Assessing Security and Defining Adequately Safe Zones

Assessing the security situation and determining adequately safe zones required the close cooperation of the prehospital incident commander, the police, and rescue services. ^{Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16} Sometimes, a joint command team was established, wherein minute-to-minute information sharing enabled informed decisions. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Zhang, Wang and Fan17–Reference Hardy19} A common strategy for handling security threats was to divide the scene into different zones described by the level of danger, such as “dangerous” (“red”), “relatively safe” (“orange”), and “safe” (“green”) areas. ^{Reference Carli15,Reference Idrose, Abu-Zidan and Roslan16} In most events, the security situation developed over time, requiring constant evaluation. Security threats included secondary attacks directed at EMS ^{Reference Hansen, Mikkelsen and Alstrøm14} and the possibility of chemicals or explosives causing serial explosions. ^{Reference Zhang, Wang and Fan17} The presence of upset or aggressive civilians also posed security risks. ^{Reference Safi Keykaleh and Sohrabizadeh18} Failing to continuously assess the security situation could result in fatalities among primary victims and EMS personnel, in the latter case reducing EMS’s ability to respond to the event.

Physically Accessing Victims

In many events, the location of the scene, most often combined with damaged infrastructure, adverse weather conditions, or security issues, made it difficult for EMS to physically access victims. Obstacles included narrow spaces, ^{Reference Idrose, Abu-Zidan and Roslan16} roadblocks, ^{Reference Hansen, Jepsen and Mikkelsen20} power lines crossing the scene, ^{Reference Hansen, Jepsen and Mikkelsen20} or strong winds. ^{Reference Hansen, Jepsen and Mikkelsen20} In some cases, access was hindered by security threats such as active shooting. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Jaffe, Wacht and Davidovitch21,Reference Carli, Pons and Levraut22} A strategy for enabling the provision of medical care was to establish medical posts in “safe enough” zones and move victims to these zones. ^{Reference Carli15}

Understanding the Situation and its Consequences

In some cases, the first indication of an MCI was a flux of emergency calls overwhelming the dispatch center. In one example, approximately 550 calls were recorded within a few minutes, ^{Reference Hansen, Mikkelsen and Alstrøm14} and in another example, the emergency calls increased by 400% during the first hour. ^{Reference Carli15} In other cases, the first indication of an MCI was when EMS met with a crowd fleeing the scene as they approached it. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Hardy19} Determining the exact or potential number of victims was challenging. Wide-spread scenes, spontaneous evacuations, the movement of people at the scene, and insecure environments often make it hard to make good estimations of numbers of injured. ^{Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16,Reference Hansen, Jepsen and Mikkelsen20,Reference Maruhashi, Takeuchi and Hattori23} Sometimes, the prehospital incident commander estimated the number of victims based on location, event type, and a “gut feeling.” ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15}

Lack of a physical overview of the scene, ^{Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16,Reference Hansen, Jepsen and Mikkelsen20,Reference Koning, Ellerbroek and Leenen24} uncertainty and rumours, ^{Reference Hansen, Mikkelsen and Alstrøm14} and challenges to obtaining information from the victims ^{Reference Maruhashi, Takeuchi and Hattori23} made it difficult to gain situational awareness and to analyze its medical consequences. The incident commander had to consider not only obvious injuries, but also pre-event conditions ^{Reference Choi, Lim and Cha25} and secondary medical effects such as contamination of victims, ^{Reference Zhang, Wang and Fan17} cardiac infarction or other acute medical conditions, ^{Reference Hirsch, Carli and Nizard26} secondary injuries from falling debris, ^{Reference Gamberini, Imbriaco and Flauto27} hypothermia risks, ^{Reference Koning, Ellerbroek and Leenen24} or dehydration. ^{Reference Hardy19} The ability to foresee such needs was limited and required medical knowledge and experience. ^{Reference Idrose, Abu-Zidan and Roslan16,Reference Hirsch, Carli and Nizard26}

Communicating Situational Awareness

It was emphasized that the prehospital response had to be integrated into the overall medical response. One of the greatest challenges to enable that was the sharing of information between the prehospital scene and the hospital, as well as other strategic levels within the crisis management system. Where information sharing failed, hospitals and strategic EMS management could not adapt their responses. ^{Reference Hardy19,Reference Koning, Ellerbroek and Leenen24,Reference Choi, Lim and Cha25} Communication technologies affected information sharing. Not all prehospital responders deployed units had the possibility or were familiar with the radio communication systems used. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Idrose, Abu-Zidan and Roslan16,Reference Safi Keykaleh and Sohrabizadeh18} Where many units were deployed, it was necessary to default to a “listen only, do not answer” basis to ensure radio discipline and clear communication channels, ^{Reference Hansen, Mikkelsen and Alstrøm14} and it was a common problem that much of the information shared through technical systems was not perceived by its intended recipients. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Idrose, Abu-Zidan and Roslan16,Reference Zhang, Wang and Fan17,Reference Hansen, Jepsen and Mikkelsen20,Reference Maruhashi, Takeuchi and Hattori23}

Adapting the Standardized Plan to the Event

Successful prehospital MCI management required the determination of a clear prehospital strategy and its communication to all actors. ^{Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16} As situations developed over time, these strategies had to be regularly adjusted. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15} Factors influencing the prehospital strategy included the estimated number of victims and their conditions, the location of the scene and of hospitals, logistical matters and the available resources, including staff and means of transportation. Several decisions had to be made based on these factors. A core component of the strategy was to get an effective flow of patients from the scene to the hospital, or designated points such as medical posts, for which there were several options. If the turnaround time for available ambulances was short, weather conditions were severe, or the scene was presumed too dangerous for on-site medical care, a strategy relying on the “load and go” principle was chosen. In such cases, medical treatment was not provided at the scene, but rather, in transit to the hospital, regardless of the standard plan or guidelines. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Jaffe, Wacht and Davidovitch21,Reference Maruhashi, Takeuchi and Hattori23} In other situations, the strategy was to gather victims for triage and care at the scene or at medical posts in safe areas before transferring them to hospitals. ^{Reference Carli15,Reference Koning, Ellerbroek and Leenen24} Sometimes, it was necessary to keep ambulances on standby at short distances from the scene due to security risks or to avoid crowding at the scene. ^{Reference Hansen, Mikkelsen and Alstrøm14} In other situations, infrastructural damage or adverse weather conditions forced the flow in certain unplanned directions, despite the original plan and most suitable hospitals. ^{Reference Hansen, Jepsen and Mikkelsen20}

Improvising

Even where general prehospital MCI management principles and guidelines existed, the complexity of the events and the presence of severe security issues required medical commanders’ quick decision making and improvisation. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15,Reference Pasquier, Dami and Carron28} Some such decisions were to transport several patients in one ambulance ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Jaffe, Wacht and Davidovitch21} or to use other means of transportation. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Pasquier, Dami and Carron28} Others involved abandoning the plan to use triage areas or medical posts due to security risks. ^{Reference Carli15,Reference Idrose, Abu-Zidan and Roslan16} If the strategy was to immediately transport all patients to the hospital, the use of pre-planned key functions such as ambulance loading officers or triage officers could be omitted to reallocate manpower to increasing transport capacity. ^{Reference Hansen, Mikkelsen and Alstrøm14}

Efficiently Distributing the Injured

A question raised across events was how to best distribute the injured, considering both the prehospital and hospital situations. In most events, both uninjured and injured victims went from the scene to nearby hospitals without assistance from EMS. Such spontaneous evacuation started before the arrival of EMS. ^{Reference Hansen, Mikkelsen and Alstrøm14–Reference Zhang, Wang and Fan17,Reference Hardy19,Reference Hansen, Jepsen and Mikkelsen20,Reference Hirsch, Carli and Nizard26,Reference Pasquier, Dami and Carron28,Reference Helou, El-Hussein and Aciksari29} In dangerous situations, such behaviors could be seen as a way of both saving oneself from the scene seeking medical care and were sometimes life-saving. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15}

Overall, EMS distributed patients in two main ways. The first was to transfer them to the nearest hospital, resulting in short ambulance turnaround times; however, this risked crowding in emergency rooms, especially if many victims had spontaneously evacuated there. ^{Reference Jaffe, Wacht and Davidovitch21,Reference Choi, Lim and Cha25,Reference Gamberini, Imbriaco and Flauto27,Reference Helou, El-Hussein and Aciksari29} The other option was to transfer to hospitals farther from the scene. This required more ambulances due to the longer turnaround time, but gave the receiving hospitals more preparation time and allowed for fewer secondary transports. ^{Reference Jaffe, Wacht and Davidovitch21,Reference Alpert, Assaf and Nama30} Regardless of the strategy, it was important to register and track where each patient had been sent. ^{Reference Koning, Ellerbroek and Leenen24}

Extracting Victims and Providing Care Under Severe Threats

Some of the events required civilian EMS not only to provide medical care but also to safely extract victims from danger zones. This necessitated close cooperation with the police and military; one strategy was to form a secure corridor, protected by armed police or soldiers, from the scene of the event to an ambulance collecting point. ^{Reference Hansen, Mikkelsen and Alstrøm14} In other situations, injured persons were sheltered in places protected by the police, unable to move. ^{Reference Carli15} These cases illustrate that EMS personnel sometimes have to assist in both dangerous extractions and provide care under fire. ^{Reference Carli15,Reference Jaffe, Wacht and Davidovitch21,Reference Alpert, Assaf and Nama30}

Providing Services Beyond Traditional Prehospital Medical Care

In most events, natural triage (ie, the on-scene death of victims with severe injuries) was high, and medical interventions were limited to clinical assessment, triage (often “eyeballing triage”), and treatment of minor injuries. ^{Reference Carli15,Reference Idrose, Abu-Zidan and Roslan16,Reference Hardy19,Reference Hansen, Jepsen and Mikkelsen20,Reference Maruhashi, Takeuchi and Hattori23,Reference Gamberini, Imbriaco and Flauto27} However, in some, interventions were performed to stop severe hemorrhaging (eg, tourniquets or wound packing) or to provide intravenous analgesics. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15,Reference Maruhashi, Takeuchi and Hattori23,Reference Hirsch, Carli and Nizard26} Some events required the use of “ad-hoc” triage systems or treatment guidelines due to the nature of the medical conditions. ^{Reference Pasquier, Dami and Carron28} An important aspect of prehospital medical care was to ensure the maintenance of ethical principles and to provide quality care for all victims, including suspected perpetrators, even under severe circumstances. ^{Reference Carli15}

Following an event, prehospital EMS also involved providing victims and their relatives with care and services other than life-saving aid (eg, treating minor injuries or assisting with psychological support). ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Idrose, Abu-Zidan and Roslan16,Reference Hansen, Jepsen and Mikkelsen20} Victims who had received medical care at the scene but were directly discharged therefrom required information about their clinical conditions and more extensive advice about self-care in everyday situations. ^{Reference Pasquier, Dami and Carron28} Where victims had to remain at the scene or in collecting areas for extended periods of time, EMS personnel, with the help of local authorities, had to provide food, water, and shelter. ^{Reference Hardy19} They were also required to orient family members who arrived at the scene looking for their loved ones. ^{Reference Koning, Ellerbroek and Leenen24} They thus had to prepare for such duties, most often in close collaboration with the police and local authorities.

Planning for a Long-Lasting Prehospital Response

Most events required the presence of EMS for hours after the initial alarm. In the reviewed events, EMS presence ranged from four-and-a-half ^{Reference Maruhashi, Takeuchi and Hattori23} to five, ^{Reference Koning, Ellerbroek and Leenen24} eight, ^{Reference Zhang, Wang and Fan17} or ten hours. ^{Reference Hardy19} It was important not to withdraw prehospital resources too soon, as victims could be found during repeat sweeps of the scene. ^{Reference Hansen, Mikkelsen and Alstrøm14} Since most events lasted several hours, the need for food and refreshments for both victims and EMS personnel had to be addressed within a few hours of the start of the event. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Hardy19} Even where emergency care was completed, response activities such as victim identification were on-going, sometimes requiring medical backup. ^{Reference Jaffe, Wacht and Davidovitch21}

Balancing Resources

Everyday emergencies do not cease when MCIs occur. In one case, only 40% of the day’s EMS calls were related to the MCI. ^{Reference Jaffe, Wacht and Davidovitch21} Therefore, strategic prioritization of how to use the available EMS resources to increase the response capacity was challenging. It likewise had to be decided early whether to assign all available ambulances to the incident or to hold some back in case of multiple-site or time-staggered incidents. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15} A common strategy was to request additional EMS resources from other parts of the country as backup or in response to unrelated emergency calls. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15,Reference Clancy, Christensen and Cortacans31} In foreseeable events, such as weather-related events, such preparations were possible to do before the event. ^{Reference Clancy, Christensen and Cortacans31} The need for secondary transport, which could emerge during or after the event and last for several days, ^{Reference Alpert, Assaf and Nama30} also had to be weighed against regular emergency calls.

Promoting Resilience among Prehospital Responders

Since the reviewed MCIs required unusual and demanding effort from all EMS personnel involved and lasted several hours or days, actions to promote resilience among EMS personnel were important. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Hansen, Jepsen and Mikkelsen20,Reference Jaffe, Wacht and Davidovitch21,Reference Alpert, Assaf and Nama30,Reference Clancy, Christensen and Cortacans31} Examples of such actions included pre-deployment briefings for incoming personnel, ^{Reference Carli15,Reference Clancy, Christensen and Cortacans31} the provision of food and water during deployment, ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Hardy19} and the implementation of clear stand-down strategies for EMS personnel at the end of their shifts and beyond. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Clancy, Christensen and Cortacans31} Such strategies included short, technical post-action reviews, the monitoring of EMS personnel’s well-being over a period of three weeks to three months after the event, and the provision of professional individual psychosocial support. ^{Reference Hansen, Mikkelsen and Alstrøm14,Reference Hansen, Jepsen and Mikkelsen20,Reference Jaffe, Wacht and Davidovitch21}