1. 11 March 2004 Madrid Bombings A Prehospital Analysis
Alfredo Serrano Moraza, M.D.
María Jesús Briñas Freire, E.M.D.
Andrés Pacheco Rodríguez, M.D.
Alejandro Pérez Belleboni, M.D.

2. Evidence-based disaster medicine
Scientific approach
Evidence-based disaster medicine
Analytical work
Systematic sources acquisition and register
Exhaustive methodological evaluation
Ethical principles
Patiens and relatives confidentiality
EMS teams’ work respect
Useful and exportable approach
Look for and design an evaluation-tool for similar MCIs
Whe outline this is a technical document strongly bound to these general principles.
Our principal aim is to make some light on some specific lessons from that day.

3. The key EMS Emergency does NOT finish on scene
While Police and Fire-Rescue Emergency could finish on focus
EMS Emergency
does NOT finish on scene
Critical-bed needs coordination
has impact on pts. morbi-mortality
As you really know, while Police and Fire-Rescue Emergency could, perhaps, finish on focus,
EMS Emergency does not finish on scene.
This is one of the milestones of mass-casualty incidents (MCI) prehospital assistance. It’s the key for integrated work.
After initial units dispatch efforts, this was the preferential Coordination Centre work.
Indeed, critical-bed needs coordination has impact on patients morbi-mortality.
Up to date, our present data suggest this could happen on March-11.
* No references yet

4. NY 9-11 vs. Madrid March-11 Approx. one / multiple focus
9/11 McKinsey report 9/11 Commission full report
No official report
Approx. one / multiple focus
Critical patients almost absent / overload
EMT-Parameds. EMS / Phys. based EMS
No victims between Emergency teams
Others
ED red labels
...when they arrived
We begin showing the principal differences between NY 9-11 and Madrid March-11.
Our comparison data arise from NY McKinsey’s report.
Specially, in March-11 our prehospital system took directly care of more that 500 patients.
Hospital registers show 1430 patients assisted in the first 24 hours. The total amount rises to approximately 1900 total patients.
In NY 9-11, these patients did NOT arrive at ED Hospitals.
Finally, our prehospital model, a more european modelo, is physician-based from the begginnig, with essential changes in prehospital care.

5. Advanced support 31 18 13 8 + 1 Coord. (4-8 coord.) 11 2 mICUS mICUS
María Jesús Briñas Rescue Jeseník 2004 31
mICUS
Phys + Nurs + 1 EMT 18
mICUS
Phys + Nurs + 2 EMTs
8 + 1 Coord.
Phys + Nurs + 1 EMT
VIR 13
(4-8 coord.)
VIR
Phys OR Nurs + 1 EMT
Phys + 1 EMT
usually for home non-emergency medical visit
UAD 11 2
Phys + Nurs EMTs
+ pilot + mechanic
HEMS
Total approx. 80

6. Atocha
María Jesús Briñas Rescue Jeseník 2004
SAMUR
SUMMA
mICUs VIR UAD
Feedback information
Medical Post organization
Dead 34
Total victims SUMMA/SAMUR
6 deceased in place
12 critical SUMMA
15 critical SAMUR
30 severe wounded
Work time approx. 2h
7:49-8:00

7. Santa Eugenia SAMUR 2+1 2 - SUMMA 4+1 - -
María Jesús Briñas Rescue Jeseník 2004
7:50
mICUs VIR UAD
SAMUR
SUMMA
MP organization
Dead 17
Total victims 52 SUMMA/SAMUR
4 critical SAMUR
10 severe SAMUR
6 severe SUMMA
Work time approx. 1 h 15 min.

8. El Pozo
The face of death
María Jesús Briñas Rescue Jeseník 2004
First units: Police, Fire-Rescue
and basic support
Heroical citizen support
Wild massive evacuation
Hour ?
mICUs VIR UAD Helo
SAMUR
SUMMA
There’s no physical MP
8:50 More units, also Helo
9:00-9:15 There’s another bomb
Train evacuated
Rescue stopped
Dead 67
Total victims 56 SUMMA/SAMUR
4 critical SAMUR
2 critical SUMMA
45 almost unknown ambulances
Work time approx. 1 h 15 min.

9. Téllez St. SAMUR 2+6 2 - - SUMMA 4 - 2 -
María Jesús Briñas Rescue Jeseník 2004
Confussion for ½ hour
Original IC is not available
Victims are evacuated to next sports centre
SAMUR
SUMMA
mICUs VIR UAD Helo
Dead 64
Total victims 83
perhaps 2 deceased in place ??
7 critical
rest is confusing
Work time approx. 2h 25 min.

10. Hospital data Dead Wounded Discharged Critical Hard severe Severe
Slight injuries
Dead
As you know, these are the official data from the same March-11 night.
Hospital data
Consejería de Sanidad
March 11, 21 h

11. Closest hospital overcrowd
Robregordo
Montejo
de la
Sierra La
Hiruela
Acebeda
Prádena
del Rincón
Horcajo
Madarcos
Braojos
Nava-
rredonda
Puentes
Viejas
Buitrago
Lozoya
Gargantilla
Berzosa
Puebla de
la Sierra
Robledillo
Garganta
de los
Montes
Lozoyuela
El Atazar
Cervera de
Patones
El Berrueco
La Cabrera
Valde-
manco
Bustarviejo
Canencia
Rascafría
Torrelaguna
Caba-
nillas
Navala-
fuente
Venturada
Miraflores
de la Sierra
Talamanca de
Jarama
Valdepié-
lagos
Soto del Real
Colmenar Viejo
Manzanares
el Real
El Vellón
Valdetorres
del Jarama
Collado
Mediano
Cercedilla
Guadarrama
cerrada
Los
Molinos
Villalba
Hoyo de
Tres
Cantos
San Sebastián
de los Reyes
Alcobendas
Algete
Fuentelsaz
Valdeolmos
Alapardo
Ribatejada
Valdeavero
Fresno de
Torote
Cobeña
Daganzo
Meco
Camarma
Esteruelas
Paracuellos
Alcalá de
Henares
Los Santos de
la Humosa
Anchuelo
Santorcaz
Torrejón de
Ardoz
Coslada
San Fernando
Villalbilla
Corpa
Pezuela
Alameda
Valverde
Pozuelo
del Rey
Nuevo
Baztán
Olmeda
de las
Fuentes
Ambite
Villar del
Olmo
Velilla
Rivas-
Vaciamadrid
Arganda del Rey
Campo Real
Valdilecha
Orusco
Carabaña
Brea de
Tajo
Valdaracete
Estremera
Fuentidueña
de Tajo
Villarejo de
Salvanés
Villamanrique
Belmonte
Tielmes
Perales de
Tajuña
Valdelaguna
Chinchón
Villaconejos
Morata de
Aranjuez
Ciempozuelos
Valdemoro
Getafe
Pinto
Parla
Fuenlabrada
Leganés
Casarrubuelos
Serranillos
del Valle
Móstoles
Pozuelo de
Alarcón
Villamanta
Villaviciosa
de Odón
Navalcarnero
Aldea del Fresno
Villa del Prado
Cadalso de
los Vidrios
Cenicientos
Rozas de
Puerto
Real
Alcorcón
Boadilla del
Monte
Brunete
Majadahonda
Las Rozas
de Madrid
Torrelodones
Galapagar
Valdemaqueda
Santa María
de la Alameda
El Escorial
Zarzalejo
San Lorenzo
de El Escorial
Navas del
Rey
Pelayos de
la Presa
San Martín de
Valdeiglesias
Robledo de
Chavela
Fresne-
dillas
Navalagamella
Valdemorillo
Villanueva
del Pardillo
Villanueva de
la Cañada
Colme-
narejo
Quijorna
Colmenar
de Arroyo
Ajalvir
Mejorada
del
Campo
Loeches
de las Torres
Torres de la
El Molar
Serna
Pinilla
Valle
Ala-
me- da
Villa-
vieja
El Álamo
Arroyo-
molinos
Moraleja
de Enmedio
Batres
Cubas de
la Sagra
Griñón
Humanes
la Calzada
Somosierra
Villamantilla
Perales
Chapi-
nería
Sevilla la
Nueva
Velasco
San Martín de la Vega
de Oreja
Titulcia
Guadalix
Pedrezuela
San
Agustín
Becerril
El Boalo
Moralzarzal
Torre-
mocha
Gascones
Piñuécar
Horca
juelo
Redueña
Alpedrete
MADRID
Madrid
Red labels 5 17 H
Gómez Ulla
Doce Oct.
Gregorio M. 1 1 14 5 91 15 30 1
But, correctly presented, the reality talks by itself of nearer ED overcrowding.
Three nearer hospitals, Gregorio Marañón, Doce de Octubre y Gómez Ulla received 159 red labels.
We show some preliminar causes for this in next slide. 38 2 12

12. Different EMS-ED data Why ?
Deceased # 191 minus 20
Red labels
bypass
SAMUR
44 to 49*
1 fallecido de camino
SUMMA
21* plus 20**
Random
Assignment*
On-scene deceased
14* to 20**
Communications irregular failure ?
Hospital EDs
233
85-90
143 ?
Admittable sub-triage
or no available unit
basic transport ?
Massive evacuation ?
Different classification systems
Ex: ED no yellow labels
Official SAMUR data talk us of patients evacuated in advanced support units. One patient died on the way.
Same data of SUMMA patients show they assisted and transported a total advanced amount of patients.
On scene estimations and some other data tell us about people deceased.
Then, we may have a total red labels of
Hospital data register 243 red labels in the first night.
The, what’s the reason of these different EMS-ED data?
First of all, it’s clear both have different classification systems.
Second, all EMS-assisted MCI may have a legitimate sub-triage difference. Or, perhaps, no available unit.
In the image on the right, we can see a green-label walking patient who received a craneotomty afterwards.
Third point, data collection in focus is not always easy.
Fourth, and in some instances, the most important factor –in fact, focus-dependent-, tragedy’s size and some other factors contributed to the existence of a variable people-guided scoop and run evacuation.
Difficult focus data collection
* official data
** estimated

13. evacuated to hospitals by EMS?
In MCI, are most victims
evacuated to hospitals by EMS?
Madrid March 11
38.6 % red labels
58.6 %
global
© Jeffrey Arnold, MD

14. Two differents services Two different Coord. Centers
Lessons learned 80 % accuracy*
Two differents services
Two different Coord. Centers
Infrastructural deficiencies
Enormous citizens’ collaboration
SUMMA Communications irregular failing
Enormous Firefighters, Police
and public-private efforts
SUMMA Planification deficiencies
EMS good job
Four simultaneous focus
Incident related
SAMUR on-scene good organization
SUMMA Dispatch Center good job
SAMUR random-Hospital
evacuation philosophy
Inadequate philoosphy ?
ED and Hospitals good job
Mild to moderate Massive evaquation
and Scoop and run
63 % red labels
Closest hospitals
critical patients’ overload
Impact on morbi-mortality ?
* 80 % accuracy

15. Thank you Madrid, my friends, Madrid, my brothers:
You cannot see my tears:
- I have no more
but can you really hear my words crying for you?
Thank you very much.