Madrid March-11 a prehospital analytical view From evidence-based disaster medicine Alfredo Serrano Moraza María Jesús Briñas Freire Andrés Pacheco Rodríguez Alejandro Pérez Belleboni

The conscientious, explicit, and judicious use of current best evidence in making decisions about the management of disasters Badenoch D. Evidence-based Medicine Toolkit. BMJ Books 2002 Jeffrey Arnold, MD Yale University School of Medicine Yale-New Haven Center for Emergency and Terrorism Preparedness Jeffrey Arnold, MD Yale University School of Medicine Yale-New Haven Center for Emergency and Terrorism Preparedness Evidence-based disaster medicine

Ev-b Disaster Method Maximal rigour Information sources strict control –almost ALWAYS indicated –special comments in less reliable ones –uncertain data are outlined as estimated Every work hypothesis must support scientific contrast and validation Exhaustive methodology Only used if no critical information no other sources availables Enormous personal number working in different focus Information still not totally available (approx. 70 %) ED and ICU survival data and correlations – still collecting Many difficult or irresoluble questions

General principles Scientific approach Respect imperative Ethical principles Learning from our errors must have priority on new information acquisition McIntyre N, Popper K. Br Med J 1983;287: No criticism for EMS (and others) professsionals, volunteers and general public No cruel victims images nor confidential data No internal fighting No general press publications Relatives and friends psychological support...to grow together

The key 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 * No references yet

NY 9-11 vs. Madrid March-11 Approx. one / multiple focus Critical patients almost absent / overload EMT-Parameds. EMS / Phys. based EMS No victims between Emergency teams Others ED red labels 233 System power 100 % real operative extraordinary Máx. total 9/11 McKinsey report 9/11 Commission full report No official report...when they arrived

Ideal aims Optimal focus work Secure access and workControlled evacuation On-scene triageHospital critical victims distribution Initial treatmentsGreen-labels control On-time arrival Phys-EMS triage and stabilization [...] Adequate transport in time, way and level Promote victim-care Hospital level adequation Critical-bed coordination Prevent ED-overcrowding Evaluation points massive evacuation scoop and run and its consequences Reduce

Citizens collaboration They were present from the first minute Many victims cared for the other ones They even made in situ tourniquets Their stories are a rich technical source and plenty of humanity Massive evacuation x and Scoop and run x They saved a lot of lives and, perhaps, our image Causes Enormous casualty numbers and severity Initial EMS delays (two-four focus) Some difficult accesses Effects Different EMS-ED data (in part) Non-assisted transport of severe pts. Not always the worst option Low in itinere mortality ( 2 victims ??) What about ISS ??

Citizens 2

Activation 1 EMS units Two differents services – two different Coord. Centers x SUMMA 112 Peak and relief hour: double shift A lot of units without inside stretcher More personnel - enormous collaboration Even Coord. Center personnel - Perhaps more confusion ? x Ambulances critical factor x x No group calls mechanism by all the ways (phone / radio / others) Preference: first, send units x Difficult real-time registering x No specific Disaster Software Communications critical factor x GIRECA New software from [Bigger] problem than all other factors combined* *

Activation 2 Non-shift personnel No-shift personnel variable activation x SAMUR protocol - Difficult on real-time Not accomplished SUMMA has NO protocol x x TV / radio diffusion Dependent on Personal availability Clear city ways Favoured by police network and citizens collab. x The real: Everyone available went to help, most on their own Someone to Comm. Central, some others to focus x x But, their presence is neither desirable nor secure

Four focus The most determinant factor Difficult to preview ?? EMS teams did really penetrate in hot EVOLUTIVE areas x Every focus needs an individual analysis Evidence-research not finished yet x against all academic recommendations, they knew when they were almost alone and lay people also did it Perhaps it has a difficult solution

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

48 conveniated ambulances SERMAS 47 SAMUR ambulances 32 Red Cross ambulances 20 Civil Protection ambulances 3 ambulances from SAMER N private ambulances Basic support N ambulances + more than 100 vehicles (most SAMUR) for logistics and some other services

7:49-8:00 Atocha IC organization Dead 34 Total victims 145 SUMMA/SAMUR 6 deceased in place 12 critical SUMMA 15 critical SAMUR 30 severe wounded Work time approx. 2h SAMUR SUMMA mICUs VIR UAD Feedback information

Santa Eugenia 7:50 mICUs VIR UAD SAMUR SUMMA IC organization Dead 17 Total victims 52 SUMMA/SAMUR 4 critical SAMUR 10 severe SAMUR 6 severe SUMMA Work time approx. 1 h 15 min.

El Pozo The face of death First units: Police, Fire-Rescue and basic support Heroical citizen support Wild scoop and run Hour ? mICUs VIR UAD Helo SAMUR SUMMA Theres no physic IC 8:50 More units, also Helo 9:00-9:15 Theres 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.

Téllez Original IC is not available Confussion for ½ hour 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.

Téllez St.

Téllez St. 2

Téllez St. 3

SUMMA Communications UHF (personal mobile radio) Trunking (analogic) x Difficult bed-assignation x Difficult redispatch-reallocation in case of another focus or changes in already known open network x no walkies x now in closed network x low performance x shared with CYII, not own Wired phone (in EMS bases) x limited low saturation Wireless mobil phone x almost operative for the first 40 min. x totally interfered in focus (Police) Consequences Radio Phone Hazardous solutions x Frequent network messages Ex: For all the units: Hospital X is overcrowded... x again, wired phone in focus from cabins, cafes, etc.

Major lesions Distance 1º Blast 56% 2º Penetrating 50% 3º Closed (ejected) 53% 4º Burns 31% MODS without any other lesions 0% Data from 50 patients (240 – 190 pts) in Doce de Octubre Hospital Confined space explosion Acoustic 58 % Blast Lung 56 % Bowel 0 % Craneal trauma 28 % Maxillofacial 16 % Spinal cord inj. 16 % Thorax trauma 24 % Abdominal 7 % Orthopaedic 17 % Open fractures 73 %

Hospital data Consejería de Sanidad March 11, 21 h Critical Hard severe Severe Wounded Discharged Slight injuries Dead

Madrid Closest ED hospitals overcrowding Red labels H H H H H H H H H Gómez Ulla Doce Oct. Gregorio M. H H H H H H H

SAMUR 44 to 49* 1 fallecido de camino SAMUR 44 to 49* 1 fallecido de camino Red labels SUMMA 21* plus 20** SUMMA 21* plus 20** On-scene deceased 14* to 20** On-scene deceased 14* to 20** * official data ** estimated Hospital EDs 233 Hospital EDs 233 Communications irregular failure ? Random Assignment* 143 ? Different classification systems Ex: ED no yellow labels Difficult focus data collection Massive evacuation ? Admittable sub-triage or no available unit basic transport ? Deceased # 191 minus 20 Different EMS-ED data Why ?

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

Hospital-critical beds EMS coordination Habitual SCU task from 1989 Real-time coordination of critical care available beds Interhospital network control (14 major hospitals) Special needs Burn beds – only two hospitals Thorax surgery Available operative helipads (3). Only 1 habitually Acute phase Real time coordination Subacute period Predicted secondary avalanche didnt really happen Interfacility transports

Essentials 80 % accuracy Two differents services Two different Coord. Centers Four simultaneous focus SUMMA Communications irregular failing SAMUR random-Hospital evacuation philosophy Moderate massive evacuation and Scoop and run Nearer ED red-labels overcrowding Enormous Citizen collaboration Enormous EMS work Enormous Comm-Centers work Impact on morbi-mortality? Enormous Fire-Rescue, Police and public-private work Enormous In-Hospital work * estimated

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?