History of “Disaster Resuscitology.” The late Rudolf Frey, Professor of Anesthesiology at the Johannes Gutenberg University of Mainz, West Germany (see pages VIII-X), founded the “Club of Mainz” in September 1976, following initiating discussions with Peter Safar at the “International Symposium on Mobile Intensive Care and Advanced Emergency Medical Services (EMS) Delivery Systems” in September 1973 in Mainz (1), and the drafting of objectives and plans with the founding members in 1976 in Geneva and Mainz. Throughout the initiating discussions, Safar stressed the following: Presently active national and international disaster relief organizations are public health oriented. In mass disasters, such as major earthquakes, these organizations have been rendering effective aid to uninjured survivors, usually starting one day or later after the disaster event.

“The Club of Mainz for Improved Emergency and Disaster Medicine Worldwide” was founded in 1976 by ten concerned resuscitologists from seven countries under the leadership of the late Rudolf Frey, who then was Chairman of the Department of Anesthesiology at the Johannes Gutenberg University in Mainz, West Germany. The Club was founded because the potentials of modern resuscitation and life support are not realized in most everyday emergencies and natural and manmade disasters throughout the world. The idea was initiated in discussions between Frey and Safar during the International Symposium on Advanced Emergency Medical Services (EMS) Delivery Systems in Mainz in September 1973.

The League of Red Cross Societies is the international federation of the 130 National Red Cross and Red Crescent Societies, which together have a membership of more than 230,000,000. The League is one of the three components of the International Red Cross, the others being the International Committee of the Red Cross (ICRC) and the National Red Cross/Red Crescent Societies.

The ICRC acts as a neutral intermediary in humanitarian matters during international conflicts, civil wars and internal disturbances, providing protection and assistance to victims, prisoners of war and civilian detainees. The League objective is to facilitate, encourage and promote the humanitarian activities of its member societies and thus contribute to the promotion of peace in the world.

Rudolf Frey, known as “Rolf“ in Europe and “Rudi” in America — a leading star of anesthesiology, emergency medicine and disaster medicine — has ended his life's struggles. He influenced many lives positively. His years were rich with experiences and contributions.

Surgery and anesthesiology were his base specialties. Alone, these fields would have been too narrow for him. He initiated the first professorship of anesthesiology in Germany at the University of Heidelberg in the 1950's; the first autonomous university department of anesthesiology in Germany at the Gutenberg University of Mainz in 1960; the journal Der Anaesthesist, the first textbook of anesthesiology in German; one of the first physician-staffed advanced life support ambulance and ambulance helicopter services in Europe; numerous training programs, symposia and congresses; and the Club of Mainz and its associated monograph series Disaster Medicine, originally published by Springer-Verlag.

Asmund Laerdal, a patron, catalyst and leader for resuscitation developments worldwide, died from cancer at his home in Stavanger, Norway on November 19, 1981. At the funeral services on America's Thanksgiving Day, we said thanks for what he has given the world. He was a great man, whose quiet, but determined, manners and eagerness to help whenever he perceived a need, earned him much respect and love.

Asmund Laerdal was born in Norway on October 11, 1913. He went to business school, traveled throughout Europe by bicycle during his youth, married Margit in 1939, and started a small printing business in 1940. Nazi occupation between 1941 and 1945 threatened his life, but did not wreck his little company. Throughout the 1940s and 1950s he printed childrens' books and calendars and made inexpensive wooden and plastic toys. The latter included “Anne Doll,” the “toy of the year,” made of soft plastic, with sleeping eyes and natural hair.

The relatively young scientific field of health services research, whose practitioners are still struggling to establish legitimacy within the vast domain of health care, owes much to Michael Pozen. Indeed, Michael must be counted as one of the founders of this new speciality in that his brief but incredibly productive career began as the field of health services research took form and emerged as a distinct career specialty. His very significant contributions to health care can be assessed from two perspectives.

The most visible perspective upon Michael Pozen's professional work can be obtained from a review of his research as reported in his published articles and presented papers. Michael clearly established himself as a creative and resourceful scholar and researcher who had a particular interest in improving the design and delivery of emergency medical services as well as the clinical aspects of emergency medical care.

The time has come when it may be asserted quite categorically that a new medical science, the theoretical foundation of reanimation, has emerged on the medical scene. At the International Congress of Traumatology held in Budapest in 1961, I proposed to call this new science reanimatology. My suggestion was based on the medical tradition of using the Latin roots of words. I am pleased that not only this term but also its notion are being increasingly used by experts in the field.

Research on acute dying processes, emergency resuscitation (cardiopulmonary-cerebral resuscitation, CPCR) and long-term resuscitation (intensive therapy) have the potential of leading to so far unimagined restoration of total body function, including human mentation, after sudden cardiac death from ventricular fibrillation, asphyxia or exsanguination; and also after prolonged terminal states from trauma or other insults—conditions which have so far been considered irreversible. Since the 1950's, an increasing number of investigators have embarked on resuscitation-related research.

Functional and structural disturbances of the brain produced by sudden impact to the skull represent a fundamental problem in neurosurgical treatment of head trauma. A proper experimental approach to brain trauma requires the development of an adequate animal model useful in defining both the biomechanical and physiological variables relevant to mechanical injury to the human central nervous system (CNS). The development of appropriate animal models has proved essential to progress in other clinically related research and is a prerequisite for the development of rational modes of diagnosis and treatment of head injury.

Clinical management is exceedingly difficult to evaluate in emergency patients because resuscitation is often chaotic, disorderly, and frantic. Resuscitation depends upon many factors: the primary illness or injury, the amount of blood and fluid losses, the patient's age, the prior state of health, the associated medical conditions, the time delay in instituting therapy, the volume and rate of fluids administered, and, finally, the choice of fluids given. Although it is difficult to control the effects of these complex interrelated factors, their influence may be evaluated by stratifying patients and then comparing the direct effects and outcome measures within each stratum.

There has been persistent controversy over the relative merits of crystalloids and colloids in fluid resuscitation. We studied reviews of fluid management of all hypotensive patients seen in the adult surgical section of the Emergency Department (ED) during a 2½ year period, to compare the conventional crystalloid resuscitation which had been standard for this busy university-run county hospital with a fluid management protocol consisting of about 1/4 A colloids depending on age, cardiac history, and CVP.

Preservation of the brain is the obvious goal of every cardiopulmonary resuscitation, but resumption of heart and lung function is the only chance to achieve that goal. In the field, basic life support without equipment remains the mainstem of resuscitation. But what should we do if we are not successful, if even advanced life support does not restart the heart? Should we give up or should we add to the advanced life support a new concept: extended cardiopulmonary resuscitation by mechanical support? This would allow more time for the heart to recover or to begin definitive therapy. Prolonged mechanical support could support weak function of the failing heart or lungs until they return to full performance.

To emphasize the importance of pathologic studies to physicians and biomedical scientists should be “preaching to the converted.” Unfortunately there are disturbing signs that this is not so, particularly in clinical medicine. The autopsy rate is declining globally and some authors have even unwisely implied in print that modern diagnostic techniques render the autopsy and other pathologic studies superfluous. Fortunately, pathologists continue to expose and resist such attitudes by means of analytical discussion of the problem. The role of pathologic study remains an essential one in both clinical and experimental studies of therapy of all types.

The term pathologic studies includes: pathologic anatomy (the autopsy and surgical biopsy); clinical pathology (hematology, chemistry, microbiology, immunologyl and experimental pathology.

To even pose the question, “Can you do worthwhile pathophysiological research on critically injured patients?” practically suggests that we give up and surrender a field of medical science that is both challenging and laden with potential. Rather we should be posing the question, “Can we really afford not to be doing this research?” The purists of science must shudder when they think of trying to make sense out of the apparent chaos which surrounds a victim of multiple trauma. Sometimes we do as well, but perhaps we cannot afford to turn our backs because our egos perk at the recognized challenge. Perhaps we look at the heart-rending deterioration of a previously healthy 20–year old and say to ourselves, “What can I do differently the next time?” For these reasons and more, we all continue in our endeavors.

Methodological considerations should be discussed within the context of emergency medical services (EMS) and disaster research. The fast pace and the information explosion of the society in which we live open new opportunities for epidemiological research and evaluation of care in disasters. The many methodological considerations necessary to generate useful and valid research is the topic of this article.

I would like to discuss four major issues which raise a series of questions and suggest a variety of alternatives. The four major areas are: (l) the taxonomy required to do this type of research; (2) the elements of care; (3) comparative samples; and (4) planned as opposed to unplanned disasters.

The development of emergency medical services (EMS) systems in the United States, incorporating various levels of sophistication in prehospital care and echelons of capability in hospital resource availability, has brought new connotations to the word “triage” (sorting).

Heretofore, triage consisted entirely of estimating treatment needs so that prioritized transfer of patients could be made to hospitals. The decision is no longer binary, since the introduction of Trauma Centers requires the triage decision maker to not only decide which patient first, but also which patient to which hospital. Clear cut decision rules for this process applied to routine civilian emergency medical practice have yet to emerge.

Our ability to manage disaster relief activities at regional, national or international levels of socio-political organization has, according to many analysts, not kept pace with the knowledge and technical capability presently available to contend with disasters. In a report released in 1977 a panel of experts assembled by the United Nations Association characterized disaster relief efforts as being routinely mismanaged. For example, the panel described what has been considered one of the better organized disaster relief efforts (the 1976 earthquake in Guatamala) in the following way.

A Controlled Clinical Trial is the formal experimental approach to treatment evaluation. In such a trial, the investigator controls the assignment of treatments—ideally by randomization— to experimental groups. When well executed, such a trial provides the strongest evidence for the relative effectiveness of the different therapeutic interventions. Some people, myself among them, believe that the clinical trial approach should be used early when a new therapeutic modality is first introduced.

The purpose of a controlled clinical trial is to answer the question of whether the new therapy is preferable to standard therapies. If no standard therapy exists, then new therapy has to compete either with no treatment or placebo.

In an emergency medical services (EMS) system, a certain number of events come to the attention of the pre-hospital subsystem that are subsequently characterized as having required “life-supportive” care. Such cases represent an undetermined portion of the persons, in the population served, who actually require such care. Generally, the life-support units that are available in a community are dispatched on the basis of information received at a medical emergency dispatching center. Very often, the information obtained from the caller is too ambiguous for a clear decision and, inevitably, there is a significant portion of “false-positive” or inappropriate runs. In systems in which little or no attempt is made to screen calls, the dispatching procedure inevitably becomes a “first come, first served” phenomenon and the inappropriateness of the responses is bound to be even greater.