Triage is the process of classifying injured patients according to a predetermined hierarchy. Triage typically involves the urgency prioritization of trauma patients in mass casualty circumstances. The triage process is also used daily in Emergency Medical Systems that incorporate trauma care systems to identify how severely a patient is injured and to channel the patient into the appropriate treatment echelon, i.e., to determine a threshold level of severity that merits a specific level of care.

Many disaster plans are based on the presence of a physician at the scene to perform triage. This requirement originated when there were no trained paramedical personnel in the field and may actually delay care in rural areas where a physician may not be readily available or may be the only physician at the hospital.

It is our hypothesis that properly trained Advanced Emergency Medical Technicians (AEMT's) may serve as triage officers for rural disasters with little difference, and perhaps improvement, in the outcomes of medical care. AEMT's are among the first responders to arrive at scenes of accidents and often triage from three to five trauma patients in multiple victim accidents on the highway. They are on duty, available and strategically located both day and night. The AEMT's are familiar with working under field conditions, i.e. at night by headlight, in rain, snow, and darkness, and know extrication procedures. They are aware of environmental hazards. They have radio and telemetry communication with a physician when needed.

Although road accidents account for about 17% of hospital emergencies, they are the third commonest cause of death. Polytrauma is the main cause of death below the age of 40 years. Legislative action and safety measures (i.e. speed restriction, safety belts, safety helmets) and improvement in the hospital emergency care system in Germany resulted in a continuous reduction in road accident victims from about 19,000 in 1979 to about 12,000 in 1983. Additionally, the fall in personal injury resulted in savings of about 7,900 DM (US $3,000) in cases of minor injury, 79,000 DM (30,000 US$) in cases of severe injury and about 685,000 DM (280,000 US$) in cases where lives were saved.

Head injury has been demonstrated to be one of the most important lesions in polytrauma patients and of very decisive relevance to the posttraumatic prognosis. Moreover, other lesions and their sequelae (e.g. shock, thorax trauma) are known to worsen the primary cerebral injury by causing secondary brain damage due to hypotension and hypoxemia. This study considers the influence of prehospital emergency care to the posttraumatic prognosis in severe head injuries.

Controlled mechanical ventilation using positive and expiratory pressure (PEEP) is a well-established therapeutic measure in intensive care. Its early application has been shown to markedly decrease morbidity and mortality, especially in polytraumatized patients with an acute respiratory distresss syndrome. It therefore seems reasonable to use positive end expiratory pressure as early as possible in the clinical treatment of emergency patients before extensive pulmonary changes have had time to develop completely.

The various disorders resulting from heat stress can be understood and treated from an understanding of the underlying pathophysiology. Broadly speaking, they can arise as a result of excessive heat production from the body, or impairment of heat loss to the environment. The normal responses of the body to attempt to lose heat, peripheral vasodilation and sweating, are the root causes of the main disorders. In the tropics, the high environmental heat load leads to a spectrum of illnesses ranging from chronic exhaustion to acute and lethal heat stroke. Cooling and correction of fluid and electrolyte disturbances are the key to their treatment. In temperate climates, variants seen commonly occur in those imposing a metabolic heat load by endurance exercise. In these cases, there is some evidence that hyperventilation plays a role in their development, and this merits paper-bag rebreathing in addition to cooling and rehydration, during treatment. Those assisting at sporting events should attempt to stop competitors as soon as they show signs of heat exhaustion, and must be aware that almost all competitors will be hyperthermic towards the finish, and should be cooled and rehydrated as soon as possible.

Nineteen clinical cases of accidental hypothermia were treated with airway warming (AW) and the results compared with 18 cases which were allowed to rewarm spontaneously. AW accelerated the rate of rewarming and had beneficial effects on cardiac and cerebral function. In patients with chronic hypothermia, i.e. the elderly and those suffering from malnutrition, the accelerated rewarming increased the risk of developing pulmonary and/or cerebral edema which could prove fatal. The patients with acute hypothermia all rewarmed successfully but the mortality for the chronic hypothermic patients was higher in the AW group.

The increasing popularity of scuba diving as a sport necessitates that emergency personnel become familiar with medical diving problems. It is important to understand that pulmonary barotrauma can be sustained with an uncontrolled ascent of little more than 1 meter. This can occur under any circumstance in which compressed air is breathed under water. The most common is scuba diving or submarine escape training, but it may also be encountered when a person escapes from a submerged car or a child surfaces after breathing from an inverted bucket in a swimming pool. Two cases of pulmonary barotrauma are reported and the spectrum of presentation of this condition is discussed.

Knowledge of this condition increases clinical awareness resulting in early diagnosis and effective treatment. It will be shown that it is better to over treat this condition, as the side effects of treatment are minimal and the results of failure to treat can be disastrous.

Scuba diving has become a popular sport resulting in an increased incidence of diving accidents. A survey done by the United States Navy from 1955 to 1960 revealed that decompression sickness (D.C.S.) is the most common serious complication experienced by scuba divers and the third most likely cause of death. The major cause is drowning and the second is arterial gas embolism from pulmonary barotrauma.

D.C.S. has been classified into two groups. Type I includes the less severe forms with bubbles in the skin (“itches”), joints and other tissues. Type II includes the serious conditions with neurological involvement “staggers.” A detailed knowledge of D.C.S., commonly known as “the bends,” is essential to both divers and emergency personnel in order to minimize the morbidity and mortality associated with this condition.

A case of Type II bends with spinal cord damage is presented and the condition discussed.

Fluorocarbons, which strictly speaking should perhaps be termed perfluorocarbons or perfluorochemicals (PFCs), are organic compounds produced by extensive fluorination of relatively simple alphatic and aromatic chemicals. They have, over the last thirty or forty years, been used for a wide variety of purposes in both industrial and domestic fields. As a consequence of one of their physical properties, namely their high solubility for respiratory gases, they are being developed as constituents of oxygen transporting plasma substitutes. Preliminary trials are being carried out in Japan and the United States and PFCs may well be on the verge of entering routine clinical medicine.

Fluorocarbons, or more strictly perfluorochemical (PFC) containing plasma substitutes have a high solubility for the respiratory gases, a desirable feature for a plasma substitute. This was dramatically demonstrated by their ability to sustain life for many hours in rats almost completely devoid of red cells. The ability of PFCs to carry oxygen exceeds that of other hemodilutents and they have been shown to produce better oxygenation under conditions of hemodilution than hydroxyethyl starch, dextran solutions or stroma-free hemoglobin solutions.

Perfluorochemicals (PFCs), which are also known as fluorocarbons or perfluorocarbons, are chemical substances having a high solubility for respiratory gases. At 37 degrees Centigrade pure PFCs can dissolve very large quantities of oxygen and in some instances this may amount to as much as 50 volumes %. These substances are however immiscible with blood and if introduced into the circulation in an unmodified form could cause embolic phenomena. In order to be of use as oxygen carrying blood substitutes, they are therefore emulsified in a solution containing glucose, electrolytes and an osmotic agent.

The International Veterinary Academy on Disaster Medicine had its genesis in Perth, Australia, when at the World Veterinary Congress in August 1983, Dr. Ole Stalheim extended an invitation to attend a meeting of a group under the label “World Veterinarians Against Nuclear War”. It had an auspicious beginning—we attracted some attention in the media, more indeed, than we had received during our early attempts at formation in the United States. It became apparent, however, that we were in effect replicating activities of other well-established and more financially secure groups—Physicians for Social Responsibility, the Society Against Nuclear Energy (SANE), etc. We needed greater participation to cope with “peace time” problems already confronting us as well, and it was evident that a larger veterinary audience would be reached and our services to the community enhanced if we broadened the commitment.

The kidney plays a fundamental role in the maintenance of the homeostasis of all body fluids; it operates as an efficient buffer system in the prevention of dehydration, hyperhydration, acid base and electrolyte imbalance and it removes toxic metabolites. It is not surprising, therefore, that post traumatic acute tubular necrosis (ATN) is characterized by a mortality that exceeds 80% in spite of the progress offered by dialysis and clinical nutrition. The mechanisms of this critical pathological condition are summarized in Figure 1.