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Victim-tracking cards in a community disaster drill
CONCEPTS, COMPONENTS,AND CONFIGURATIONS
Victim-Tracking Cards in a Community Disaster Drill Michael L. DeMars, MD* Richard M. Buss, MA t Leslie C. Cleland, MPH* Detroit, Michigan
During a disaster drill at Detroit-Wayne County Metropolitan Airport in September 1978, an attempt was made to evaluate the effectiveness of triage by tracing the routes of "victims" using a system of tracking cards. The cards were placed with the victims during make-up and collected at the receiving treatment facility. The system, despite several problems encountered in its use, provided an accurate method for evaluating the manner in which "victims" were handled during the "rescue" effort. DeMars ML, Buss RM, Cleland LC: Victim-tracking cards in a community disaster drill. Ann Emerg Med 9:207-209, April 1980.
disaster planning, drills, tracking cards; emergency health services, evaluation studies; triage, tracking cards INTRODUCTION W i t h the increased organization of emergency medical services and the occurrence of a n u m b e r of a c t u a l disasters, t h e c o m m u n i t y aspects of d i s a s t e r plann i n g have a t t a i n e d g r e a t e r significance. 1 Disasters (multiple c a s u a l t y incidents) which occur in a c o m m u n i t y n e c e s s a r i l y involve m a n y agencies to provide services vital to the victims. 2 This has r e s u l t e d in the formation of d i s a s t e r plans encompass i n g m u l t i p l e organizations and agencies. 1-4 To test the effectiveness of these plans, the d i s a s t e r drill h a s become accepted as an i m p o r t a n t and necessary tool.2, 5 A l t h o u g h c e r t a i n l i m i t a t i o n s r e s u l t i n g from the s i m u l a t e d n a t u r e of the exercise m u s t be accepted, the drill nonetheless provides a test of the a b i l i t y of the p l a n - - and the c o m m u n i t y - - to respond to the emergency. Such a drill was staged in S e p t e m b e r 1978 by the Detroit M e t r o p o l i t a n - W a y n e C o u n t y (Metro) Airport, in compliance with F e d e r a l A v i a t i o n Agency r e g u l a t i o n s r e q u i r i n g a test of its d i s a s t e r plan. A v a r i e t y of agencies were involved in the p l a n n i n g , organization, and conduct of the drill. One of the most i m p o r t a n t functions in i m p l e m e n t i n g any d i s a s t e r p l a n is t r i a g e of the victims. 2 S a l v a g i n g the g r e a t e s t n u m b e r of victims possible depends o n the r a p i d and efficient identification of those r e q u i r i n g i m m e d i a t e attention, those whose care can be delayed, a n d those a l r e a d y beyond h e l p 2 Because a n u m b e r of hospitals v a r y i n g in size a n d capability will be involved in a large-scale disaster, it is i m p o r t a n t to avoid t r a n s p o r t i n g a victim to a hospital which m i g h t be ill-equipped to deal with his injury. This would necessitate a second transfer, From the Emergency Department, St. John Hospital, and the Section of Emergency Medicine, Wayne State University School of Medicine;* Wayne County Health Department;J- and Southeastern Michigan Council on Emergency Medical Services,:~ Detroit, Michigan. Address for reprints: Michael L. DeMars, MD, Department of Emergency and Ambulatory Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, Michigan 48070.
521207
Ann
Emerg Med
9:4 (April) 1980
resulting in delay of definitive treatment and use of vehicles and personnel which should be available to return to the scene. As important as the function of triage is, however, it is also one of the most difficult to e v a l u a t e d u r i n g a simulated disaster. With large numbers of casualties and several t r i a g e personnel, it is virtually impossible for members of an evaluation committee to personally observe each victim's route from time of the incident to arrival at the final t r e a t m e n t facility. In an attempt to fill this gap in t h e evaluation process, we d e v i s e d a method of tagging v i c t i m s w i t h a tracking card to provide the information necessary to effectively e v a l u a t e this important function.
METHOD Triage and Transportation Triage was begun by emergency medical technicians (EMT-As) from the airport fire department who were later relieved by a team of physicians and nurses. Victims w e r e t a g g e d using the Medical Emergency T r i a g e Tag (METTAG) o b t a i n e d from t h e Journal of Civil Defense, S t a r k e , Florida. Triage c a t e g o r i e s were: I (red), highest priority; II (yellow), urgent; and III (green), " w a l k i n g wounded." T r a n s p o r t a t i o n w a s by ground vehicle to one of eight a r e a community hospitals or the field hospital (first aid station) in the airport terminal, or by helicopter to one of two area burn centers. Those "dead-onthe-scene" were to be left at the crash site for transportation to a t e m p o r a r y morgue at the conclusion of the drill.
The Tracking Card The tracking card used is illustrated (Figure), At the time of makeup, the injury being s i m u l a t e d was noted on the victim's card (1). A space was provided for noting the category into which the victim was placed by the triage officer (2) and the hospital to which the victim was sent (3). The victim was asked to note the t i m e he was removed from the crash site and a space for this was provided on the card (4). Since transportation was simulated, we thought t h a t time of removal from the crash site would be a more accurate indicator of t h e o r d e r in which victims were transported t h a n wouldthe time of a r r i v a l at the hospital. Personnel were stationed at each of the participating community hospitals, the field hospital, and the temporary morgue to collect the cards as the victims arrived.
9:4 (April) 1980
PATIENT TRACKING CARD 1. Type of Injury: 2. Tag Code/Color:
3. Arrived at (Destination):
(Name of Facility or Hospital)
4. Time of Transport from
the Disaster Site: INSTRUCTIONS:
Please turn in to an evaluator (with yellow cards) when you arrive at a final location, eg, hospital or
field station. Please record or remember your time leaving scene. Your card will be filled in by evaluators at the site and when turned in at your destination.
F i g . 1. Victim-tracking card. The collector m a d e the notations on the cards, m a k i n g it u n n e c e s s a r y to provide all victims with pencils and lessening interference with their s i m u l a t i o n of injury. The c o l l e c t o r noted the t r i a g e category from the t a g placed by the t r i a g e officer, e n t e r e d t h e n a m e of the receiving hospital, a n d obtained the t i m e of removal from the crash site from the victim. The cards were t u r n e d in by the collectors at the critique session i m m e d i a t e l y following t h e drill.
RESULTS E a c h of t h e 206 p e r s o n s p a r t i c i p a t i n g in the drill as victims was g i v e n a t r a c k i n g c a r d (Table). Of these, 178 cards w e r e r e t u r n e d for e v a l u a t i o n . T w e n t y - f i v e of the lost cards were those given to the victims who were to be considered "dead-att h e - s c e n e . " T h e s e v i c t i m s , in a m{x-up in communications, were not t r a n s p o r t e d to the t e m p o r a r y morgue a n d the card collector at the morgue was, therefore, unable to obtain the cards. The remaining three cards were lost by the victims during the exercise. T h e c a r d s w e r e r e v i e w e d for t h e i r usefulness in e v a l u a t i n g t r i a g e (that is, the actual sorting of victims into t r e a t m e n t priorities) and destination. A card was considered usable in assessing t r i a g e if it contained the description of the victim's injury and the t r i a g e priority category assigned b y t h e t r i a g e officer. It w a s considered usable in assessing the destination of the victim if it contained e i t h e r t h e d e s c r i p t i o n of i n j u r y or t r i a g e category and the n a m e of the r e c e i v i n g f a c i l i t y . If a c a r d n o t e d both description of injury and t r i a g e code, the decision was based on the
Ann Emerg Med
code, as d e s t i n a t i o n would most app r o p r i a t e l y be based on this, the decision of the t r i a g e officer. Incomplete cards were e x a m i n e d for possible use in e v a l u a t i n g a t l e a s t one of the functions (triage category or destination) u n d e r consideration. F o r example, a card would be usable for assessing t r i a g e if it noted type of injury and t r i a g e category assigned even t h o u g h it did not contain t h e n a m e of the r e c e i v i n g f a c i l i t y and c o u l d not, t h e r e f o r e , be u s e d to e v a l u a t e destination. Conversely, a card could be used to e v a l u a t e dest i n a t i o n if it contained the description of injury and n a m e of receiving facility even t h o u g h the t r i a g e code was missing. One h u n d r e d twenty-four cards were found to be usable in assessing t r i a g e (Table). C a r d s w e r e e l i m i n a t e d b e c a u s e t h e t r i a g e t a g was missing from the victim when he arr i v e d a t t h e h o s p i t a l or t h e t r i a g e category was not noted on the tracking card. One h u n d r e d forty c a r d s w e r e found to be usable in assessing the p r o p e r d e s t i n a t i o n of t h e v i c t i m s (Table). C a r d s were e l i m i n a t e d because the receiving facility was not noted or the victim h a d been carried b y helicopter.
DISCUSSION A n u m b e r of p r o b l e m s w e r e identified in the i m p l e m e n t a t i o n of this s y s t e m of evaluation. A major difficulty r e s u l t e d from i n a d e q u a t e briefing of the personnel assigned t o collect t h e t r a c k i n g cards. Since the victims were w e a r i n g the t r i a g e tags, an airport security pass, and a sticker noting t h e i r injury, in addition to c a r r y i n g t h e t r a c k i n g card,
208/53
Table OUTCOME OF VICTIM-TRACKING CARDS No. Cards Cards placed Cards returned Cards missing Lost by "victims" Cards from "deadat-the-scene" Cards usable to assess triage Eliminations Triage tag lost from "victim" Triage category not on tracking card Cards usable to assess destination Eliminations Military personnel Destination not on tracking card
206 178 28 3 25 124 54 4 50 140 38 9 29
some collectors incorrectly identified the card they were to collect. Others, u n f a m i l i a r with t h e t r i a g e coding system, entered the wrong information on the card or left t h e space blank. None of the victims noted the time he was removed from the crash s i t e e v e n t h o u g h each h a d b e e n asked to do so and the instructions
54/209
were printed on the card. This was most likely due to their own excitem e n t at p a r t i c i p a t i n g in the drill, and, possibly, because some may not have been wearing watches. A t r u l y effective method for d e t e r m i n i n g the order in which the victims are actually transported r e m a i n s to be worked out. Some v i c t i m s lost t h e i r cards, probably an unavoidable factor. The description of the injury on some cards was too vague, rendering retrospective evaluation of the card somewhat inaccurate. For example, some cards stated merely "3 ° b u r n " without indicating extent or location, i n f o r m a t i o n v i t a l i n d e c i d i n g how such a victim should be handled. F i n a l l y , t h e loss of the cards from the victims "dead-at-the-scene" could be avoided by a s s u r i n g these v i c t i m s were t r a n s p o r t e d to t h e proper place or by collecting these cards at the crash site r a t h e r t h a n w a i t i n g to collect them at a temporary morgue. Since these victims are left at the site u n t i l last in a n y drill, and then u s u a l l y t r a n s p o r t e d en masse, the cards could effectively be collected at this time. The strengths of this system are t h a t it provided accurate t r a c k i n g of victims in the majority of cases; it e n a b l e d e v a l u a t i o n of the triage of those cases in which the injury was accurately described; and it enabled t h e e v a l u a t i o n c o m m i t t e e to spot some major errors in the triage and t r a n s p o r t a t i o n of the victims. It also
Ann Emerg Med
p o i n t e d out the s t r e n g t h s a n d accuracies of these two most i m p o r t a n t functions. For example, 78% of the v i c t i m s received a p p r o p r i a t e treatm e n t priorities and 81% were transported to the appropriate t r e a t m e n t facility.
CONCLUSION Triage is both one of the most i m p o r t a n t f u n c t i o n s ~of a d i s a s t e r p l a n and one of the most difficult to evaluate d u r i n g a drill. The use of the card system described here, with correction of the problems encount e r e d , p r o v i d e s a n i n v a l u a b l e ins t r u m e n t for e v a l u a t i n g this function. The use of this s y s t e m - - or some modifications of it - - is recommended for incorporation into every c o m m u n i t y disaster drill.
REFERENCES 1. Theoret JJ: Exercise London: a disaster exercise involving numerous casualties. Can Med Assoc J 114:697-699, 1976. 2. Hays MB, Stefanki JX, Cheu DH: Planning an airport disaster drill. Aviat Space Environ Med 47:556-560, 1976. 3. Fishel ER: Exercise "Med-Ex" 73. Md State Med J 23:46-48, 1974.
4. Mayo ER: Community disaster drill. Med Times 98:164-169, 1970.
5. Clark RB: Disaster drills, letter to the editor. J A C E P 7:416, 1978. 6. Evans D: Simulated aircraft disaster instructional exercises at BaltimoreWashington International Airport. Aviat Space Environ Med 47:445-448, 1976.
9:4 (April) 1980
Victim-Tracking Cards in a Community Disaster Drill Michael L. DeMars, MD* Richard M. Buss, MA t Leslie C. Cleland, MPH* Detroit, Michigan
During a disaster drill at Detroit-Wayne County Metropolitan Airport in September 1978, an attempt was made to evaluate the effectiveness of triage by tracing the routes of "victims" using a system of tracking cards. The cards were placed with the victims during make-up and collected at the receiving treatment facility. The system, despite several problems encountered in its use, provided an accurate method for evaluating the manner in which "victims" were handled during the "rescue" effort. DeMars ML, Buss RM, Cleland LC: Victim-tracking cards in a community disaster drill. Ann Emerg Med 9:207-209, April 1980.
disaster planning, drills, tracking cards; emergency health services, evaluation studies; triage, tracking cards INTRODUCTION W i t h the increased organization of emergency medical services and the occurrence of a n u m b e r of a c t u a l disasters, t h e c o m m u n i t y aspects of d i s a s t e r plann i n g have a t t a i n e d g r e a t e r significance. 1 Disasters (multiple c a s u a l t y incidents) which occur in a c o m m u n i t y n e c e s s a r i l y involve m a n y agencies to provide services vital to the victims. 2 This has r e s u l t e d in the formation of d i s a s t e r plans encompass i n g m u l t i p l e organizations and agencies. 1-4 To test the effectiveness of these plans, the d i s a s t e r drill h a s become accepted as an i m p o r t a n t and necessary tool.2, 5 A l t h o u g h c e r t a i n l i m i t a t i o n s r e s u l t i n g from the s i m u l a t e d n a t u r e of the exercise m u s t be accepted, the drill nonetheless provides a test of the a b i l i t y of the p l a n - - and the c o m m u n i t y - - to respond to the emergency. Such a drill was staged in S e p t e m b e r 1978 by the Detroit M e t r o p o l i t a n - W a y n e C o u n t y (Metro) Airport, in compliance with F e d e r a l A v i a t i o n Agency r e g u l a t i o n s r e q u i r i n g a test of its d i s a s t e r plan. A v a r i e t y of agencies were involved in the p l a n n i n g , organization, and conduct of the drill. One of the most i m p o r t a n t functions in i m p l e m e n t i n g any d i s a s t e r p l a n is t r i a g e of the victims. 2 S a l v a g i n g the g r e a t e s t n u m b e r of victims possible depends o n the r a p i d and efficient identification of those r e q u i r i n g i m m e d i a t e attention, those whose care can be delayed, a n d those a l r e a d y beyond h e l p 2 Because a n u m b e r of hospitals v a r y i n g in size a n d capability will be involved in a large-scale disaster, it is i m p o r t a n t to avoid t r a n s p o r t i n g a victim to a hospital which m i g h t be ill-equipped to deal with his injury. This would necessitate a second transfer, From the Emergency Department, St. John Hospital, and the Section of Emergency Medicine, Wayne State University School of Medicine;* Wayne County Health Department;J- and Southeastern Michigan Council on Emergency Medical Services,:~ Detroit, Michigan. Address for reprints: Michael L. DeMars, MD, Department of Emergency and Ambulatory Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, Michigan 48070.
521207
Ann
Emerg Med
9:4 (April) 1980
resulting in delay of definitive treatment and use of vehicles and personnel which should be available to return to the scene. As important as the function of triage is, however, it is also one of the most difficult to e v a l u a t e d u r i n g a simulated disaster. With large numbers of casualties and several t r i a g e personnel, it is virtually impossible for members of an evaluation committee to personally observe each victim's route from time of the incident to arrival at the final t r e a t m e n t facility. In an attempt to fill this gap in t h e evaluation process, we d e v i s e d a method of tagging v i c t i m s w i t h a tracking card to provide the information necessary to effectively e v a l u a t e this important function.
METHOD Triage and Transportation Triage was begun by emergency medical technicians (EMT-As) from the airport fire department who were later relieved by a team of physicians and nurses. Victims w e r e t a g g e d using the Medical Emergency T r i a g e Tag (METTAG) o b t a i n e d from t h e Journal of Civil Defense, S t a r k e , Florida. Triage c a t e g o r i e s were: I (red), highest priority; II (yellow), urgent; and III (green), " w a l k i n g wounded." T r a n s p o r t a t i o n w a s by ground vehicle to one of eight a r e a community hospitals or the field hospital (first aid station) in the airport terminal, or by helicopter to one of two area burn centers. Those "dead-onthe-scene" were to be left at the crash site for transportation to a t e m p o r a r y morgue at the conclusion of the drill.
The Tracking Card The tracking card used is illustrated (Figure), At the time of makeup, the injury being s i m u l a t e d was noted on the victim's card (1). A space was provided for noting the category into which the victim was placed by the triage officer (2) and the hospital to which the victim was sent (3). The victim was asked to note the t i m e he was removed from the crash site and a space for this was provided on the card (4). Since transportation was simulated, we thought t h a t time of removal from the crash site would be a more accurate indicator of t h e o r d e r in which victims were transported t h a n wouldthe time of a r r i v a l at the hospital. Personnel were stationed at each of the participating community hospitals, the field hospital, and the temporary morgue to collect the cards as the victims arrived.
9:4 (April) 1980
PATIENT TRACKING CARD 1. Type of Injury: 2. Tag Code/Color:
3. Arrived at (Destination):
(Name of Facility or Hospital)
4. Time of Transport from
the Disaster Site: INSTRUCTIONS:
Please turn in to an evaluator (with yellow cards) when you arrive at a final location, eg, hospital or
field station. Please record or remember your time leaving scene. Your card will be filled in by evaluators at the site and when turned in at your destination.
F i g . 1. Victim-tracking card. The collector m a d e the notations on the cards, m a k i n g it u n n e c e s s a r y to provide all victims with pencils and lessening interference with their s i m u l a t i o n of injury. The c o l l e c t o r noted the t r i a g e category from the t a g placed by the t r i a g e officer, e n t e r e d t h e n a m e of the receiving hospital, a n d obtained the t i m e of removal from the crash site from the victim. The cards were t u r n e d in by the collectors at the critique session i m m e d i a t e l y following t h e drill.
RESULTS E a c h of t h e 206 p e r s o n s p a r t i c i p a t i n g in the drill as victims was g i v e n a t r a c k i n g c a r d (Table). Of these, 178 cards w e r e r e t u r n e d for e v a l u a t i o n . T w e n t y - f i v e of the lost cards were those given to the victims who were to be considered "dead-att h e - s c e n e . " T h e s e v i c t i m s , in a m{x-up in communications, were not t r a n s p o r t e d to the t e m p o r a r y morgue a n d the card collector at the morgue was, therefore, unable to obtain the cards. The remaining three cards were lost by the victims during the exercise. T h e c a r d s w e r e r e v i e w e d for t h e i r usefulness in e v a l u a t i n g t r i a g e (that is, the actual sorting of victims into t r e a t m e n t priorities) and destination. A card was considered usable in assessing t r i a g e if it contained the description of the victim's injury and the t r i a g e priority category assigned b y t h e t r i a g e officer. It w a s considered usable in assessing the destination of the victim if it contained e i t h e r t h e d e s c r i p t i o n of i n j u r y or t r i a g e category and the n a m e of the r e c e i v i n g f a c i l i t y . If a c a r d n o t e d both description of injury and t r i a g e code, the decision was based on the
Ann Emerg Med
code, as d e s t i n a t i o n would most app r o p r i a t e l y be based on this, the decision of the t r i a g e officer. Incomplete cards were e x a m i n e d for possible use in e v a l u a t i n g a t l e a s t one of the functions (triage category or destination) u n d e r consideration. F o r example, a card would be usable for assessing t r i a g e if it noted type of injury and t r i a g e category assigned even t h o u g h it did not contain t h e n a m e of the r e c e i v i n g f a c i l i t y and c o u l d not, t h e r e f o r e , be u s e d to e v a l u a t e destination. Conversely, a card could be used to e v a l u a t e dest i n a t i o n if it contained the description of injury and n a m e of receiving facility even t h o u g h the t r i a g e code was missing. One h u n d r e d twenty-four cards were found to be usable in assessing t r i a g e (Table). C a r d s w e r e e l i m i n a t e d b e c a u s e t h e t r i a g e t a g was missing from the victim when he arr i v e d a t t h e h o s p i t a l or t h e t r i a g e category was not noted on the tracking card. One h u n d r e d forty c a r d s w e r e found to be usable in assessing the p r o p e r d e s t i n a t i o n of t h e v i c t i m s (Table). C a r d s were e l i m i n a t e d because the receiving facility was not noted or the victim h a d been carried b y helicopter.
DISCUSSION A n u m b e r of p r o b l e m s w e r e identified in the i m p l e m e n t a t i o n of this s y s t e m of evaluation. A major difficulty r e s u l t e d from i n a d e q u a t e briefing of the personnel assigned t o collect t h e t r a c k i n g cards. Since the victims were w e a r i n g the t r i a g e tags, an airport security pass, and a sticker noting t h e i r injury, in addition to c a r r y i n g t h e t r a c k i n g card,
208/53
Table OUTCOME OF VICTIM-TRACKING CARDS No. Cards Cards placed Cards returned Cards missing Lost by "victims" Cards from "deadat-the-scene" Cards usable to assess triage Eliminations Triage tag lost from "victim" Triage category not on tracking card Cards usable to assess destination Eliminations Military personnel Destination not on tracking card
206 178 28 3 25 124 54 4 50 140 38 9 29
some collectors incorrectly identified the card they were to collect. Others, u n f a m i l i a r with t h e t r i a g e coding system, entered the wrong information on the card or left t h e space blank. None of the victims noted the time he was removed from the crash s i t e e v e n t h o u g h each h a d b e e n asked to do so and the instructions
54/209
were printed on the card. This was most likely due to their own excitem e n t at p a r t i c i p a t i n g in the drill, and, possibly, because some may not have been wearing watches. A t r u l y effective method for d e t e r m i n i n g the order in which the victims are actually transported r e m a i n s to be worked out. Some v i c t i m s lost t h e i r cards, probably an unavoidable factor. The description of the injury on some cards was too vague, rendering retrospective evaluation of the card somewhat inaccurate. For example, some cards stated merely "3 ° b u r n " without indicating extent or location, i n f o r m a t i o n v i t a l i n d e c i d i n g how such a victim should be handled. F i n a l l y , t h e loss of the cards from the victims "dead-at-the-scene" could be avoided by a s s u r i n g these v i c t i m s were t r a n s p o r t e d to t h e proper place or by collecting these cards at the crash site r a t h e r t h a n w a i t i n g to collect them at a temporary morgue. Since these victims are left at the site u n t i l last in a n y drill, and then u s u a l l y t r a n s p o r t e d en masse, the cards could effectively be collected at this time. The strengths of this system are t h a t it provided accurate t r a c k i n g of victims in the majority of cases; it e n a b l e d e v a l u a t i o n of the triage of those cases in which the injury was accurately described; and it enabled t h e e v a l u a t i o n c o m m i t t e e to spot some major errors in the triage and t r a n s p o r t a t i o n of the victims. It also
Ann Emerg Med
p o i n t e d out the s t r e n g t h s a n d accuracies of these two most i m p o r t a n t functions. For example, 78% of the v i c t i m s received a p p r o p r i a t e treatm e n t priorities and 81% were transported to the appropriate t r e a t m e n t facility.
CONCLUSION Triage is both one of the most i m p o r t a n t f u n c t i o n s ~of a d i s a s t e r p l a n and one of the most difficult to evaluate d u r i n g a drill. The use of the card system described here, with correction of the problems encount e r e d , p r o v i d e s a n i n v a l u a b l e ins t r u m e n t for e v a l u a t i n g this function. The use of this s y s t e m - - or some modifications of it - - is recommended for incorporation into every c o m m u n i t y disaster drill.
REFERENCES 1. Theoret JJ: Exercise London: a disaster exercise involving numerous casualties. Can Med Assoc J 114:697-699, 1976. 2. Hays MB, Stefanki JX, Cheu DH: Planning an airport disaster drill. Aviat Space Environ Med 47:556-560, 1976. 3. Fishel ER: Exercise "Med-Ex" 73. Md State Med J 23:46-48, 1974.
4. Mayo ER: Community disaster drill. Med Times 98:164-169, 1970.
5. Clark RB: Disaster drills, letter to the editor. J A C E P 7:416, 1978. 6. Evans D: Simulated aircraft disaster instructional exercises at BaltimoreWashington International Airport. Aviat Space Environ Med 47:445-448, 1976.
9:4 (April) 1980