edition - 1991: 1. CPR system (resuscitation bag - mask â mayo cannule â suction device â oxygen supply) ... rescue scissors. 20 rapid disinfection systems. 10.
AIRPLANE ACCIDENTS AND AIRPORT TERRORISM: MEDICAL EMERGENCY PLAN Villa G.F. – Paganelli M. S.S.U.Em. 118 Lecco e Provincia, Italy I.R.C.C.S. - H. San Raffaele, Milan
INTRODUCTION In the third millennium air transport catastrophes will be the most probable emergencies from a statistical point of view, as more and more people will be using the airplane as means of transport. In the Airport Area in particular, great emergencies can be grouped in two main categories: AB-
airplane accident on the ground: air crash within the airport area or airplane accident during take-off, landing or while taxying illicit act within the airport or unexpected destruction of airport structures. Terroristic attempt at the airport or at the airplane, air piracy or collapse and explosion of fixed structures.
While it is easier and intuitive to analyse the reasons of an airplane accident on the ground, it is more difficult to understand the reasons leading to many criminal actions. One of the possibilities under consideration is the conflict existing between the “Western” world and “Emerging Countries” that wish to emerge. This conflict increases the possibilities of damage to people, airplanes or infrastructures and installations caused by illicit terroristic actions. OPERATIVITY The gap existing between the resources that are immediately available and the extensive assistance required by these events highlights the need of an organisation aimed at reducing improvisation and the inevitable confusion through the exploitation of predetermined resources. Airport rescue should be operative throughout the day and night for 365 days a year in view of obtaining an adequate initial treatment and the final qualified assistance to a high number of injured people. A-
Airplane accident on the ground
Based on specialised literature, rescue operations in an airplane accident on the ground are estimated to involve 25% of the injured population (the remaining people are usually dead or only slightly injured). Standardised rescue plans should therefore cover the primary medicalisation of 80 -100 individuals prior to their evacuation from the accident area (see Enclosure 1). When the accident status is declared, specific rescue plans for each airport service must be actived in view of proper interaction throughout the emergency stages.
After the first “RESCUE” phase involving only the firemen and police, the “MEDICAL RESCUE” algorithm shall include: 1)
primary scene survey by the doctor on duty for the “flight line” of the medical service for the airport area to assess assistance requirements and proper activation of the rescue operation
2)
the first "TRIAGE" by the airport physician while awaiting the activation of the medical resources
3)
immediate evacuation of the uninjured and slightly injured people by the airport assistance personnel
4)
establishment of a forward medical post according to logistic possibilities (mobile system or airport area or other appropriate structure) for the primary medicalisation of the injured people
5)
evacuation of the injured people according to hospitalisation priority following the directives of the competent operative medical centre.
At the end of the medical evacuation, the “CONCLUSIVE PROCEDURES” will include both the monitoring of uninjured subjects and the final assessment of the deceased for the implementation of forensic procedures. A critical review of the technical and medical approach will be carried out at a later date (see enclosure 2). B-
Terroristic attempt or unexpected destruction of structures
Airport rescue plans for these events should not be substantially different from those of the previous category (point A). Operative modifications will essentially concern the different logistics of the event, which cannot be classified a priori, and the timing of the medical rescue which should be started only when the police or firemen (e.g. Police in terroristic acts, Firemen for collapses and explosions) have established acceptable safety conditions. See enclosure 3 for a flow chart of the procedures to be carried out in these situations. PRACTICAL REQUIREMENTS The effectiveness of the rescue operation depends on the preparation of the following: 1)
suitable medical equipment (permanent supplies)
2)
specific medical rescue transport means within the airport
3)
a dedicated medical communication system between the airport physician responsible for the “flight line” and the “118” emergency centre of the territory involved or other medical emergency centre temporarily replacing the 118 service to organise rationalised hospitalisation.
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4)
a field-rescue training programme every three years for all airport personnel
5)
a V.R.Q. programme based on the results of drills carried out at on an annual basis
The following equipment is required for the first two points: a-
equipment for airways management, ventilatory support, venous infusion and drugs for at least 50 injured people for a 2-hour field rescue operation
b-
stretchers, thermic protection systems and equipment to assist at least 100 injured people, 50 % of whom considered in urgent need of vital parameter monitoring and body stabilisation
c-
appropriate protective clothing for at least 20 on-field rescuers with proper identification systems
d-
a 4-wheel drive medical rescue car with adequate radio communication for the establishment of a mobile command post
e-
at least 2 ambulances for transfers within the airport area and one 4-wheel drive rescue ambulance with a large sanitary module to be used as Forward Medical Post in unfavourable logistic conditions
f-
at least 2 emergency trolleys to carry the above-mentioned medical equipment to the rescue areas (and proper transport means) or other all terrain vehicles with the same functions
g-
proper co-ordination plan with the craft of the Harbour Master’s Office for the airports located on or near the sea
Moreover, a sheltered area within the airport (preferably close to the customs zone) with proper lighting, water and a sewerage system shall be reserved for the bodies of the deceased. Immediate diagnosis confirmation procedures shall be carried out in this area and/or the bodies recomposed (Morgue). The area will also be accessible to the vehicles transporting the bodies in and out of the shelter. The Airport Medical Service, if available, or other territorial Medical Service will be responsible for the means of transport, equipment and medical material and will guarantee specialised operators for proper maintenance of the equipment and continuous revision of the efficiency and legal expiry dates of the medical supplies. This model is applicable to all Italian airports classified > 5th class according to the ICAO classification (International Civil Aviation Organisation), and can be implemented and operative in the medium term. The general organisation should anyway be based on the following points: 1) optimal quantification and qualification of the structures, means, required material and personnel and services involved;
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2) planning of rescue phases on the accident area for the operators of all the different services inside and outside the airport; 3) implementation of specific disaster medicine protocols for the medicalisation of the injured; 4) definition of medical transport coordination by territorial services 5) activation of internal mass emergency plans in the nearby hospitals as per document no. 27/93 of the Civil Defence Department 6) preparation of protocols for logistics and road network management that may keep into account the safety requirements of the operator and population involved; 7) concomitant presence of a physician for the “flight line” for the emergencies in which the airport remains open. Due to the current lack of specific regulations for airport accidents in Italy the only guidelines to be followed are the recent I.C.A.O. 1991 regulations (International Civil Aviation Organisation), the D.C.A. procedures (Direzione Circoscrizione Aeroportuale del Ministero dei Trasporti) which are different for each airport, and the universally accepted indications of disaster medicine for the medical treatment of the injured. The solutions proposed in the enclosures aim at enhancing the effectiveness of the rescue operation by compressing the time required for the different steps, thus increasing the possibilities of survival of the subjects involved in the catastrophe. REFERENCES G. Bergot, M.: Le secours dans l’ Aeroport de Paris; Convergences 5, 4-5, 1986. P.J.F. Baskett: Schemi Operativi per interv. sanit. in aereop.; Collana Sago 1989 G.F.Villa: Organizzazione di un piano di soccorso per una grande emergenza aeroportuale, 9° Convegno Naz. sull’ Emerg. Sanit., Arabba 1993. I.C.A.O. doc. 9137 – AN/858 Part 7, second edition - 1991
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ENCLOSURE 1
MEDICAL EQUIPMENT AND MATERIAL RECOMMENDED FOR THE PERMANENT SUPPLY OF MAJOR AIRPORTS (6th class and higher)
Minimum equipment recommended as permanent medical supplies according to updated ICAO regulations, doc. - AN/858 Part. 7, second edition - 1991:
100
stretchers, 50 of which backboards, scoop or similar and 50 to be stacked on-site
20
kits for extensive burns
50
splints for immobilisation of different types of fractures
20
cervical collars for neck immobilisation
20
kits containing equipment and devices for advanced life support for at least 20 patients
50
kits containing medication and nursing
20
O2 portable oxygen supply for at least 30 minutes
2
monitor defibrillators
5
suction devices
5
portable mechanical ventilators
500
body bags for the deceased or to collect body parts.
ENCLOSURE 2
MEDICAL EQUIPMENT AND MATERIAL RECOMMENDED FOR MINIMUM SUPPLY IN MINOR AIRPORTS (5th class and lower) Minimum equipment recommended as permanent medical supplies according to updated ICAO regulations, doc. - AN/858 Part. 7, second edition - 1991: 1
CPR system (resuscitation bag - mask – mayo cannule – suction device – oxygen supply)
1
intubation kit with five tubes
20
i.v. needles with obturator or anti-reflux system
4
tourniquets
1
BP monitor and stethoscope
1
rescue scissors
20
rapid disinfection systems
10
rolls of sterile gauze
10
haemostats
10
burn medications
1
straight scissors
5
sterile disposable surgical scalpels
20
disposable syringes of different volumes
10
ace bandages (different widths)
10
elastic bandages (different widths)
5
net bandage systems
6
20
safety pins
5
band aid rolls (different widths)
1
box of 100 band aids
10
large thermic metal blankets (180X180)
2
cervical collars
1
set of splints
100
casualty identification tags
7
pencils with rubber
10
large plastic sheets
1
scoop stretcher
1
backboard with straps
1
immobilisation mattress with pump
This material should be stored in a single container together with the stretchers to be transported on the scene by a rescue car.
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ENCLOSURE 3
MEDICAL EMERGENCY FLOW CHART STATE OF EMERGENCY stand by medical means
STATE OF ACCIDENT
End of emergency
wait for “on scene intervention” authorisation
POSITIONING in the area indicated by the Firemen
Traffic Control Office Confirmation (T.C.O.)
RECONNASSAN CE with appropriate rescue means or by foot
RESCUE ACTIVATION as needed and transfer of information to Traffic Control Office and Medical Emergency Centre (S.S.U.Em.118)
EVACUATION
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uninjured by airport personnel ENCLOSURE 3bis ESTABLISHMENT OF F.M.P. and secondary triage sending update to Medical Emergency Centre (S.S.U.Em.118)
MEDICALSATION OF THE INJURED airways monitoring venous infusion body stabilisation Analgesia (S.T.A.R.T.)
EVACUATION BY PRIORITY of the injured and hospitalisation following notification to Medical Emergency Centre (118)
FINAL REVIEW OF THE DECEASED and notification of T.C.O. and Airport Medical Service; review of “uninjured“ subjects preparation of on-site mortuary
END OF EMERGENCY DECLARATION collection of clinical data and fulfilment of legal requirements and review of resources used
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ENCLOSURE 4
MEDICAL EMERGENCY FLOW CHART FOR TERRORISM OR PIRACY
STATE OF EMERGENCY Stand-by for the rescue and activation of plan with strategic positioning of medical means
INTERVENTION Only after satisfactory safety conditions
RECONNAISSANCE AND TRIAGE With establishment of area for medicalisation or rapid evacuation of the injured
MEDICALISATION OF THE INJURED And their evacuation by priority(S.T.A.R.T.)
FINAL CONTROL OF CASUALTIES Transfer of the deceased according to the regulations of the competent authorities and completion of legal requirements
END OF EMERGENCY DECLARATION Collection of clinical data and review of resources used
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