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a new generator system that makes the emergency room and surgery virtually independent of the rest of the hospital," says Jorgensen. "We also have a walkie-talkie system in case communication goes out, and the switchboard has been revamped so that even if the main phone system fails, there will still be power for 40 key phones."

The hospital has solved its personnel-assignment problem by establishing a manpower center. "Everyone comes here to be reassigned to jobs created by the emergency, like security, escorting patients, and filling out tags," he says. The hospital also must deal with 100 simulated casualties in an annual citywide disaster drill.

Jorgensen is generally satisfied with the way things went five years ago. "I am especially happy about our wide-open policy of not withholding the names of victims," he says.

New York's Bellevue Hospital Center not only has a disaster plan that is constantly updated and practiced, it has a separate disaster unit to provide on-the-scene medical care to victims anywhere in the five boroughs of the sprawling city. In a place where the bizarre and unexpected are almost daily events, the unit must be capable of dealing with everything from the victims of a politically

EMERGENCY CRISIS

inspired bombing or tenement fire to a plane crash or the sinking of an ocean liner (it received victims of the Andrea Doria and set up a morgue in tents at the docks). It handled 16 such events in 1970 but responded to many more false alarms.

Mainstay of the unit is its disaster truck, an over-age International Harvester ambulance that has been carefully outfitted with oxygen tanks, fracture boards, cots, blankets, airways, medicine, and bandages to handle whatever situation exists when the unit arrives at a disaster.

The disaster unit goes into action as soon as a notification call is received by the hospital switchboard from the police communications center. The telephone operator rings the Bellevue alarm system (seven bells repeated three times) and pages the on-call disaster team, the duty officer, and the nursing supervisor.

The team, consisting of physicians, the emergency nursing supervisor on duty, nurses, the disaster administrator, and a security officer, then assembles by the ambulance-dispatch desk at the rear door of the hospital. The truck has already been moved out and is warming up. When it leaves the hospital, the truck carries a surgeon, the administrator, the nursing supervisor, and the security officer and is followed by two ambulances, each with two doctors and two nurses.

The Bellevue emergency department is by then being staffed by the on-call emergency team, which waits for the first patients to arrive. In the past, all on-duty physicians in

the hospital would respond to the call, but this practice was abandoned because it resulted in confusion when 150 doctors wound up milling around waiting for emergency patients. Often, Bellevue itself may not get any of the patients the disaster unit discovers. That depends on geography.

At the scene, the disaster administrator reports to the police or fire officials and finds out where to establish the triage area. He then assesses bed availability and operating room capability at nearby hospitals.

A typical disaster to which the unit responded occurred last November. Ryan's bar in lower Manhattan exploded when a faulty gas line ruptured, killing several people and injuring about 50.

"By the time we got there, the seriously injured had

been removed to Beekman-Downtown Hospital," recalls Catherine O'Boyle, assistant director of the adult emergency service and the nursing supervisor on duty. "What we had were people not physically injured but hysterical. Some had literally been blown out of the building. It was very confusing, and we had no idea how many might be inside. This is typical because we get a great deal of misinformation. I had been told to expect approximately 45 injured, mostly from smoke and burns. It took 20 minutes to find out they had all been evacuated. This is why it is crucial for one person to coordinate."

Another big problem for the unit is getting through traffic as the truck nears the scene of a disaster. "That's why we bring one of the hospital security guards along," continues Miss O'Boyle. "He jumps out and directs traffic along the way."

Although she believes in preparedness and the constant updating of supplies ("The time to find that equipment is burned out is not when you're at the scene," she says), she is not sold on carrying out dry runs: "I have my doubts. It is nice to paint people bloody, but you can't simulate stress, confusion, and chaos."

With all the financial constraints, apathy, and confusion over exactly what to do, it is not surprising that an attitude of invincibility prevails among many hospital administrators, smug and calm with the printed brochure in the gathering dust on the bottom shelf.

"Under the best of circumstances, response to a disaster will be a disorganized one," says Stormont-Vail's Jorgensen. "But hospitals have to try. What amazes me is the lack of interest by people from other institutions I encounter at meetings. They aren't interested in taking advantage of the experience of others. Their lethargy is almost impossible to overcome. They are too busy seeing the problems day-to-day. It takes experience to reinforce the main point: You've got to have a disaster plan and practice it."

Concluded Engelmohr at the Institute on Disaster Planning: "Every hospital, every single hospital, has a moral responsibility to stand ready to serve, to the extent of its capability, whenever called upon to do so. It is your duty to be certain that when the time arrives, your hospital will be ready."■

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and with a single, controlled explosion, safely removes the driver's side of the car Carefully, the two men strap the woman to a backboard, and a moment later, with both patients aboard, the ambulance is off.

Nearby is a small country hospital, staffed only with a physician on call, it is clearly inadequate Next nearest is a somewhat larger community hospital, better staffed and equipped, but not up to an emergency as severe as this one The run must be to a hospital still farther away, but one equipped with a Class-I FD

The driver runs smoothly, controlling the traffic lights ahead of him electronically from his cab. He has no trouble finding his way, roadside signs clearly direct him to the hospital By radio the police warn him of a traffic tie-up and direct him around it.

In the back, the attendant is talking hy radio to a senior resident in emergency care. who is on duty at the hospital, and he is working under the doctor's instructions. He starts an IV for the woman The man suffers a coronary In a moment, the attendant has wired him. Cardioscopes light up in both ambulance and hospital, and in both places an ECG tape begins to snake out The attendant is prepared to do CPR. administer medication, or defibrillate, as the doctor may order.

At the hospital, appropriate special sts have heen notified and are gathering in the ED Specially trained nurses are ready and with them are other highly skilled ambulance attendants, working in the hospital hetween runs. When the ambulance pulls to a stop the resident comes aboard to give the patients a preliminary examination and direct their removal into the spacious, well-equipped ED The man goes directly to the ED's CCU the woman to the traumia unit I ah and x-ray results are produced in minutes by technicians with equipment night at hand

The woman has AB-negative blood The hospital has only two units on hand: she will need much more A nurse picks up what looks like a telephone but is not and dials a number The message is flashed by radio to every hospital in the vicinity Within minutes, the blood is on its way

The orthopedist, thorien surgeon, cardiologist, and others do their work but the resident in emergency care re

mains responsible for the patients as whole human beings until their own doctor is ready to take over that duty Since it was obvious from the beginning that both patients would be admitted, they have been treated from the start as inpatients and full medical records kept On a simple, multipurpose form, the ambulance men also make a report that becomes part of the record. They then take interchangeable equipment from the ED to replace what they have had to leave there and return to their station

Next morning, the resident makes his customary report to the director of emergency medical service (EMS), who is a senior member of the medical hierarchy at both the hospital and the medical school Later, the records of the cases will be subject to the usual peer review Because the ambulance men and the ED nurses have rendered the med ical services for which they were trained they will have appropriate representation on the review committee And since this story is fiction, all hands win high praise from the committee, while the patients make full recovery

The sad thing about the story is that it is fiction and that it need not be. No such whole system of emergency care exists anywhere, though elements of it may be found in use in scattered places. There is no Buck Rogers fantasy in the system, we have the basic knowledge and skill to develop every component that is not already in use. plus man. others that were not mentioned.

President Nixon's $100-million war on cancer is a gam ble in two respects Ultimate success rests on the hope tha we will discover scientific principles now unknown and there is no way of even guessing how many lives may eventually he saved. To declare war on unnecessary death in the ditch, in the ambulance, and in the ED is no gamble it all If we merely apply existing knowledge, thenly ques tions are whether we will save more than 20 000 or only 10 000 of the more than 100,000 trauma patients who now die yearly, whether we can really prevent 30. of sudden cardiac deaths or whether the figure will be somewhat smaller or greater, whether the estimate of 25.000 persons permanently disabled or injured every year by untrained ambulance attendants is low or high, how vast will he the magnitude of the savings in human suffering and money

House.

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many places where ground ambulances are just not good enough, subject as they are to getting stuck in traffic. ice, snow, and so on," says Dr. John A. Waldhausen, chairman of surgery. "But if Dr. X out in some little town has a man with a severe head injury, with one call he can reach the doctors here, and a helicopter will be there in half an hour."

Dr. Waldhausen sees the helicopter as a partial answer to the maldistribution of physicians. He envisions rural and small-town areas served by a regional helicopter ambulance system. "Yes, it would have to be subsidized, but if government says everybody has the right to quality medical care, then they've got to come up with some dough. It would be a lot cheaper to fly a few helicopters out into the country than to build another Hershey center out there. even if you could do it. And medical advances make it more important than it has ever been to get the patient here. Take the growing treatment of myocardial infarction by surgery. You could never get that in a small town."

There are other approaches to the problems of rural communities. Because the town of Rancho Santa Fe, Calif.. has only 2,700 people, it has no hospital and no hope of one, though there are good hospitals 20 miles away. The town's answer was to build what is essentially a mobile emergency room manned by trained fire department personnel. At a cost of $15,000 cash, plus an estimated $7.500 worth of free services, the townspeople put together a unit completely outfitted with the necessary equipment for cardiac cases. plus such items as a hydraulically operated operating table, two oxygen systems, a suction system, and running water. In serious emergencies, if a doctor is called to meet the ambulance at the scene, he finds just about everything he could need to stabilize the patient.

A problem that is deeply felt in the profession, but seldom talked about openly, is how to get the doctor in the field to yield his patient to the major hospital without feeling that he is being "taken over by that bunch of hotshots." At Hershey. Dr. Waldhausen believes the answer must be to make both that doctor and his little community hospital feel that they are integral parts of the system, not outsiders, He thinks it will help, not only to bring the field man into

Dr. Waldhausen believes 'copters can help relieve maldistribution of physicians

the center for professional refreshment, but to send people out to him and to his hospital to see their problems firsthand and offer assistance and guidance. "The doctor must feel that he's not sending his patient away, but that he s sending him to his own mother house." says Dr. Waldhausen. "But that involves emotions, so it won't come about immediately."

But for any transfer arrangements to work, there must be an effective communications system. More is needed than radio between ambulance, central dispatch, and hospital. In any disaster, there must also be instant, effective communication between hospitals.

In a disaster situation, the hospital is flooded with calls. often to the extent that real emergency calls can get neither in nor out. Some administrators solve the problem partially by installing a special phone with an unlisted number so that they can at least get calls out. But what if, as often happens in disasters, all phone service goes out?

To solve such problems, the Hospital Council of Southern California decided to establish its own interbospital radio network. They wanted a system that was relatively cheap, portable within the hospital, and simple enough to be operable by a busy nurse or orderly with no technical training. Only one manufacturer, Motorola, was interested in trying to develop what was wanted, but they came up with the answer. The equipment is no bigger than an office typewriter, weighs 17 pounds, and has a handset and dial As far as the user is concerned, it operates like a telephone

The council divided the vast Los Angeles area into four regions, says associate executive director Stephen W. Gam ble, and designated one hospital in each as a regional radio center. Each of the 118 hospitals in the network has enough power to reach a cluster of others around it. Regional hospitals have full power and can reach other regions. A central station at council headquarters can reach any hospital. a combination, or all hospitals at once, by dialing a single number. Individual hospitals paid about $3,000 each for equipment and installation. Regional hospital installations cost about $700 more, with the additional expense being borne by the council. The system is tested continually.

The system proved its worth from the beginning. Hospitals used it to send out calls for such things as a magnet to remove a needle from a man's back, a fetal monitor, a pressure suit. Pomona Valley Community Hospital had a critically injured patient with AB-negative blood and only two units on hand. A call on the regional network brought 11 units from six hospitals, rushed in by police car and taxı But the real test came during the February earthquake, which knocked out telephones in the stricken area. The system fell down briefly at only one point, the San Fernando VA Hospital, and that was because the hospital had fallen down upon the equipment. Gamble, shaken out of bed by the early-morning temblor, used the network's mobile unit to find out what was happening and learned that there was a serious situation at Olive View Medical Center By the time he got to the scene, hospital staff were moving out the patients, 115 of them psychotic and anxious.

Through the network Gamble found the places to which the patients could be sent, and they were moved in ambulance, buses, even a police paddy wagon. By 10 30