Many of the world leaders in emergency medicine and in disaster medicine systems have made advances in these fields, and I compliment them on the accomplishments that I have seen over the years. Dr. Safar charged me to look ahead, if that is possible, and offer some perspective—obviously my own—on the next five to ten years. Hopefully, our future can be controlled in certain limits. Toynbee philosophized that when new and unanticipated challenges are presented, they represent great opportunity for response. If we fail to respond or if we respond in an inappropriate way, we may become a fossil in history—in this case, in the history of medicine. I have attempted to look at important challenges that I see in emergency medicine, and to predict from these a course that I think represents a proper response.

The first challenge, one that you have heard of before, clearly is the most important one. It is the challenge of limited or relative resources. The term “relative” means that fraction of a country's or region's output or wherewithall that is available in a logical or rational way for emergency medicine.

At 15:15 hrs on 17 October 1977, the Lufthansa Medical Service in Frankfurt was notified about the hijacking of a 737 Boeing aircraft. At 15:30 hrs the Crisis Management Staff (CMS) asked me if I would accompany a stand-by crew on the rescue mission. The intention of the CMS was to come to an agreement with the hijackers to exchange the crew of the hijacked plane for a stand-by crew accompanied by an airline physician. I agreed. Medicines and medical equipment for the treatment of injured and sick passengers were packed by medical assistants. At 16:30 hrs highly confidential information was received from CMS—GSG 9 that the Border Patrol Special Commando led by Commander Wegner would accompany the rescue mission which would henceforth be termed “Special Mission”. The hijacked plane was to be followed and seized. It was likely that in the course of this operation an unpredictable number of burns, gunshot wounds and other serious injuries could occur. In a very short time, medical assistants packed further huge crates full of first-aid packs, Macrodex infusions, analgesics, and so forth. I asked Dr. Straub, a medical colleague, and Mr. Reiser, a nursing assistant, both employees of the Lufthansa Medical Service, to accompany me as volunteers, and they agreed. At 16:45 hrs the CMS approved the medical team and the medical equipment.

This report refers to interviews with 53 of the passengers of the Lufthansa aircraft “Landshut,” liberated in 1977 in Mogadishu, Somalia and to information acquired during group-psychotherapy with 16 of these passengers. The psychological care during hijacking depends on the aim and situation of: a) the hijackers; b) the hostages; and c) the extorted.

a) The hijackers are usually motivated by political aims. They feel that their crime is mitigated by their ideology. They are aware of the high risk of their undertaking and the violent counter-actions of the authorities, but they are highly motivated personally and socially. Hence, they are continually in a state of extreme expectant tension with most intensive perception and alert awareness. This activates the high intelligence they may have, but it is combined with a disturbance of their perception of reality. Usually there are several hijackers. Their communication with each other is characterized by a strong hierarchy structure, where the giving and acceptance of command is strictly defined. Their social situation is that of a “group”. The group interactions give them some relief of anxiety.

b) Unlike the hijackers, the social situation of the hostages is that of a “crowd”. They have arrived at this situation by chance and usually without knowing each other personally. Since the formation of a group among the passengers would be an additional danger for the hijackers and would disturb their orientation and weaken their power, any verbal or non-verbal communication and any moving among the passengers is prohibited.

I would hope that there is no question regarding the need for physician leadership in an EMS system; and that the question, if there is any, concerns the amount required, where it is to be applied, and its quality. EMS, I would remind you, stands for emergency medical services. Medical delivery systems, in my opinion, require physicians for their design and implementation. That does not mean that all the services have to be delivered by physicians, but they need physician leadership.

If this outlines the area of physician authority, then there is by definition a concomitant responsibility—authority without responsibility would be tyranny. The responsibility should provide an appropriate level of medical care that is current in concept, appropriate to the needs, considerate of the resources available, and coherent with the overall health care system. It must not be just an isolated EMS system.

Every airport large and small should have a disaster plan to involve all rescue and medical services. (Jessen, Reich, Rørmark, Fahey, Bergot)

Communications between participants at a disaster must be of the highest caliber if patients are to receive optimal care. Communications between fixed operational bases should be by dedicated telephone (intercom lines) and radio on an appropriate frequency. Redundancy must be incorporated into the system. Education for personnel must be reinforced by regular drills. (Baker)

Disaster planning must take into account the fact that in many cases there will be survivors even from “hard impact” crashes taking place away from the airport. (Domres, Baker)

Regular disaster drills using actual aircraft and involving all agencies for disaster management, including physicians, must occur. (Fahey, Jessen, Star)

The principles of triage, field stabilization, and rational evacuation through an ambulance dispatch area must be incorporated into all plans. (Baker, Bergot, Fisher, Oyen)

In a major disaster triage is essential in order for medical help to be most effective. (DeSinnger, Oyen, Matthews.) Triage should be carried out by the most experienced person available. Casualties should be categorized into the following groups: 1) those dead or about to die; 2) those who will benefit from immediate resuscitation and treatment; 3) those who will benefit from treatment at any early stage; and 4) those who have trivial or no injuries.

A status report of CCM in different countries varies considerably. In the USA, resuscitation and intensive care were pioneered by anesthesiologists in the 1950s, but CCM evolved later as a multidisciplinary movement through the initiative of the Society of Critical Care Medicine (SCCM) starting in 1970. Recently, CCM has been introduced as a subspecialty of anesthesiology, internal medicine, pediatrics, and surgery. Australia has already, for a couple of years, had a primary specialty of intensive therapy, but there are two tracks, one in medicine and one in anesthesiology. In the Scandinavian countries, as well as in Italy, CCM is an integral part of anesthesiology, since intensive care was initiated there in the early 1950s by anesthesiologists. In several Ibero-Latin American nations, we find a primary specialty in intensive therapy.

The 1973 Emergency Medical Services System Act in the United States mandates that one of the 15 functions to be performed by every EMS system is coordinated disaster planning. Implicit in the legislation is the assumption that everyday emergency medical service (EMS) systems will be the basis for the provisions of EMS in extraordinary mass emergencies, or in the language of the act, during “mass casualties, natural disasters or national emergencies.” Policy interpretations of the Act specified that the EMS system must have links to local, regional and state disaster plans and must participate in biannual disaster plan exercises. Thus, the newly established EMS systems have been faced with both planning for, as well as providing services in large-scale disasters.

The Royal Victoria Hospital, Belfast, over a four-year period, used its disaster plan more than 100 times due to the civil disturbances in Northern Ireland. The concept of classifying these patients into three or four triage categories made me critical of assumed methods and articles dealing with triage. None of it measured up to my own experience. What is triage? Triage is the French word for “sorting.” I, therefore, addressed myself to the kind of sorting I had seen, where it was done and what categories were used.

The triage (i.e., sorting) of casualties is the most important task of a physician in a disaster. This function is so extensive that only an experienced doctor can fulfill it satisfactorily. To do so, he needs comprehensive information. This article will demonstrate a time-saving method of receiving and giving information for triage in connection with the registration of casualties.

The immediate situation determines classification. A rigid pattern cannot be applied. The doctor must know the number of casualties and helpers, transportation facilities, hospital capacities, and medical supplies. To help him assemble these data, the doctor has at his disposal an assistant registrar. This assistant is equipped with a walkietalkie to communicate with ambulance control. He also has a registration list and can enter important data concerning the patients clearly thereon (Figures 1 A, B).

In order to introduce EMS problems in large urban communities, I will first tell you the parable of the County of Smog. It covers an area of about 4,000 square miles and includes areas of mountain wilderness, dense urban population, coastal ocean communities and a peculiar blend of heat, foul air, and residential and industrial communities known simply as “The Valley.” About ten years ago, Smog County health officials established a pilot program to train a handful of firemen in reading electrocardiograms, the pharmacology of emergency cardiac drugs, intravenous infusions, and defibrillation. The firemen responded in a station wagon from a hospital. It was readily learned that these paramedical personnel could impact positively on the outcome of patients with cardiac conditions.

Resuscitation in the prehospital phase is feasible. As intensivists, however, we know that many cases could reach our intensive care units (ICU's) in far better condition if prehospital care were improved. We have learned from feedback on our cases in the unit that we physicians are indeed the best prepared specialists for fast and efficient intervention outside the hospital. Diagnosis and, hence, titrated therapy are more and more transportable and, under acute conditions, it is often safer to transport medicine to the patient, rather than the patient to medicine. Technological problems are no longer an excuse for the doctor to refuse to go to the scene.

The goal of critical care medicine is to provide specific care to the patient in whom one or more vital systems are threatened or deficient. The methods of critical care medicine are monitoring, support or temporary substitution of vital systems, and the application of titrated therapy. The specific objective of each link in the chain of medical facilities involved with the critical patient deserves to provide the same expertise and should act according to the same protocol.

The different links of the chain are these: (l)recognition of the critical condition; (2) emergency call; (3) care on the spot of the emergency; (4) care during transport; (5) further diagnostic and therapeutic work in the emergency department; and finally (6) if indicated, continued intensive care.

During the last ten years, both in Western Europe and in the USA, the attitude towards medical transport activities has radically changed. From being a purely transportation vehicle the ambulance is now increasingly regarded as an extended arm of medical care. At the same time as ambulance crews have received more qualified medical training, the equipment of the ambulances themselves has been improved. In several countries such as the USA, France and West Germany, a differentiated ambulance organization has been built up, with specially equipped emergency ambulances manned by paramedics, and standard ambulances with emergency technicians for planned transports. During this time helicopters have been put into increasing use as a supplement to ambulances for emergency long distance transport to units such as trauma and burn centers.

Planning for emergency medical services (EMS) in a large state with a sparse population like Alaska poses unique challenges that EMS planners in urbanized areas never have to consider. Alaska is the largest state in the USA in land area, covering 586,000 square miles, or an area more than twice the size of the state of Texas. Alaska also has more miles of coastline than the rest of the USA. Despite its large size, Alaska continues to have the smallest year-round population of any state in the nation (400,481–1980 census). Many of Alaska's villages and towns are not accessible by road, including Juneau, the state capital, which can only be accessed by air or water. This means that, with Alaska's often harsh climate, many communities have no available ingress or egress for several hours, or even several days at a time. In these conditions, response times can not be measured in minutes, as they often are in some urbanized areas in other states. For example, Unalaska in the Aleutian Islands, one of Alaska's major fishing ports, is over 900 miles from the nearest hospital in Anchorage.

Due to the development of modern resuscitation during anesthesia and surgical operations, methods of intensive therapy have been introduced in clinical medicine. Efforts, through cardiopulmonary resuscitation (CPR), to give any patient in need the chance to survive resulted in systems of emergency medical services (EMS). A short account of the present state of CCM in the CSSR is given here. The principle of “differentiated patient care” is outlined, with accepted definitions of resuscitative and intensive care. The terminology of different steps in CCM is offered for discussion.

In Czechoslovakia, the Constitution of 1960 proclaims the right to health care for every citizen. Medical care is provided to all citizens free of charge by the State. The State took over the responsibility for planning, organizing and providing medical care on the highest attainable contemporary level. In the last ten years, special programs have been launched in order to cover most actual health areas such as neonatal and maternal health care, cardiovascular disease programs, oncology, geriatric care, and, last but not least, the care of patients with acute organ systems' failure.

Improvements of results in emergency care of critically ill patients can be realized if EMS organizations are properly based on local conditions. The Emergency Medical Unit is the first of three parts of the Integrated Health Service in Poland. The second part is in-hospital treatment. The third part is outpatient care. In most hospitals, the head of the department of anesthesiology and intensive therapy coordinates each emergency medical unit. Each unit consists of ambulances (mobile intensive care units), admission (emergency) rooms, and an intensive medical care unit (ICU). A specialization program was created and physicians who complete this type of training obtain the title “specialist in anesthesiology and intensive therapy.”

This four year specialization program contains the educational elements necessary to administer all types of modern anesthesia, and provides full preparation for work in mobile and stationary intensive medical care units as well. Such training has also given these specialists the chance to initiate treatment methods for chronic pain. An examination consisting of practical tests, multiple choice written knowledge tests, and oral tests completes the program. The latter is a conversation with a commission, consisting of full professors and associate professors in anesthesiology and intensive therapy.

Mobile intensive care units (MICU) will take care of all real emergency patients with presumed or proven disturbances of vital functions. These vehicles are equipped according to standardized criteria, and usually stationed at emergency hospitals. MICU's are accompanied by one rescue assistant, one emergency medical technician (EMT) and one physician.

Eighty-five to 90% of the total number of emergency calls were primary emergency calls, where the emergency patient had to be treated at the scene; 10% to possibly 20% were emergency patients who had already received treatment by medical or paramedical personnel.

Our emergency medical services (EMS) system is called SAMU (“Service d'Aide Medicale d'Urgence”). It was initiated in Paris in 1956. Since that date, it has developed a new concept of emergency transportation, which excludes speed as the best way for saving life threatened by danger. Indeed, this EMS System is based upon the same principles that are used everywhere, but there are some practical differences which are characteristic of the service in France. One example is the medicalization (physician-staffing), which permits excluding speed in transportation.

Everywhere, the fundamental EMS principle is to struggle against time to give efficient care as soon as possible. In emergency situations, all things are simpler and all treatment is more efficient if you can do it within the limit of time available for resuscitation. If this limit is surpassed, success is dubious. The means to reach it are more sophisticated and cost increases tremendously; however, the mortality goes up inexorably to death in all severe cases.