Mass civilian shootings: Are we ready to face this new threat?

COL A Puidupin (MD), CPT C Hoffmann (MD),CPT N Cazes (MD), COL S

Margerin (PCD), LTC T Provost-Fleury (MD), LTC O Gacia (MD)

French Armed Forces Health Service, Paris, Clamart, Marseille

outlines:

1. New threat

2. Lessons learned from the battlefield

3. Strategy

4. Management of Mass Civilian shooting

« The opinions or assertions expressed herein are the private

views of the authors and are not to be considered as official

or as reflecting the views of the French Military Health Service

3 Waves of clandestine supply of small guns :

• Eastern Europe (1989) • Balkans: former Yugoslavia (1991-2001) • Libya (2011)

Antoine JC. Le trafic d’armes en provenance

d’Europe de l’Est.

La banalisation et le renouveau dû aux Printemps

arabes.

Revue « Regard sur l’Est ». 15 février 2012.

1. New threat:

3 spots of « Global War on Terrorism » :

• Central Asia: Afghanistan, Pakistan • Middle East: Syria, Iraq • West Africa: Mali, Burkina Faso, Chad, Niger, Nigeria

London: 7th July 2005

Victims: 56 death, 700 injured

Usual terrorists’attack :

Threat due to terrorism:

Mass hostage taking

Paris Porte de Vincennes (9th January 2015):

20 hostages • 4 hostages killed by terrorist, terrorist killed by RAID/BRI

New threat due to terrorism:

Mass hostage taking

Marseille-Marignane Airport (25th december 1994):

160 Hostages

• 4 Hijackers killed by GIGN

Paris Porte de Vincennes (9th January 2015):

20 Hostages • 4 Hostages killed by terrorist, terrorist killed by RAID/BRI

New threat because of terrorism:

Mass shooting

Oslo and Utoeya Island (22th July 2011)

• Bomb attack against Governement of Oslo

• Gun shooting during youngsters meeting on Utoeya Island • Death toll: 77 • Injured: 220

Charlie Hebdo in Paris (7th January 2015):

• Death toll:12 • Injured:11

Tunis (18th March 2015)

2 Terrorists

21 Casualties

(Including 20 foreign tourists),

Répartition des blessures

selon le mécanisme lésionnel

(thèse Hoffmann)

2.Lessons learned from battlefield Epidemiology

Wound type sorting

according to lesion

mechanism (Hoffmann

thesis)

Where Do Battlefield Casualties Die?

87.3% Pre hospital (4016/4596)

87.3%(n=4,016)

12.7%(n=580)

0

10

20

30

40

50

60

70

80

90

100

Pre-MTF DOW

Pe

rce

nt

Mortality Site

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press.

What is the Cause of Death?

91%(n=888)

7.9%(n=77) 1.1%

(n=11)0

10

20

30

40

50

60

70

80

90

100

Hemorrhage Airway Obstruction Tension Pneumothorax

Pe

rce

nt

Physiologic Cause

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press.

Extremity [119/888] = 13.5% Junctional [171/888] = 19.2% Truncal [598/888] = 67.3%

Haus-Cheymol R, Mayet A, Verret C, Duron S, Meynard JP, Pommier de Santi V, Decam C, Pons F,

Migliani R. Blessures par arme à feu dans les armées. Rapport préliminaire. 2010.

(thèse Hoffmann)

Which Part of the Body? Head & Neck

Lower limbs

Upper limbs

Limbs

Bellamy RF. The causes of death in conventional land warfare : Implications for combat casualty care

research Mil Med 1984 ; 149 : 55-62

(Deaths avoided thanks to proper care)

20 to 30% of Causes of Death

Notion of Preventable Death:

Where Can We Save the Most Lives?

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. Journal of Trauma, 2011. 71(Suppl 1):4-8.

Surface Ship Survivability.

Naval War Publication 3–20.31. Washington, DC: Department of Defense; 1996.

Damage control

OBJECTIVES OF DAMAGE CONTROL

The three basic objectives of shipboard damage control are

PREVENTION, MINIMIZATION, and RESTORATION

3. Military Strategy

Damage control surgery

Rotondo MF. 'Damage control': an approach for improved survival in

exsanguinating penetrating abdominal injury.

J Trauma 1993 ;35 :S375-82

Letal

“bloody vicious cycle” (Moore)

INCISION

“damage control”

STOP BLEEDING

STOP CONTAMINATION

LESS THAN ONE HOUR

Damage control surgery

+ Damage control resuscitation

Holcomb JB. Damage control resuscitation. J Trauma 2007 ;62 :S36-7

Rotondo MF. 'Damage control': an approach for improved survival in

exsanguinating penetrating abdominal injury.

J Trauma 1993 ;35 :S375-82

Small volume ressucitation and inotropic support if necessary

DAMAGE CONTROL ressucitation

Ratios during Massive Transfusion

1:1 Ratios 1 RBC / 1 FFP

Treatment is aimed at stopping the bleeding and

correcting hypo perfusion:

Tranexamic Acid

Rossaint R, Bouillon B, Cerny V,Coats TJ, Duranteau J, Fernandez-Montejar E, et al. Management

of bleeding following major trauma: an updated European guideline. Crit Care 2010;14:R52

• Whole Blood Transfusion

FOCUS on Military skills

• Relevance of the FLYP to control the coagulopathy of war injuries

• Safety of FLYP

• French lyophilized plasma

Damage control

Damage control surgery

+ Damage control resuscitation

+

Holcomb JB. Damage control resuscitation. J Trauma 2007 ;62 :S36-7

Rotondo MF. 'Damage control': an approach for improved survival in

exsanguinating penetrating abdominal injury.

J Trauma 1993 ;35 :S375-82

Damage control Ground zero

– Fluid Resuscitation: Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.

• (a) If not in shock – No IV fluids necessary

– PO fluids permissible if conscious and can swallow

Damage control ground zero

Treatment is aimed to stop the bleeding

and at correcting hypoperfusion

during pre hospital period

“an instrument of the devil that sometimes saves lives.”

Coupland. Care in the Field for Victims of Weapons of War: Geneva: International

Committee of the Red Cross 2001

Tourniquet

STOP BLEEDING

Hemostatic Dressing

Extremity Hemorrhage Control!

Kragh, and al – Tourniquet Study

• Ibn Sina Hospital, Baghdad, 2006

• Tourniquets are saving lives on the battlefield

• 31 lives saved in 6 months by use of pre hospital tourniquets

• Author estimates 3000 lives were saved with tourniquets in this conflict as of 2012

Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 2009. 249(1):1-7.

Is tourniquet « safe »?

In Israël:

– Whithin 4 years, 91 Injured, tourniquet applied in less than15 mins (80%),

– Efficency Upper Limbs>Lower Limbs, (93% vs 71%)

– 550 Injured, 0 death after tourniquet

– 50% unnecessary

– 5 % complications (Duration > 150mins) but short MEDEVAC time (between 1.5 hr and 3 hr)

Dror Lakstein, J Trauma. 2003;54:S221–S225.

• Education =>Trauma System: First Aid Guide Lines

Mogadiscio, Somalia (1993)

Mabry J, United States Army Rangers in Somalia: an analysis of

combat casualties on an urban battlefield. J Trauma 2000 ; 9 : 515-29.).

Tactical Combat

Casualty Care (T3C)

PHTR RESEARCH ELIMINATING PREVENTABLE DEATH ON THE BATTLEFIELD

Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB Archives of Surgery, 2011. 146(12): 1350-8.

INTRODUCTION: The 75th Ranger Regiment comprehensively integrated TCCC training with a pre hospital trauma registry (PHTR) through a command-directed casualty response system. This system is evaluated in terms of battlefield survival.

METHODS: Battle injury data were analyzed for combat missions conducted by the 75th Ranger Regiment in Afghanistan and Iraq over 8.5 years, from October 2001 through March 2010. Each casualty was scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made to official Department of Defense (DoD) casualty data for the military as a whole.

RESULTS: 419 battle injury casualties. Regiment’s 10.7% KIA, 1.7% DOW, and 7.6 CFR rates were lower than the 16.4%, 5.8%, and 10.3 rates for U.S. military as a whole. Of 32 fatalities, 0 were DOW from infection, 0 were potentially survivable through additional pre hospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial pre hospital care was provided by non-medical personnel.

CONCLUSION: Tactical leader management of a casualty response system that trains all personnel in TCCC and receives continuous feedback from PHTR data resulted in unprecedented reduction of KIA, DOW, and preventable combat death.

Categorization of triage

Urgent => 2H

Priority => 4H

Routine => 24H

Triage in Afghanistan

• Triage is aimed at avoiding Preventable Death

Death that could have been avoided thanks to adequate medical-surgical care.

Holcomb Ann Surg 2007 C. Willy Chir urg. 2008

Damage Control Surgery Damage Control Ground Zero

Holcomb Ann Surg 2007 C. Willy Chir urg. 2008

Holcomb JB. Damage control resuscitation. J Trauma 2007 ;62 :S36-7

• Stop bleeding on site

• Immediat treatment in MTF=>

Damage control Surgery

Gerhardt al. Evaluation of combat casualty care outcomes after the introduction of

emergency medicine providers and an EMS systems approach to the setting of

tactical ground combat.

Ann Em Med 2005 ; 46 : 45-6.).

Survival Improvement (44%) after the introduction of EMT

(Shock Trauma Platoon)

In case of Mass Civilian Shooting

4. Are we ready?

First Aid and EMT

SWAT

Special Weapons And Tactics: SWAT

ORGANISATION?

EDUCATION AND TRAINING?

EQUIPMENT?

Conclusion: American Journal of Emergency Medicine