These large discrepancies have necessitated the development of a supplemental test, such as the psychometric battery, to determine generalized cerebral dysfunction.

Extensive experiments in animals and humans, as well as clinical experience in disaster areas, have shown that expensive devices and complicated inhalation narcotics are not suited for anesthesia under disaster conditions. Today, the most important drugs are intravenous and, in emergencies, also intramuscular preparations which do not cause any significant central respiratory depression:

1. Ketamine, suited for routine anesthesia under disaster conditions; and

2. Gamma-Hydroxy-Butyric-Acid (Somsanit), suited for poor risk patients with hypoxic injuries and/or shock.

The setting up of anesthesia units and any future planning in this field has to be considered in the context of the social and economic development of the country. The situation requires a different attitude towards the handling of anesthesia, where malnutrition, kwashiorkor and parasites are the dominant diseases. One sixth of the world's population is permanently undernourished, and the figure might even be higher in many “developing countries.” Problems of an esthesia in most areas in Africa include: (1) insufficient supply of drugs; (2) inadequate equipment; (3) lack of anesthetic manpower; and (4) underestimation of the importance of anesthesia.

In a considerable number of cases, many polytraumatized patients in a state of hemorrhagic shock, who require immediate surgical treatment, there is craniocerebral trauma. Ketamine is viewed, on one hand, as an appropriate induction anesthetic, due to its circulatory stimulating effect in treating shock victims, and, on the other hand, it is rejected for treating patients with craniocerebral injuries, because of the danger of possible increase in intracranial pressure (ICP). Therefore, we examined the effects of ketamine on ICP and calculated the cerebral perfusion pressure, using test animals in a state of hemorrhagic shock and a space occupying intracranial process.

Diazepam is a commonly used drug for suicidal attempts. The antagonistic effect of physostigmine in these patients is poorly understood.

We studied the interaction of large doses of diazepam and either physostigmine or galanthamine hydrobromide using dose-response curves in 21 cats. After establishing dose-response curves for diazepam, half of the animals received 0.02 mg/kg of physostigmine intravenously. Two minutes later 8, 10, 12, or 14 mg/kg of diazepam was administered intravenously. After 2, 5, and 10 min, animals were evaluated for their response to noise and pain stimuli. The other half of animals were given 0.2 mg/kg of galanthamine intravenously and evaluated for diazepam effect using the same criteria. Sufficient number of days were allowed for the animals to recover from diazepam.

Ether is almost a unique anesthetic agent, because it may be given to traumatized patients without any additional oxygen supply. But the significantly high stage of excitement during ether anesthesia can be dangerous, especially in disaster situations.

In the Netherlands, Crul developed a training program for application of ether anesthesia combined with droperidol as adjuvant. Incited by Crul's clinical training method, we studied, in comparison with Guedel's Table, the behavior of clinical signs during induction of ether anesthesia, using droperidol, diazepam or ketamine as adjuvants. We controlled especially the duration of induction, as well as the intensity of clinical signs in the stage of excitement.

A major man-made disaster, like a nuclear attack, may suddenly reduce a highly developed country to very primitive conditions. The choice of anesthetics for the field depends on medical suitability, but, primarily upon a country's production possibilities in disaster conditions. Simple anesthesiological procedures must be preferred. Provisions are to be made for ketamine, atropine, narcotics (pethidine, morphine), in order to make possible intravenous/intramuscular anesthesia. For inhalation anesthesia, diethylether with a simple inhalation anesthesia apparatus is needed. Ether remains important for disaster conditions, because of its relative safety in less experienced hands and because its production is both cheap and simple. When possible, self-administered inhalation analgesia with methoxyflurane would greatly help to alleviate the suffering of the seriously wounded. In Czechoslovakia inhalation of methoxyflurane (AnecotanSPofA) from a simple “Analgizer” (vaporizer) proved to be of greatest help in mine casualties and in traffic accidents, before extrication of the casualties. As long as ether is considered as the “anesthetic for the field” it remains necessary to keep young anesthetists informed and skilled in ether anesthesia.

The Club of Rome is limited to 100 persons around the world, representing more than 35 countries, and a very wide spectrum of experiences, professions, backgrounds, and views.

With such a small organization, it should be obvious that its power – if, indeed, it has any power – derives not from the size of its membership or the imposing structure of the institution supporting it, for there is none. To the extent that The Club of Rome exerts any power, it is the power of ideas to more individuals, societies, and governments. And that is precisely what The Club of Rome has styled itself as a catalyst of ideas. (See references.)

The members of The Club of Rome around the world represent no single social, political, economic, geographic, or ideological viewpoint. But they are united in the belief that the societies and governments can, and must, do a much better job of preparing themselves to deal effectively with the multiple crises that many agree are emerging on the global horizon.

We recognize that priorities in disasters are most often the supply of shelter, water and food, but to streamline this paper we have limited ourselves to aspects of Disaster Preparedness pertaining to medical intervention.

It is essential to understand that the overall responsibility in disaster preparedness and for coordination in case of disaster remains under all circumstances with public authorities. National Red Cross Societies, being auxiliary to their governments, are usually given a clearly defined role in disaster. In many cases the tasks assigned to the Red Cross include medical, paramedical and welfare assistance in varying degrees.

The activities described hereafter are therefore not necessarily to be seen as a standard applied to all National Red Cross Societies.

The American Red Cross is an independent, voluntary body dedicated to performing the relief obligations entrusted to it by the Congress of the United States. The American Red Cross is required by congressional charter (Act of Congress of January 5, 1905, as amended, 36 U.S. Code 3, Fifth) to undertake relief activities for the purpose of mitigating the suffering caused by disasters. A disaster is an occurrence such as a hurricane, tornado, storm, flood, highwater, wind-driven water, tidal wave, earthquake, drought, blizzard, pestilence, famine, fire, explosion, building collapse, transportation wreck, or other situation that causes human suffering or creates human needs that victims cannot alleviate without assistance.

Through internal planning, policy setting, and implementation, and cooperation with private and governmental bodies, the American Red Cross at all levels gives priority to preparing for and providing assistance in disasters of any size.

The American Heart Association is a voluntary health agency with approximately 100,000 members. It has affiliate offices in every state and in major cities throughout the country. The primary objective of the organization is to decrease and eventually eliminate disability and death from cardiovascular disease. This is accomplished through three general areas of program responsibility, namely support of research, community programs, and public and medical education. Its financial support is derived from public voluntary contributions.

There are close to one million deaths in the United States annually from cardiovascular disease, which include over 640,000 heart attack victims. Those of us working in the area of heart disease regard the problem as one of catastrophic proportions, and in fact, “disaster medicine.” With the cause of most cardiovascular diseases unknown, special emphasis is placed on research. However, the American Heart Association also has a responsibility to impart to the medical profession, and the public at large, what knowledge is known. Therefore, a great deal of emphasis is placed on prevention, particularly how it relates to heart attacks.

In essence, the United Nations Organization was born out of disaster to avert disaster. Be they the work of nature or of man, catastrophic emergencies are not rare occurrences and all studies indicate that they are increasing in frequency and severity.

Within the international community, the UN and its component organizations is only one of the three principal partners in disaster relief. The other are the Non-Governmental Organizations (NGO) – including the Voluntary Agencies (VOLAGS) – and the bilateral donor countries. Collaboration among these sectors is vital if international action is to be effective.

This article deals with the UN System only, and in particular with the role of the World Health Organization (WHO) in disaster relief and preparedness.

The Pan American Health Organization (PAHO) has two components: (1) The Pan American Sanitary Bureau (PASB), founded in 1902, serves as the health agency affiliated with the Organization of the American States (OAS); in 1947, the PASB became the Regional office of the World Health Organization for the Americas. (2) The Emergency Preparedness and Disaster Relief Coordination office.

In October 1976, the Directing Council of PAHO, “anxious that the international assistance given to countries affected by natural disasters should be better coordinated, rational, and more effective”, requested that the Director set up a “disaster unit with instructions to define the policy of the Organization, to formulate a plan of action for the various types of disasters, to make an inventory of the human and other resources available, to train the necessary personnel, to prepare and disseminate the appropriate guidelines and manuals, and to promote operational research.” In March 1977, a permanent office for Emergency Preparedness and Disaster Relief Coordination was established at PAHO Headquarters in Washington, D.C.

In the late 1960's and early 1970's, several major disasters occurred in rapid succession. The most devastating of them was no doubt the earthquake in Peru in 1970, which claimed some 50,000 lives and caused untold damage and destruction in that country.

Experience in these, and indeed in other disasters, made it clear that much of the generous aid provided by the international community in the wake of these disasters was, in the absence of co-ordination, often wasted or did not correspond to the real needs of victims. Enormous quantities of goods, some of them quite unsuitable, would pour in, together with countless well-meaning individuals wishing to help. Unfortunately, many of them were more hindrance than help. Obviously, some order had to be created to rectify this haphazard approach, and to ensure that relief supplies of the right kind and in appropriate quantities would reach the survivors rapidly to cover their basic and most urgent requirements during the emergency period.

The Agency for International Development (AID) of the U.S. Department of State administers most U.S. bilateral foreign aid for development. The AID Administrator is the President's Special Coordinator for International Disaster Assistance. The office of U.S. Foreign Disaster Assistance (ofDA) coordinates all U.S. Government assistance to help alleviate suffering of people affected or threatened by natural or manmade disasters that occur abroad. Persons in developing countries are the main beneficiaries of the program. In addition to providing emergency relief, AID's disaster assistance program aims to strengthen the capabilities of other governments to respond to disasters. It is hoped that such efforts will help decrease dependence on the donor community.

OFDA response to disasters takes place only at the request of a foreign government to the U.S. Ambassador in the affected area. The Ambassador must then declare the existence of a situation warranting U.S. Government assistance. Once that disaster declaration has been made, he/she has the use of up to $25,000 which may be used as a donation or as a vehicle to purchase locally-available supplies to aid in relief efforts. Any amount above $25,000 must be approved by the OFDA.

Following the founding of the Society of Critical Care Medicine (SCCM) in the USA in 1970, and of other national Critical Care Medicine (CCM) societies in Europe, Australia and New Zealand, Japan, Israel, South Africa and Central and South America, a World Congress on Intensive Care Medicine (ICM) was held in London in 1973. This first World Congress was organized by Drs. Alan Gilston of the National Herat Hospital in London and Iain McA. Ledingham of Western Infirmary in Glasgow. During the Congress, Dr, Gilston initiated formation of The World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) which sponsored the second World Congress on Intensive and Critical Care Medicine (ICCM) in Paris in 1977 and the Third World Congress on ICCM in Washington, D. C. in 1981. The Fourth World Congress will be held in Jerusalem, June 23–28, 1985.

The World Federation of Societies of Anesthesioologists (WFSA) is a federation of some 76 anesthesia societies throughout the world. Our role in the management of disasters is very minimal; in fact, we have no specific service role. It does have a role to play in education and research aspects of acute medicine. The World Federation's aims are those of education of anesthesiologists of our member societies. This educational role is fulfilled by the staging of meetings, by the foundation of training centers in anesthesiology, by the production of special manuals and by meeting some of the expenses of visiting educational teams that travel to various parts of the world as visiting professors. These are all educational functions. Included in this function, of course, would be education in emergency medicine and disaster medicine.

From the Medic Alert Foundation International, PO Box 1009, Turlock, CA 95381 USA.

Medic Alert Foundation International is dedicated to the thesis that one universally recognized symbol of emergency medical identification will best serve all people. This is why Medic Alert conducts an active program to expand its services internationally.

Volunteer groups in 17 countries presently provide Medic Alert services to over 1.7 million people worldwide. The Foundation's purpose is to give a lifetime of fast reliable protection for a modest, one-time fee. Medic Alert is a non-profit, tax-exempt and charitable organization.

The volunteer organizations in these 17 countries are affiliated with the international headquarters in the United States, but each is autonomous in providing protection to the people of its nation. National boards and staffs actually deliver the total services to their members within their country.