COMMENTARY

Emergency Care in Response to Terrorist Attacks

Prof Pierre Carli, Prof Frédéric Lapostolle

September 06, 2019

A special session at the European Society of Cardiology (ESC) Congress 2019 heard French doctors describe the challenges of dealing with terrorist attacks.

Prof Pierre Carli, head of the emergency medical service SAMU, in Paris and president of the National Council of Hospital Emergencies, from Necker University Hospital, told delegates there have been 21 terrorist attacks in France since January 2015 to 2018. There were 266 deaths and more than 791 people were injured.

   

Prof Pierre Carli

Prof Carli, shared his experience with Medscape French Edition along with Prof Frédéric Lapostolle, another emergency doctor.

Prof Pierre Carli talked about the attacks in Paris in November 2015: "Attacks, this is always a very tough subject which is extremely difficult to deal with since there are many victims.  During the congress, many doctors and cardiologists from all over the world attended our presentation, which was not actually about cardiology, because we talked about the organisation of care and management of the seriously wounded."

The important point to keep in mind, he said, is that the threat persists: "It has been 5 years now since we had the terrorist attack in Paris, and the attack in Nice followed several months later, an extremely difficult period for the rescue teams, for the care teams, for the hospitals, for our authorities too, who have to tackle these issues." 

His message was clear: "We must never be alone in these circumstances and we must work internationally.  We had prepared the response to these attacks with the help of our colleagues in London and Madrid who had suffered from terrorist attacks.  We have benefited, through medical networks and in particular through congresses, from a considerable amount of dialogue and exchange.  So the first thing is: it's a network topic, a global topic, where professionals exchange their points of view and everyone will help advance our understanding a little, our ability to have more effective support to save as many lives as possible, which is the very clear goal at that time.

Preparation, Adaptability

"What I explained in this conference is that we had been prepared, and we had been faced with the real situation - and we learned from these.  On every occasion, there are things that worked as expected, and there are others where you have to adapt.  And adaptability, being able to move from a rigid organisational plan to actually being on-the-spot, an organisation or technique that will be as effective as possible - this is something that needs to be prepared.  We must expect to be surprised and not be shocked by the fact that the situation we face is not what we had planned for, but we must adapt.

"Taking care of victims during a shooting means finding oneself in a dangerous situation.  You have to protect yourself, you have to protect the victims, you have to evacuate them, you have to prioritise actions - we have seen in other programmes cardiac arrest, cardiac massage ... tying a tourniquet on a bleeding victim, it's the same as massaging the heart.  It is just as vital, as fast and as necessary.

"The other point, after adaptability, is that you need practice. This is one of the messages that I tried to convey to our colleagues: when faced with a situation like the Stade de France where there are explosions, shooting, or hostages being taken like in Bataclan, if you do not know how to work with the Police, with the Army, with the specialist squads, with colleagues from the other emergency services, if your response is not global, you have little chance of being effective. 

"On the other hand, when everyone knows one another and has rehearsed together, we can do extremely powerful things, extremely fast things, extremely fluid things, and that's really very important. 

"So organising exercises is not easy, it can take a lot of time.  But we can do very simple exercises and I showed, for example, that here in Paris, we have developed playing with Playmobil toys.  It made everyone in the room laugh a lot but it works very well and is cheap - it's something that allows you to understand the main concepts. 

"Preparation also means pre-empting a new situation. Unfortunately, terrorists still exist and you have seen in France, since the attacks in Paris and Nice, there have been a further 20 terrorist attacks - less important, but just as dangerous.  So we must know how to pre-empt, protect our medical teams, protect our hospitals and prepare for more complex risks such as chemical attacks."

Prof Carli spoke to the conference about wartime-like sights when the team arrived at the scene, so it is important to have links with the armed forces: "This is one of the important points.  We pre-empted these situations with the French army's health service, which had been served in Afghanistan, which had seen those wounded by war. Our military colleagues returning from these warzones, said 'You have never seen people wounded like that'. And we worked on this for 2 or 3 years before dealing with the terrorist attacks. It was the right move - it helped us considerably.  In the same way, as the information was clear that the risk of attack was gradually increasing in France, we could practise a number of techniques, we could also do exercises, and for example, the very morning of the attacks in Paris, at 9am, 12 hours before the terrorist attack, we carried out an exercise.

"It was a coincidence and I remind you that this is the time when there was a big American congress on cardiology and we were also there, so everyone was involved, had discussed these topics, had done some preparation."

Victims' Hospital Care

What about care of many injured patients of all ages in hospital, and implementation of Emergency Management Plans?

Professor Frédéric Lapostolle was clear that doctors of any specialty or seniority have to know how to apply a tourniquet, and the whole hospital team gets involved: "Doctors, regardless of their specialisation, must be involved because when patients arrive at hospital, the whole hospital, the entire operation, is affected. 

"There is an influx of victims - everyone has seen the photos of these floods of victims in hospitals which were not prepared to receive them… many traumatised patients: injured by firearms, blast injuries, possibly stab wounds.  So it's really up to the whole hospital to make it work and there are plans, and all hospitals, not just our hospitals in the big cities, but all hospitals must have an Emergency Management Plan.  And the Emergency Management Plan is broken down service by service, and even in each service, broken down into professional category by professional category. 

"And that can only work if everyone knows what he or she has to do. It implies that we have been prepared, we have met one another, we have had discussions, that things are clear .. and we practised. 

"For the Emergency Management Plan, we must indeed practise, so either there is a non-hospital exercise which ends up in the hospital, and we set up the arrival of victims, either with a Playmobil set or around a table, where we do the exercise. 

"But, just like outside the hospital, preparation and exercise are absolutely crucial because we must tell ourselves that this will happen again.  And if this is not through an attack, the massive influx of casualties can occur due to an everyday life accident, a fire, a building collapsing and so on.  It's our daily job to prepare for it."

Protecting Medical Teams

Doctors and paramedics need to be aware of the risk that terrorists will attack ambulances which take the wounded to hospitals, or attack the hospital itself, Prof Pierre Carli said: "These multi-site attacks, which we call 'multi-modal' because there are many different invasive agents used - explosions, hostage taking, shooting - these are strategies that are planned, not improvised.

"So, faced with this, we must do the same thing: we must reason, we must put things in place.  In Paris, in the Île-de-France region, for several years we had planned our response so that, for example, not all ambulances go to the same place, where some hospitals do not receive patients. So we had prepared all that. Faced with reality, we have adapted these points, but if you have not thought about it before, you will not be able to improvise and, conversely, you risk being paralysed, and so our message for our international colleagues is: let's exchange information - what we do every day - let's be prepared, let's prepare our public.

"The public, do you know what terrorists call us? 'Soft targets', that is, people who are easy to reach. 

"We must, at all costs, toughen up to be able to react effectively, not to expose ourselves unnecessarily or stupidly, to protect ourselves, to save the lives of others by applying a tourniquet, alerting the police forces, who are very quick to intervene and who, believe me, do extraordinary work under these circumstances."

ESC 2019, Paris: Emergency Care in Response to Terrorist Attacks, Saturday 31st August 2019.

Translated and adapted from Medscape French Edition

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