MASS CASUALTY MANAGEMENT:

What we’ve learned in EuropeLinda E. Pelinka, MD, PhD

Medical University of Viennaand Ludwig Boltzmann Institute

for Experimental & Clinical TraumatologyVienna, Austria, European Union

TRAUMA

LONDON

MADRIDISTANBUL

What happened?

Management: what went right?

Management: what went wrong?

Lessons learned

Management & support priorities

Command & controlSafetyCommunicationTriageTreatmentTransport

Istanbul, TurkeyTargets Synagogues

Date Sunday, November 15th, 2003

Time 9.30 a.m.

Number 2 truck bombs: improvised (400 kg) explosive devices. Ammonium sulfate, ammonium nitrite, compressed fuel oil mixed in containers

Attack Type Suicide bombing

Dead 30

Injured ~300

SYNAGOGUE BOMBING

Neve Shalom & Beth Israel SYNAGOGUES

DAMAGED STREETS: wide craters 2 m deep

DAMAGED BUILDINGS >100 m away,

windows shattered >200 m away

INJURED SHOPPERS outside > worshippers

inside (protected by façade of synagogue)

5 days later5 days later

Istanbul, TurkeyTargets Hong Kong Shanghai Banking

Corporation, British Consulate

Date Friday, November 20th, 2003

Time 10.55-11.00 a.m.

Number 2 truck bombs, improvised (700 kg) explosive devices

Attack Type Suicide bombing

Dead 33

Injured 450

Blast destroys 6 buildings

Damages another 38 buildings

Rips out storefronts

Blows out windows hundreds of m away

Downs electrical and phone lines

Flings body parts through the air

ISTANBUL : what went RIGHT?

3 min after blast, ambulances start arriving at

disaster sites

ISTANBUL: what went WRONG?

30 AMBULANCES arriving

at disaster sites within 15 min of blasts

POLICE just beginning

to establish site security

FIRST RESPONDERS rushing

to sites without protective

equipment despite stench of

ammonia

ISTANBUL: what went WRONG?

CHAOS AND CONFUSION

TV headquarters across the street from scene, broadcasts disaster & confusion within 12 min of the blast, causing more confusion,

more bystanders

Public receives info from the media only, is shocked by images shown.

Turkish government bans broadcasting.

TRAFFIC GRIDLOCK EMS CANNOT REACH VICTIMS

Streets clogged by debrisTraffic, narrow streets parked carsAmbulances, medical personnelPolice, fire brigadeMedia, bystanders, volunteers

ISTANBUL: what went WRONG?

MALDISTRIBUTION of INJUREDNO TRIAGE

Severely injured require slower transport and

need to travel further (maldistribution)

Lightly injured hurry to nearest hospitals,

overloading hospital capacity

Transportation: ambulances, private vehicles, on

foot. Patients with minor injuries grab passing

ambulances.

2003 Terrorist bombings in Istanbul

Problems related to triage:

• No knowledge of first aid (citizens, police)

• No knowledge of triage (police in charge of evacuation)

• Turkish mentality

no confidence in public/medical authorities

family transports patient to hospital

try to load patients before ambulance halts

K Taviloglu et al, Int J Disaster Med 3/1-4: 45-49; 2005

Mass-Casualty Terrorist Bombings in Istanbul: Events and Prehospital

Emergency Response

Main problems:

• First responders risked exposure to secondary

hazards “come-hither” bombs

• Maldistribution of patients: minor injuries

overload closer hospitals, severe injuries need

to travel further

U Rodoplu et al, Prehosp Disaster Med 19: 134-145; 2004

NO COMMAND

NO CONTROL

Police unable to establish control Scene not securedAll ambulances dispatched simultaneously,

many not needed No protective gear (stench of ammonia)Bystanders in the way, digging

independentlyCommunication network collapses

Mass-Casualty Terrorist Bombings in Istanbul: Events and Prehospital

Emergency Response

Lessons learned:

• Establish emergency plan and preparedness

• Establish unified command to coordinate/organize

• Establish/upgrade communication links between EMS and hospitals

• Establish uniform EMS triage protocols

• Conduct regular disaster training and practice

U Rodoplu et al, Prehosp Disaster Med 19: 134-145; 2004

WHAT DID

THE TERRORIST ATTACK

TEACH THE TURKISH?INDEPENDENCE &

IMPROVISATION

MAY BE GOOD, BUT……STEP BY STEP TEAMWORK

IS BETTER

Madrid, SpainTargets Commuter Train

Date Thursday, March 11th, 2004

Time 7.30-8.00 a.m.

Number 13 bombs (22 lbs of explosives each) on 4 trains in 3 stations. 3 bombs failed to explode

Attack Type Backpacks, cell phone detonation

Dead 191

Injured 2050

7.37 a.m.

7.39 a.m.

Train 1 inside Atocha Station

Train 2 approaching Atocha Station 2 min late

8.00 Ambulances arrive

8.30 EMS sets up field hospital

at sports stadium

nearby

8.40 a.m. Spanish Red Cross issues urgent

appeal for blood, supplies running low

Number of victims higher than in any similar

action in Spain, far surpassing Basque

attacks.

Worst incident of this kind in Europe since

Lockerbie bombing in 1988.

MADRID: what went RIGHT?

Sufficient resources availableGood in-hospital care

Atocha station, doors of train open: less

deaths8.00 “Cage Operation” goes into effect to

prevent terrorists from escaping from Madrid8.45 National & international rail traffic in

and out of Madrid shut down completely

MADRID: what went RIGHT?

According to experience from ETA attacks

stay and stabilize policy in the field

prevents immediate hospital overload

Minor injuries

treated at temporary hospitals at each station

and at a sports stadium nearby

Severe injuries

flown to hospitals by helicopter

Insufficient

COMMAND

CONTROL

COMMUNICATION

MADRID: what went WRONG?

London, United Kindom

Targets Underground and bus

Date Thursday, July 7th, 2005

Time 8.50-9.47 a.m.

Number 4 bombs, 10 lbs of high explosives each (home-made acetone peroxide)

Attack Type Suicide bombings

Dead 52 + 4 suicide bombers

Injured ~700

Daily morning commuters in London

370,000 Underground passengers

325,000 Bus passengers

“The deadliest single act of terrorism in

the United Kingdom since the Lockerbie

incident, the bombing of Pan Am Flight

103 in 1988, killing 270.”

BBC

Underground bombs explode within 50 secs, as trains are passing each other,

thus affecting 2 trains each plus tunnels.

ORIGINAL TERRORIST PLAN:

CROSS OF FIRE centered at King’s Cross by 4 Underground

bombs. Because Northern Line is temporarily

suspended (technical problems), 4th bomber

takes bus instead.

Circle Line Liverpool St eastbound

Sub-surface cut and cover,

21 ft deep, and wide to

accommodate 2 parallel tracks

Circle Line Edgeware Rd westbound

Piccadilly Line King’s Cross southbound

Deep-level, 100 ft, 11ft single-track tube, 6 in clearance

BLASTS VENT FORCE

INTO TUNNEL,

REDUCING LETHALITY

BLAST FORCE

REFLECTED BY TUNNEL,

INCREASING LETHALITY

9.19 Code Amber Alert. London Underground

shut down, all passengers evacuated

9.35 Bus 30 arrives at Euston Station,

continues to Hackney Wick.

This bus is on a diversion route due to King’s

Cross road closures.

9.47 Rear of Bus 30 explodes on Tavistock

Square. Roof ripped off.

“..half a bus flying through the air”.

LONDON: what went RIGHT?

Large areas evacuated and sealed

off entirely

All traffic re-routed. Monitors on ring road:

“Avoid London: area closed – turn on radio”

I have trained for such a situation for years, but on

the assumption that I would be part of a rescue team,

properly dressed and equipped, moving with

semi-military precision. Instead, I am in shirtsleeves.

Technically, I am an uninjured victim.

My objectives: command, control, communication,

coordination and cooperation. Fail to achieve these,

and we will have chaos, losing lives needlessly.

PJP Holden, NEJM 353/6: 541-543; 2005

The London attacks – a chronicle. Improvising in an emergency.

The London attacks – a chronicle. Improvising in an emergency.

Until supplies arrive, we have nothing except

bandages, chin lift, jaw thrust, and c-spine control.

Our aim is

To get each patient to the right hospital in the right

time frame.

Our function is

To triage, resuscitate, prioritize for transport, and feed

patients into the rescue chan in an orderly fashion.

PJP Holden, NEJM 353/6: 541-543; 2005

London bombings July 2005: The immediate pre-hospital medical

response.

• Critical interventions on scene provided for seriously injured (n=350).

• Quick transport to appropriate hospitals.• Local medical infrastructure was able to cope. • Injury assessment areas were set up for patients

with minor injuries. Thus, patients with serious injuries had the full attention of the EDs.

• Helicopters allowed rapid deployment of staff and equipment (not patients) in gridlocked traffic.

DJ Lockey et al, Resuscitation 66; 2005

LONDON: what went WRONG?

PUBLIC TRANSPORTATION CRIPPLED

underground and busses shut down

CONFUSION

CAUSE of blasts: not due to power surge

because of person under train. Vice versa!

NUMBER of blasts: 3 rather than 6,

because blasts were between stations,

people exiting from both stations

COMMUNICATION

“I was left with the clear impression

that opportunities to pass vital

Information between the services were

missed.”

D. Fennell, OBE, investigation into King’s Cross Underground Fire.

DELAYS DUE TO POOR COMMUNICATION

Poor communication within

underground and from tunnel to

surface

Managers at scene unable to

communicate with control

Ambulances meant for Russel Sq.

misdirected to Tavistock Square

INTERCOMS & RADIOS

Many trains have no facility for

driver to talk to passengers in an

emergency

Train radios failed on all 3 affected

trains: antennae damaged by blasts

CELL PHONES

Heavy reliance by all EMS on cell phones

Cell phones and hospital switchboards went

out due to overload.

Incident commanders isolated

because cell phones were not working

“We have become too reliant

on cell phones and this must

change.”

London Ambulance Service

LACK OF COMMUNICATION

“Effective communication from trains

could have led to more rapid assessment

of what happened and where.”

“The way we obtained info was from

station staff running down the tracks.”

“All time and access to communication are

valuable. If you have nothing to say, stay

off the air.”

TREATMENT: What can and did happen in London

Ran out of

Tourniquets

Fluids

Triage tags

Limiting factors

OR space

ICU beds

Personnel

London bombings July 2005: The immediate pre-hospital medical

response.

• Mobile telephone networks: overload and location (underground)

• Unsuitable attire: Hospital workers were sent to the scene in OP clothing. The could not and did not work underground.

• Scene safety: Not secured. Any of the scenes might have contained secondary explosive devices. Additionally: risk of structural collapse, inhalation of airborne particles, contamination.

DJ Lockey et al, Resuscitation 66; 2005

The London bombings of 7 July 2005: what is the main lesson?

The fragmentation in planning, with each agency

thinking inwards rather than outwards,

with each agency declaring a major incident

individually rather than collectively,

is where the real lesson lies.

Too many cooks are spoiling the broth.

G Hughes, Emerg Med J 23: 666; 2006

LESSONS LEARNED

fighting TERRORISM

MANAGEMENT & SUPPORT PRIORITIES

COMMAND & CONTROL

SAFETY

COMMUNICATION

TRIAGE

TREATMENT

TRANSPORT

COMMAND & CONTROL

COMMAND

Vertical transmission

of authority within

each emergency and

support service.

Each service

has one individual

in command

CONTROL

Horizontal transmission

of authority across

each emergency and

support service.

Each incident

has one individual

in overall control

COMMAND & CONTROLCornerstones of effective major incident

management

All health services attending an incident

must report to the Ambulance Command

Point

Medical and nursing staff at the scene

should complement rather than challenge

the role of ambulance personnel

COMMAND & CONTROLMedical providers at the scene must be

properly equipped, personally & medically

If ill equipped, inexperienced, inadequately

killed, or UNDISCIPLINED, they may pose a

threat to the welfare of the casualties and to

other rescuers

There are no official guidelines for this. The

standard of preparation, equipment and

training is variableTJ Hodgetts, Major Incident Medical Management, BMJ Books, 2002

There are no official guidelines for

COMMAND

& CONTROL.

The standard of

preparation, equipment & training is variable.

SAFETY: PROTECTIVE CLOTHING

hazard Protective clothing

Emergency vehicles High visibility jacket

Elements: wind, rain Waterproof, insulated

Injury to head Hard hat with chinstrap

Injury to eyes Safety goggles

Injury to face Visor

noise Ear defenders

Injury to hands Heavy duty gloves

Blood, body fluids Patient treatment gloves

Injury to feet Heavy duty boots, acid resistant

“COME-HITHER” BOMBS

Terrorists often

install a second bomb,

designed solely to kill

health care providers

after first attack

COMMUNICATION

Poor communication

is the most common failure

in mass casualty management

Lack ofInformationConfirmationCoordination

ACCOLC ACCess OverLoad Control

EMS may have access to phones operating

on special cells: ACCOLC

ACCOLC (cell phone lines which can be

opened centrally) were only partially

activated

City of London police activated ACCOLC

around Aldgate: Immensely improved

communication

ONSITE COMMUNICATIONAmbulance provides radio gear for

communication between

Key medical staff at scene

Ambulance vehicles at scene

Ambulance Control

Receiving hospitals

Police and Fire Stations

Ambulance control will establish control &

maintain radio communications with

Ambulance services command vehicle at

scene

Ambulances traveling to scene or to

hospital

Receiving hospitals

Neighboring ambulance services

OFFSITE COMMUNICATION

COMMUNICATION METHANE

acronym of key info to be passed

M Major incident Standby or declaredE Exact location Grid referenceT Type of incident Rail, chemical, roadH Hazards Present and potentialA Access Direction, approachN No of casualties Incl type and severityE Emergency services Present and required

Quick and simple, based upon:

PATTERN OF INJURY

VITAL SIGNS

AGE

Aim:

Survival for greatest number of patients.

Color-coded tagging systems for

Rapid identification of victims in the field.

TRIAGE Rapid Patient Assessment

RED TAG: IMMEDIATE CARE

Severely injured patients with

high probability for

survival

requiring procedures of moderately

short duration to prevent death

(e.g. emergency amputation).

YELLOW TAG: DELAYED CARE

sufficient for good outcome

(e.g. major fractures,

uncomplicated major burns).

GREEN TAG: MINIMAL CARE

No serious injury

to vascular structures or nerves.

Walking injured requiring

minimally trained personnel.

BLACK TAG: DECEASED OR EXPECTANT

Complicated, time-consuming requirements

Slim chance of survival. In natural disaster scenario:

analgesia & sedation until yellow and red tags have been treated.

TRIAGE

Use whenever number of casualties

> number of skilled

rescuers available

Triage is a dynamic process:

Assessment and re-assessment

TRIAGE =

ASSESSING & RE-ASSESSING

Total chaos:

Several injuries missed

during primary assessment

TRIAGE = LIMITED TIME

The worst decision

is the lack of a decision.

TREATMENT

Treatment is the SECOND step,

after triage

First treatment likely to be basic

first aid from unskilled people

Attention to ABC is most often all

that is required at the scene

TREATMENT: HOW MUCH & WHAT?

Aim at the scene: allow casualty to

reach hospital safely

Amount of treatment at the scene

corresponds to triage priority

Most treatment at the scene

directed at ABC, simple equipment

TREATMENT

BASIC ADVANCEDSpinal control

Manual CS stabilization

Cervical collar, spinal board

AirwayOpening:chin lift, jaw thrust

Oro/nasopharyngeal airway, ETT, surg. airway

BreathingMouth/mouthmouth/nose

Mouth to mask, bag valve mask, chest drain, needle thoracocentesis

CirculationControl ext. hemorrhage

Peripheral/central venous intraoss access, defib

TREATMENT: First AidLife Saving Intervention

Equipment

Clear airway Manual suction apparatus

Maintain airway Oro/nasophar airway

Support ventilation Pocket mask

Seal open pneumothorax

Asherman chest seal

Arrest hemorrhage Absorbent pressure dressings

ADDITIONAL EQUIPMENT for ALS

INTERVENTION EQUIPMENT

Secure airway LMA/ETT

Deliver oxygen Portable O2 source & mask

Support ventilation Bag valve mask

Spinal immobilization Cerv collar, vac mattress

Decompress tension pn Needle thoracocentesis

Treat cardiac arrest Defib/i.v. drugs

Replace fluid I.v. cannula, intraoss, fluid

Relieve pain Splint, i.v. drugs

CRITERIA for TRANSPORT

Capacity

Availability

Suitability

TRANSPORTEffective organization of ambulance

circuit vital for smooth evacuation

Ambulances form mainstay of

transport

Helicopters more suitable when

road transport cannot be used

Short flight may be safer than

ambulance transfer

TRANSPORT

The most severely injured patients

reach hospital later

than less severely injured patients

Less severely injured patients

self-evacuate and go to hospital

on their own,

sometimes

clogging resources

FINAL THOUGHTS

20% of the population live in the rural

United States.

80% of the population live in the urban

And suburban United States.

Guess where the next terror attack

is going to be.Carr, Prehosp Emerg Care 2006

FINAL THOUGHTS

A bioterrorism attack

in the 21st century

Is inevitable.

A Fauci, Clin Infectious Dis 32: 678; 2001

FINAL THOUGHTS

The Geneva Convention

was based on reciprocity

“I help my wounded enemy and vice

versa.”

Henri Dunand, Red Cross

FINAL THOUGHTS

“It couldn’t happen to us” is not

an acceptable excuse for being

ill-prepared to deal with a major incident.A major incident may occur at any time,

anywhere.

Colonel TJ Hodgetts, Emergency Med & Trauma University of Birmingham, UK, 2005

Nothing replaces well-trained,

competent, motivated people. Nothing.