Madrid March-11a prehospital analytical view

From evidence-based disaster medicine

Alfredo Serrano MorazaMaría Jesús Briñas FreireAndrés Pacheco RodríguezAlejandro 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 MedicineYale-New Haven Center for Emergency and Terrorism Preparedness

Jeffrey Arnold, MD Yale University School of MedicineYale-New Haven Center for Emergency and Terrorism Preparedness

Evidence-based disaster medicineEvidence-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 informationno other sources availables

Enormous personal number working in different focusInformation still not totally available (approx. 70 %)ED and ICU survival data and correlations – still collectingMany 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;287:1919-1923

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 Emergencydoes NOT finish on scene

Critical-bed needs coordinationhas 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 report9/11 Commission full report

No official report

...when they arrived

Ideal aims

• Optimal focus workSecure access and work Controlled evacuationOn-scene triage Hospital critical victims distributionInitial treatments Green-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 evacuationscoop and run and its consequencesReduce

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 1EMS 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 factorx

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 factorx x

GIRECA

New software from

[Bigger] problem than all other factors combined*

* http://ccforum.com/content/pdf/cc1060.pdf

Activation 2Non-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 analysisEvidence-research not finished yet

x x

against all academic recommendations, they knewwhen they were almost aloneand lay people also did it Perhaps it has a

difficult solution

2

Phys + Nurs + 1-2 EMTs + pilot + mechanic

HEMS

18

mICUS

Phys + Nurs + 2 EMTs

8 + 1 Coord.Phys + Nurs + 1 EMT

VIR

Phys + 1 EMTusually for home non-emergency medical visit

UAD

11

31

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

150 + N ambulances

+ more than 100 vehicles (most SAMUR)

for logistics and some other services

7:49-8:00

Atocha

IC organization

Dead 34Total victims 145 SUMMA/SAMUR

6 deceased in place 12 critical SUMMA 15 critical SAMUR 30 severe wounded

Work time approx. 2h

SAMUR 2+13 8 - SUMMA 4 5 5

mICUs VIR UAD

Feedback information

Santa Eugenia

7:50

mICUs VIR UAD

SAMUR 2+1 2 - SUMMA 4+1 - -

IC organization

Dead 17Total victims 52 SUMMA/SAMUR

4 critical SAMUR 10 severe SAMUR 6 severe SUMMA

Work time approx. 1 h 15 min.

El PozoThe face of death

First units: Police, Fire-Rescue and basic support Heroical citizen support

Wild scoop and run

Hour ?

mICUs VIR UAD Helo

SAMUR 5 3 - - SUMMA 5 1 1 1

There’s no physic IC

8:50 More units, also Helo9:00-9:15 There’s another bomb

Train evacuated Rescue stopped

Dead 67Total 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 2+6 2 - - SUMMA 4 - 2 -

mICUs VIR UAD Helo

Dead 64Total 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 Hospitalhttp://www.jemu.net/images/documents/madrid_blanco.ppt

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 dataConsejería de Sanidad

March 11, 21 h

Critical

Hard severe

Severe

Wounded

Discharged

Slight i

njurie

sDea

d

224 + 9

Madrid

Closest ED hospitals overcrowding

Robregordo

Montejode laSierra La Hiruela

LaAcebeda

Prádenadel Rincón

Horcajode laSierra

MadarcosBraojos

Nava-rredonda PuentesViejasBuitragoLozoya

Gargantilla Berzosa

Puebla dela Sierra

RobledilloGarganta de losMontesLozoyuelaEl Atazar

Cervera deBuitrago

PatonesEl BerruecoLa CabreraValde-manco

Bustarviejo

CanenciaRascafría

TorrelagunaCaba-nillasNavala-fuenteVenturadaMirafloresde la Sierra

Talamanca de Jarama

Valdepié- lagos

Soto del Real

Colmenar Viejo

Manzanaresel Real

El Vellón

Valdetorresdel JaramaColladoMediano

Cercedilla

Guadarrama

Nava-cerrada Los Molinos

ColladoVillalbaHoyo deManzanares TresCantos

San Sebastiánde los ReyesAlcobendas

Algete

Fuentelsazdel JaramaValdeolmosAlapardoRibatejada

ValdeaveroFresno de Torote

CobeñaDaganzoDaganzo MecoCamarma deEsteruelas

Paracuellos de Alcalá deHenaresLos Santos dela Humosa

AnchueloSantorcazTorrejón de Ardoz

CosladaSan Fernando VillalbillaCorpaPezuelaPezuelaAlamedaValverde

Pozuelodel ReyNuevoBaztánOlmedade lasFuentes

AmbiteVillar del Olmo

Velilla

Rivas-Vaciamadrid

Arganda del Rey

Campo Real

ValdilechaOrusco

Carabaña Brea de Tajo

ValdaraceteEstremera

Fuentidueña de Tajo

Villarejo deSalvanés

Villamanrique

Belmontede Tajo

TielmesPerales deTajuña

ValdelagunaValdelagunaChinchón

Villaconejos

Morata de Tajuña

Aranjuez

Ciempozuelos

Valdemoro

GetafePintoParla

Fuenlabrada

Leganés

CasarrubuelosSerranillosdel Valle

Móstoles

Pozuelo de Alarcón

Villamanta

Villaviciosade Odón

NavalcarneroAldea del Fresno

Villa del Prado

Cadalso delos Vidrios

Cenicientos

Rozas de Puerto Puerto Real

Alcorcón

Boadilla del MonteBrunete

Majadahonda

Las Rozasde Madrid

TorrelodonesGalapagar

Valdemaqueda

Santa María de la AlamedaEl EscorialZarzalejoZarzalejo

San Lorenzo de El Escorial

Navas del ReyPelayos dela Presa

San Martín deValdeiglesias

Robledo de ChavelaFresne-dillas

Navalagamella

Valdemorillo Villanuevadel Pardillo

Villanueva de la Cañada

Colme-narejo

QuijornaColmenar de Arroyo

Jarama

Ajalvir

Mejorada delCampoLoechesLoeches

de las Torresde las TorresTorres de la

El Molar

Serna

PinilladelValleAla- me- da dadelValle

Villa-vieja

El Álamo

Arroyo-molinos Moralejade Enmedio

BatresCubas de la SagraGriñón

Humanes

Torrejón dela Calzada

Somosierra

Villamantilla

Villanueva de PeralesChapi-nería Sevilla laNueva

Torrejón de Velasco

San Martín de la Vega

Colmenar de Oreja

Titulcia

Guadalix de la SierraPedrezuela

SanAgustíndeGuadalix

BecerrilEl Boalo

Moralzarzal

Torre-mocha

GasconesPiñuécar

Horcajuelode laSierra

Redueña

Alpedrete

MADRID

Red labels

H

HH

HH

H

H

H

HGómez Ulla

Doce Oct.

Gregorio M.

H

H

H

HH

H

H

91

38

30

15

17

14

12

5

5

1

2

1

1

233

SAMUR44 to 49*

1 fallecido de camino

SAMUR44 to 49*

1 fallecido de camino

Red labels

SUMMA21* plus 20**

SUMMA21* plus 20**

On-scene deceased 14* to 20**

On-scene deceased 14* to 20**

* official data** estimated

85-90 Hospital EDs 233

Hospital EDs 233

Communicationsirregular failure ?Random

Assignment*

143 ?

• Different classification systemsEx: ED no yellow labels

• Difficult focus data collection

• Massive evacuation?

• Admittable sub-triage

or no available unit

basic transport?

Deceased # 191 minus 20Deceased # 191 minus 20

Different EMS-ED dataWhy ?

23

36

7 7

0

5

10

15

20

25

30

35

40

Percentage transported by ambulance

1989 LomaPrieta

Earthquake

1995 OKCity

Bombing

1995 TokyoSarin attack

2001 NewYork City

9-11 ©© Jeffrey Arnold, MDJeffrey Arnold, MD

In MCI, are most victims evacuated to hospitals by EMS?

MadridMarch 11

38.6 %red labels

58.6 % global

www.mebe.org

Hospital-critical bedsEMS 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 avalanchedidn’t really happen

Interfacility transports

Essentials80 % 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?