11 March 2004 Madrid Bombings A Prehospital Analysis Alfredo Serrano Moraza, M.D. María Jesús Briñas Freire, E.M.D. Andrés Pacheco Rodríguez,

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11 March 2004 Madrid Bombings

A Prehospital Analysis

Alfredo Serrano Moraza, M.D.María Jesús Briñas Freire, E.M.D.Andrés Pacheco Rodríguez, M.D.Alejandro Pérez Belleboni, M.D.

www.mebe.org Scientific approach

• Analytical work– Systematic sources acquisition and register– Exhaustive methodological evaluation

• Ethical principles– Patiens and relatives confidentiality– EMS teams’ work respect

• Useful and exportable approach– Look for and design an evaluation-tool for similar MCIs

Evidence-based disaster medicineEvidence-based disaster medicine

www.mebe.org 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

www.mebe.org 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

9/11 McKinsey report9/11 Commission full report

No official report

...when they arrived

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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

María Jesús Briñas Rescue Jeseník 2004

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7:49-8:00

Atocha

Medical Post 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

María Jesús Briñas Rescue Jeseník 2004

www.mebe.org Santa Eugenia

7:50

mICUs VIR UAD

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

MP organization

Dead 17Total victims 52 SUMMA/SAMUR

4 critical SAMUR 10 severe SAMUR 6 severe SUMMA

Work time approx. 1 h 15 min.

María Jesús Briñas Rescue Jeseník 2004

www.mebe.orgEl Pozo

The face of death

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

Wild massive evacuation

Hour ?

mICUs VIR UAD Helo

SAMUR 5 3 - - SUMMA 5 1 1 1

There’s no physical MP

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.

María Jesús Briñas Rescue Jeseník 2004

www.mebe.org Téllez St.

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.

María Jesús Briñas Rescue Jeseník 2004

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Hospital dataConsejería de Sanidad

March 11, 21 h

Critical

Hard severe

Severe

Wounded

Discharged

Slight i

njurie

sDea

d

224 + 9

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Madrid

Closest hospital overcrowdRobregordo

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

www.mebe.org

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 ?

bypass

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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

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SUMMA Communications irregular failing

Enormous citizens’ collaboration

EMS good job

SUMMA Dispatch Center good job

Impact on morbi-mortality ?

Enormous Firefighters, Police

and public-private efforts

ED and Hospitals good job

Closest hospitals

critical patients’ overload

SUMMA Planification deficiencies

SAMUR on-scene good organization

SAMUR random-Hospital evacuation philosophy

Ina

deq

ua

te

ph

iloo

sph

y ?

Four simultaneous focus

Inci

den

t re

late

dLessons learned

80 % accuracy*

Mild to moderate Massive evaquation

and Scoop and run63 % red labels

* 80 % accuracy

Two differents servicesTwo different Coord. Centers

Infr

ast

ruct

ura

l def

icie

nci

es

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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?

Thank you