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
MADRID
ISTANBUL
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
Number
9.30 a.m.
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
Rips
another 38 buildings
out storefronts
Blows
out windows hundreds of m away
Downs
Flings
electrical and phone lines
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
 Police
unable 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
 8.40
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 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
Circle Line
Liverpool St
eastbound
Sub-surface cut and cover,
21 ft deep, and wide to
Edgeware Rd
accommodate 2 parallel tracks
westbound
BLASTS VENT FORCE
INTO TUNNEL,
REDUCING LETHALITY
Piccadilly Line
King’s Cross Deep-level, 100 ft, 11ft singlesouthbound 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
 “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
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
 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 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
Emergency vehicles
Elements: wind, rain
Injury to head
Injury to eyes
Injury to face
noise
Injury to hands
Blood, body fluids
Injury to feet
Protective clothing
High visibility jacket
Waterproof, insulated
Hard hat with chinstrap
Safety goggles
Visor
Ear defenders
Heavy duty gloves
Patient treatment gloves
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
Police
hospitals
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
E Exact location
T
H
A
N
E
Standby or declared
Grid reference
Type of incident
Rail, chemical, road
Hazards
Present and potential
Access
Direction, approach
No of casualties
Incl type and severity
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
 Rapid
tagging systems for
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
control
Manual CS
stabilization
Cervical collar, spinal
board
Airway
Opening:chin Oro/nasopharyngeal
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
Intervention
Equipment
Clear airway
Manual suction apparatus
Maintain airway
Oro/nasophar airway
Support ventilation
Pocket mask
Seal open
pneumothorax
Arrest hemorrhage
Asherman chest seal
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
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 illprepared to deal with a major incident.
 A major incident may occur at any time,
anywhere.
 Nothing
replaces well-trained,
competent, motivated people. Nothing.
Colonel TJ Hodgetts, Emergency Med & Trauma
University of Birmingham, UK, 2005