MASS CASUALTY

MANAGEMENT:
What we’ve learned
in Europe
Linda E. Pelinka, MD, PhD
Medical University of Vienna
and Ludwig Boltzmann Institute
for Experimental & Clinical Traumatology
Vienna, Austria,
European Union TRAUMA
What happened?

LONDON

ISTANBUL
MADRID

Management: what went right?

Management: what went wrong?
Lessons learned
Management & support priorities

Command & control

Safety
Communication
Triage
Treatment
Transport
 Istanbul, Turkey
Targets 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 later
 Istanbul, Turkey
Targets 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.
 ISTANBUL:
what went WRONG?
TRAFFIC GRIDLOCK
EMS CANNOT REACH VICTIMS
Streets clogged by debris
Traffic, narrow streets parked cars
Ambulances, medical personnel
Police, fire brigade
Media, bystanders, volunteers
MALDISTRIBUTION of INJURED
NO 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
K Taviloglu et al, Int J Disaster Med 3/1-4: 45-49; 2005

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
 Mass-Casualty Terrorist Bombings
in Istanbul: Events and Prehospital
Emergency Response
U Rodoplu et al, Prehosp Disaster Med 19: 134-145; 2004

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
 NO COMMAND
NO CONTROL
 Policeunable to establish control
 Scene not secured
 All ambulances dispatched simultaneously,
many not needed
 No protective gear (stench of ammonia)
 Bystanders in the way, digging
independently
 Communication network collapses
 Mass-Casualty Terrorist Bombings in
Istanbul: Events and Prehospital
Emergency Response
U Rodoplu et al, Prehosp Disaster Med 19: 134-145; 2004

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
 WHAT DID
THE TERRORIST ATTACK
TEACH THE TURKISH?
INDEPENDENCE & IMPROVISATION
MAY BE GOOD, BUT…
…STEP BY STEP TEAMWORK
IS BETTER
 Madrid, Spain
Targets 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
 Train 1 inside Atocha Station

Train 2 approaching Atocha Station 2 min late

7.37 a.m.

7.39 a.m.
 8.00 Ambulances arrive
 8.30 EMS sets up field hospital
at sports stadium nearby
 8.40a.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 available
Good in-hospital care

 Atocha station, doors of train open: less

deaths
8.00 “Cage Operation” goes into effect to
prevent terrorists from escaping from Madrid
8.45 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
 MADRID:
what went WRONG?

Insufficient

COMMAND

CONTROL

COMMUNICATION
 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
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.

Underground bombs explode within 50

secs, as trains are passing each other,
thus affecting 2 trains each plus tunnels.
Circle Line Liverpool St Sub-surface cut and cover,
eastbound
21 ft deep, and wide to
Circle Line Edgeware Rd
accommodate 2 parallel tracks
westbound
BLASTS VENT FORCE
INTO TUNNEL,
REDUCING LETHALITY

Piccadilly Line King’s Cross Deep-level, 100 ft, 11ft single-

southbound track tube, 6 in clearance
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”
 The London attacks – a chronicle.
Improvising in an emergency.
PJP Holden, NEJM 353/6: 541-543; 2005

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.
 The London attacks – a chronicle.
Improvising in an emergency.
PJP Holden, NEJM 353/6: 541-543; 2005

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.
 London bombings July 2005:
The immediate pre-hospital medical
response.
DJ Lockey et al, Resuscitation 66; 2005

• 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.
 LONDON:
what went WRONG?
CONFUSION
PUBLIC TRANSPORTATION CRIPPLED
underground and busses shut down
NUMBER of blasts: 3 rather than 6,
because blasts were between stations,
people exiting from both stations
CAUSE of blasts: not due to power surge
because of person under train. Vice versa!
 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
 “Wehave 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 Limiting factors

Tourniquets OR space

Fluids ICU beds
Triage tags Personnel
 London bombings July 2005:
The immediate pre-hospital medical
response.
DJ Lockey et al, Resuscitation 66; 2005

• 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.
 The London bombings of 7 July
2005: what is the main lesson?
G Hughes, Emerg Med J 23: 666; 2006

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.
LESSONS LEARNED
fighting TERRORISM
MANAGEMENT & SUPPORT
PRIORITIES
COMMAND & CONTROL
SAFETY
COMMUNICATION
TRIAGE
TREATMENT
TRANSPORT
 COMMAND & CONTROL
COMMAND CONTROL
Vertical transmission Horizontal transmission
of authority within of authority across
each emergency and each emergency and
support service. support service.
Each service Each incident
has one individual has one individual
in command in overall control
 COMMAND & CONTROL
 Cornerstones 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 & CONTROL
 Medical providers at the scene must be
properly equipped, personally & medically
 Ifill 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 variable
TJ 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 of
Information
Confirmation
Coordination
 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 COMMUNICATION
Ambulance provides radio gear for
communication between
Key medical staff at scene
Ambulance vehicles at scene
Ambulance Control
Receiving hospitals
Police and Fire Stations
 OFFSITE COMMUNICATION
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
 COMMUNICATION
METHANE
acronym of key info to be passed
M Major incident Standby or declared
E Exact location Grid reference
T Type of incident Rail, chemical, road
H Hazards Present and potential
A Access Direction, approach
N No of casualties Incl type and severity
E Emergency services Present and required
 TRIAGE
Rapid Patient Assessment
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.
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 ADVANCED
Spinal Manual CS Cervical collar, spinal
control stabilization board
Opening:chin Oro/nasopharyngeal
Airway lift, jaw thrust airway, ETT, surg. airway
Mouth/mouth Mouth to mask, bag valve
Breathing mouth/nose mask, chest drain, needle
thoracocentesis
Control ext. Peripheral/central venous
Circulation hemorrhage intraoss access, defib
 TREATMENT: First Aid
Life Saving
Equipment
Intervention
Clear airway Manual suction apparatus
Maintain airway Oro/nasophar airway
Support ventilation Pocket mask
Seal open Asherman chest seal
pneumothorax
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
 TRANSPORT
Effective organization of ambulance
circuit vital for smooth evacuation
Ambulances form mainstay of
transport
Helicoptersmore suitable when
road transport cannot be used
Shortflight 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
 “Itcouldn’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.
 Nothingreplaces well-trained,
competent, motivated people. Nothing.
Colonel TJ Hodgetts, Emergency Med & Trauma
University of Birmingham, UK, 2005