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.

In spite of extensive research, the question of fluid therapy for hemorrhagic shock is still controversial. Certain drawbacks in the experimental models are among the reasons for this controversy. These drawbacks are mainly related to the animal species used, to the way the shock insult is initiated and to the effects of deep anesthesia on the response to shock.

Dogs were used in more than 90% of shock studies—although their response to bleeding is different from the human response. The dog has a large, contractile spleen, which can modify its cardiovascular response to bleeding.

Treatment of severe hemorrhage with adequate concurrent administration of plasma substitutes leads to acute normovolemic hemodilution (NVHD). Advantages of hemodilution include: l) reduced risk of infection; 2) decreased thromboembolic phenomena; 3) improved microcirculation; and 4) less use of banked blood resulting in reduced patient cost.

In the 1960's, Takaori and Safar described the types of response to various degrees of hemodilution (HD) and demonstrated that dogs survived when hemodiluted with dextrans to a hematocrit (hct) of 10%. In contrast, HD with Lactated Ringers (LR) was unable to support survival.

Volume substitutes for restoring circulating blood volume are eminently important for emergency care. In addition to side effects, the intravascular volume effect immediately after infusion and the duration of this volume effect are determining factors for the selection of volume replacement solutions available on the market today. Therefore, we controlled the intravascular volume effect of 16 test solutions, immediately as well as 90 and 240 min after the end of infusion.

The question of whether colloids are better than crystalloid solutions for resuscitation of hypovolemic patients remains to be answered.

The purpose of this study was to investigate how the closing lung volume is affected by a reduction of colloid oncotic pressure.

We measured closing lung volumes of anesthetized dogs in the presence of undisturbed serum proteins (COP= 18.9–22.1 mmHg). Following these determinations, we reduced the colloid oncotic pressure to 10.9–12.9 mmHg by administration of 50 ml/kg of 5% dextrose solution. Closing lung volumes were evaluated repeatedly from 10 to 90 minutes following the completion of infusion.

There is controversy concerning the best method for rapid fluid administration in shock secondary to severe or continuing blood loss. Some authors recommend immediate cutdown, while others support percutaneous central intravenous lines. In addition, the data available on maximum flow rates for various catheters is limited and does not compare different solutions. To gain more insight into these problems we have studied the flow rates for different lengths and gauges of catheters utilizing various physiologic solutions.

In fluid therapy, colloid plasma substitutes are especially suitable for emergencies and mass disasters because they can be obtained in unlimited quantities and can be used immediately.

The initial volume effect is greater than that of Gelatin or HES 40 but is much weaker than 10% Dextran 40. In this respect, HES 200/0.5 is comparable with 6% Dextran 70. The volume effect of HES 200/0.5 lasts for about 3 hrs and thus is comparable to Gelatin, HES 40 or 10% Dextran. Six percent Dextran 70, however, lasts for 6–8 h. Ten percent HES 200/0.5 is more easy to regulate.

Hydroxyethyl starch does not influence the coagulability to the extent that can occur with Dextran.

Resuscitation in disasters must be effective, prompt, safe and uncomplicated. Clinical experience in severe, extensive thermal burns in numerous clinics has shown that balanced hypertonic sodium solution (BHSS) can achieve effective resuscitation with: administration of less volume of fluid; early onset of excretion of sodium-containing urine; less generalized edema and without pulmonary edema. This experience is now being transferred to patients after trauma and major surgical procedures often complicated by peritonitis. In an ongoing study of randomly selected adults following surgical trauma, either Ringer's lactate (RL) or the BHSS (0.9% NaCl plus 100ml of one molar sodium acetate, total 1100ml yielding Na230, Cl 140, acetate 90mEq/l) was administered. All patients received daily (or more frequent) electrolyte and osmotic analyses of plasma and urine, continuous ICU monitoring of pulmonary and cardiac function, and similar wound care.