Hostname: page-component-7dd5485656-zklqj Total loading time: 0 Render date: 2025-10-31T16:18:47.808Z Has data issue: false hasContentIssue false
  • English
  • Français

Triage in Complex, Coordinated Terrorist Attacks

Part of: Prehospital and Disaster Medicine Counterterrorism Collection

Published online by Cambridge University Press:  07 August 2019

Matt Pepper Open the ORCID record for Matt Pepper [Opens in a new window] ,
Frank Archer  and
John Moloney
Matt Pepper*
Affiliation:
Monash University Accident Research Centre, Melbourne, Victoria, Australia
Frank Archer
Affiliation:
Monash University Accident Research Centre, Melbourne, Victoria, Australia
John Moloney
Affiliation:
Monash University Community Emergency Health and Paramedics, Melbourne, Victoria, Australia
*
Correspondence: Matt Pepper, MPhil, Monash University Accident Research Centre, 4 Karloo Pde, Newport, Sydney, NSW, Australia 2106, E-mail: Matt@atma.net.au
Get access Rights & Permissions [Opens in a new window]

Abstract

Introduction:

Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed.

Methods:

Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs).

Discussion:

Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and “tactical triage.”

Conclusion:

Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Keywords

Emergency Medical Servicestactical medicineterrorismtriage

Information

Type
Special Report
Information
Prehospital and Disaster Medicine , Volume 34 , Issue 4 , August 2019 , pp. 442 - 448
Copyright
© World Association for Disaster and Emergency Medicine 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Brown, N, Rutherford, K. The London Bridge attack: managing multiple victims of penetrating trauma. Journal of Paramedic Practice. 2017;9(12):512–514.CrossRefGoogle Scholar
Hannes, K, Lockwood, C. Pragmatism as the philosophical foundation for the Joanna Briggs meta-aggregative approach to qualitative evidence synthesis. J Adv Nursing. 2011;67(7):1632–1642.CrossRefGoogle Scholar
Nakao, H, Ukai, I, Kotani, J. A review of the history of the origin of triage from a disaster medicine perspective. Acute Med Surg. 2017;4(4):379–384.CrossRefGoogle ScholarPubMed
Kilner, T, Brace, SJ, Cooke, M, Stallard, N, Bleetman, A, Perkins, GD. In ‘big bang’ major incidents do triage tools accurately predict clinical priority? A systematic review of the literature. Injury. 2011;42(5):460–468.CrossRefGoogle ScholarPubMed
Lidal, IB, Holte, HH, Vist, GE. Triage systems for pre-hospital emergency medical services-a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21(1):28.CrossRefGoogle ScholarPubMed
Braziel, R, Straub, F, Watson, G, Hoops, R, editors. Bringing Calm to Chaos: A Critical Incident Review of the San Bernardino Public Safety Response to the December 2, 2015, Terrorist Shooting Incident at the Inland Regional Center. Washington, DC USA: United States Department of Justice Office of Community Oriented Policing Services; 2016.Google Scholar
Roy, N, Kapil, V, Subbarao, I, Ashkenazi, I. Mass casualty response in the 2008 Mumbai terrorist attacks. Disaster Med Public Health Prep. 2011;5(4):273–279.CrossRefGoogle ScholarPubMed
Bhandarwar, AH, Bakhshi, GD, Tayade, MB, Borisa, AD, Thadeshwar, NR, Gandhi, SS. Surgical response to the 2008 Mumbai terror attack. Br J Surg. 2012;99(3):368–372.CrossRefGoogle ScholarPubMed
LeBlanc, VR, MacDonald, RD, McArthur, B, King, K, Lepine, T. Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care. 2005;9(4):439–444.CrossRefGoogle Scholar
LeBlanc, VR, Regehr, C, Tavares, W, Scott, AK, MacDonald, R, King, K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med. 2012;27(4):369–374.CrossRefGoogle ScholarPubMed
Pottier, P, Dejoie, T, Hardouin, J, et al. Effect of stress on clinical reasoning during simulated ambulatory consultations. Medical Teacher. 2013;35(6):472–480.CrossRefGoogle ScholarPubMed
Keitel, A, Ringleb, M, Schwartges, I, et al. Endocrine and psychological stress responses in a simulated emergency situation. Psychoneuroendocrinology. 2011;36(1):98–108.CrossRefGoogle Scholar
Wegner, M, Koedijker, JM, Budde, H. The effect of acute exercise and psychosocial stress on fine motor skills and testosterone concentration in the saliva of high school students. PloS One. 2014;9(3):e92953.CrossRefGoogle ScholarPubMed
Arora, S, Sevdalis, N, Nestel, D, Woloshynowych, M, Darzi, A, Kneebone, R. The impact of stress on surgical performance: a systematic review of the literature. Surgery. 2010;147(3):318–330.CrossRefGoogle ScholarPubMed
Renden, PG, Landman, A, Geerts, SF, et al. Effects of anxiety on the execution of police arrest and self-defense skills. Anxiety Stress Coping. 2014;27(1):100–112.CrossRefGoogle ScholarPubMed
Nieuwenhuys, A, Oudejans, RR. Effects of anxiety on handgun shooting behavior of police officers: a pilot study. Anxiety Stress Coping. 2010;23(2):225–233.CrossRefGoogle ScholarPubMed
Nieuwenhuys, A, Caljouw, SR, Leijsen, MR, Schmeits, BA, Oudejans, RR. Quantifying police officers’ arrest and self-defense skills: does performance decrease under pressure? Ergonomics. 2009;52(12):1460–1468.CrossRefGoogle Scholar
Kollek, D, Welsford, M, Wanger, K. Canadian operational and emotional prehospital readiness for a tactical violence event. Prehosp Disaster Med. 2010;25(2):164–169.CrossRefGoogle ScholarPubMed
DoH. Learning for Better Emergency Preparedness. The Medical Response to the Terrorist Incidents of 22 July 2011. Oslo, Norway: Norwegian Directorate of Health; 2012.Google Scholar
Englund, L, Michel, P-O, Riddez, L, Örtenwall, P. The bomb attack in Oslo and the shootings at Utøya, 2011: Kamedo Report No. 97. Socialstyrelsen. 2012.Google Scholar
Sollid, SJM, Rimstad, R, Rehn, M, et al. Oslo government district bombing and Utoya island shooting July 22, 2011: the immediate prehospital emergency medical service response. Scand J Trauma Resusc Emerg Med. 2012;20:3.CrossRefGoogle ScholarPubMed
Lesaffre, X, Tourtier, J-P, Violin, Y, et al. Remote damage control during the attacks on Paris: lessons learned by the Paris Fire Brigade and evolutions in the rescue system. J Trauma Acute Care Surg. 2017;82(6S):S107–S113.CrossRefGoogle ScholarPubMed
Breeze, J, Penn-Barwell, JG, Keene, D, O’Reilly, D, Jeyanathan, J, Mahoney, PF. Ballistic Trauma: A Practical Guide. Berlin, Germany: Springer; 2017.CrossRefGoogle Scholar
Service Médical du RAID Fdidlpn, Bièvres, France. Feedback on terrorist attacks on November 13, 2015. Bataclan’s terrorist attack management by the tactical medical support of the French police. Annales Françaises de Médecine d’Urgence. 2016;6:3–8.Google Scholar
Van Stralen, D, Mckay, SD, Williams, GT, Mercer, TA. Tactical Improvisation: After-Action/Comprehensive Analysis of the Active Shooter Incident Response by the San Bernardino City Fire. San Bernardino, California USA.Google Scholar
Bobko, JP, Sinha, M, Chen, D, et al. A tactical medicine after-action report of the San Bernardino terrorist incident. West J Emerg Med. 2018;19(2):287.CrossRefGoogle Scholar
Rimstad, R, Sollid, SJM. A retrospective observational study of medical incident command and decision-making in the 2011 Oslo bombing. Int J Emerg Med. 2015;8(1).CrossRefGoogle ScholarPubMed
Franchin, M, Frattini, B, Briche, F, Travers, S, Bignand, M, Tourtier, J-P. Feedback on terrorist attacks on November 13, 2015. First aid response and interactions with medical teams. Annales Francaises De Medecine D Urgence. 2016;6(1):9–12.CrossRefGoogle Scholar
RAID SMd. Feedback on terrorist attacks on November 13, 2015. Bataclan’s terrorist attack management by the tactical medical support of the French police. Annales Françaises de Médecine d’Urgence. 2016;6(1):3–8.Google Scholar
Crews, C, Heightman, A. EMS Crews Share their Experience of the San Bernardino Terrorist Attack. JEMS. 2016.Google Scholar
Rimstad, R, Njå, O, Rake, EL, Braut, GS. Incident command and information flows in a large-scale emergency operation. J Contingencies Crisis Manage. 2014;22(1):29–38.CrossRefGoogle Scholar
RAID SMd. Tactical emergency medicine: lessons from Paris marauding terrorist attack. Crit Care (London). 2016;20(1):37.CrossRefGoogle Scholar
Lockey, DJ. The shootings in Oslo and Utoya island July 22, 2011: lessons for the International EMS community. Scand J Trauma Resusc Emerg Med. 2012;20(1):4.CrossRefGoogle ScholarPubMed
Ashkenazi, I, Kessel, B, Khashan, T, et al. Precision of in-hospital triage in mass-casualty incidents after terror attacks. Prehosp Disaster Med. 2006;21(1):20–23.CrossRefGoogle ScholarPubMed
Kilner, T, Hall, FJ. Triage decisions of United Kingdom police firearms officers using a multiple-casualty scenario paper exercise. Prehosp Disaster Med. 2005;20(1):40–46.CrossRefGoogle ScholarPubMed
Lerner, EB, Schwartz, RB, Coule, PL, Pirrallo, RG. Use of SALT triage in a simulated mass-casualty incident. Prehosp Emerg Care. 2010;14(1):21–25.CrossRefGoogle Scholar
Nilsson, A, Åslund, K, Lampi, M, Nilsson, H, Jonson, C-O. Improved and sustained triage skills in firemen after a short training intervention. Scand J Trauma Resusc Emerg Med. 2015;23(1):81.CrossRefGoogle ScholarPubMed
Navin, DM, Sacco, WJ, Waddell, R. Operational comparison of the Simple Triage and Rapid Treatment method and the Sacco Triage Method in mass casualty exercises. J Trauma Acute Care Surg. 2010;69(1):215–225.CrossRefGoogle Scholar
Risavi, BL, Salen, PN, Heller, MB, Arcona, S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care. 2001;5(2):197–199.CrossRefGoogle ScholarPubMed
Rehn, M, Sollid, S. Guidelines for mass casualty triage have been established. Tidsskrift for den Norske Laegeforening: Tidsskrift for Praktisk Medicin, ny Raekke. 2013;133(19):2029.CrossRefGoogle ScholarPubMed
Aylwin, CJ, König, TC, Brennan, NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219–2225.CrossRefGoogle ScholarPubMed
Garner, A, Lee, A, Harrison, K, Schultz, CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38(5):541–548.CrossRefGoogle ScholarPubMed
Hunt, P. Lessons identified from the 2017 Manchester and London terrorism incidents. Part 1: introduction and the prehospital phase. J R Army Med Corps. 2018.CrossRefGoogle Scholar
Challen, K, Walter, D. Major incident triage: comparative validation using data from 7th July bombings. Injury. 2013;44(5):629–633.CrossRefGoogle ScholarPubMed
Aydelotte, JD, Lammie, JJ, Kotora, JG, Riesberg, JC, Beekley, AC. Combat Triage and Mass Casualty Management. Front Line Surgery. Berlin, Germany: Springer; 2017:17–37.Google Scholar
Eastridge, BJ, Butler, F, Wade, CE, et al. Field triage score (FTS) in battlefield casualties: validation of a novel triage technique in a combat environment. Am J Surg. 2010;200(6):724–727.CrossRefGoogle Scholar
Holcomb, JB, Niles, SE, Miller, CC, Hinds, D, Duke, JH, Moore, FA. Prehospital physiologic data and lifesaving interventions in trauma patients. Mil Med. 2005;170(1):7–13.CrossRefGoogle ScholarPubMed
Cancio, LC, Wade, CE, West, SA, Holcomb, JB. Prediction of mortality and of the need for massive transfusion in casualties arriving at combat support hospitals in Iraq. J Trauma Acute Care Surg. 2008;64(2):S51–S56.CrossRefGoogle Scholar
McManus, J, Yershov, AL, Ludwig, D, et al. Radial pulse character relationships to systolic blood pressure and trauma outcomes. Prehosp Emerg Care. 2005;9(4):423–428.CrossRefGoogle ScholarPubMed
Cross, KP, Cicero, MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61(6):668–676.CrossRefGoogle ScholarPubMed
Meredith, W, Rutledge, R, Hansen, A, et al. Field triage of trauma patients based upon the ability to follow commands: a study in 29,573 injured patients. J Trauma. 1995;38(1):129.CrossRefGoogle ScholarPubMed
Keating, B. Development of new triage and scene management techniques to provide a more effective response to active shooter situations. Prehosp Disaster Med. 2017;32(S1):S12–S13.CrossRefGoogle Scholar
Lerner, EB, Schwartz, RB, Coule, PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(S1):S25–S34.CrossRefGoogle ScholarPubMed
Coroner’s Inquest into the London Bombings of 7 July 2005. The National Archives 2010 http://webarchive.nationalarchives.gov.uk/20120216080255/http://7julyinquests.independent.gov.uk/hearing_transcripts/19102010pm.htm. Accessed December 1, 2018.Google Scholar
King, DR, Larentzakis, A, Ramly, EP; Boston Trauma Center. Tourniquet use at the Boston Marathon bombing: lost in translation. J Trauma Acute Care Surg. 2015;78(3):594–599.CrossRefGoogle ScholarPubMed
Hirsch, M, Carli, P, Nizard, R, et al. The medical response to multisite terrorist attacks in Paris. Lancet. 2015;386(10012):2535–2538.CrossRefGoogle ScholarPubMed
Vassallo, J, Smith, JE, Bruijns, SR, Wallis, LA. Major incident triage: a consensus-based definition of the essential life-saving interventions during the definitive care phase of a major incident. Injury. 2016;47(9):1898–1902.CrossRefGoogle ScholarPubMed
Kragh, JF Jr, Walters, TJ, Baer, DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.CrossRefGoogle ScholarPubMed
Shokoohi, H, Pourmand, A, Boniface, K, et al. The utility of point-of-care ultrasound in targeted automobile ramming mass casualty (TARMAC) attacks. Am J Emerg Med. 2018;36(8):1467–1471.CrossRefGoogle ScholarPubMed