Disaster Medicine: Dealing With the Paris Terror Attacks

Jean-Bernard Gervais

December 10, 2015

PARIS — After the attacks of November 13, Medscape France interviewed the Surgeon General Henri Julien, MD, president of the French Society for Disaster Medicine, who gave us his analysis of the care given to the victims.

Medscape: What is the context of disaster medicine? How does it differ from emergency medicine?

Surgeon General Henri Julien, MD: Disaster medicine was developed in the 1980s by three doctors: Pierre Huguenard, Alain Larcan, and Surgeon General René Noto. Unlike emergency medicine, where one is dealing with a patient, disaster medicine has to deal with a group of patients. The number of doctors and care personnel is no longer sufficient for personalized medical care, and a different type of organization is required involving patient triage, focusing initially on those most seriously injured while the others are placed on standby. This is the first major difference.

Second, disaster medicine uses particular techniques and equipment. The images of the attacks of November 13 show people being carried by their arms and legs, because there were not enough stretchers. In disaster medicine, lightweight folding stretchers were invented for transportation in large quantities. We also designed what are referred to as advanced medical posts, otherwise known as field hospitals, for emergency intensive care among other things.

Henri Julien, MD. Source: Courtesy of Henri Julien, MD

In disaster medicine, it may be necessary to carry out an amputation to release a person trapped under rubble by one of their limbs. There is a specific organization, because caring for disaster victims involves numerous disciplines. The police are there to secure the perimeter, but also to organize clear routes in and out. The fire brigade are also needed, and they are responsible for freeing trapped victims and for searching for and rescuing people under the rubble. They also carry out first aid to stop bleeding, give oxygen, and so on. The doctors and healthcare personnel are also naturally involved. Ambulance drivers are present, as are hospital staff. The town hall has to organize an assembly point for reception and for providing comfort to those who need it. An entire chain has to adapt to the collective emergency. The more complex the disaster, the more rigorous the emergency response has to be.

The more complex the disaster, the more rigorous the emergency response has to be. Dr Henri Julien

Medscape: How did the events of November 13 involve disaster medicine?

Dr Julien: In technical terms, the terrorists wounded people on several sites, as in Madrid [on March 11, 2004], where there were three sites, but also in London [July 7, 2005]. The Alpha Red Plan defined by the Paris fire brigade was therefore activated for the first time. This Red Plan was activated in coordination with the White Plan for hospitals and the SAMU emergency doctors (Editor's note: SAMU stands for Service d'Aide Médicale Urgente, or Urgent Medical Aid Service).

There were three types of attacks: (1) shootings, with the gunshot wounds causing numerous rapid fatalities; (2) explosions leading to blast wounds, another type of injury well-known in disaster medicine, with multiple penetrations and possible pulmonary damage. In this case, the victims do not die as rapidly as those who were shot. Finally, there was also (3) a hostage taking: I believe that this is the first time we were faced with these three types of attacks simultaneously.

Medscape: How would you analyze the care given to the victims of November 13?

Dr Julien: It's still too early to say. We generally analyze the feedback and look at what worked and what didn't. We can, however, say that the response to the events by the emergency service benefited from two favorable factors: the Paris fire brigade, which has some 8000 personnel, covering four departments, brought considerable weight to bear. Coverage was thus extremely rapid and effective on the part of the fire brigade. With regard to the doctors and SAMU, the situation was very similar. The SAMU in the Paris region is a powerful force. We were thus able to draw on the extraordinary treatment capacity of the Paris hospitals. We have enormous hospital capacity, with [Assistance Publique–Hôpitaux de Paris], the public hospital system of the city of Paris and its suburbs) being the largest hospital system in Europe.

What are the differences between the White, Red, and Yellow Plans?

In the event of a disaster in France, two complementary plans are activated: the Red Plan and the White Plan.

The Red Plan concerns what is happening in the field. It is based on the principle of extracting and grouping the injured. The injured are grouped in the field hospital, the triage and care center where the treatment that is strictly necessary is given, to ensure survival, calm the pain, and be able to transport the victims without making their condition worse. The field hospital is placed under the authority of the medical response coordinating physician.

The Alpha Red Plan, such as that activated on the night of November 13, is designed to deal with multisite events.

The Yellow Plan is a variant of the Red Plan adapted to nuclear, radiological, biological, and chemical risks. At the same time, the hospitals must be prepared to deal with an influx of victims: this is the responsibility of the White Plan.

On November 13, the emergency services counted 479 victims: operations on chronic cases therefore had to be put on hold in order to deal with the urgent cases.

The White Plan includes setting up a unit tasked with communication with the media, informing families, programming the release of beds, calling in reinforcements, etc. In line with the Social Security Modernization Act of 2004, the White Plan was extended to cover all establishments around the hospital, including clinics.

Medscape: Which physicians are trained in disaster medicine in France? Are they evenly distributed around the country?

Dr Julien: No, there are no organizations as such. Two historical events led to the development of disaster medicine. The first was the El Asnam earthquake in Algeria in 1980. I was sent out there by the French government. We were two doctors and we saw that the work to be done was absolutely overwhelming. We didn't sleep for 10 days. And then there was the Orly attack [bomb attack on July 15, 1983]. There again, we realized that a group of victims cannot be treated in the same way as a single patient. A curriculum of disaster medicine was thus created and is currently being taught in Nancy, Amiens, Lille, Paris, Créteil, Toulouse, Lyon, Marseille, and Bordeaux.

Every year, about 40 doctors sign up for this course. Books have been written, and then the French Society for Disaster Medicine was created, with the aim of learning as much as possible from major disasters, in order to constantly improve what can be done for the victims. The history of disaster medicine is made up of three phases. Initially, we had responsibility for most of the treatment of the injured. In 1990, the psychiatrists arrived and we then became interested in the psychological wounds. In the 2000s, chemical risks appeared because of the sarin used in the Tokyo metro attack by the Aum Shinrikyo sect. Then came anthrax, SARS, flu, Ebola, and so on. So we also became interested in that. Disaster medicine is constantly evolving.

Medscape: What lessons can disaster medicine learn from the November 13 attacks?

Dr Julien: There is something new about these attacks, what I call "man-in-the-street terrorism." Via social media, people decide on a whim to become terrorists. Remember the one who shot himself in the foot [Sid Ahmed Ghlam, an Algerian student who planned to attack two churches in Villejuif in 2015, but who gave up after accidentally shooting himself twice]? We're not dealing with networks as organized as those of the resistance. It's a bit like Uber: I suddenly decide to play the taxi with my car, then I forget about it for a couple of months. This man-in-the-street terrorism must be counteracted with a man-in-the-street emergency response. The French must start to learn how to manage by themselves. For example, during the attacks, some of them took their shirts off to make tourniquets; unfortunately, not enough people know about this perfectly simple technique.

Medscape: So how does one go about setting up this "man-in-the-street" first aid?

Dr Julien: As a member of the Academy of Medicine, I wrote a report on how to rejuvenate the first aid system. On January 27 I am organizing a meeting about advanced disaster techniques. I modified the program to bring in some important speakers to give firsthand accounts. As doctors, it is our duty to think about what we are doing and try to do better. We must continue to work and to move forward.


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