Organization in response to massive afflux of war victims in civilian practice - experimental feedback from the November 2015 Paris terrorist attacks

Learning trauma surgery through cytoreductive surgery

OBJECTIVES

Regarding war surgery (WS), the initial and continuing education of French military gastrointestinal surgeons (FMGIS) is considered flawed and inappropriate. This results from the low incidence of gastrointestinal (GI) trauma, its predominantly non-surgical management, and a daily surgical practice that strongly differs from WS. Conversely, cytoreductive surgery (CRS) of peritoneal metastases has similarities with WS which led us to assess its potential contribution to the initial and continuing education of FMGIS in WS.

METHODS

We reported the activities of the GI surgery departments of the military teaching hospitals of Percy and Begin. The first one dedicated to traumatology and the second to CRS. We then specifically looked into the surgical procedures conducted by the FMGIS during deployment from January 2004 to December 2014.

RESULTS

Amongst the 600 severe trauma patients admitted to the Percy trauma center between January 2019 and December 2020, 17 underwent abdominal surgery with a total of 25 procedures performed. During the same period, 61 patients undertook CRS in Begin with an average of 7 surgical processes per patient carried out and a total of 418 abdominal surgical procedures. Outside abdominal packing and nephrectomy (not performed in CRS), the numbers of splenectomy, gastrointestinal / gynecological resections (hysterectomy and/or adnexectomy), or liver resection were higher during CRS compared to abdominal trauma surgery with 10 times less patients (10 vs 1, 43 vs 9, 20 vs 0, 6 vs 0, respectively).

CONCLUSION

CRS, through its similarities with WS, seemed to be an appropriate tool for the initial and continuing education of FMGIS in WS and, to an extent, of civilian trauma surgeons who could eventually treat terrorist attacks casualties on the national territory.

Lessons learned from terror attacks: thematic priorities and development since 2001-results from a systematic review

Purpose

The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001.

Methods

PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018.

Results

Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied.

Conclusions

The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.

An overview of forensic operations performed following the terrorist attacks on November 13, 2015, in Paris

On the evening of November 13, 2015, the city of Paris and its surroundings was hit by a series of attacks committed by terrorist groups, using firearms and explosives. The final toll was 140 people deceased (130 victims and 10 terrorists or their relatives) and more than 413 injured, making these attacks the worst mass killings ever recorded in Paris in peacetime. This article presents the forensic operations carried out at the Medicolegal Institute of Paris (MLIP) following these attacks. A total of 68 autopsies of bodies or body fragments and 83 external examinations were performed within 7 days, and the overall forensic operations (including formal identification of the latest victims) were completed 10 days after the attacks. Over this period, 156 body presentations (some bodies were presented several times) were provided to families or relatives. Regarding the 130 civilian casualties, 129 died from firearm wounds and one died from blast injuries after an explosion. Of the 10 terrorists or their relatives who were killed, eight died from suicide bombing, one was shot by police and one died from crush injuries due to partial collapse of a building following the police raid against a terrorist’s hideout after the attacks. All mass shootings were perpetrated with AK-47 or Zastava M70 assault rifles using 7.62 mm × 39 mm cartridges. In the case of ballistic injuries, death was most often obviously caused by craniocerebral injuries, extensive organ lacerations and/or massive haemorrhage. Among the terrorists killed by bombing, the lesion patterns were body transection, multiple amputations, extreme organ lacerations and the presence of foreign bodies owing to the shrapnel load (steel nuts, glass fragments) or the explosive charge fastening system of the devices. This discussion highlights the particular difficulties of interpretation encountered within the framework of ballistic injuries, a conclusion that should lead to a modest and realistic approach in these exceptional situations where forensic operations involve a very large number of victims in a constrained time.

Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury

PURPOSE

The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma.

METHODS

This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds.

RESULTS

337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min].

CONCLUSION

The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack.

FUNDING

Assistance Publique-Hôpitaux de Paris.