THE ORGANIZATION OF MEDICAL RELIEF IN NUCLEAR DISASTERS

Magliacani G.

Centro Grandi Ustioni, Torino, Italia

SUMMARY. Nuclear disasters are predictable and they can therefore be prepared for. The particular dangers of this type of technological accident are nuclear radiation and contamination. The various stages of relief are described, together with the general principles on which relief must be based. The importance of preparedness is stressed. New developments in information sciences have improved communication and allow link-ups between central operational headquarters, rescue teams and outlying hospitals. Ten basic principles of planning are listed.

Peacetime nuclear catastrophes can be categorized as technological disasters of known type, i.e. they correspond to situations that have already occurred and been analysed as to their causes and their short- and long-term consequences.
The persons affected may only have been exposed to nuclear radiation and contamination or they may present associated lesions, especially burns or traumas of various nature and gravity.
In the event of radiation the victim can be treated without any particular precautions, while in the presence of contamination it is necessary to limit the risk for the patient, by avoiding the danger of the contamination of non-contaminated parts, and to protect the rescue-workers, who have to observe some simple but strict norms.
The first treatment therefore has to be decontamination, which must not however in any way delay the treatment of other lesions, particularly burns. Patient triage must be based on 'criteria of emergency:

1. absolute emergency - life-threatening injuries and radiation, or life-threatening injuries alone;
2. relative emergency - injuries with a less severe prognosis and radiaiion or non life-threatening injuries and contamination.

As far as the organization of relief is concerned, nuclear disasters do not however differ from other types of disaster. Given the characteristic shortage of available means and the difficulties of their appropriate use in such conditions, it is necessary that all available resources should be used rationally in order to maximize their performance and to achieve a positive cost/benefit ratio.
An adequate organization plan must therefore be drawn up, which must be rigid in certain aspects (communication, approach routes, hospitals to be alerted) but also elastic enough to be able to cope efficiently with an event which, though provoked by a specific cause, can present victims with traumas of various nature.
There are some general principles which if carefully followed make it possible to provide a functional response to nuclear disasters.

1. As many disasters, whether natural or caused by man, are predictable, a permanent state of preparedness is imperative - the higher the degree of preparedness the more effective the response will be.
2. Although no disaster is identical to any other, the problems arising are to a large extent comparable. It is therefore possible to develop a model for each type of disaster and to prepare a management plan.

This applies also to the organization of medical relief, both immediate and subsequent, which must fit harmonically into the wider context of the organization of rescue work.
Medical relief can be schematically divided into six interdependent moments:

• alarm
• activation of rescue-work
• operation of prepared plan
• triage and medicalization
• evacuation
• hospitalization.

For effective management of an emergency with a high number of victims the rescue chain requires the presence of a pre-existing organization at local level. In other words, the capacity of dealing with this type of situation depends upon appropriate programming based on the identification of hospitals, personnel and means belonging to health structures that already exist and can be immediately activated (and if necessary reinforced), and that are capable of facing any type of catastrophe.
Medical relief is in three successive stages.

1. An initial generic but immediate intervention at the scene of" the disaster, provided by local hospitals, however few, with medical staff and/or nurses already present or transferred to the scene from neighbouring areas.
2. Planned intervention of specialized personnel and means from other organized structures and centres, capable of operating with the appropriate equipment in relation to the specific nature of the disaster. This phase sees the achievement of the highest level of operational efficiency.
3. Transfer of patients, involving various means of transport and medical relief in outlying areas, making use of local or regional hospitals, and if necessary of other hospitals in the national territory if the number of patients is very high.

The first phase begins at the scene of the disaster and is followed a few hours later by the second phase. The first to be called into action are mainly public structures and their personnel, normally employed in other activities but in a state of preparedness for disasters. This first response is of considerable importance for the correct prosecution of the subsequent phases, particularly with reference to the eventual destination of the disaster victims.
The beginning of the third phase corresponds to the evacuation of the patients. With reference to patient transfer, the vehicles used represent a very important link in the efficiency of the rescue chain. The choice of vehicle depends on the distance between the site of the disaster and the intermediate or final destination and on the technical specifications of the various means of transport.
Various forms of transport are possible -ambulances and vehicles converted for sanitary transport by road, rail or air.
The final stage is medical relief in hospitals in outlying areas.
For this relief to be effective, the hospitals must be able to adapt their facilities and operational rhythms to the collective demands of the emergency, which is possible only if certain essential points are taken into consideration:

• the hospital buildings and services must be prepared for the influx of large numbers of patients;
• the personnel must be increased in number, ensuring that they have the specific training for the specific work required;
• it is essential to abandon the mentality of an exclusively traumatological emergency and to be prepared for other types of collective emergencies;
• reserve stocks of materials and drugs must be maintained, not forgetting that different emergencies require the use of particular drugs that are usually available only in small quantities.

The architectural lay-out of the hospital buildings will require a certain number of modifications, both internally and externally. We recommend separate access and exit routes for ambulances, one or more acceptance areas large enough to handle large numbers of patients, the creation of secondary routes towards one or more triage points prior to transfer to the various hospital departments, the transformation of existing services for the acceptance of patients with different pathologies, and the increase in the number of hospital beds available by the discharge of all in-patients whose condition, given the state of emergency, can be treated on a out-patient basis.
The extra staff called in must be of all categories so that all the various activities can be provided. The mobilization of this back-up staff is an exercise that requires careful planning.
The pluridisciplinarity of the medical teams is a guarantee of the versatility necessary to ensure the adequate assistance of victims suffering from traumas, burns, and nuclear contamination and radiation.
As the demand for materials and drugs increases enormously after a disaster, it is necessary to prepare and maintain stocks appropriate for the main types of lesion that may occur; these stocks must therefore be created on the basis of precise studies that predict the potential risks.
The organization of this type of medical relief, which should limit the risks of failure, presents some fundamental points that need careful evaluation if the results of previous experiences are to be improved upon.
Among these is the creation of a national organism that centralizes all information relating to the various types of disasters, particularly with regard to medical information, such as the number of dead, the types of lesion, the measures taken and the inadequacies observed.
This would permit the constitution of interdisciplinary working groups capable of co-ordinating all the data gathered and of drawing the necessary conclusions.
The medical and nursing staff in health facilities in at-risk areas must be instructed in the basic elements of the pathologies that may have to be treated; they must attend refresher courses and have working experience in specialized departments, in order to standardize materials and methods and thus facilitate their diffusion.
In order to meet the needs arising from a nuclear disaster it is necessary to establish permanent communication links between the various specialized hospitals in the territory and if possible between these and decentralized hospital facilities.
This can be achieved by means of a network of information systems, creating a two-level support infrastructure which is complemented by a third nucleus organized in turn on various levels.
The first level consists of either a main, nation-wide, interactive "mesh" network which connects all the main treatment Centres and is organized by several interacting computers, or a star-type network connected to a central computer.
The second level comprises a series of "star" networks distributed in one or more regions, on a lower hierarchic level, which organizes the link-up of General Hospitals with the nearest specialized Centre; this enables a large number of users to contact the specialized Centre so that patients can be admitted to other hospitals depending on it. This first system needs to be supported by an Operational Centre, linked up to the main network responsible for the organization of patient transport on a nation-wide scale.
The main network must guarantee a flow of information that includes the availability in real time of beds in the various national Centres. The regional network would permit the use of non-specialized departments for the hospitalization of patients under the diagnostic and therapeutic management of the principal Centre in the network. In other words, in the event of a disaster, the first-level national network (either mesh or star) would make it possible to fill up all the main Centres without any waste of time, and subsequently, thanks to the second-level regional link-ups, it would be possible to occupy the General Hospitals nearest to the scene of the disaster. The patient transport network has the task of organizing and. effecting the distribution of victims to their various destinations. It makes use of already existing organization such as the Army, the Police Forces and the Fire Brigade, which must however co-ordinate their activity with a view to this specific purpose by the creation of link-ups with the main hospitalization centres. Helicopter services, where they exist, can provide valuable help in this respect.
An example of this link-up system can be seen in the solution proposed in Italy for bum emergencies, with the establishment of a "Severe Burn Victirn" network, in the context of the existing nation-wide ARGO system. This network guarantees the satellite link-up of all Centres in Italy, through a central headquarters.
The ARGO system has a star network for the transmission of analogic and digital data. The network produces a display in real time of bed availability throughout the country and, in connection with a Central Headquarters for Patient Transport (known in Italy as COTA) makes it possible to arrange the necessary measures for early care and immediate transport to the nearest available Burns Centres.
This system could be completed by a series of secondary star networks on a regional or multiregional basis~ at a lower hierarchic level, which would link up General Hospitals with the nearest specialized facility. These networks would be activated in emergency conditions in order to permit admission to hospital facilities other than the main Centre.
This would make it possible to use nonspecialized departments for the hospitalization and treatment of disaster victims, with the benefit of the diagnostic and therapeutic assistance of the main Centre in the network.
The ARGO system will make it possible to fully occupy all the national centres without delay and when the secondary link-ups have been created with the decentralized hospitals, it will also be possible to make more rational use of the General Hospitals nearest to the disaster.
The Operational Headquarters will be responsible for the organization of means of transport and operative details for the provision of transport and, through its link-ups, it will localize the position of the necessary means, organize their mobilization, arrange flight plans and routes for other means of transport necessary for the emergency mission, and alert contacts in the destination area for the co-ordination of relief vehicles.
It is therefore indispensable for the success of the relief programme that an emergency plan should be prepared that concerns not only the specialized Centres but also the secondary structures that need to be activated in emergency conditions.
However, in the presence of any disaster with large numbers of victims, even the best organization can prove to be inadequate because of the prevailing state of confusion - due also to the influence of the inevitable mass psychosis - which hampers methodic and rational rescue operations. Failure is a virtual certainty if relief has not been properly planned beforehand, for in this case the only possible results are the negation of the rescue-workers' efforts together with errors of evaluation as to the gravity of the survivors' conditions and therefore as to the therapy to initiate and the hospitals to be used. All this sets off a series of negatively interacting reactions.
This is certainly not the best way to face a disaster, which is an emergency that must not be passively awaited but accurately predicted. It is unthinkable to attempt to resolve these problems with extemporary measures - the only possible way is through the involvement of personnel, structures and materials in a state of perfect efficiency, adaptable to whatever situation arises thanks to operating methods that remain valid in exceptional circumstances.
The conclusion to be drawn is that a state of preparedness is necessary that takes into account the following ten points:

1. preparedness of local resources, available in the neighbourhood of areas at potential risk, as located and marked on maps;
2. location of preferential access routes in order to speed up traffic to and from the disaster scene;
3. training of local medical workers for Phase 1 interventions, according to pre-established plans;
4. creation of a specialized mobile sanity nucleus provided with equipment necessary for Phase 2;
5. establishment, if not already in existence, of link-ups between specialized Centres and between the latter and neighbouring hospitals, in order to make the best possible use, without any delay, of all hospital beds;
6. organization of patient transfer away from the disaster area, without haste, making rational use of the most appropriate means of transport, not forgetting that the first need is not hospitalization but immediate medical treatment;
7. selection of patients with the best survival prospects for admittance to specialized Centres;
8. utilization of temporary facilities set up in loco for treatment of minor lesions, in order to avoid unnecessary hospitalization;
9. rational deployment of volunteers in order to prevent their assistance from turning out to be negative in the overall management of the disaster;
10. co-ordination of all the forces present in the disaster area, with the assignment of specific and complementary tasks to each one.

RESUME. Les catastrophes nucléaires sont prévisibles et it est done possible d'&tre en état de préparation. Les dangers de cc type particulier d'accident technologique sont la radiation et la contamination nucléaire. Les phases successives des secours sont décrites, comme aussi les principes généraux sur lesquels les secours sent basés. On souligne Pimportance d'&re préparé. Les nouveaux dévéloppements dans l'informatique ont facilité les communications et permettent des liaisons entre le Centre opérationnel, les équipes de secours et les hépitaux périphériques. En conclusion, it y a une liste des 10 principes fondamentaux de la planification.