46 to free federal funds for help. It urged local communities or areas to organize councils on emergency medical services to assume a similar coordinating rule "Many communities are unaware of the way to secure outside assistance in rescue, first aid, and medical help available through the American National Red Cross, the U.S. Public Health Service, civil defense agencies, and field units of the Armed Forces," continued the report. which ended by recommending the development of a center to document and analyze types and numbers of casualties, identify by on-site medical observation problems encountered in caring for disaster victims, and serve as a national educational and advisory body. Concluded the report. "Emphasis should be placed on employment of all elements of disaster services on a dayto-day basis so that they will be functioning smoothly when the load of casualties suddenly increases." tions, toward pooling of resources to assemble substantial Given money, commitment, and cooperation from all elements of the community concerned, what is the ideal disaster plan? Jack H. Engelmohr, executive director of Pittsburgh's Homestead Hospital, offered a basic set of recommendations to the 1969 Institute on Disaster Planning "Each is important as you contemplate the total situation that you're going to be faced with sooner or later. It is unlikely that it will happen to you this year, but sooner or later you will face a disaster situation of some magnitude." Engelmohr specified the importance of radio contact between hospital and disaster site, police, fire, ambulance and ambulance dispatching, and other hospitals, dial and "hot-line" telephone systems; adequate signs for traffic control; adequate control of elevators and all entrances and exits; and procedures to discharge patients quickly, or move them away from the emergency department. He also noted the need for emergency and reserve medical supplies, reserve food supplies, press facilities, security measures, identification for hospital personnel, and maintaining the physical plant. Added Dr. David W. Clare, chairman of the disaster committee of the Allegheny County (Pa.) Medical Society. at the same conference: "Maybe your hospital and staff cannot afford to be an island, a safe haven of medical care, at times when the stormy seas of disaster are engulfing your community. So what do you do? One, the responsibility for stimulating community awareness to the special problems posed by disaster and emergency medical care lies directly and unequivocally with the hospitals and their professional staffs. It is not the responsibility of the Mayor's office. It is not the responsibility of the police or the firemen. It's our responsibility to make people who must know about it aware of these problems. "Second, planning for good emergency medical care should precede planning for good disaster medical care. Third, the emergency medical care plan should be put into practice and modified as needed to be as effective as possible, and the appropriate community disaster medical care plan should involve the entire community, since a huge fire or explosion, a tornado, or a bus accident, the House Interstate and Foreign Commen 47 collapse of a public auditorium, or some other unnamed and unthought-of disaster might be of such magnitude as to require the resources of the entire community. . . ." Adds Dr. Huntley of the PHS: "No community can effectively plan to cope with a disaster unless it is already meeting day-to-day medical care needs." He also emphasizes the importas ce of good communications equipment: "It is the first thing a community ought to look at. A central dispatch facility is necessary for ambulances and hospitals and also a single telephone number to call. No hospital disaster plan is worth any more than the paper it's written on unless it is tied into a communication system. Within the hospital, traffic control is crucial. If there is a lack of security, the hallways become crowded with relatives of the injured and with curiosity seekers." Do the best paper plans work in real, nonpaper disasters? A close examination of how hospitals in various parts of the country responded to three kinds of situations indicate that their disaster plans worked to a certain extent. But enough flaws were exposed along the way to indicate the validity of the expert opinion already cited. Gilman Hospital serves the sleepy fishing village of St. Marys, Ga., (population 3,300). Normally its 35 beds are filled with elective surgery and obstetric patients, which it handles very nicely. Last month, however, the placidity of the place was interrupted when a Thiokol Chemical Corp. plant, manufacturing magnesium flares for Vietnam, exploded at Woodbine, 20 miles away, killing 25 and injuring 34. "The first call came in from Thiokol," recalls administrator Earl H. Johnson. "They said they'd had a disaster and for us to muster all available aid." Soon after, Johnson also got a call from Capt. John M. Waters Jr., director of public safety of nearby Jacksonville, Fla., who told him that helicopters and doctors were on the way. The call came in shortly after 11 a.m., and by 11:45 the first patients were beginning to arrive at the front door of the small facility-by private automobile, pickup truck, and emergency vehicle. Soon, the helicopters were also setting down in the side yard with more victims. Dr. Eduardo Oliveira, president of the hospital staff, immediately set up a triage area in the waiting room. "I stationed people in their proper places and told them what to do," he says. "If you don't limit the functions of people in an emergency, you don't have the elasticity you need. When the patients started coming in, they were routed to ON, LISTENING, DIGGING, AND CRAWLING INTO HOLES For some physicians, disasters bring forth heroism. The Los Angeles earthquake thrust Dr. Masato Takahashi abruptly into that position. The 38-year-old pediatric cardiologist at Childrens Hospital of Los Angeles was among the first doctors on the scene after a portion of the VA Hospital was destroyed by the quake, with a number of patients left trapped in the rubble. Childrens Hospital first got word of the damage to VA at 8:45 a.m., and a team of 16 doctors led by Dr. Alan Finley, director of outpatient service, left immediately for the trying to coordinate the medical re- At first, however, there were few Dr. Finley sent Dr. Takahashi and Tom Scatoni, a radiology tech extent of their injuries and see if they were still trapped," says the doctor. One man had a heavy beam across his extremities, and Dr. Takahashi gave him a shot of Demerol to ease the pain. Some of the casualties had been crushed under slabs of concrete. Along the way, work crews consulted Dr. Takahashi about extricating the men with the least amount of additional injury. "I'm certainly not an expert at this," he says. "I just used my intuition." The doctors and the rescue crews worked throughout the day and into the night, and when it was over, the exhaustion set in. "I was scared to walk into that place," says Dr. Takahashi, a graduate of Indiana University School of Medicine. "It was unbelievably tragic. After a while, I became sort of numb. It is surprising how you can keep your cool once you overcome the fear. But physicians can function under pressure. Your training conditions you to function, to do the appropriate thing." Adds Dr. Finley: "He did a great job. Nobody had to go down there." me, and I had them sit on chairs and wait. In a way, it is cruel to do this, but it is a feature of triage you have to take on your shoulders. I went to those who could not walk. I found three DOAS in cars, and I had them put in a special place on the side porch so identification could be done without interfering with the hospital." He separated fracture patients from the majority of the injured who were suffering from burns. One nurse was put in charge of dispensing sedatives, another tetanus toxoid. "Anyone with better than 30% of their body burned or with a fracture where there was a chance of amputation, I had put in a helicopter," says Dr. Oliveira. These were rushed to the Duval Medical Center and St. Luke's Hos pital in Jacksonville. By 1:15, everything was under control at Gilman, with 39 patients treated and seven admitted. at the time of the original call to Gilman, someone at Thiokol also called the city of Jacksonville. There had been no doctor on duty at the isolated plant and only one nurse. The tremendous confusion of the moment was accentuated by a forest fire ignited by the blast. Helped by state police, however, the injured and dead were soon being removed. After the call came into Duval Medical Center, its executive director Michael J. Wood put the disaster plan into effect. Fortunately, Jacksonville has one of the finest city emergency systems in the U.S. (MWN, Dec. 4, '70), in which the local hospitals are also involved. As the staff rounded up extra burn dressings and moved furniture to make way for beds, two doctors left on a Navy helicopter for the blast site. Wood says he knew there would be no trouble in handling whatever happened. "The only trouble was we expected 40 patients and got 11," he says. "We were over-geared." The others had been sent to hospitals like Gilman nearer the scene. Duval's entire ground floor is given over to the emergency department and outpatient clinic, about 80,000 square feet, so there was plenty of space. Disaster committee chairman Rudolph Nudo set up the whole area for burn patients, minor injuries, major injuries, and any emotional disturbances. The platform at the rear of the building was designated as the triage area. One of the first patients was brought in a car with a flat tire. Soon, helicopters with victims were landing in a park across the street, where ambulances picked them up for the short drive to the hospital. The doctor conducting triage quickly assessed the conditions of the victims, who were tagged with special disaster control forms, one copy for admitting and the other for public relations so a list of those treated and admitted could be released to the press quickly. Amid the popping flash bulbs and cries of patients, the doctor routed victims into appropriate areas. At the height of the confusion, a regular emergency case-a cardiac patient-was brought in and treated. Handling disasters has become second nature at Duval. "For a number of years we have stressed preparedness and stressed disaster practice, not just plans," says executive Victims of blast were handled swiftly at small hospital by administrator Johnson (above, left) and Dr. Oliveira (above, right) but Dr. Bomhard (right) flew in and found supplies inadequate director Wood. "We are blessed with people in the fire department and central city government who are disasterpreparedness-minded. Also, we have been through enough actual disasters to know the importance of communications and handling things in a way that we don't waste manpower. (A fire in the Roosevelt Hotel killed 20 people several years ago, as did a construction lift that fell at the site of the new court house. The hospital gained the bulk of its mass-casualty experience two years ago, when 200 students were admitted with salmonella poisoning.) The city plan administered by the fire department includes the staging of disasters, even the simulation of burns and trauma. "The city fire marshal actually tries to surprise us," says Wood. "He borrows make-up from the military and goes to the school of nursing and gets 70 or 80 girls to act as victims. Out of these practice drills, followed by critiques, we get to know our weaknesses." Success at Duval and in the city of Jacksonville generally was probably assured by preparedness. This was not the case at Gilman, in rural St. Marys. Because of the small staff and the familiarity of both Johnson and Dr. Oliveira with the disaster plan, things ran smoothly But at least one doctor who arrived by helicopter from Duval was distressed by what he saw. Dr. James S Bomhard, an intern, went to the blast site first. By the time he got to Gilman, triage was well under way. "We just speeded it up," he says. What bothered Dr. Bomhard was the lack of supplies. The only thing they had were needles -no I.Vs, and they were short on dressings." Administrator Johnson admits the hospital had not had a trial run on its disaster plan for several years but denies any supply shortage. The director of nursing. Pearl Hayes, says she had never been briefed about the plan but House. Interstate and Forevan Commern. 49 doesn't think that hampered operations, "We occasionally have partial drills," says Johnson, adding that he thinks drills are more important in larger, multistory facilities "to get the proper person to the proper place." Dr. Oliveira agrees: "Dry drills don't produce. What produces is applying people to the jobs they do every day. You can drill them to death but you have to have people who will do what you say." He is supported by Dr. George Kidera, medical director of United Air Lines and an expert in disaster planning. "Periodically run drills look beautiful. But in the disasters I've been involved in, the unfortunate thing is you can't select the place-in a swamp, on a mountain peak, in the middle of a remote area. The important thing is to have the flexibility in any program and depend not on plans but the ingenuity of those involved and the ability to improvise. The airline industry has settled on a set of guidelines that indicate everyone's role in a disaster but do not specify every detail. "United has stopped writing a new plan after each disaster," he says. But the value of conducting frequent trial runs of dis aster plans was borne out in another major catastrophe. On June 8, 1966, a devastating tornado struck Topeka, Kan, killing 16 people and injuring 550. Five hospitals received the dead and injured that day, but the 288-bed Stormont-Vail Hospital treated more than the others160 persons, 31 of whom were admitted. The hospital had had a disaster plan for 15 years, but until 1965 it was untried except for small rehearsals," says C. Jerome Jorgensen, now executive director but then assistant director. "In 1965 we held the first large-scale disaster exercise using 100 simulated casualties. From that, personnel had a concept of what the problems would be, what it would be like to take care of a significant disaster, and the impact on the hospital." Because the executive director was then in the hospital coronary care unit, Jorgensen had to take over disaster coordination. He was notified of the tornado threat at home and immediately ordered blankets issued to all patients, blinds pulled, and all exits opened. The tornado hit while he was on the way to the hospital. Abandoning his car because of all the traffic congestion and extensive damage to buildings, he reached the hospital on foot to find it already on emergency power with enough for minimum lighting and the surgery suite. The telephone switchboard was already out of service. Many wounded were milling around, and triage was already under way. "The personnel of the hospital responded well, and the outside doctors did, too," recalls Jorgensen. "The big weakness was in the physical plant. Some of the areas designated to hold patients had no lights or water. We also didn't have control over manpower distribution. People returned to jobs they had done before, but in disaster, certain normal requirements don't exist. We also did not have ample security. Halls were jammed with relatives and friends looking for missing people." Since the tornado, the hospital has altered parts of its disaster plan and modified its physical plant. "We have { ON, |