The establishment and maintenance of pre-hospital patient care delivery systems requires that special emphasis be placed on key areas. Those areas include post start-up activities beginning with a commitment from the business, government and medical communities in order to commission an investigative study aimed at gaining local medical authority and funding approval.

Additionally, once the system is established, there exists several challenges to program managers, including the provision of appropriate and timely leadership and medical education and the establishment of a quality data collection system which supports the expansion and reevaluative processes.

The Incident Command System is a personnel and resource management scheme which has several interactive components which make it an effective plan.

This system is being used effectively in the State of California for the control of large scale incidents on a daily basis. Dr. Rodney Herbert of London advised us not long ago, during his presentation of the “Moorgate Incident”, an event in which he participated, that a valuable lesson was learned as that catastrophe unfolded and was managed by local emergency services agencies. The lesson learned was that “special plans” for disaster management which sit on a shelf to collect dust while awaiting the event soon become of little use through inactivity. His message was that the protocols used by emergency services agencies for disaster management should merely be an extension of the day-to-day activities of that agency.

We believe the National Disaster Medical System is of benefit to each participant, to his community, and to the nation. The National Disaster Medical System will enhance local, State, and national ability to respond to emergencies. The system is now under development with the support of the health care professions and institutions of the country.

One of the most serious bottle-necks in the discussions concerning the medical disaster relief is the lack of any uniformity of the concept “Disaster.”

In the summary of the International Congress on Disaster Medicine (Mainz 1977) (1) we can read “The definition of a disaster. This question hung over many of the discussions of the Congress. Several speakers drew attention to the fundamental differences between relief services for an air or train crash and those for an earthquake or flood. Armed conflicts can present different problems again which in themselves vary enormously. While numbers of victims were submitted as a basis for one classification, numbers alone are not enough.”

The disaster committee is a mechanism for educating health care workers for the unpredictable consequences of serious natural and manmade calamities. Planning is the key, and the disaster committee must strive toward this challenging objective.

A persistent and positive attitude can make the difference between the disaster committee's success of failure. By using some very old principles of good management and organization, and adding some new concepts, a disaster committee can be an effective and worthwhile venture.

Of all the natural disasters, none has a greater potential to cause widespread casualties and destruction of property than a large earthquake centered in an urban area. This scenario was tragically illustrated in 1976 when two large earthquakes occurred in heavily populated areas. In February, an earthquake measuring 7.6 on the Richter Scale struck Guatemala and left 30,000 dead and 100,000 people injured. In July ofthat same year, a Richter 7.8 earthquake devastated the city of Tangshan, China. The earthquake destroyed over 90% of the buildings in that city and caused the deaths of over 240,000 people. Since earthquakes strike without warning, preparation and disaster planning are mandatory in order to reduce injury and mortality.

In introducing this session on Military Medical Methods, I wish to set the scene. While the principles of First Aid and the methods of management of the injured are broadly the same in most scenarios, i.e. accidents and disasters do not occur in convenient places or at convenient times, there is one enormous difference with respect to Military affairs-casualties must be managed in the circumstances of war.

War injury carries a high mortality, particularly for soldiers. In some individuals it may be necessary to recognize that the nature of the injury precludes any successful treatment. In the vast majority, life threatening situations can be averted by proper front-line management on the way to surgery and to the adherence by anesthetists and surgeons of the principles of war surgery which have slowly evolved over many years.

Throughout history complications of military trauma and in particular infection, have been responsible for countless deaths and other serious morbidity. In fact in major conflicts in the not too distant past, deaths from infection of battle wounds have almost equalled the number of deaths from the enemy action itself. It is obviously a tragic and avoidable situation and one that surgeons can be directly instrumental in removing.

Unfortunately, we are guilty of not learning from the lessons of history. Every major conflict brings either a new surgical technique or therapeutic aid which tempts surgeons and physicians alike to ignore simple principles of military surgery, and by their treating these wounds incorrectly, creates a whole new chapter of iatrogenically induced mortality.

In Rotterdam with half a million inhabitants in 1974, we set up an integrated approach to pre-hospital coronary care consisting of ambulances equipped with monitoring and resuscitation equipment and staffed with specially trained nurses, who have a central role in cardiac emergencies (Figure 1). In 1979 we started a training program in cardiopulmonary resuscitation for the lay public, with training courses of three hours duration, following the Seattle model.

A bachelor's degree in EMS management was the initial course of studies in an academic program designed to prepare people to work in a variety of occupations in EMS.

This paper includes a brief history of that program, its purposes, goals and curriculum and the first data on follow up of its graduates.

In the United States of America, the Emergency Medical Systems (EMS) act of 1973 stimulated people from a variety of fields and backgrounds to work together to develop and manage emergency systems of care; it also raised the question of how to prepare people to meet the future needs of the system. At that time, and with few exceptions, there was little or no academic involvement directed to the concept of the system of EMS and there was a dearth of persons with predictable knowledge and skills in this area. The apparent need for preparing leadership personnel for EMS became the focus of thinking by the Maryland Institute of Emergency Medical Services Systems (MIEMSS) and the University of Maryland, Baltimore County (UMBC).

In the United States, pre-hospital immediate care generally is practiced by paramedical personnel. These individuals are either firemen or civilians who have specific training in the assessment and management of acutely ill or injured patients outside the hospital. In most systems, once the initial evaluation of the patient is made, radio or telephone communication occurs between the pre-hospital team and a hospital-based physician or specially trained nurse. These hospital-based personnel are the responsible medical authority for the care delivered by the paramedical staff. Based on data reported by the field unit, the hospital team gives medical direction and specific therapeutic orders to the paramedics. This style of immediate care seems to work well for us in America although it is different in many ways from immediate care schemes elsewhere in the world, in that the physician or nurse is rarely on the scene, able to assess firsthand and provide medical care to the victims.

A tremendous impact can be made on prehospital care by Emergency Department nurses, and whether that impact is positive or negative depends on the groundwork that has been laid for the prehospital program. If the program is based on the team concept, with all members having the same goal to provide the highest level of patient care possible, then nursing can have a very positive impact. The key phrase is “include nursing,” in all aspects of the program planning and operation. If nurses are excluded, they can hardly be expected to be part of the team, when they haven't even been told the game plan. A survey of Emergency Department nurses from hospitals that range from University teaching facilities to small rural hospitals was conducted. The survey focused on two areas; the first dealt with the degree of nursing involvement in the prehospital program, and the second addressed nurses' attitudes toward the program.

Each year in the United States 700,000 people die from the sudden onset of heart attack symptoms. Of these deaths over 350,000 occur in the prehospital setting. Many of these deaths are felt to be avoidable if a greater number of the lay public were trained in Cardiopulmonary Resuscitation.

In the twenty-five years since Kouwenhoven, et al, suggested that closed chest cardiac compression and mouth-to-mouth artificial ventilation may artificially produce a satisfactory oxygenated systemic blood flow, there have been thousands of published research reports and articles focused upon a broad spectrum of subtopics ranging from the improvement of these techniques to the training of the lay rescuer. Knopp has suggested some parameters within which new CPR techniques must fall. First, any new skill should be applicable to the field setting. Second, the techniques should be simple to apply. And thirdly, any new techniques must be statistically linked with a significant increase in survival rates. Citizen Cardiopulmonary Resuscitation (CPR) has taken on almost religious connotations. A national strategy has been adopted by the American Heart Association and American Red Cross to train the lay public using a variety of training techniques of varying lengths.

In a field of medicine where precise procedure and clear-cut decision making should be the rule, it is perhaps depressing to address a subject where too little is certain and possibilities are almost endless. I regret that this should be so in respect to medicolegal problems in air transport, but such are the facts which have to be reported.

A clear-cut authoritative guide to each and every situation is not only impossible in the air, it is also impossible on the ground. Were it not so, there would be no need for lawyers—and herein as we may see could lie an important clue.

In 1967 an apparently new viral hemorrhagic disease appeared in research workers in the cities of Marburg and Frankfurt in West Germany, and in Belgrade in Yugoslavia. In all, 35 workers became ill, of whom 9 died. The only common factor between the three centers was a batch of green monkeys, imported from Uganda. These animals had been used throughout the world to provide tissue cultures with up to 12,000 being imported annually into the USA, with no previous disease noted. Eventually a virus was isolated and called the Marburg virus, but as yet it has not been detected to give any symptoms in the monkeys.

Individual cultures, as shown in folklore, have practiced some form of resuscitation. For instance the Celts traditionally carried a large cauldron or cooking pot with them into battle. This was not, as might be supposed, to cook their enemies but in which to throw the heroes slain in battle, who then re-emerged whole to continue fighting. The well known practice of the inhabitants of the West Indies in blowing tobacco smoke per rectum as a means of revival may well have had its origins in distant mythology. In addition to the observed, better preservation of the lower intestines after death, and the obvious irritant and stimulative effects of the apparatus and fumes towards an involuntary breath, there may well have been a more philosophical concept of the reintroduction of the spirit—the anima.

In 1823, Sir William Hilary published a pamphlet entitled “An Appeal to the British Nation on the Humanity and Policy of forming a National Institution for the preservation of Lives and Property from Shipwreck” —and there is no doubt that his drive led to the formation of the Royal National Lifeboat Institution in 1824.

Two short quotations from his pamphlet read: “The succour and support of those persons who may be rescued, the promptly obtaining medical aid, food, clothing and shelter for those who may require such relief,” and “The assistance of medical men who would enrol themselves to be ready to attend, might frequently be of the utmost importance to succour and restore those who might have sustained severe injury or whose lives might be nearly extinct.”

Extensive coastlines, varied weather conditions, scattered industrial centers and a large rural population create special problems with regard to the delivery of health care services in the Great Lakes area, which are further complicated by the discrepancies in the level and type of care available within the region. Hospital based helicopter emergency medical services (HEMS) providing very specialized life support (VSLS) provides safe and rapid transport for patients needing a higher level of care than is available at the accident scene or local hospitals. This service assists local efforts to meet the medical needs of the population. Air transport systems are an integral part of an EMS system. Even though they are costly, they help avoid duplication of more expensive resources, such as hospitals and personnel.

Trauma kills more people in the USA under 14 years of age than die of heart disease, cancer, pneumonia and intestinal disease combined. It is the leading cause of death in those under 38 years of age and it is the fourth commonest cause of death for the entire population. Advances in trauma emergency care are important from both the medical and economic standpoint since fatalities cost over twice the amount of non fatalities.