The Solent is that stretch of seaway separating the Hampshire Dorset coast from the Isle of Wight. It is one of the busiest sea routes in the United Kingdom. Approximately 134 shipping movements take place weekly into the Docks and Naval Base at Portsmouth, the Docks and Ocean Terminal in Southampton and the nearby Esso Oil Refinery. During the height of the summer season there are numerous local Ferry Services to and from the mainland and the Isle of Wight, which is a popular summer resort, and at weekends as many as 35,000 pleasure craft may be afloat. Major collision is rare and reflects the high standard of seamanship, local pilotage and strict port control, but the possibility of disaster is ever present in such a congested seaway.

To meet this eventuality the Solent and Southampton Water Marine Emergency Plan was developed from preexisting Southampton and Portsmouth schemes in the early 1960's. Since that time it has been put into action on three occasions for episodes of fire at sea, with good effect.

The Khao I Dang Holding Center for Kampucheans opened November 21, 1979 as part of an effort to bring relief to the thousands of Cambodian on the eastern frontier of Thailand. The camp population increased from 4800 that first day to 50,000 by December 1, 1979 and 110,000 by mid-January, 1980. Sixty-one percent (61%) of the population were 15 years of age and older; 12% of these over 44. Thirty-nine percent (39%) were children under 15.

Although each disaster is unique, the medical problems for a type of disaster in a stated area are considered predictable. This was not the case at Khao I Dang for hospital pysicians in providing patient care. It has been shown that relief efforts are amenable to study, yet such studies have been handicapped by a lack of data. Since major disasters involving international aid are reported several times a year, the problem is considerable.

During the latter part of 1979, hundreds of thousands Kampuchean refugees fled from all parts of their war- and hunger-ridden country to the Thai-Cambodian border, thousands perishing from hunger, disease and stepping on mine fields on the way. The majority of those who survived settled in several large villages straddling the border in relative security from the advancing Vietnamese army, receiving food and medical supplies from many international welfare organizations.

Widespread public interest in the plight of these refugees arose in Israel after a television program late in October 1979, and a public campaign initiated by Mr. Abie Nathan, an Israeli citizen. The ensuing fund-raising efforts resulted in 1.2 million dollars, most of which originated from private donations. These contributions enabled the Israeli government to equip 5 medical teams and send them to Thailand, covering the last two months of 1979 and the first 4 months of 1980.

A survey conducted among Indochinese refugees in Thailand in 1979, revealed significant levels of Vitamin A deficiency blindness (xerophthalmia). A Vitamin A supplementation program for children was implemented. Recent events in South East Asia have resulted in the mass movements of thousands of Kampucheans. These people underwent extreme deprivation for several years before migrating in large numbers to the Thai-Kampuchean border and later into Thailand. This massive influx of starving and ill men, women and children stimulated a large international relief effort aimed at providing food, shelter and health care. Under the supervision of the United Nations High Commission for Refugees, several holding centers or camps were established within Thailand.

Early reports indicated severe problems with malnutrition among the children reaching these areas. Since these malnourished children were susceptible to a blinding affliction, xerophthalmia, Helen Keller International, a voluntary agency long interested in the disease, became alarmed. I was dispatched as a consultant public health ophthalmologist to the holding center for an on-site investigation.

Disaster plans in response to a nuclear crisis involve extended forays into uncertainty. Controversy arises over whether or not a nuclear disaster or war might ever occur. Estimates of destructive parameters vary widely. Planning must take into account a wide range of issues, from the nature of radiation injury to the survival capacity of social systems. From the standpoint of analyzing possibilities for emergency response, we will discuss: l) medical effects of radiation; 2) severe core meltdown at a nuclear power plant; and 3) a scenario for a nuclear bomb explosion over one city in the USA, in the setting of a strategic nuclear exchange.

First of all, I would like to express gratitude on behalf of academician Eugeni I. Chazov, who was kindly invited by Professor Safar to attend this Congress. Unfortunately, some circumstances connected with work prevented Dr. Chazov's attending. Most of you are probably informed about his attitude toward the movement known as Physicians for Nuclear Disarmament. In 1981, Dr. Chazov delivered his paper at the First Congress of International Physicians for the Prevention of Nuclear War (IPPNW), held in Airlie, Virginia, USA. The Academy of Medical Sciences of the USSR has established a special Council to help guide this disaster prevention movement among Soviet physicians. Academician Chazov is the chairman of this Council.

In May 1981, our central newspaper, Pravda, published an appeal to the scientists of the world, signed by many prominent Soviet scientists, Lenin and State Prize winners of the USSR, and Nobel Prize winners, calling upon their colleagues and urging all scientific workers to do everything possible to avert the danger of nuclear war. Professor Chazov was among those who signed.

In view of public concern about health impairment from accidental radiation exposure, the record of forty years experience in the utilization of nuclear energy was reviewed. All reported exposure incidents producing health effects from external radiation sources and internal radionuclide contamination in the United States and some in other countries have been included. Preparations for the management of such accidents will be considered briefly. The relationship of this actual accident experience to the unresolved problems in management planning and professional and public education for future accidents like that at the Three Mile Island nuclear power station in Middletown, Pennsylvania, March 1979, but with potential associated health impairment, was discussed. The complete paper is published in the Proceedings of the 3rd World Congress for Emergency and Disaster Medicine, organized by the “Club of Mainz” in Rome, Italy, 1983 (see Manni, C and Magalini, S, Springer Publ, Heidelberg, 1984).

An understanding of combined injuries caused by both whole-body irradiation and wounds or burns is still at the present, in a clinical sense, largely lacking. This is, in part, due to the fact that Japanese and American scientists paid attention mainly to the individual injuries, especially those of subjects with acute radiation diseases, which had not been observed until then. Under the threat of a global nuclear confrontation, an intensive radiation biological investigation was initiated, especially in the military laboratories in the USA, the European countries, and the Soviet Union. The study of combined injuries, however, was relatively neglected. This may be because many investigators have considered combined injuries to be just modified radiation injuries, for which the same treatment principles are valid, that apply to radiation diseases.

On March 28,1979, a near nuclear catastrophe occurred at Three Mile Island (TMI) near Harrisburgh, Pennsylvania, USA. I was at that time Pennsylvania's Secretary of Health. It was an accident that just “could not happen.” After all, nuclear power plants were built so safely that they could not possibly affect public health.

As a physician, lam compelled to say that I am unalterably opposed to nuclear warfare. I am sure that most physicians would agree that there can be no adequate preparedness for the devastating medical consequences of nuclear war. Prevention of nuclear war is the only reasonable medical response to the hazards posed by nuclear weapons.

By contrast, many of you may not share my position on nuclear power. Nuclear power can be made relatively safe if we do not ignore the public health lessons of the past. I belive that physicians need to increase and update their understandings of the medical consequences of radiation accidents and be trained to triage and to treat blast, radiation, and burn injuries.

At 0400 hours on Wednesday, March 28, 1979, an extremely small and initially thought unimportant malfunction occurred at the nuclear power plant at Three Mile Island (TMI). Within a short period of time, that malfunction would turn into an event of momentous impact with repercussions felt over most of the world. The events of that malfunction would cause TMI to be labelled as the worst commercial nuclear incident in history and transform it into the nuclear test tube of the universe. What really happened at Three Mile Island? Thirty-six seconds after 0400 hours, several water pumps stopped functioning in the unit 2 nuclear power plant. In the minutes, hours and days that followed, a series of events—compounded by equipment failure, inappropriate procedures and human errors—escalated into the worst crisis yet experienced by the nation's nuclear power industry. This resulted in the loss of reactor coolant, overheating of the core, damage to the fuel (but probably no melting) and release outside the plant of radioactive gases. Hydrogen has was formed, primarily by the reaction between the zirconium casing that holds the radioactive fuel and steam. There, however, was no danger of the bubble inside the reactor vessel exploding, because of the absence of oxygen within the reactor.

Disaster preparedness as developed by civil authorities and hospitals has not adequately addressed the special characteristics of mass casualties from nuclear accidents, as demonstrated during the accident at the Three Mile Island (TMI) Nuclear Power Generating Plant. Experiences gained by the Radiation Emergency Task Force of the Milton S. Hershey Medical Center, established during the TMI incident, have resulted in reexamination of emregency medical services (EMS) systems response, population and hospital evacuation, decontamination procedures, communications, triage and psychologic impact during such an event. From these investigations, it is now possible to restructure disaster protocols to accommodate accidents involving toxic contamination. Although this report primarily deals with nuclear accidents, it is also useful in planning for large-scale biologic or chemical accidents.

The growing number of nuclear power, research, and industrial facilities places increasing numbers of people and places at risk from an accident involving radioactive material. Fortunately, such accidents are infrequent. Unfortunately, this rarity often results in very limited hospital and physician interest and awareness. The incident at the nuclear facility at Three Mile Island (TMI) in Pennsylvania, USA, has demonstrated that despite its rarity, a radiation accident may not only occur, but occur on a scale large enough to require more than the radiation accident protocol which each hospital is required to have. There is a need, therefore, for the incorporation of radiation accidents into disaster planning and triage systems. We address the considerations to be made in planning an emergency medical system's response to a large radiation accident. We describe the application of a triage team in such a plan.

The problem of forecasting the number of injured in need of treatment as a consequence of earthquake damage, and the percentage of those in need of diversified forms of therapy, still remains unresolved. Past experience provides us with partial and variable figures. It may thus be useful to propose as a working hypothesis some degree of comparability between the effects caused by the energy released by earthquakes and those resulting from nuclear explosions, especially as regards some of their predominant aspects (collapse of buildings).

On November 23, 1980, an earthquake equivalent to 10 degrees on the Mercalli scale struck two regions of Southern Italy: Campania and Basilicata. Its epicenter was identified in the area of Colliano. The destruction caused by the earthquake extended to 7 provinces and affected 685 communities distributed over an area of 23,570 Km with a population of approximately 4 million. The material damages ascertained —not counting the consequences to industrial, agricultural and commercial activity—amount to approximately 17,000 billion Italian lire. In terms of the medical sector, 3 regional hospitals (722 beds) and 20 smaller hospitals were totally destroyed; another 16 hospitals (for a total of 9,495 bedsl suffered varying degrees of serious damage. In economic terms, the damage sustained by the medical structures amounted to 88 billion lire.

The medical and nursing staff of the Niguarda-Ca' Granda Hospital of Milano has been involved in three major disasters that occurred in Italy in the years 1976 and 1980: (1) the earthquake of May 6, 1976 in a northeastern region (Friuli); (2) the ICMESA plant explosion of July 10, 1976 in Seveso (Milano) and (3) the earthquake of November 23, 1980 in the region of Irpinia (Southern Italy).

Friuli Earthquake 1976

On May 7, 1976, about 12 hours after the earthquake struck, the Udine Hospital, located at about 15 km from the border of the disaster area, contacted by phone the director of the Ca' Granda Hospital in Milano, requesting a relief staff of operating room and ICU nurses. The Udine Hospital was undamaged and was overburdened by work for the surgical, orthopedic and medical treatment of the rescue victims. The staff requested was needed to relieve the exhausted local nursing staff. Extra staff was needed also to accompany ambulances with patients that, after initial triage and treatment, were evacuated to other hospitals outside the seismic area.

On October 10, 1980, the town of El-Asnam (130,000 inhabitants) and villages within a 50 km radius (229,000 inhabitants) were 80% destroyed by an earthquake of intensity 7.5 on the Richter scale (Figure l). The first unofficial estimates reported 50,000 dead and 100,000 injured. These numbers were probably based on data from the Agadir earthquake of February 29, 1960, when 12,000 out of the 30,000 inhabitants were killed. The official figures now list for the El-Asnam earthquake 2,600 dead and 8,250 injured. That was nevertheless a sufficiently heavy toll to fully justify the volume of relief that came from practically all over the world. The relief of Baden-Wurttenberg was organized by the German Air Rescue Guard of Stuttgart, in collaboration with the German Red Cross in Karlsruhe, as well as with physicians from Karlsruhe, Stuttgart and Tubingen. In a very short time the necessary aircraft (Merlin IV/Metro and BAC 1–11) for the transport of material and personnel from the German Headquarters were ready for takeoff.

Of the more than one million earthquakes which occur each year on our planet, very few involve areas of major population concentration. During the last decade, however, a significantly large number of earthquakes involved populations in cities or areas of large population density. The injuries, therefore, are multiplied by the collapse of large buildings or of walls of houses of poor design and construction of adobe brick. Crashing upon people asleep, they entrap, entomb or mutilate defenseless and often aged, ill, and diseased and helpless pediatric victims. The three earthquakes we witnessed recently have resulted in 70,000 deaths in Peru;, 12,000 in Managua, Nicaragua;, and 22,000 in Guatemala City and large suburban cities.

Most of the injuries are orthopedic fractures. Fatalities often occur from compression and permanent restriction of respiratory movement. These megaton disruptions of the environment cause the following types of respiratory challenge: (l) The unbelievably large and dense dust clouds from falling buildings, created by pulverization of the walls of mud, straw, and limestone, create suffocating chemical damage of some degree to the nasal mucosa, the bronchial tree and the respiratory bronchioles, immediately initiating endothelial edema, airway obstruction and collapse, and irritational bronchitis.

A strong earthquake occurred in the Tangshan-Fengnan area in Hopei Province of North China at 03:42 hours on July 28, 1976. A general headquarter was set up immediately to perform the functions of organization and administration. This was the most essential authority in keeping everything in order in such a disaster area. Mine Rescue Corps and mobile medical teams from many parts of the country were called and rushed to the scene. Critical care was organized into 3 stages: (1) digging and rescue; (2) preliminary treatment and transfer; and (3) treatment after transfer.

The Mine Rescue Corps, existing normally in every coal mine, was the most efficient and valuable element in digging out victims and carrying out the most urgent resuscitative management. They dug and rescued, and also patrolled in the pits. They cleared the way for the coal miners. More than 10,000 miners, who were working in the pits during their night shift, were less able to return to the ground safely. As it was very difficult to locate every working group in such a labyrinth pits system, some coal miners had been left in the pits for long periods of time. There were, for instance, five coal miners who were working 850 meters underground and could not find their way out because the pits were badly damaged.

Once an earthquake or similar disaster has occurred, and the salvage operation begins, it must be viewed as something that can do further damage to the victims as well as help them. The more ambitious the rescue and salvage effort—the effort to minimize the human casualties—the more serious the problem becomes of preventing the salvage operation from doing more harm than good after the obvious and easy cases have been located and treated. The key engineering elements can be reviewed from the position of the rescuer or of the victim and his ability to participate actively or passively in his own rescue and treatment. In either case, the main improvement would appear to result from, first, improved sensors and receptors; second, improved methods for timely debris removal; third, improved aids to active self-indicated survival efforts, including rescue and treatment; and fourth, improved methods of restoring vital services (water, sewage, heat, light, food, transportation and communication).

Anesthesia in disaster medicine, especially as practiced in developing countries, is fundamentally different from the anesthesia that is practiced during normal situations. Anesthetic procedures suitable for disaster situations must often take place under minimal conditions of instrumental availability and in a setting of less than modern technology. Such conditions, of course, limit the use of inhalatory anesthetics.

The key factor present in disaster situations is the disturbed relationship between the number of injured, on the one hand, and the available resources to treat them, on the other. This includes medical personnel—both professional and para-professional. This has been substantiated by the earthquakes in Iran, Guatemala, China and Turkey. The earthquake which occurred in Tabas, Iran in December 1978, for example, lasted only thirty seconds, but left behind more than 20,000 dead and countless thousands of injured.