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OF

B y H. L. GLYN HUGHES,D.S.O., M.C.,

South East Metropolitan Regional Hospital Board.

y

OU have done me the honour to invite me to address you this evening on the subject of evacuation of casualties. This I have taken to mean the clearance of the wounded following a m a j o r incident and d u r i n g a state of war ; not just the evacuation of casualties in a n y m a j o r railway, air, or other type of accident. I n other words, it is a problem of mass evacuation u n d e r modern conditions, conditions which involve the use of atomic weapons of v a r y i n g power. I would wish to state at this stage that a n y t h i n g I say this evening, a n y suggestions I make, are entirely m y own personal opinion based on previous experience and not coloured in a n y way by official representations of memoranda. I n the past few years we have experienced the problems of planning to deal with destruction caused by atomic weapons of v a r y i n g strength, firstly the nominM 20 kiloton bomb a n d now more recently the vastly increased requirements associated with the 10 megaton bomb. W i t h the exception of certain i m p o r t a n t factors, I would stress that t h e r e - a r e certain basic principles associated with the evacuation of casualties which are the same f o r all stations in which a large n u m b e r of casualties have to be cleared f r o m what m i g h t be described as the forw a r d areas. The most i m p o r t a n t one of these which I should like you to remember while we are considering this problem is that to achieve the quickest a n d best results and to exercise the greatest economy in ambulance cars the r u n of each vehicle in this f o r w a r d area must be as short as possible, a n d that no cars f r o m this zone should be sent on long runs to hospitals situated more t h a n a p p r o x i m a t e l y 4-5 miles behind the clearance line to which cars can proceed in the f o r w a r d zone. There are other factors which emphasise this point, to which I will refer later, but it is the chief of all basic principles and one which does influence the whole of one's planning. Evacuation of casualties over longer distances t h a n this must be organised by a different procedure. I think now it would be well to p a i n t a picture, which would cover a n y size of bomb, but one which would illustrate the various problems applicable to all. Special ones arising f r o m the 10 megaton bomb I will deal with later. I n all cases there will be an area of total destruction or irreparable damage v a r y i n g f r o m half a mile to 6 miles; outside this damage which m a y v a r y f r o m moderate to severe f r o m 2 to 16 miles, and light damage beyond this again f o r some miles. The worst picture in the blocking of streets is that difficulty, which can be quite serious, m a y exist f r o m 2 to 13 miles, a n d beyond this even light debris, which m a y need clearance. The blockage will of course v a r y with the width of the street, the character of the buildings, and the direction in which the street runs in relation to the burst of the bomb, whether radial or at right angles. Address delivered, by invitation to the Section of Public l=l:ealth, Royal Academy of :Medicine, 5th February, 1957.

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This problem of debris is obviously the one of m a j o r importance in the collection a n d evacuation of casualties, but there are others which provide even g r e a t e r hazards. I r e f e r to the fire situation a n d the effects of radiation. Fires m a y extend a n y t h i n g up to 14-16 miles f r o m the ground zero of the burst ; in v a r y i n g intensity, of course, but in a n y case there will be a v e r y appreciable m a i n zone which will v e r y quickly add to the risk and difficulty of extricating casualties and getting them away. This is one of the more i m p o r t a n t reasons f o r ensuring t h a t local ambulance cars are kept on short runs in the f o r w a r d areas to clear as m a n y casualties as possible, a n d not to prejudice their economic use b y sending them on long journeys. A p a r t f r o m other difficulties produced b y the congestion on roads arising f r o m the mass of population t r y i n g to get out a n d the q u a n t i t y of rescue a n d fire-fighting vehicles t r y i n g to get in, these two problems o£ debris and fire are the main ones which immediately affect the evacuation of casualties whatever the calibre of the weapon. W i t h the increased power of the 10 megaton bomb, however, there is one h a z a r d which, although it does exist with the smaller bomb, has been multiplied out of all p r o p o r t i o n a n d now presents m a n y and v a r y i n g problems. I r e f e r to the effects of heat and the fall-out of residual g a m m a radiation which, as you will recall f r o m the case of the J a p a n e s e fishermen, m a y now, down wind, extend f o r some hundreds of miles and involve areas unaffected by other hazards. The heat effects are the normal s y m p t o m of burning, but depend entirely on exposure in the open. These m a y extend for 20 miles. The plotting of the p a t t e r n of the fall-out will v a r y with m a n y factors, p r i m a r i l y the direction of the wind, complicated by the fact t h a t direction will v a r y at different heights, but also the nature of the burst whether it be air, ground, or water. The tima of arrival of this fall out at different distances will also depend on v a r y i n g factors. Another complication will be the possibility of nuclear explosion in other locations, even at considerable distances away. I cannot, of course, in this lectul'e, in the time at m y disposal, deal with the m a n y other details associated with this m a j o r problem, except to stress at this point the importance, in the documentation of casualties, of recording the exact locality where the casualty was at the time of the b u r s t and whether u n d e r cover or in the open. I will r e f e r to this again later. These, then, are the m a i n problems affecting the actual m a c h i n e r y to deal with the evacuation of casualties, but the problem is obviously v e r y much wider t h a n this and must affect the hospital service as a whole, as it is only by p r o d u c i n g the right structure that the vast numbers can possibly be dealt with. I think t h a t now it would be wise to assume the worst p i c t u r e - - t h a t of the 10 megaton bomb and its area of serious damage of a p p r o x i m a t e l y 14 miles, an area in which it will be difficult to envisage the possibility of o r d i n a r y hospital life continuing. One will, therefore, have to plan for the evacuation of hospitals of every t y p e f r o m this ~rea, a n d at the same time to have a flexible plan which will range f r o m no w a r n i n g at all, through the possibility of a limited w a r n i n g to the best picture of a

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longer period of rising tension. I n all these plans the essential population remaining in the area to c a r r y on essential duties must be catered f o r a n d a skeleton service provided in certain of the general hospitals to cover emergencies. Given a moderate degree of warning, it should be possible to evacuate all the patients and equipment f r o m the hospitals in the f o r w a r d zone, taking into account that a large n u m b e r of patients can be sent to their homes direct. Those patients t h a t still require hospital care should be sent right back to the base areas and not to the hospitals that it is expected will take in the bulk of casualties in the first instance. W h a t will be the picture behind the f o r w a r d areas which, unlike the picture in battle of a comparatively straight f r o n t line, is now that of a circle? W i t h the smaller nominal 20 kiloton bomb one h a d hoped in the case of the larger cities t h a t certain of the hospitals on the outskirts and outside a 4-mile radius would have survived and provided accommodation for the reception of casualties where u r g e n t surgery and t r e a t m e n t could have been carried out ; one is now faced with the prospect that stretching f r o m the 14-mile circle of severe damage there m a y be long distances to cover before suitable hospital accommodation either exists or can be made available. I t is this that must determine the method of using ambulance cars and the procedure that must be adopted in handling casualties on the spot and in providing the various types of hospital accommodation required. Let us assume that, just as in w a r time, there are three zones : (a) The f o r w a r d areas, say up to 18-20 miles f r o m ground zero; (b) An area behind this which in size, location, shape and width m u s t depend on the existence of hospitals and suitable accommodation which could be requisitioned for the reception of a v e r y large n u m b e r of casualties. This could well be called a hospital a r e a ; it could be pre-dctermined in relation to the evacuation f r o m a large city, and alternative areas m u s t be available to allow for the p a t t e r n of radiation fallout. There might well be a distance of 10-20 miles between the r e a r unit of the f o r w a r d area and the entrance to this hospital area. (c) Behind this again a base area, which will consist of existing hospitals and requisitioned buildings. Ill all these areas considerable use m a y need to be made of tentage. I n the hospital area (b) and base area (c) for actual hospitals, and in (a) to provide large tented reception areas. To cover the procedure now in an orderly way, and assuming that we have existing or made provision for hospital accommodation in areas (b) and (c), let us trace the machinery of evacuation from before backwards; in doing this I do want you to keep in y o u r minds the vast numbers of casualties that might have to be dealt with. I will go into greater detail in regard to the middle zone, or hospital area, when we have the casualty safely there, but we must first consider what personnel we shall have available to deal with the casualties in the f o r w a r d areas before they embark on what m a y be quite a long j o u r n e y to the midzone or hospital area. The lessons of the last war must be remembered,

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the one in particular, MOBILITY. There m a y be m a n y ways of organising personnel to deal with this problem, but no m a t t e r what is decided the following types are essential : Rescue workers to free casualties, Stretcher bearers, F i r s t - A i d teams auxiliaries.

consisting

of

doctors,

trained

nurses

and

I will not go into, the problem of the rescue workers and stretcher bearers, but I think t h a t the F i r s t Aid t e a m s must be organised d u r i n g times of peace so that they m a y be highly trained a n d exercised in what m a y be expected of them. They should be organised in large n u m b e r s a n d a general policy decided in the methods of using them. I t is the civilian population from which they will be d r a w n and the policy laid down, irrespective of a n y help t h a t might be provided b y the a r m e d forces. I t is essential t h a t they should be mobile and t r a n s p o r t provided for them. I f there is any w a r n i n g or, better still, a period of rising tension these t e a m s m u s t be w i t h d r a w n f r o m a n y areas considered especially ~ulnerable back into the mid-zone or hospital area. There will already be some of these teams in this area and also the base area. W h e r e v e r they m a y be, t h e y can c a r r y on with hospital duties until such time as they m a y be required to be deployed f o r the m a j o r incident. The nuclear explosion has now taken place, and the extent of the d a m a g e known, but there can be f o r some time no definite knowledge of the numbers of casualties nor the p a t t e r n of the radiation fall-out. This will give some breathing space which can well be m a d e use of for redeployment purposes. I t m a y well be t h a t in certain areas the population in the area who have escaped m a y have to stay p u t in their houses or shelters for a long period, possibly f o r several days and down-wind until they are told they m a y come out. This provides a v e r y large p e g on which to h a n g the a r g u m e n t that the whole population must be made F i r s t Aid conscious, and trained in the first principles of home n u r s i n g a n d essential F i r s t Aid. Whilst they are compelled to stay put, there m a y be injuries or sickness to deal with, and no lessons learned at any time are wasted. Let us assume t h a t it is possible to evacuate casualties, that there is also a fire risk and t h a t large n u m b e m can be got out fairly quickly. The hospital area is some w a y away, the near edge quite 12-15 miles. R e m e m b e r now the basic principle of casualty evacuation I mentioned early on ; that is, that to produce economy and a good service the f o r w a r d area must be kept flooded with ambulance cars. I f you do appreciate this it is obvious t h a t there must be a buffer between the f o r w a r d area and the mid-zone hospital area, and no car f r o m the f r o n t line sent back on a long journey. This can only be provided b y some f o r m of Casualty Collection Centre in which large quantities of casualties can be gathered together a f t e r they have been released and brought there, n o r m a l l y b y the local ambulances f r o m the f o r w a r d area who know all the local roads a n d w a y s of approach to damaged areas. I t is essential t h a t this unit must cover a wide space. E i t h e r a big building in which large numbers can be accommodated or, perhaps even

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better still, a large tented space which can more easily be organised to provide good approaches and exits for ambulance cars a n d p a r k i n g space for the other ambulance cars a n d coaches required to take the casualties back to the hospital area. A t this centre should be stationed several F i r s t Aid teams, the n u m b e r depending on the casualties to be expected. Assuming that each team might consist of a p p r o x i m a t e l y 12 (to include one doctor), it would ensure there was available sufficient personnel to c a r r y out essential F i r s t Aid if this had not been done and to look a f t e r the cases if there was likely to be a n y delay in their transfer. I t must be strictly understood that nothing elaborate should be carried out at such a Collecting Centre. I t is mainly triage that is needed and, as I have said, essential F i ~ t A i d ; on no account should a n y surgical procedures be carried out, nor should a n y f o r m of blood transfusion be included except in cases of dire emergency. This is much better carried out where surgery is available. Careful triage is essential, p a r t i c u l a r l y to avoid evacuating to hospital a n y minor injuries or ailments which would make unnecessary use of ambulances or beds. This careful sorting should also ensure t h a t if there are a n y special hospitals in the mid-zone or base areas cases f o r them could be diverted at this stage. I refer in the main to psychiatric cases. Unless they already exist there will not have been time to organise a n y special units in the early stages; these will come later. I would again stress t h a t this reception area should be as big as possible to allow freedom of movement among the stretchers. The size of it and the n u m b e r of F i r s t Aid teams must depend on the volume of casualties expected on a n y p a r t i c u l a r main route out of a large city. The circular n a t u r e of the f r o n t line increases the difficulty in this respect, but p r e - p l a n n i n g to some extent is possible and if the local ambulances with their local knowledge are used correctly time in getting casualties out of the danger area will be saved. F r o m the collecting centre there can be an orderly distribution of casualties to the rear areas wherever these m a y be, I t is almost certain t h a t no one city would have enough ambulance t r a n s p o r t of its own to deal efficiently with the casualties to be expected in an incident of this kind; ambulances will be required from other sources and also civilian t r a n s p o r t of all kinds; buses for the ambulant cases. The evacuation f r o m the Casualty Collecting Centre should be organised on the lines of a motor ambulance convoy. This is all on the assumption that the hospital area is some long distance away and that definite ambulance routes to it have been laid down and sign-posted as soon as possible. On each route there should be some f o r m of check point at the e n t r y to the hospital area so that convoys or individual ambulances can be directed to the right hospital. I f this is done it is a point to which information must be sent of the closure of any hospital or other details which might be required. Much confusion will be avoided if this procedure is adopted, and also valuable information quickly available of the total n u m b e r of casualties that have passed t h a t way. Now that we have got to the hospital area, I think we should take stock of what we mean by this term. I t certainly cannot be a tidy

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p a t t e r n easily defined, but must obviously be the most suitable area behind one or other of the sides of a l a r g e city where hospitals already exist, a n d on which can be built up a large hospital organisation either by the requisitioning of suitable large houses and buildings a n d / o r by the addition of tentage if this is available. No possible size can be laid down f o r such an area ; it might well be, a n y t h i n g u p to 12 miles square or even bigger. I t is more the organisation and administration of such an area t h a t matters, and the fact t h a t to produce the best results it must be u n d e r our control. There will be problems of all kinds to be dealt with, medical, lay and nursing, which affect the whole area and it would be well to have one t i t u l a r head f o r each of these, but over all of them there must be one " C o m m a n d e r " who in this case should be a doctor as every single problem must have a medical flavour whoever deals with it. The same organisation to a lesser degree will be requ;~red in each hospital .or group of hospitals within the area. I f we are assuming t h a t this area has been chosen because some hospitals already exist there, the new ones that arise within this area, either by improvisation or requisitioned buildings or tents, should be linked for administrative purposes with them. I t would simplify the chain of control. The a d v a n t a g e s of such an area are m a n y a n d obvious. The orderly distribution of casualties or e n t r y to the area has a l r e a d y been r e f e r r e d to. There are m a n y other problems which m a y include supplies, water, burial of the dead, communications, sign-posting, policing, stretcherbearing within hospitals, nursing, provision of medical equipment, special medical and surgical teams, Blood Transfusion Service, relief of F i r s t Aid teams, and countless others which can be organised and a r r a n g e d if there is centralisation of these m a n y problems within a definite area. H o w e v e r good the set-up, there is bound to be confusion in the early days. Buildings cannot be taken over, equipped and staffed in a flash, but if there is such an administrative hospital area p r o p e r l y thought out beforehand it m u s t lighten the burden. As the days a f t e r the first attack go on the problems will become simpler a n d it will then be possible to organise even better selection a n d build up special units. W i t h this system, too, the evacuation f r o m this area to base areas, wherever they m a y be, will be m a d e easier, p a r t i c u l a r l y if this involves travel by air or rail. I t is an organisation which has already proved its worth and would I think be the only one t h a t might stand up to the strain of the immediate reception of large numbers of casualties. I said v e r y little at the beginning of m y talk about the evacuation of the hospitals f r o m the f o r w a r d areas; there are details connected with this which can be i m p o r t a n t in relation to the hospital area I have been speaking about. I have already said t h a t no patients f r o m the evacuated hospitals should be sent to it, but all to the Base areas and with them, of course, the staff required to nurse them. Stressing on this point t h a t the ratio of n u r s i n g staff to patients in all hospitals must perforce be on a very m u c h reduced scale. There will be, however, 'the need to equip and staff requisitioned or tented buildings both in the hospital and Base areas, a n d p r e - p l a n n i n g should cover the w a y in which this m u s t be carried out. I t might be advisable to link each hospital a r e a with

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certain base areas. I n that case all staff, whether medical or nursing, could be evacuated with this hospital to a base area and then by p r i o r a r r a n g e m e n t redistributed to make up the staff for the additional beds set up wherever they m a y be. E q u i p m e n t is somewhat different, and if it is possible, this should be moved f r o m the evacuated hospital a n d stock-piled in chosen locations f r o m which it can be drawn as required. The same procedure should be carried out with tentage and p a r t i c u l a r l y that required in the mid-zone or hospital area, as it is here t h a t the problem of the radiation fall-out will affect the picture. I t certainly should not be erected and occupied before the nuclear explosion takes place as the patients would have to be evacuated, but whether it is erected beforehand on chance, left e m p t y and then decontaminated if necessary by washing down, or whether erected a f t e r w a r d s is a m a t t e r for discussion. I personally p r e f e r the latter as with good drill erection can be effected so rapidly p a r t i c u l a r l y if all arrangements, m a r k i n g out, w a t e r supplies etc., have been organised beforehand. W i t h r e g a r d to the base area I propose to say v e r y little. I t can differ v e r y little f r o m our normal peace time set-up, except in so f a r that there m u s t be v e r y considerable additions to the n u m b e r of beds required. These m a y be of three kinds. Either the acute, general type if the area is short of these, secondly, special units of various kinds, and thirdly recovery units to which cases requiring much less attention can be admit'ted and where the trained nursing staff can be on an even smaller ratio. I think you will realise that the time has been all too short for me to deal with this vast subject except in a somewhat sketchy manner, but I do hope it has given you a picture of how I see the only way of dealing with a mass casualty evacuation of the kind that one might expect. Discussion. Dr. J. D. M c C o r M i c k : As I l i s t e n e d t o :Dr. t t u g h e s a n d t h e m o r e h e spoke, t h e m o r e i t w a s b o r n e in on m e t h a t he is too k i n d l y a m a n in s p i t e of hi s m i l i t a r y career, a n d I w a s n o t c o m f o r t e d . I a m g r a t e f u l t h a t ]: h a v e r e a c h e d t h e t i m e of life w h e n I c a n p r a y t h a t I w o u l d be in t h e f o r w a r d d e s t r u c t i o n area. W h e n £ s a y t h a t he is t oo k i n d a n d t o o h u m a n e , i t is b e c a u s e h i s p l a n s do n o t a l l ow for d e a l i n g w i t h a m o n s t e r l i k e me. G r e a t B r i t a i n is g o i n g t o be a t t a c k e d b y R u s s i a a n d , s u p p o s i n g I a m t h e R u s s i a n for t h e t i m e b e i n g , I a m g o i n g to p l a n m y a t o m i c w a r on G r e a t B r i t a i n a n d t h e U.S.A. q u i c k l y a n d callously. I a m n o t g o i n g t o s t a r t i t w h e n t h e y t h i n k I a m goin g t o s t a r t it. I a m n o t g o i n g to s t a r t it u n t i l I h a v e l u r e d t h e m i n t o a s e ns e of false s e c u r i t y b y a c t i n g t h e l a m b . I w i l l choose t h e t i m e of y e a r w h e n I c o u l d e v a c u a t e m y cities b e f o r e h a n d . I do n o t care if y o u b l o w Moscow t o s m i t h e r e e n s , :[ w i l l b e l a u g h i n g a t you, b u t if I s t a r t w a r on G r e a t B r i t a i n I a m g o i n g t o b l a s t h y d r o g e n b o m b s on L o n d o n , E d i n b u r g h , G l a s g o w , B r i s t o l a n d t h e n T w i l l r a n g e g u i d e d m i s s i l e s on t h e m w h i c h w i l l m a k e e v a c u a t i o n a n i m p o s s i b i l i t y . T h e n i t w o u l d b e a n e a s y m a t t e r for m e t o s t a r t m y g r o u n d forces. T h a t b e i n g so, ][ w i l l hope t o h e a r t h a t I a m e n t i r e l y w r o n g in m y s t r a t e g y , b u t I d o agree t h a t i t is a b s o l u t e l y n e c e s s a r y for t h e m o r a l e of a n y n a t i o n t h a t t h e r e s h o u l d be p l a n s , b e c a u s e if y o u h a d no s u c h p l a n s y o u w o u l d h a v e n o t h i n g b u t p a n i c , a n d w h a t w a s h o r r i b l e w o u l d b e c o m e I=~ell t h e n , a n d I t h i n k it is n e c e s s a r y t o h a v e t h e m to lull t h e pe opl e i n t o a sense of false s e c u r i t y . B u t w e d o c t o r s h a v e g o t to be r e a l i s t i c , a n d I w o n d e r how m a n y of t h i s g a t h e r i n g w i l l ag ree w i t h m e t h a t t h e o n l y hope we h a v e of t h e r e b e i n g no s u c h w a r in t h e f u t u r e ls to i n s t i l t h i s fear i n t o e v e r y o n e . L e t us hope i t w i l l n e v e r occur, b e c a u s e I b e l i e v e t h e s u r v i v o r s of s u c h a t r a g e d y are t o be p i t i e d a n d t h e d e a d e nvi e d. Dr. POWELL : Dr. ~ t u g h e s h a s g i v e n us a clear p i c t u r e of t h e e v a c u a t i o n of m a s s casualties. T h e t r o u b l e a b o u t e v a c u a t i o n is t h a t h i t h e r t o i t h a s b e e n a m i l i t a r y p r o b l e m a n d t h e c h i e f t h i n g in such e v a c u a t i o n is t h e s o r t i n g of easuMties. N o w w e

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have to deal w i t h h u n d r e d s of t h o u s a n d s if the a t o m b o m b hits us. All ages, all classes, all sexes. We will require m o r e t h a n the m i l i t a r y m e n , we will require all our professional people, doctors, dentists, vets, nurses a n d e v e r y b o d y w h o k n o w s a n y t h i n g a b o u t nursing. W o u l d we be ready to deal w i t h s u c h a p r o b l e m in this c o u n t r y ? Are we even m e n t a l l y r e a d y to deal w i t h it ? I t h i n k it is u p to us in the profession to t h i n k a b o u t t h i s even if we do n o t do a n y t h i n g a b o u t it, because it is we a n d only we w h o could a n s w e r this question. I w o u l d like to t h a n k Dr. I-~ughes v e r y m u c h . :Mr. COgCORAN : I was shocked b y the picture draw~l o f the y e a r s to come. F r o m the practical p o i n t of view I t h i n k t h a t the t r u t h o f t h e situation, as it applies to this country, is t h a t we are n o t aware of the possibility of w h a t m a y lie in f r o n t of us. I do n o t t h i n k t h a t 1 per cent. of the people in t h i s c o u n t r y have the slightest knowledge t h a t a b o m b is in the offing, nor even of the possibility of this fall-out. P e r h a p s t h a t is j u s t as well, b u t I t h i n k t h a t the first t h i n g we h a v e got to do is to t r y a n d educate t h e people as to the possibilities, which are v e r y real. As y e t ~here h a s been no real experience of the w o r s t type of a t o m or h y d r o g e n b o m b a n d so there is a need for real e d u c a t i o n of the people as to the dangers. T h e m o r e practical a p p r o a c h m i g h t be n o t to s t a r t a t the top, b u t r a t h e r at the b o t t o m , a n d gradually b y such a c a m p a i g n to educate the o r d i n a r y m e n a n d w o m e n in s o m e simple FirstAid. T h a t would n o t cost m u c h a n d would be of practical use. I n this w a y t h e y would h a v e some idea h o w to deal w i t h simple casualties a n d f r o m t h a t develop our plans gradually as the d a n g e r approaches so as to be in some w a y p r e p a r e d for the awful catastrophe. Mr. T. C. J. O'CoNNELL : I a m horrified b y the r e m a r k s of Dr. ~IcCormack. I n this very city we have, I suppose, a b o u t 40 general surgeons a n d 20 specialist surgeons, able to do general surgery. A b o u t "60 altogether. ~V[ost of these w o r k all d a y in the city. I do n o t t h i n k it w o u l d need a n y h y d r o g e n b o m b to deal w i t h t h a t lot. Outside the city there are a b o u t a n o t h e r 60 surgeons in the c o u n t r y w h o are b u s y in their own centres a n d possibly t h e y would have evaded the fall-out. I w a s t r y i n g to figure o u t h o w the surgical p r o b l e m could be attacked. ]~ow could we place s u r g e o n s ? T h e y are n o t w a n t e d inside, t h e y are w a n t e d outside. I t h i n k m y s e l f y o u need blood transfusions and you do n o t need surgeons to do t h a t , b u t y o u need to h a v e the b l o o d t r a n s f u s i o n outside. Y o u need surgeons w h o can deal w i t h the o r d i n a r y casualties such as fractures, a n d t h e n the b u r n s surgeon, one w h o could deal w i t h electrolytes. Y o u h a v e got to k n o w w h e n it will h a p p e n a n d get a s m a l l n m n b e r of s u r g e o n s w h o are n o t b u s y inside, outside. I f we are going to have a Pearl I-~arbour I do n o t k n o w h o w we are going to deal w i t h the surgical p r o b l e m . The p r o b l e m to us n o w s e e m s so unreal. I n t h i s c o u n t r y it is a very difficult t h i n g to get people to believe this is real at all. You can talk a b o u t it as m u c h as y o u like, b u t n o b o d y believes a w o r d of it. I n the last w a r we could n o t get t h e m frightened into doing a n y o r d i n a r y jobs, b u t it did affect us in a s m a l l w a y , a n d I h a v e no d o u b t w h a t e v e r t h a t in the n e x t w a r we shall be in it. I am only concerned w i t h the surgical side a n d I w o u l d like to h e a r a little m o r e of the p l a n s to get the people out. I suppose we will all be told w h a t we have to do, b u t if the d a y comes it will h a v e to be m o r e t h a n a v o l u n t a r y thing. The people will have to be told w h a t to do a n d m a d e to do it. Mr. CRAWFOI~D : I Would like to say h o w very m u c h I h a v e enjoyed this lecture because e v e r y t h i n g he s a y s s e e m s to tie up w i t h w h a t we h a v e learnt over the last four or five years going over to the British Civil Defence Staff College. There is one link b e t w e e n the engineer a n d the medical side which seems a great p r o b l e m to me, a n d I h a v e never h a d an a n s w e r to it, W h e n casualties have been given First-Aid h a v i n g been got o u t of the debris, where do the stretcher bearers come from to bring t h e m t o the a m b u l a n c e s ? The theory is t h a t the a m b u l a n c e will provide personnel to p u s h in over the debris a n d will organise the stretcher bearer parties. F r o m w h o m are t h e y going to organise t h e m ? T h e y are s u p p o s e d to take t h e m f r o m the people c o m i n g out. These people h a v e been t h r o u g h a lot a n d m a y h a v e lost m e m b e r s of t h e i r o w n families. I s it reasonable to expect t h e m to t r y a n d do stretcher bearer w o r k ? Stretcher b e a r i n g leaves one completely exhausted. I h a v e tried carrying a stretcher ~nd h a v e been completely e x h a u s t e d in a v e r y s h o r t time. I f y o u could possibly get arr~_y or i n f a n t r y m e n in t h e y w o u l d be m u c h better. I s there a n y o n e else y o u could get ? One t h e o r y is t h a t it is a good t h i n g to give a p e r s o n like t h a t w h o has come o u t s o m e t h i n g to do. W h a t does Dr. H u g h e s t h i n k ? Dr. :I-It~G~,r,s : I agree w i t h Mr. Crawford. Stretcher bearing is one of the h a r d e s t t h i n g s y o u could do, even u n d e r good conditions. I t w o u l d be quite impossible to get a person w h o is on his w a y o u t to bear a stretcher. I f he w a s a m a r r i e d m a n he w o u l d be looking after his family. The only hope is to get the W a r d e n s , etc. from a n area w h i c h h a s n o t been b a d l y d a m a g e d to provide help. I f there is a large n u m b e r of casualties cut off inside the debris area I hope to deal w i t h t h a t p r o b l e m b y h a v i n g

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a large n u m b e r of First-Aid t e a m s a t the collecting centre a n d detaching f r o m t h e i r personnel to go in and do w h a t e v e r is necessary a n d keep t h e m inside a n d t r y to feed a n d organise t h e m in there, until there are decent conditions to get t h e m out. P e r h a p s y o u could get t h e m o u t b y helicopter. I f you have got a large p a r k or s o m e t h i n g of t h a t n a t u r e it c a n n o t be completely covered w i t h debris so there will be r o o m to organise things there. W i t h regard to surgeons here y e a ar3 in a difficult position w i t h limited n u m b e r s , b u t e v e r y b o d y has got t o get d o w n a n d do general s u r g e r y a n d this brings o u t the importance of the b r e a t h i n g spae~ which m a y h a v e to exist because of the delay caused b y the radiation fall-oat. I f there is a n y w a r n i n g a t all you m u s t get out y o u r key people. I do n o t k n o w w h a t th+ an~w~:r to t h a t one is. EvelBzone w i t h a medical qualification is expected to get his co~t o% a n d get d o w n to the problem. I agree w i t h Dr. MeCormaek as to th~ m~tho:l~ I w o u l d use i f I w a s the enemy. I hope this situation will never come, b u t th+ m o r e wa a t t a c k t h s p r o b l e m in the field of First-Aid the b e t t e r we will be. Dr. MAGNER: I e n j o y e d this p a p e r very m u c h and Dr. H u g h e s w a s one of the people w h o w a s v e r y m u c h to the fore in 1940 w h e n the medical services in the field were being reorganised. I really m u s t consider a n y t h i n g t h a t he says very seriously for he has the experience a n d the " k n o w - h o w . " I imagine t h a t our mesh likely p r o b l e m w o u l d be to deal w i t h fall-out, a n d I suppose that, in an attack we would get s o m e idea as to where the line of fall-out w o u l d come. I imagine t h a t all comm u n i c a t i o n s b y individual g r o u p s w o u l d h a v e to be done b y " walkie-talkie " and I c a n n o t imagine a n y b o d y here a t t a c k i n g the p r o b l e m w i t h the p r o p s r e q u i p m e n t unless the A r m e d Forces took it on. T h e y have e q u i p m e n t and t h e y have the field a m b u l a n c e a n d troops w h o could guide people a n d keep the roads clear. There are several incidents of the medical services t a k i n g a d v a n t a g e of an3" w e a p o n t h a t t h e y could get hold of to e v a c u a t e casualties, a n d ]E t h i n k if y o u are travelling in E n g l a n d t o d a y you will realise t h a t t a n k s are three a penny. T h e y could be used in a n area w h e r e there is general destruction. We h a v e n o t got e q u i p m e n t , b u t every f a r m e r in the c o u n t r y h a s a hayrick a n d a t a r p a u l i n a n d we could use these as tents. There is no d o u b t t h a t in cases like this, one h a s to use the resources t h a t one finds in the c o u n t r y . We would also consider air e v a c u a t i o n b y helicopters w i t h sling e q u i p m e n t to get casualties off the ground. People m u s t come to realise t h a t we are living in a danger zone a n d t h a t e v e r y b o d y should be capable of doing a certain a m o u n t of first aid or nursing. Dr. ~-~OLMES IVERS: There is one little p o i n t t h a t Dr. ~Y~cCormack w o u l d have to take into consideration a n d t h a t is the expense of these b o m b s so t h a t if y o u are a t t a c k i n g a t a r g e t you are going to a t t a c k one w o r t h y of the expense of the bombs. As far as I can see the m a i n fall-out here will be if a b o m b is t h r o w n in Liverpool. A v e r y i m p o r t a n t p o i n t c o m e s o u t of the fall-out. We h a v e the a d v a n t a g e t h a t the prevailing w i n d is f r o m here. Of course if we do get a b o m b ourselves and if it were d r o p p e d in the centre of the city a n y b o m b t h a t h a s a total destruction area of four miles would p u t out every hospital in D u b l i n if it struck, say, in College Green. T h e real p r o b l e m w o u l d be if we did get one ourselves in this c o u n t r y w h a t are We going to do. The A r m y will h a v e a job of their own. I t h i n k the only thing to do is to s t a r t w i t h the people w h o have to deal w i t h the p r o b l e m a n d t h a t is the }~edieal Officer of ]~ealth. I f t h e y t h r o u g h the schools a n d the teachers could teach the y o u n g people the p o i n t s necessary in dealing w i t h m a s s casualties it w o u l d n o t be tong before y o u w o u l d h a v e a v e r y large trai1~ed body. T h e y w o u l d influence their o w n people at h o m e so t h a t it w o u l d be t h e quickest w a y of spreading the education. I f y o u do s t a r t y o u r p r o p a g a n d a a m o n g the ordinary people you m a y do a great deal more t h a n t h a t , because you m a y s t a r t a m a s s h y s t e r i a w h i c h would prove to be a problem. T h e schools m i g h t become possible hospitals and you would have trained m e n there. W i t h regard to e q u i p m e n t we will have to get a w a y from the e q u i p m e n t used so far s u c h as h e a v y m a s s i v e stretchers. I h a v e seen v e r y light b u t strong deck chairs of a substance like a l u m i n i u m a n d these w o u l d certainly be a help. Mr. BUCKlViASTER: I h a v e a v e r y direct interest, in this subject, b u t I have n o t the responsibility of t r y i n g to solve this problem. There is n o t m u c h t h a t I can cont r i b u t e to this discussion to-night. I w a s v e r y interested to hear w h a t Mr. O'Connel[ said. H e said it w a s a p r o b l e m to get people to take it seriously. Our D e p a r t m e n t o f Defense has b e e n w o r k i n g on it, a n d I m u s t confess t h a t t h a t is the difficulty. W e h a v e p u t a n u m b e r of people t h r o u g h our school over the p a s t four or five years, a n d it is encouraging to realise t h a t we h a v e found t h e m v e r y enthusiastic, a n d it w a s v e r y easy to i m b u e in t h e m a willingness to help. I w a s delighted w i t h the c o n t e n t o f this lecture tonight. Mrs. EDMUNDSON : There is one p o i n t w h i c h I w o u l d like to make. I w a s acting as First-Aid instructor in the Civil Defenee in E n g l a n d a n d the point I feel is t h a t

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I entirely agree t h a t it is v e r y essential to keep the p o p u l a t i o n as well trained in F i r s t Aid as possible, h u t it did p r e s e n t g r e a t difficulties. You h a v e a u n i t of people together. Y o u are only able to give t h e m a m o s t e l e m e n t a r y training in F i r s t Aid and unless you keep it u p all the t i m e t h e y become o u t of d a t e ; we did find it a h e a v y b u r d e n to keep t h e m u p to d a t e a n d a b r e a s t of their t r a i n i n g a n d it did require a v e r y large personnel. ~ r . B U R ~ : I t is m y d u t y to p r o v i d e the resuscitation t e a m s t h a t w o u l d go into action first, and :[ should t h i n k t h a t the doctors will h a v e quite a n a m o u n t of t i m e to m a k e the necessary a r r a n g e m e n t s . The difficulty as I see it is to m a k e the people aware of the seriousness of the p r o b l e m . There is t h a t t e n d e n c y to rely on t h e G o v e r n m e n t to do this, t h a t a n d the other thing. W e should t r y to get the people to develop a real c o m m u n i t y spirit. The whole idea of self-help. T h a t is t h e spirit we will h a v e to get here before a n y e q u i p m e n t . I f t h e y realise the seriousness of the p r o b l e m I believe our people will rise to the difficulties. I believe there will be a certain a m o u n t of panic a n d disorganisation for a time. The w a y ~ see it is to get the resuscitation t e a m in first to get the people out, b u t we m u s t have t r a i n e d l~ed Cross personnel. I f there is a big fall-out the resuscitation t e a m can only go in for a certain time. ~[ w o u l d like to see all the m e m b e r s of the c o m m u n i t y t a k i n g an interest in this q u e s t i o n of civil defence. W e have a m i x t u r e of all classes a n d if w e get t h a t interest f r o m all sections of the c o m m u n i t y I t h i n k we can face up to t h e situation, i a m v e r y glad to be p r e s e n t here t o n i g h t a n d I w o u l d like to c o m p l i m e n t Dr. I-Iughes on h o w far he h a s got in his planning. Dr. C R o w s : Seldom h a s a speaker w i t h m o r e personal experience s p o k e n to ar~ audience here. W i t h r e g a r d to r a d i a t i o n he spoke a b o u t the J a p a n e s e fishermen. J u s t a b o u t t h a t t i m e we got w o r d t h a t a big c o n s i g n m e n t of J a p a n e s e s a h n o n w a s in the P o r t of Dublin. We took s o m e of the t i n s and b r o u g h t t h e m u p to Dr. O ' R i o r d a n w h o tested t h e m for radiation, b u t did n o t find anything. Suppose there h a d been some form of r a d i a t i o n could you experience a n y disease f r o m eating t h a t s a l m o n ? Some of these fishermen got their r a d i a t i o n s y m p t o m s m a n y y e a r s after the explosion. I n the m e a n t i m e could t h e y h a v e been well a n d if t h e y gave s o m e blood for a t r a n s f u s i o n w o u l d t h i s produce r a d i a t i o n sickness s u b s e q u e n t l y ? Dr. DEENY : E v e r y t i m e I go t h r o u g h the village of Leixlip I a l w a y s w o n d e r w h a t t h a t bridge will be like. I t could n o t s t a n d up to a n y t y p e of w a r - t i m e traffic a n d u n t i l t h i n g s like t h a t are looked after w e could n o t go in to do a n y t h i n g in Dublin. I t is all v e r y well p u t t i n g t h i s t h i n g o u t of our m i n d , a n d it is the sensible t h i n g to do, b u t we h a v e seen t w o m o n s t e r s in our life-time. People t h o u g h t years ago t h a t t h e y w o u l d n e v e r use aeroplanes b u t t h e y did, a n d in the s a m e w a y it is p r o b a b l e t h a t in o u r life-time s o m e b o d y will use an a t o m i c b o m b . I would like to t h a n k Dr. :Hughes. Dr. :I-IuGn~S : $ t h i n k the p r o b l e m of the blood t r a n s f u s i o n is a m u c h m o r e imp o r t a n t one t h a n the other, a n d t h a t is w h y I a m so keen on d o c u m e n t a t i o n . I entirely agree w i t h X~Ir. Burke. T h e w a y we t r y to do it is to get the local a u t h o r i t y going in the w a y of W a r d e n s a n d so on. I w o u l d love to see a n a t i o n a l R e g i s t r a t i o n Card organised again on which w o u l d be y o u r blood group, y o u r civilian occupation, y o u r t r a i n i n g in a n y civil defence, etc. so t h a t the people t a k i n g particulars w o u l d be able to delegate y o u to t h e b e s t work. I t is so h a r d to keep the interest up. Y o u are b o u n d to get apathetic. We t r y to do it b y recruiting c a m p a i g n s , b u t I do n o t k n o w w h a t the a n s w e r is except to go on trying. I t h i n k the v o l u n t a r y organisations could help. I t h i n k m a t r o n s of hospitals can keep it going. We will h a v e to use the schools as hospitals a n d if we could teach the senior pupils n o w t h a t w o u l d be a good help later on. T h e fall-out is a real danger a n d y o u m u s t s t a y u n d e r cover a n d tell everybody, b u t you ~o get a w a r n i n g and as long as y o u k n o w the danger a n d the drill it should n o t be too b a d a proposition. The difficulty of c o m m u n i c a t i o n is great b u t all our mobile F i r s t Aid t e a m s are equipped w i t h m o t o r cycles.