Official journal of the Australian Tactical Medical Association
How Does the Response and Management of Terrorist Attacks by Emergency Medical Services in the UK Compare to Europe and the USA? Alex Grant, BSc (Hons) 1, Simon Dady, BSc 1 1Anglia Ruskin University, Essex, United Kingdom.
Abstract (EPRR), casualty triage, and tactical emergency medical services (TEMS). Research question These themes were present in 90%, 70% How does the response and management and 40% of the papers respectively. of terrorist attacks by emergency medical services (EMS) in the United Kingdom Conclusion (UK) compare to Europe and the United New and innovative EMS response States of America (USA)? strategies occurred over the study period, in part due to dissemination of lessons Introduction learned. Despite advances in response to Terrorist attacks and active shooter events mass violence events, significant gaps account for a growing number of mass remain, in part due to lack of adoption of casualty and major incidents in the UK, recommendations. Recent experience Europe and the USA. In order to better with advanced TEMS providers capable of prepare for future incidents, analysis of operating within the inner perimeter prior events is essential. suggest that this approach should be further evaluated as part of the response Methods plan for future events. Systematic literature searches of papers published between 1/1/2004 and Keywords 5/31/2018 were conducted using two key Terrorist attack, terrorism, medical databases: CINAHL Plus and PubMed response, emergency medical services, (indexed from MEDLINE). Key contents of tactical emergency medicine, UK, Europe, identified papers were abstracted, USA, bombing, marauding terrorist including EMS response and patient firearms attack, EPRR, active shooter, management, with emphasis placed upon mass casualty incident identified recommendations and lessons learned.
Results Four hundred and forty-two records were identified in the preliminary search, with 176 records further screened using the title and abstract. Ten papers were included in the final review, reflecting 13 events from five countries across two continents. Three major themes identified throughout the papers were emergency preparedness, resilience and response
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Official journal of the Australian Tactical Medical Association
Background study was to perform a systematic review A “terrorist attack” is the use of violence or of recent mass violence events and threats of violence by terrorists to attempt establish some fundamental areas for to publicise their beliefs and achieve their improvement. goals, by influencing or exerting pressure upon governments (MI5, 2018). In recent Methods years, terrorism has evolved to use This was a structured database review diverse methods of attack, ranging from using the online databases CINAHL Plus firearms to bladed weapons to vehicular and PubMed. The inclusion dates 1/1/2004 assaults to improvised explosive devices. – 5/31/2018 were selected to capture Regardless of the mechanism of injury, extensive literature on terrorist attacks and harm inflicted upon innocent civilians has active shooter events. The decision to limit been substantial (Rozenfeld et al, 2019). studies to the United Kingdom, Europe, Since 2004, more than 24 discrete and the USA was taken due to similarities terrorist mass violence events have been in societal structure and government perpetrated in Europe, ranging from the response. Searches were conducted on Madrid train bombings to the Manchester 31st May 2018 into both databases using Arena attack (USA Today, 2016; BBC the inclusion criteria listed in Table 1. News, 2017). UK security services Exclusion factors and the screening reported thwarting 16 terror plots between process have been listed in figure 1 and a March 2017 and February 2018 summary of the literature is reported in (Metropolitan Police, 2018). Table 2.
In addition to terrorist attacks, active shooter incidents can produce similar deadly results. The U.S. Federal Bureau of Investigation defines an active shooter incident as “an individual actively engaged in killing or attempting to kill people in a populated area” (FBI, 2018). According to the most recent statistics, 27 active shooter events occurred in 2018, resulting in 85 fatalities and 128 wounded individuals (U.S. Department of Justice, 2018).
Prior studies have highlighted the need to review major incidents, identify common themes, and make recommendations for policy adoption and response agency practice (Moran et al, 2017; Thompson et al, 2014). The purpose of the current
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Official journal of the Australian Tactical Medical Association
Literature Summary Table 2: Literature summary of selected studies for review.
Citations Event Summary Key Findings Limitations
Hunt, P. Lessons Five terrorists killed Command and Sole author not identified from the 36 people using IEDs, control structure is involved in 2017 Manchester vehicles and knives in critical, with the response. and London Westminster, London ability to collapse Qualitative terrorism Bridge and and expand as the methodologies. incidents. Part 1: Manchester Arena. incident introduction and progresses. the prehospital Triage proved phase, (2018). challenging due to the unsafe nature of the scenes. Over triage and changes in patient priority happened before arriving at hospital. Multi-agency collaboration and training exercises are factors for a successful response. Logistical issues, particularly stretchers, were a significant response constraint at Manchester Arena. Patients self- presented at hospitals via private vehicles or police transport prior to EMS arrival, thereby impeding attempts at MCI triage.
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Data was collected Bobko, J., Sinha, In 2015, two terrorists TEMS were via an M., Chen, D. et al, carried out a training nearby at unstructured after- A Tactical marauding terrorist the time of the action review, Medicine After- firearms attack incident and rather than action Report of (MTFA), killing 17 entered the hot structured debriefs the San people and injuring zone alongside of all involved Bernardino over 30. IEDs were tactical units, personnel. Terrorist Incident, placed but not performing triage Qualitative (2018). detonated. and life-saving methodologies. interventions. Command posts were set up within discovered IED blast radii, requiring relocation and causing disruption to the tactical operation Rescue Task Force (RTF) enabled warm zone operations and augmented TEMS personnel; SWAT medic. The combination of TEMS and RTF enabled synergistic operations throughout the event. The first patients to arrive at medical facilities were by brought by police, not EMS.
Carli, P., Pons, F., In 2015, 137 people In the aftermath of Limited details. Levraut, J. et al, died and over 400 the Paris attack, Qualitative review. The French were injured during a civilian EMS emergency multisite terrorist responders medical services attack in Paris. In consulted with after the Paris and 2016, an 18-wheel military medical Nice terrorist heavy goods vehicle services for struck hundreds of education and staff training, including
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Official journal of the Australian Tactical Medical Association
attacks: what have people, killing 87 and damage control we learnt? (2017). injuring 458 in Nice. resuscitative concepts and ‘care under fire’ awareness.
Service Médical In 2015, three TEMS physicians Qualitative review. du RAID., Tactical terrorists entered the successfully Potential bias in emergency Bataclan theatre and operated within the favour of authors’ medicine: lessons murdered 89 civilians inner perimeter, methods. from Paris using military grade performing triage marauding firearms and IEDs. A and life-saving terrorist attack, specialist law interventions. (2016). enforcement team, A pile of dead RAID (research, bodies may have assistance, obstructed intervention, identification and deterrence), access to living immediately patients with responded to the potentially Bataclan theatre survivable injuries. scene. A shortage of stretchers led to casualties being removed from the area on crowd barriers. By the time civilian EMS teams were granted access, all surviving casualties had been extricated.
Gates, J., Arabian, At the 2013 Boston Due to the nature Qualitative S., Biddinger, P. et Marathon, terrorists of the event methodologies. No al, The Initial planted two IEDs (ground-level structured Response to the near the finish line IEDs), many interviews. Boston Marathon (where the medical casualties Bombing: Lessons tents were located). sustained injuries Learned to Both detonated in amenable to Prepare for the quick succession, tourniquet use. Next Disaster, killing 3 and injuring Rapid extraction to (2014). 281 people. hospitals trained and prepared to manage surges of
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severely injured casualties is critical to patient survival.
Sollid, S., In 2011, a lone The light Structured data Rimstad, R., terrorist in Norway emergency collection. Limited Rehn, M. et al, killed 77 people using stretcher system data sources. Oslo government a vehicle-borne IED, (LESS), part of the district bombing and later carried out disaster plan, and Utøya island an MTFA on an proved highly shooting July 22, isolated island. effective in the 2011: The extraction of large immediate numbers of prehospital casualties. emergency No civilian medics medical service were permitted response, (2012). access to the VBIED hot zone and were denied access to the island for an extended period. Prior to the event. no triage system existed for major incident situations.
Wild, J., Maher, J., In 2009, an active Scene safety was Qualitative Frazee, R. et al, shooter incident a significant methodologies. The Fort Hood occurred at Fort concern, due to On-going criminal Massacre: Hood, Texas. Over a conflicting investigation at the Lessons learned period of 10 minutes, information about time of publication from a high profile 11 people were killed location and limited contents. mass casualty. and over 30 were number of (2012). injured. attackers. Scene safety concerns compromised patient triage. Patients were transport by private vehicles rather than EMS, further impacting triage.
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To improve MCI response, regional training exercises and post-event debriefing sessions are required.
Kaplowitz, L., In 2007, a single Scene safety Qualitative Reece, M., active shooter remained a analysis. Hershey, J. et al, attacked a university, significant concern Regional health killing 32 students throughout the system response and injuring 26. event. to the Virginia Two TEMS medics Tech mass were able to follow casualty incident, law enforcement (2007). teams into the hot zone to initiate treatment and stabilisation of victims. Due to the high proportion (67%) of seriously injured patients, emphasis was placed on rapid extraction and transport rather than triage. Mass over-triage subsequently occurred, which led to a strain on down-stream hospital resources.
Lockey, D., In 2005, three On scene Qualitative study. Mackenzie, R., terrorists detonated challenges during Potential bias in Redhead, J. et al, IEDs on the London casualty extraction favour of authors’ London bombings Underground System, from all methods. July 2005: the while a fourth terrorist underground immediate pre- detonated his bomb locations included hospital medical on a double decker heat, light, and response., (2005). bus in central distance from the London. This resulted point of explosion in the deaths of 56 to the exit.
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Official journal of the Australian Tactical Medical Association
people and injured Multiple complex over 700. scenes led to difficulties with EMS command and control. Scene safety concerns led to rapid extraction and transport of seriously injured patients.
Carresi, A., The In 2004, 10 IEDs Inadequate Single author 2004 Madrid train placed on trains in command and analysis. bombings: an Madrid were control structure Qualitative analysis of pre- simultaneously resulted in methodologies hospital detonated via mobile conflicting orders using limited face- management, phones by an given to EMS to-face interviews. (2008). unknown number of personnel. terrorists. 191 people On-scene died as a result of this confusion led to terrorist attack. inaccurate information provided by EMS to command and control structure. Scene safety concerns compromised patient triage. Only 33% of patients were transported to hospital by ambulance, with the rest transported by private vehicle.
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Official journal of the Australian Tactical Medical Association
Results After data abstraction, three major themes Four hundred and forty-two records were were identified (Table 3). These were: identified in the preliminary search, with 176 records further screened using the title 1. Emergency preparedness, and abstract. Ten papers were included in resilience and response (EPRR) the final review, reflecting 13 events from with subgenres of multi-agency five countries across two continents (Figure collaboration, disaster planning 1). and command principals. Identified in 90% of analysed papers. Figure 1. PRISMA Diagram. 2. Triage, including impact of scene safety. Identified in 70% of analysed papers. 3. The role of specialised Tactical Emergency Medical Services. Identified in 40% of analysed papers.
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Official journal of the Australian Tactical Medical Association
Table 3. Major Themes in Papers. Papers Emergency Preparedness, Triage Tactical Emergency Resilience and Response Medical Services Hunt, P., Lessons identified from the 2017 Manchester and London terrorism incidents. Part 1: ✔ ✔ - introduction and the prehospital phase, (2018). Bobko, J., Sinha, M., Chen, D. et al, A Tactical Medicine After-action Report of the ✔ ✔ ✔ San Bernardino Terrorist Incident, (2018). Carli, P., Pons, F., Levraut, J. et al, The French emergency medical services after the Paris and Nice ✔ - ✔ terrorist attacks: what have we learnt? (2017). Service Médical du RAID., Tactical emergency medicine: lessons from - ✔ ✔ Paris marauding terrorist attack, (2016). Gates, J., Arabian, S., Biddinger, P. et al, The Initial Response to the Boston Marathon Bombing: ✔ - - Lessons Learned to Prepare for the Next Disaster, (2014). Sollid, S., Rimstad, R., Rehn, M. et al, Oslo government district bombing and Utøya island shooting July 22, 2011: The ✔ ✔ - immediate prehospital emergency medical service response, (2012). Wild, J., Maher, J., Frazee, R. et al, The Fort Hood Massacre: Lessons learned ✔ ✔ - from a high profile mass casualty, (2012).
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Kaplowitz, L., Reece, M., Hershey, J. et al, Regional health system response to ✔ ✔ ✔ the Virginia Tech mass casualty incident, (2007). Lockey, D., Mackenzie, R., Redhead, J. et al, London bombings July 2005: the ✔ - - immediate pre-hospital medical response, (2005). Carresi, A., The 2004 Madrid train bombings: an analysis of pre-hospital ✔ ✔ - management, (2008).
Discussion of patients across a large area overwhelmed on scene ambulance Emergency Preparedness, Resilience, commanders. A breakdown in command and Response (EPRR) from the operations centre meant The London bombings of July 2005, which ambulance units were not reaching their struck three underground trains and one destinations. In both Madrid and London, bus, killing 54 people and injuring over responding units were diverted to other 700, demonstrates the sheer complexity of locations, without necessarily informing managing four simultaneous mass control centres. In contrast, although more casualty sites. Command systems were limited in scale, command and control at severely stretched as a result of patient the San Bernadino MTFA was improved numbers and locations, and ambulance by the presence of on-scene command commanders were posted to the control assets and shared tactical decision room to act as a central command source. making. Patients emerged from different underground stations (Kings Cross and Further confounding initial on scene Russell Square), leading to mistaken confusion and concerns regarding scene assumptions of two sperate incidents at safety were frequently noted, leading to these locations. Unfortunately, the compromised decision-making in triage increasingly mobile nature of these events and patient care. Scene safety was a key makes multiple site control an increasing factor in the overall response to the reality, and one that must be planned for. injured in the classrooms and buildings of Virginia Tech, based upon uncertainty The Madrid train bombings of 2004 over shooter location. Similarly, Wild et al similarly involved multiple IEDs detonated (2012) describes the chaos of on-scene on 10 trains during rush hour, resulting in operations at the Fort Hood shooting. 191 killed and more than 2000 injured. Unconfirmed reports and confusing Command and control was identified as statements led responders to believe the an area for improvement in the response presence of multiple active shooters, to this event. Responders stated that the leaving commanders to make difficult sheer confusion caused by the magnitude decisions about triage and transportation.
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Official journal of the Australian Tactical Medical Association
In contrast, sometimes the threat is point of injury on makeshift stretchers underestimated. During the London Bridge such as crowd control barriers. Although attack, some initial calls suggested a mass casualties were encountered by simple traffic accident, resulting in responders in Oslo and Utoya Island, responders being unaware of the actual Norwegian EMS teams have developed a threat, compromising scene safety. Similar light emergency stretcher system (LESS) findings have been noted in analyses in as part of major incident preparedness. Air the United States, in which more than ambulances transported LESS, which 15% of calls failed to relay a safety risk contains 5 light stretchers in a single bag, concern to responding EMS personnel to the scenes at Utoya Island and Oslo (Klassen et al, 2018). Command (Sollid et al, 2012). structures must anticipate this “fog of war” and make decisions to mitigate the On-going major incident training is critical confusion. On-scene command and in responding to these extreme events. control may assist with this. Lockey et al (2005) noted that an emergency services exercise was Direct threats from gunmen are not the conducted on the London Underground sole concern for responding crews. During network shortly prior to 7/7 as a the San Bernardino MTFA, lack of IED preparedness response to the Madrid train awareness resulted in the tactical bombings of 2004, which may have command post and casualty collection helped mitigate some of the issues noted point being located within the blast radius. in Madrid. Similarly, Manchester Furthermore, the IEDs were only emergency services drilled a terrorist discovered during extrication of patients bombing attack months prior to the from the building by conventional EMS. Manchester Arena incident as a direct This incident serves to highlight the response to events in France (Hunt, 2018; adoption of militarised tactics even by kerslakearenareview, 2018). Multiple US active shooters (Bobko et al, 2018). authors praised training exercises as an Additional threats noted include risk of invaluable resource. EPRR elements structural collapse, toxic atmospheres, should be a key aspect of such training. contamination, and situational risks such as live rails (Lockey et al, 2005; Hunt, Given the complexities of responding to 2018). mass violence events, multi-agency collaboration is a critical factor for Logistical concerns frequently impact the successful response. Both Hunt (2018) response to mass violence events. One and Carli et al (2017) note the utility of frequently identified area for improvement military assistance to civilian authorities, is the means by which non-ambulatory both from an educational and operational casualties can be rapidly extracted. During perspective. Knowledge translation of both the 2015 multi-site MTFA in Paris military injury patterns and appropriate and the 2017 Manchester Arena bombing, treatments, including tourniquets and responding emergency services were other elements of damage control faced with a lack of available stretchers resuscitation, to the civilian sector is (Hunt, 2018; Service Médical du Raid, critical for future response at both the 2016; kerslakearenareview, 2018). As a prehospital and hospital levels (King, result, patients were extracted from the 2019; Cannon, 2018).
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Official journal of the Australian Tactical Medical Association
Hunt (2018) noted how responders were requiring a secondary transfer at risk by quaternary factors such as (kerslakearenareview, 2018). These structural debris (as witnessed during 7/7); points echo the fluidity of operations in showing the consistency in bombing regard to scene safety, zoning, command characteristics. However, it is worth structure and decision-making. highlighting the success of the response due to the availability of specialist Triage resources such as advanced paramedics Triage refers to the rapid sorting of and the Hazardous Area Response Team casualties, with the intent of doing “the (HART). most for the most.” Triage has been noted to be an issue at almost every mass HART was developed in the wake of 7/7, casualty incident, often due to lack of realising the demand for a special unit to systems-knowledge or lack of ability to respond to these types of threatening perform due to concern for on-going environments. With the ability to operate threats. Although numerous triage within the warm zone of an MTFA, HART systems exist, the best triage system was utilised to extricate patients to the remains unclear and is continually cold zone where ordinary paramedics had debated (Vasallo, Smith and Wallis, 2018; erected a casualty clearing station and Silvestri et al, 2017). command point (NARU, 2018). These actions made by the commanders and At the Madrid train bombings, EMS crews paramedics on the night were correct in were unable to use the existing triage adhering to the well-established policies. system due to both a lack of knowledge The Joint Emergency Services and a lack of triage tags (Carresi, 2008). Interoperability Program (JESIP) was Similar issues with triage were noted in developed in 2013 and offers command the Norway attacks. At the time, and control principals in which police, fire Norwegian EMS had no national triage and rescue and ambulance services now system, and so responders defaulted to practise (JESIP, 2017). These command the primary survey consisting of principals may have contributed to the catastrophic haemorrhage, airway, success of the management by the breathing, circulation, disability and ambulance service at Manchester arena. exposure in order to identify critical On the contrary, few ambulance personnel patients (Sollid et al, 2012). Although a volunteered to enter the hot zone and formal triage system was lacking in this commence the triage of patients. This is response, the ad hoc approach was still against conventional practice in the UK, successful as no patients died on their however, the police authorised the access way to hospital. A standardised triage due to the perception of there being system might minimise errors in casualty minimal threat. These actions by the prioritisation. As highlighted by the personnel were directly credited by Lord Manchester Arena attack, responders Kerslake, chairman and author of the should prepare to triage and treat large Kerslake Report evaluating this terrorist numbers of pediatric casualties which attack. Kerslake continues to show poses as a unique challenge. admiration for the ambulance service, as patients were treated and transported In contrast to lack of knowledge, scene incredibly effectively, with only 1 patient safety concerns limited use of triage
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Official journal of the Australian Tactical Medical Association
systems at several events, with resultant During the San Bernardino MTFA, a over- and under-triage. During both Fort perimeter was established which Hood and Virginia Tech, a decision was prevented responding EMS units entering made to prioritise rapid transportation in to gain immediate access to victims. precedence to over accurate triage. Even Current US law enforcement doctrine in circumstances where triage was defines an active shooter event as a patrol performed appropriately by EMS level response, in contrast to a SWAT providers, patients were transported to response, in order to minimise response hospitals by private vehicles or law delays. Serendipitously, a local SWAT enforcement, arriving unannounced. team was training nearby and so was able Hospitals should anticipate and plan for an to rapidly deploy to the scene. The tactical initial wave of victims arriving outside the medic proceeded to triage and treat the EMS system, especially where hospitals casualties in the hot zone, performing are in close proximity to the point of injury. initial lifesaving interventions. As the This may particularly impact specialty or TEMS provider carries only limited general hospitals not equipped to manage supplies, the TEMS response was major trauma patients, as witnessed by a subsequently augmented by a secondary children’s hospital near to the Nicé lorry Rescue Task Force (RTF) response in the attack site. warm zone (Bobko et al, 2018).
Tactical Emergency Medical Services The RTF is a joint law enforcement- Tactical emergency medical services medical response, in which law (TEMS) involves the incorporation of enforcement provides security to medical specially trained medical assets into police personnel who rapidly treat and extract or paramilitary tactical units. Traditionally casualties. The medical component of the associated with US Special Weapons and RTF model can be most comparable to Tactics (SWAT) teams, it more recently the newly developed Hazardous Area has been adopted and advanced by Response Team (HART) in the UK. Both European counterparts. TEMS was teams are trained to enter the warm zone specifically noted to be a key component and initiate treatment and extract patients of the medical response in four papers. to the cold zone where conventional EMS awaits. The UK currently lacks both During the response to the Virginia Tech civilian medical response in the hot zone shooting, EMS were denied access to the and consistent security for medical teams scene during the period of on-going threat. in the warm zone, which may limit efficacy Two tactical medics attached to of HART. responding law enforcement teams were deployed to the hot zone (Kaplowitz et al, Most US TEMS providers are trained at 2007). The medics were able to begin either the paramedic or EMT level. triaging the wounded, perform life-saving Physician integration is unusual. In interventions, and prepare the casualties contrast, French TEMS has advanced the for extraction, prior to the arrival of process by consistent physician conventional EMS. These key actions integration (Service Médical du RAID, contributed to the success of the 2016; Carli et al, 2017). During the prehospital response. Bataclan siege, tactical physicians supporting SWAT teams from Service
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Official journal of the Australian Tactical Medical Association
Médical du RAID were able to enter the Conclusion concert hall downstairs while the terrorists Based upon the available data, were barricaded upstairs. Physicians were prehospital organisational response to able to direct triage and extraction, a mass violence events continues to evolve process made difficult by piles of dead and improve. In response to incidents in bodies, often covering living casualties neighbouring jurisdictions, specific with survivable injuries (Service Médical exercises have been undertaken to test du RAID, 2016). Once patients had been local responses to similar events. Practice extracted to the casualty collection point gaps and necessary changes have been (warm zone), advanced medical identified as part of the after-action review procedures were performed. By the time process. However, society needs to be civilian EMS crews were allowed forward vigilant and approach such changes with a into the building, every single living patient degree of caution, as to prepare for the located in the hot zone had already been next event rather than the last. extracted to the warm zone. By providing Despite great strides in preparedness and life-saving interventions without delay at response, there remain opportunities for the point of injury, this approach was improvement, some of which have been reported to save numerous lives. Whether previously identified. The lack of casualty the presence of a physician changes extraction devices noted in Paris and outcomes in the hot zone compared with Manchester had previously been paramedics has yet to be determined. highlighted in Norway, and a solution identified. Even when gaps have been The presence of TEMS provides identified, they have not always been comfortable operations in the hot zone closed. Some identified problems may and when integrated into tactical teams require significant redesign of current permitted both rapid triage and treatment, response systems. For example, the without placing unnecessary delays on impact of scene safety concerns upon first patient contact. None of the UK patient triage has been in part mitigated incidents mention provision of medical by the use of trained TEMS providers in care by police officers or any other the hot zone in both the US and France. medical care available to victims inside This capability does not currently exist in the hot zone. This suggests the presence the UK. of a potential delay in providing patient The international community continues to care, in an environment too hostile for acknowledge the severity of terrorism and conventional EMS teams to operate. This the challenges it poses to EMS providers, grey-area hints that the UK may benefit but gaps still remain. Formal study of from the addition of a TEMS framework these events is difficult due to the similar to that of the USA and France, and unpredictable and chaotic nature of actual to that currently found amongst UK special events and artificialities inherent in drills. operations forces. Continued dissemination of lessons learned is critical in developing a robust response infrastructure, designed to both protect responders and save the lives of terror casualties.
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Official journal of the Australian Tactical Medical Association
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Journal of High Threat and Austere Medicine: www.JHTAM.org Article published online: 2019 Page 18