Editorials - e85

21. Byers M, Russell M, Lockey DJ. Clinical care in the "Hot
Zone". Emerg Med J 2008; 25: 108e12
22. Park CL, Langlois M, Smith ER, et al. How to stop the dying,
as well as the killing, in a terrorist attack. BMJ 2020; 368:
m298
23. National Ambulance Resilience Unit. Available from:
https://naru.org.uk/wp-content/uploads/2021/03/NARU-
COMMAND-AND-CONTROL-GUIDE-V3.1-07.2019.pdf.
24. Lockey DJ, Crewdson K, Davies G, et al. AAGBI: safer pre-
hospital anaesthesia 2017: Association of Anaesthetists
of Great Britain and Ireland. Anaesthesia 2017; 72:
379e90
25. Gellerfors M, Fevang E, Ba € ckman A, et al. Pre-hospital
advanced airway management by anaesthetist and nurse
anaesthetist critical care teams: a prospective observa-
tional study of 2028 pre-hospital tracheal intubations. Br J
Anaesth 2018; 120: 1103e9
26. Lockey DJ, Crewdson K. Pre-hospital anaesthesia: no
longer the ‘poor relative’ of high quality in-hospital
emergency airway management. Br J Anaesth 2018; 120:
898e901
27. Crewdson K, Lockey DJ, Røislien J, Lossius HM, Rehn M.
The success of pre-hospital tracheal intubation by
different pre-hospital providers: a systematic literature
review and meta-analysis. Crit Care 2017; 21: 31
28. Saviluoto A, Ja€ ntti H, Hetti Kirves, Seta
€ la
€ P, Nurmi JO.
Significance of case volume in prehospital anaesthesia
management e a retrospective analysis of mortality in
4818 patients treated by Helicopter Emergency Medical
Services. Br J Anaesth [update; link this paper].
29. Minei JP, Fabian TC, Guffey DM, et al. Increased trauma
center volume is associated with improved survival after
severe injury: results of a Resuscitation Outcomes Con-
sortium study. Ann Surg 2014; 260: 456e64
30. Maruthappu M, Gilbert BJ, El-Harasis MA, et al. The in-
fluence of volume and experience on individual surgical
performance: a systematic review. Ann Surg 2015; 261:
642e7

British Journal of Anaesthesia, 128 (2): e85ee89 (2022)

doi: 10.1016/j.bja.2021.10.023
Advance Access Publication Date: 11 December 2021
© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Provision of pre-hospital medical care for terrorist attacks

Claire L. Park1,2,3,4,* and Gareth R. Grier1,3,5
1
Barts Health NHS Trust, London, UK, 2King’s College Hospital NHS Trust, London, UK, 3Institute of Pre-Hospital Care at
London’s Air Ambulance, London, UK, 4Specialist Firearms Department of the Metropolitan Police Service, London, UK
and 5Queen Mary University London, London, UK

*Corresponding author. E-mail: claire.park7@nhs.net

Summary
The delivery of medical care to the severely injured during major incidents and mass casualty events has been a
recurring challenge for decades across the world. From events in resource-poor developing countries, through richly
funded military conflicts, to the most equipped of developed nations, the provision of rapid medical care to the severely
injured during major incidents and mass casualty events has been a priority for healthcare providers. This is often under
the most difficult of circumstances.1,2 Whilst mass casualty events are a persistent global challenge, it is clear in
developed countries that patients and their families demand and expect a high standard of care from their rescuers, that
this care should be delivered rapidly, and this should be of the highest quality possible.3 Whilst there is respect afforded
to those who ‘run towards danger’ during a high-threat situation, first responders are subjected to a high degree of
scrutiny for their actions, even when the circumstances they are presented with are considered to be extraordinary.4
Likewise, even for those who are catastrophically injured beyond salvage, society expects the response to be dignified,
calculated, and thorough.3

Keywords: analgesia; major incident; mass casualty incident; pre-hospital medical care; preventable death; terrorist
attack

Major incidents and terrorist events definition of a terrorist attack varies, with one of the broadest
examples given by the global terrorism database as ‘the
The terms ‘major incident’, ‘mass casualty event’, ‘terrorist
threatened or actual use of illegal force and violence by a non-
attack’, and others are often used interchangeably, with the
state actor to attain a political, economic, religious, or social
former largely defined by the availability of ‘normal’ re-
goal through fear, coercion, or intimidation’.5 The motives of
sources to meet the demands on the day of the event. The
 e86 - Editorials
attackers are often unclear in the initial stages of an attack,
however, and so the response to any event can only remain
commensurate with the tactical and medical situation as it
evolves.
The multi-agency response required and emotive factors
at play during a terrorist event have often resulted in the
activation of a major incident response by many services.4,6,7
These events are tragic for the individuals involved and for
society, but more recently, the numbers of severely injured
patients have been small, compared with, for example, those
of September 11, 2001. Whilst the prospect of true mass ca-
sualty events must always be considered, the reality of the
modern-day terrorist as a ‘lone actor’, using bladed weapons,
vehicles, and firearms, is a current reality that will surely
continue to challenge medical responders beyond the
imminent future.
Opportunities for improving outcomes
It has been recognised for several decades that there are
opportunities to improve outcomes for the severely injured
through the delivery of better care in the pre-hospital phase
of the patient journey.8 Supporting the work of statutory
emergency services, the specialties of anaesthesia and
emergency medicine have been instrumental in the provi-
sion of the majority of physician-based care to severely
injured patients in this very early phase after injury. This
specialty of pre-hospital medicine is now a standard of care
within UK trauma systems,9 with the delivery of medical
interventions by ‘enhanced’ teams of clinicians often
following a physician-paramedic model.10 These teams are
often delivered by helicopter or fast-response car, and have
specific skills that can be offered to the relatively niche
group of severely injured patients. These include (not
exhaustively) the provision of pre-hospital anaesthesia,
resuscitative thoracotomy, endovascular interventions,
procedural sedation, and delivery of potent analgesia. The
importance of senior medical decision makers at the ‘front
door’ is well recognised within hospital mass casualty plans,
and the presence of senior doctors and paramedics at the
major incident scene is one that has been integrated into the
response for many years.11
There are no agreed patient outcome measures for those
involved in terrorist or other major events in the UK. Simi-
larly, given the supposed heterogeneity of the circumstances
surrounding such incidents, data collection and stand-
ardised criteria for reporting of such events could be
assumed to be highly complex. However, with an increasing
volume of similar events, the opportunity for data capture,
analysis, and then research is enhanced. The Hartford
Consensus in the USA was developed after the active
shooter disaster at Sandy Hook Elementary School. This
recognised the patterns of morbidity and mortality over
multiple events, producing a national strategy for the pre-
vention of unnecessary deaths from extremity haemorrhage
during an increasingly predictable epidemic of homoge-
neous incidents.12
Peer reviewed publications that interrogate preventability
of deaths from civilian ‘terrorist’ attacks are relatively rare, but
they provide interesting insights into the opportunities for
improved medical care; for example, 34 (16%) of all fatalities
from 19 civilian public mass shootings were found to have
potentially survivable injuries, with the most common injury
being a gunshot to the chest without haemothorax or major
vascular injury (n¼24; 71%).13 Although caution is needed in
drawing parallels with lessons from military conflict, evidence
from Iraq and Afghanistan shows 25% of pre-hospital deaths
were found to be potentially preventable, with 8% of these
being attributed to airway compromise and 91% to cata-
strophic haemorrhage. The challenge is that 80% of the pa-
tients who died from exsanguinating haemorrhage had non-
compressible bleeds that would have required temporising
endovascular resuscitation or a surgical procedure to control
the haemorrhage.14
Strategies for decreasing preventable deaths
Measures for ensuring preventability of death from injury
during a marauding terrorist event have their foundations in
the strategies used in the mitigation and elimination of any
disease. The ‘pre-event’, ‘event’, and ‘post-event’ method for
prevention of mortality from injury has useful application.15
Much energy is committed to the prevention of terrorism in
the ‘pre-event’ phase. Once an event has begun to occur, the
primary focus for the emergency services (usually the police)
is in neutralising the threat, aiming to prevent an increase in
number of patients. The terms ‘hot’, ‘warm’, and ‘cold’
zones have been used to delineate geographical areas with
differing levels of threat, although there is an ongoing debate
about the usefulness of this terminology in real-life events.3
For the emergency services, the primary challenge during
terrorist events is how patients are afforded a level of pre-
hospital care that is rapid and effective despite realities of
the situation. This triad of reality being the potential of
ongoing threat, the ‘fog of war’ around safety, and the real
risk of potential harm to those professionals who are
involved in the response. In preventing unnecessary deaths
with adequate medical intervention, the ‘golden hour’ be-
gins immediately after the point of wounding.16 Any subse-
quent time without medical intervention has been termed a
‘therapeutic vacuum’.17 Once the pre-hospital component of
an event is complete, the ‘post-event’ phase often involves
significant periods of time for patients cared for in operating
theatres, in the ICU, and in rehabilitation, inclusive of the
psychological support that may be required. These are all
vital components of the wider trauma system in reducing
preventable deaths.
Categories of on-scene interventions
There are opportunities to reduce the duration of the thera-
peutic vacuum, and therefore morbidity and mortality. Three
categories of interventions are relevant: first responder in-
terventions (FRIs), enhanced care interventions (ECIs), and
bridging interventions. First responder interventions are vital,
and whilst it was historically deemed that FRIs were the remit
of the statutory or volunteer responders, it has become clear
that bystanders have a vital role in delivering aid to their fellow
civilians. Useful FRIs include the application of tourniquets and
direct pressure over bleeding wounds, simple airway opening
manoeuvres, and the rapid removal of companions to a safer
area using whatever means necessary. First responder in-
terventions are usually only effective if performed rapidly,
often even before the arrival of the emergency services.
Evidence from recent military conflicts shows that external
catastrophic haemorrhage can be controlled with a well-
placed tourniquet. When tourniquets were introduced as a
standard of care by deployed coalition military troops in the
2000s, an 85% reduction in potentially preventable deaths was

seen from extremity haemorrhage.8 Bystanders have demon-
strated the effective placements of tourniquets under pres-
sure, for example at the Boston marathon bombing, with
improvisation of devices reported to have been highly effec-
tive.18 Tourniquets applied late are likely to be less effective,
and not all terrorist events require a focus of tourniquet
application.19
Where ambulance services and other formally trained
medical professionals are delayed in attending a scene
because of an active threat, FRIs must be carried out by by-
standers who are themselves often entrapped within the
scene, or by adequately protected emergency personnel. In the
case of a firearms incident, it is likely that these individuals
will be armed police officers who have the unenviable task of
primarily locating, confronting, and neutralising the threat,
and then also delivering life-saving interventions. The adop-
tion of these early battlefield-type casualty care concepts
known as ‘care under fire’ or ‘direct threat care’ has been
clearly described for civilian events,20 and is an approach that
has been discussed in some detail during recent inquests into
UK terrorist incidents.3
Bridging interventions are those interventions that do not
deliver a therapy, but that enable ECIs to be delivered. Exam-
ples include the insertion of i.v. cannulae. There is little evi-
dence to support additional interventions to those provided by
first responders, when these are carried out effectively.
Enhanced care interventions are those carried out by
enhanced care practitioners or teams, and include
(i) Anaesthesia for ventilatory failure in severe chest injury
and ongoing airway compromise
(ii) Thoracostomy to treat severe chest injuries in patients
who are not in cardiac arrest
(iii) Blood transfusion in specifically defined circumstances
(iv) Open-chest surgery in specific cases of penetrating
trauma
(v) Intravenous sedation for patients with multiple limb
fractures
(vi) Delivery of potent analgesia
(vii) Endovascular control of torso haemorrhage
As with day-to-day practice, the utility of these in-
terventions is weighed against the advantage of a rapid
removal to hospital. There are additional competing consid-
erations during the context of an ongoing terrorist event
related to hospital surge capacity, local geography, and the
stage of readiness of the receiving hospital teams. Even with
the speediest of pre-hospital responses, it is likely that ECIs
will not be delivered until a significant proportion of the
‘golden hour’ has been consumed by the therapeutic vacuum.
This raises an even greater sense of urgency in delivering the
appropriate teams to the incident scene. Meanwhile, even
outside of the context of terrorist events, significant data are
accumulating to suggest that the opportunities for interven-
tion sit firmly within the pre-hospital phase of care, as
follows.
A crucial contemporary paper by Holcomb21 identified that
the peak time of death after severe truncal injury is within 30
min, with an average 2.1 h to achieve haemorrhage control in
hospital. Blunt head injury remains an important entity at a
terrorist incident scene, especially one where vehicles have
been used as a weapon. Whilst the traditional approach to
head injured patients has been to rapidly transfer for neuro-
surgical care, there is an increasing appreciation that the
Editorials - e87
hypoxaemia with or without hypercapnia associated with
head injury can be remedied early, halting the development of
hypoxic axonal injury.22 Resuscitative thoracotomy has been
delivered on scene during terrorist events in the UK, as it is in
multiple cases of assaults with bladed weapons each year.2,4
Survival of a late-stage exsanguinating haemorrhage patient
after tourniquet placement, pre-hospital blood transfusion,
and cautious anaesthesia has been described following the
Fishmongers’ Hall terrorist incident in London.4
Importance of early analgesia
The importance of early analgesia cannot be overemphasised.
Whilst the provision of adequate analgesia is associated with
many proven benefits, the extrication of a patient from the
scene to a place of safety or to hospital is fraught with diffi-
culty, where adequate analgesia cannot be provided. Painful
blunt injuries, such as those suffered when vehicles are used
by terrorists as weapons, provide a real-world challenge for
analgesia provision. Traditional methods for delivery of anal-
gesia available to ambulance personnel, such as inhaled
nitrous oxide, i.v. paracetamol, or opioids (such as morphine),
may not provide the conditions for the rapid extrication of an
injured patient from a high-threat scene. Administration of
sedative doses of ketamine, widely described by enhanced
pre-hospital medical teams, is not without difficulty, where
there are multiple patients requiring attention over a large
geographical area. Recent work on the delivery of oral trans-
mucosal fentanyl citrate by the military shows promise in this
area for civilian first responders.23,24 Additionally, a number of
police forces in the UK now carry analgesic doses of inhaled
methoxyflurane for administration in high-threat areas before
ambulance arrival on scene.25 The introduction of a safe yet
potent analgesic strategy into the very early stages of a
terrorist event is essential if patients are to undergo adequate
haemorrhage control and splinting, and be moved rapidly to-
wards definitive care in time to prevent deterioration.
Options for delivering enhanced care
interventions
There is, therefore, a persuasive case for the early delivery of
ECIs at the scene of a terrorist attack, following rapidly on from
FRIs delivered by bystanders and appropriately armed police
resources. The presence of a suspected or ongoing live threat
has often precluded the rapid deployment of ambulance
personnel into this initial response.3,26,27 Multiple recom-
mendations have been made for further work in this area.3,26
Solutions include a French model, where doctors are
‘embedded’ with police units. This delivered results during the
Bataclan attack in 2015, where two doctors triaged all 100 of
the live casualties, also identifying 89 dead, whilst the tactical
situation was managed by police providing cover around
them.28 This approach requires extensive investment in
training, protective equipment, and a model that exists in
perpetuum, awaiting the trigger of a terrorist attack.
Other models focus on the urgent creation of protected ‘cor-
ridors’ and ‘islands’ through which senior clinicians can move
whilst protected by armed police. Alternatively, they may be
used for the injured to reach senior clinicians who are deployed
to ‘less hot’ areas of the scene, where they are protected to un-
dertake their roles. All models require training to ensure such
clinicians are cognisant of the potential threats associated with
 e88 - Editorials
modern terrorist attacks, and of how to move safely in and
around such threats and within a corridor or ‘bubble’ of armed
police officers.19,20 Such tactical training for pre-hospital clini-
cians currently exists within differing models internationally,
occasionally but not routinely, including enhanced care teams.
The discussion of potential educational programmes would
build on these. The potential delivery of a model where clinicians
work with, but are not embedded within the police response,
requires exemplary communication between services so that
the shared mental model is understood and delivered success-
fully. The challenge of accurate communication, especially be-
tween differing agencies during major events, has been
described extensively in reports and inquiries.2,3,26,29
Conclusions
Many recommendations suggest the need for a paradigm shift
in the inclusion of senior clinical leaders in the organisation of
the response.3,19,26 Medical decisions at the scene are the
domain of the clinician, and it has long been recognised that
the presence of senior clinicians impacts positively on clinical
care, under a host of circumstances. Tactical decisions by
ambulance and police officers in charge can only be accurately
taken where the clinical opportunities for intervention are
understood. Terrorist attacks are dynamic, constantly chang-
ing phenomena that require flexible strategic medical leaders.
These should be medical leaders who can intimately identify
with the role of the senior tactical clinicians on the ground
who will be delivering interventions to orchestrate a
malleable, precise response, tailored to the circumstances of
the event. The opportunities for appropriately trained acute
specialty clinicians to influence patient outcomes during
terrorist events are significant. Whilst the future scale and
impact of such attacks are difficult to predict, it is important
that we continue to learn the lessons of events of the past and
to invest in the survivors of the future.
Declarations of interest
The authors declare that they have no conflicts of interest.
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British Journal of Anaesthesia, 128 (2): e89ee92 (2022)

doi: 10.1016/j.bja.2021.10.022
Advance Access Publication Date: 15 November 2021
© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Higher pre-hospital anaesthesia case volumes result in lower

mortality rates: implications for mass casualty care
Peter Paal1,*, Ken Zafren2,3 and Mathieu Pasquier4
1
Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University,
Salzburg, Austria, 2Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, USA, 3Department
of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA and 4Emergency Department, Lausanne
University Hospital, University of Lausanne, Lausanne, Switzerland

*Corresponding author. E-mail: peter.paal@icloud.com

This editorial accompanies: Association between case volume and mortality in pre-hospital anaesthesia management: a retrospective
observational cohort by Saviluoto et al., Br J Anaesth 2022:128:e135ee142, doi: 10.1016/j.bja.2021.08.029

Summary
Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success
rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior phy-
sician’s skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient),
circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills
may be required to care for patients requiring pre-hospital airway management especially in hazardous environments,
such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important
tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport
decisions.

Keywords: airway management; anaesthesia; anaesthesiologist; emergency medical services; mass casualty incidents;
tracheal intubation; videolaryngoscopy

In this issue of the British Journal of Anaesthesia, Saviluoto and
colleagues1 present a retrospective registry-based cohort study
of the association between the pre-hospital anaesthesia case
volume of helicopter emergency medical services (HEMS)
physicians and mortality. Physicians were divided into three
groups according to the case volume of pre-hospital
anaesthesia in the year preceding the airway management of
a given patient. Twelve physicians treated more than 36 cases
in the preceding year (511 patients), 56 physicians treated
13e36 cases in the preceding year (2033 patients), and 88
DOI of original article: 10.1016/j.bja.2021.08.029.
physicians treated 12 cases or fewer in the preceding year
(2274 patients).
On-scene time was significantly shorter for the physicians
with higher case volumes (median time: 28 min for physicians
with >36 cases, 32 min for physicians with 13e36 cases, and 32
min for physicians with 12 cases). First-pass success rate was
significantly higher for physicians with higher case volumes
(98%, 93%, and 90%, respectively) and mortality was lower
(25%, 29%, and 36%, respectively). Overall, 30-day mortality
was 32% (n¼1469). In the multivariate logistic regression
analysis, the pre-hospital anaesthesia case volume of the
preceding year was inversely correlated with 30-day mortality.
The authors suggest that physicians with higher pre-hospital