Triage in Complex, Coordinated Terrorist Attacks

Psychological Impact on Firefighters After the 2022 Amok Attack in Berlin at Tauentzienstraße

OBJECTIVE

Exposure of emergency service personnel to disasters can lead to significant mental health challenges. The psychological impact of intentionally caused disasters, such as terrorist attacks, tends to be more severe than that of natural disasters. While much research has focused on terrorist attacks, little is known about the effects of intentional vehicular assaults (IVAs). This study examines the impact of an IVA on the mental health of firefighters. We hypothesized that firefighters deployed to the scene (deployed group (DG)) would experience more mental health problems compared to those not on duty (comparison group (CG)).

METHODS

The study included n = 115 firefighters, with 60 in the DG and 55 in the CG from the same units. Validated psychometric tools were used to assess anxiety, panic attacks (PHQ-D), and post-traumatic stress symptoms (PCL-5). Participation was voluntary, and informed consent was obtained. The study received approval from the Charité Berlin Ethics Committee (number: EA4/085/18).

RESULTS

A significantly higher prevalence of panic attacks was found in the DG (12.5%) compared to the CG (1.8%), with an odds ratio of 8.0 (95% CI: 1.0-67.3). Correlation analysis revealed a significant positive relationship between non-occupational tasks and hostility (r = 0.312, p = 0.015, n = 60), while parenthood had no significant effect on panic attacks or generalized anxiety.

CONCLUSION

These results highlight the severe mental health impact of intentional disasters like IVAs on firefighters, emphasizing the need for targeted psychological support and interventions. Future research should focus on tailored interventions to address the high prevalence of panic attacks among this population.

An assessment of mass casualty triage systems using the Alberta trauma registry

OBJECTIVE

Triage is the process of identifying patients with both the greatest clinical need and the greatest likelihood of benefit in the setting of limited clinical resources. The primary objective of this study was to assess the ability of formal mass casualty incident triage tools to identify patients requiring urgent lifesaving interventions.

METHODS

Data from the Alberta Trauma Registry (ATR) was used to assess seven triage tools: START, JumpSTART, SALT, RAMP, MPTT, BCD and MITT. Clinical data captured in the ATR was used to determine which triage category each of the seven tools would have applied to each patient. These categorizations were compared to a reference standard definition based on the patients' need for specific urgent lifesaving interventions.

RESULTS

Of the 9448 records that were captured 8652 were included in our analysis. The most sensitive triage tool was MPTT, which demonstrated a sensitivity of 0.76 (0.75, 0.78). Four of the seven triage tools evaluated had sensitivities below 0.45. JumpSTART had the lowest sensitivity and the highest under-triage rate for pediatric patients. All the triage tools evaluated had a moderate to high positive predictive value (> 0.67) for patients who had experienced penetrating trauma.

CONCLUSIONS

There was a wide range in the sensitivity of triage tools to identify patients requiring urgent lifesaving interventions. MPTT, BCD and MITT were the most sensitive triage tools assessed. All of the triage tools assessed should be employed with caution during mass casualty incidents as they may fail to identify a large proportion of patients requiring urgent lifesaving interventions.

Education and training as a key enabler of successful patient care in mass-casualty terrorist incidents

BACKGROUND AND PURPOSE

The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training.

MATERIAL AND METHODS

We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019.

RESULTS

Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events.

CONCLUSION

A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

Unmanned aerial vehicle based intelligent triage system in mass-casualty incidents using 5G and artificial intelligence

BACKGROUND

Rapid on-site triage is critical after mass-casualty incidents (MCIs) and other mass injury events. Unmanned aerial vehicles (UAVs) have been used in MCIs to search and rescue wounded individuals, but they mainly depend on the UAV operator's experience. We used UAVs and artificial intelligence (AI) to provide a new technique for the triage of MCIs and more efficient solutions for emergency rescue.

METHODS

This was a preliminary experimental study. We developed an intelligent triage system based on two AI algorithms, namely OpenPose and YOLO. Volunteers were recruited to simulate the MCI scene and triage, combined with UAV and Fifth Generation (5G) Mobile Communication Technology real-time transmission technique, to achieve triage in the simulated MCI scene.

RESULTS

Seven postures were designed and recognized to achieve brief but meaningful triage in MCIs. Eight volunteers participated in the MCI simulation scenario. The results of simulation scenarios showed that the proposed method was feasible in tasks of triage for MCIs.

CONCLUSION

The proposed technique may provide an alternative technique for the triage of MCIs and is an innovative method in emergency rescue.

Education, training and technological innovation, key components of the ESTES-NIGHTINGALE project cooperation for Mass Casualty Incident preparedness in Europe

Disasters induced by extreme weather events and terrorism-related activities, causing mass casualty incidents (MCIs) in Europe, are expected to increase in the upcoming years. This challenging scenario demands a high level of readiness and coordinated multi-disciplinary response to reduce morbidity and mortality. The European Society of Trauma and Emergency Surgery (ESTES) is one of the 23 partners of the European-funded project Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE), whose primary objective is to promote the exchange in experiences and define the best practices among first responders. Additionally, the project promotes multi-disciplinary and multi-institutional efforts to achieve technological innovation that will enhance preparedness in MCI management. This manuscript aims to describe the challenges of MCI triage, the education and training programs for MCI response in Europe, and the technological innovation that may aid optimal response. These three elements were discussed by ESTES Disaster and Military Surgery Section members during the German Society for Trauma Surgery session at the ECTES 2022 in Oslo "TDSC^® and beyond: ideas and concepts for education and training in Terror Preparedness", additionally the manuscript describes the first steps of the cooperation between ESTES and the rest of the NIGHTINGALE consortium.

Design and validation of a preparedness evaluation tool of pre-hospital emergency medical services for terrorist attacks: a mixed method study

INTRODUCTION

Terrorist attacks are one of the human problems that affect many countries, leaving behind a huge toll of disabilities and deaths. The aim of this study was to use a mixed-method analysis to design and validate an evaluation tool for pre-hospital emergency medical services for terrorist attacks.

METHODS

The present study is a mixed-method (qualitative and quantitative) study that was conducted in two phases. In the qualitative phase (item generation), semi-structured interviews were conducted with 34 Iranian emergency medical technicians who were selected through a purposive sampling method and a scoping literature review was conducted to generate an item pool for the preparedness evaluation of Emergency Medical Services (EMS) in terrorist attacks. In the quantitative phase (item reduction), for validity of tool face, content and construct validity, were performed; for tool reliability, the test and retest and intra-class correlation coefficient were evaluated.

RESULTS

At the first stage, 7 main categories and 16 subcategories were extracted from the data, the main categories including "Policy and Planning", "Education and Exercise "," Surge Capacity", "Safety and Security", "Command, Control and Coordination", "Information and Communication Management "and "Response Operations Management". The initial item pool included 160 items that were reduced to 110 after assessment of validity (face, content and construct). intra-class correlation coefficient (ICC = 0.71) examination and Pearson correlation test (r = 0.81) indicated that the tool was also reliable.

CONCLUSION

The research findings provide a new perspective to understand the preparedness of pre-hospital emergency medical services for terrorist attacks. The existing 110-item tool can evaluate preparedness of pre-hospital emergency medical services for terrorist attacks through collecting data with appropriate validity and reliability.

Developing a translational triage research tool: part two-evaluating the tool through a Delphi study among experts

Background

There are different prehospital triage systems, but no consensus on what constitutes the optimal choice. This heterogeneity constitutes a threat in a mass casualty incident in which triage is used during multiagency collaboration to prioritize casualties according to the injuries’ severity. A previous study has confirmed the feasibility of using a Translational Triage Tool consisting of several steps which translate primary prehospital triage systems into one. This study aims to evaluate and verify the proposed algorithm using a panel of experts who in their careers have demonstrated proficiency in triage management through research, experience, education, and practice.

Method

Several statements were obtained from earlier reports and were presented to the expert panel in two rounds of a Delphi study.

Results

There was a consensus in all provided statements, and for the first time, the panel of experts also proposed the manageable number of critical victims per healthcare provider appropriate for proper triage management.

Conclusion

The feasibility of the proposed algorithm was confirmed by experts with some minor modifications. The utility of the translational triage tool needs to be evaluated using authentic patient cards used in simulation exercises before being used in actual triage scenarios.

Mass Casualty Incident: Do Tactical Tag Bracelets Improve Triage Performance by First Responders? A Randomized Controlled Mass Casualty Incident Simulation and Response of A French Gendarmerie Elite Unit

INTRODUCTION

Tactical triage replaces primary triage in the exclusion zone in mass murder or terrorist events to prioritize victims requiring life-saving interventions (LSIs) and/or rapid extraction in an environment with a lack of resources and under active threat. French gendarmerie tactical unit medical teams use triage bracelets during mass casualty incidents (MCIs). This study assessed the value of these bracelets in the tactical triage performance of nonhealthcare combat rescue operators in an MCI simulation.

OBJECTIVES

To compare triage performance with and without the use of bracelets based on categorization accuracy, LSIs, and time to end triage.

MATERIALS AND METHODS

Two groups of operators were randomly assigned to participate in an MCI simulation alone (10 simulated patients) with (intervention group) or without (control) bracelets. The primary outcome was triage performance assessed by the mass casualty triage performance assessment tools. The results were measured based on the LSI required, triage category, and time of completion of the task. Secondary outcomes were operator-perceived stress and self-efficacy.

RESULTS

Eleven operators (intervention group n = 5, control group n = 6) participated. Triage performance, based on a maximum score of 90, was better for the intervention group [72.200 (SD = 10.330) vs. 57.000 (SD = 12.961), P = .045]. Self-efficacy was increased after the simulation in the intervention group [45.00 47.2 (SD = 4.147) vs. 50.400 (SD = 5.505), P = .034)].

CONCLUSIONS

This is the first study to show the best triage performance among nonhealthcare combat rescuers using triage bracelets in an MCI simulation. The small sample size did not allow for external validity of the results. The initially calculated number of participants (N = 12) was not reached for operational reasons. The use of bracelets may have a place in the medico-organizational act of tactical triage during MCIs in exclusion zones. Further studies should be conducted to assess the value of triage bracelets by other first responders, including physician-nurse teams.

Terrorist Attacks in Western Europe: A Counter-Terrorism Medicine Analysis

BACKGROUND

The modern concept of terrorism has its roots in the "old continent" of Western Europe, more specifically in France, during the "Reign of Terror" period of the French Revolution. At the time, this form of state terror had a positive connotation: it was a legitimate means of defending the young state. While no single accepted definition of terrorism exists today, it is universally considered an attack on both state and society. The health care impacts of terrorist attacks often extend disproportionally beyond the casualty toll, but the potential for such events to induce mass casualties remains a concern to Disaster Medicine and Counter-Terrorism Medicine (CTM) specialists.

METHOD

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Western Europe from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary weapon type, country where the incident occurred, and number of deaths and injured were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

RESULTS

A total of 15,306 events were recorded in Western Europe out of a total of 201,183 events world-wide between the years 1970 and 2019 inclusive. This resulted in a total of 5,548 deaths and 17,187 injuries. Explosives were used as a primary weapon/attack modality in 8,103 attacks, followed by incendiary attacks in 3,050 events and firearm use in 2,955 events. The use of chemical, biological, radiation, and nuclear (CBRN) weapons was rare and only accounted for 47 events.

CONCLUSION

From 1970 through 2019, 9.11% of all terrorist attacks occurred in Western Europe. Compared to global trends of attack methodologies in the same study period, the use of explosives as a primary attack modality in Western Europe was similar (52.94% in Western Europe versus 48.78% Global). Firearm use was comparatively low (19.31% versus 26.77%) and the use of CBRN as an attack modality was rare (0.30% versus 0.20%). The United Kingdom, Spain, and France accounted for over 65% of all terrorist attacks and over 75% of terrorism-related deaths in Western Europe.

Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care

Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.

Pre-hospital critical care at major incidents

The identification, triage, and extrication of casualties followed by on-scene management and transport to an appropriate hospital after mass casualty incidents can be complicated, delivered to variable standards, and add significant delays to care. An effective pre-hospital pathway can both increase the chances of survival of individual patients and significantly influence the effectiveness of the entire emergency response.

Mass casualty, intentional vehicular trauma and anaesthesia

The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.

Medical Coordination Rescue Members' and Ambulance Nurses' Perspectives on a New Model for Mass Casualty and Disaster Management and a Novel Terror Attack Mitigation Approach in the Netherlands: A Qualitative Study

INTRODUCTION

Mass-casualty incidents (MCIs), specifically incidents with chemical, biological, radiological, and nuclear agents (CBRN) or terrorist attacks, challenge medical coordination, rescue, availability, and adequate provision of prehospital and hospital-based emergency care. In the Netherlands, a new model for Mass Casualty and Disaster Management (MCDM) along with a Terror Attack Mitigation Approach (TAMA) was introduced in 2016.

STUDY OBJECTIVE

The objective of this study was to provide insight in the first experiences of health policy advisors and managers with a medical rescue coordinator and ambulance nursing background regarding the new MCDM and TAMA in order to identify strengths and pitfalls in emergency preparedness and to provide recommendations for improvement.

METHODS

The study had a qualitative design and was performed from January 2017 through June 2018. Purposeful sampling was used and the inclusion comprehended health policy advisors and managers with a medical rescue coordinator and ambulance nursing background involved in emergency preparedness. The respondents were interviewed semi-structured and the researchers used a topic list that was based on the literature and content of the newly introduced model and approach. All interviews were typed out verbatim and qualitative content analyzing was used in order to identify relevant themes.

RESULTS

Respondents based their perceptions on large-scale training exercises, as MCDM and TAMA were not yet used during MCIs. Perceived issues of MCDM were the two-tiered triage system, the change in focus from "stay and play" towards "scoop and run," difficulties with new tasks and roles of professionals, and improvement in material provision. Regarding TAMA, all respondents supported the principles (do the most for the most; scoop and run; acceptable personal risk; never walk alone; and standard operational procedure); however, the definitions were lacking clarity while the awareness of optimal personal safety of professionals was absent.As there are currently regional differences in the level of implementation of MCDM and TAMA, this may pose a risk for an optimal inter-regional collaboration.

CONCLUSION

The conclusions refer to experiences of professionals in the Netherlands. Elements of the MCDM and TAMA were highly appreciated and seemed to improve emergency preparedness, while other aspects needed further attention, training, and integration in daily routine. The Netherlands' MCDM model and TAMA will need continuous systematic evaluation based on (inter)national performance criteria in order to underpin the useful and effective elements and to improve the observed pitfalls in emergency preparedness.

Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention

BACKGROUND

Children are frequently injured during major incidents (MI), including terrorist attacks, conflict and natural disasters. Triage facilitates healthcare resource allocation in order to maximise overall survival. A critical function of MI triage tools is to identify patients needing time-critical major resuscitative and surgical intervention (Priority 1 (P1) status). This study compares the performance of 11 MI triage tools in predicting P1 status in children from the UK Trauma Audit and Research Network (TARN) registry.

METHODS

Patients aged <16 years within TARN (January 2008-December 2017) were included. 11 triage tools were applied to patients' first recorded pre-hospital physiology. Patients were retrospectively assigned triage categories (P1, P2, P3, Expectant or Dead) using predefined intervention-based criteria. Tools' performance in <16s were evaluated within four-yearly age subgroups, comparing tool-predicted and intervention-based priority status.

FINDINGS

Amongst 4962 patients, mortality was 1.1% (n = 53); median Injury Severity Score (ISS) was 9 (IQR 9-16). Blunt injuries predominated (94.4%). 1343 (27.1%) met intervention-based criteria for P1, exhibiting greater intensive care requirement (60.2% vs. 8.5%, p < 0.01) and ISS (median 17 vs 9, p < 0.01) compared with P2 patients. The Battlefield Casualty Drills (BCD) Triage Sieve had greatest sensitivity (75.7%) in predicting P1 status in children <16 years, demonstrating a 38.4-49.8% improvement across all subgroups of children <12 years compared with the UK's current Paediatric Triage Tape (PTT). JumpSTART demonstrated low sensitivity in predicting P1 status in 4 to 8 year olds (35.5%) and 0 to 4 year olds (28.5%), and was outperformed by its adult counterpart START (60.6% and 59.6%).

INTERPRETATION

The BCD Triage Sieve had greatest sensitivity in predicting P1 status in this paediatric trauma registry population: we recommend it replaces the PTT in UK practice. Users of JumpSTART may consider alternative tools. We recommend Lerner's triage category definitions when conducting MI evaluations.

Mobile Triage Applications: A Systematic Review in Literature and Play Store

The main objective of this paper is to review and analysis of the state of the art regarding triage applications (apps) for health emergencies. This research is based on a systematic review of the literature in scientific databases from 2010 to early 2021, following a prism methodology. In addition, a Google Play Store search of the triage apps found in the literature was performed for further evaluation. A total of 26 relevant papers were obtained for this study, of which 13 apps were identified. After searching for each of these apps in the Google Play Store platform, only 2 of them were obtained, and these were subsequently evaluated together with another app obtained from the link provided in the corresponding paper. In the analysis carried out, it was detected that from 2019 onwards there has been an increase in research interest in this area, since the papers obtained from this year onwards represent 38.5% of the relevant papers. This increase may be caused by the need for early selection of the most serious patients in such difficult times for the health service. According to the review carried out, an increase in mobile app research focused on Emergency Triage and a decrease in app studies for triage catastrophe have been identified. In this study it was also observed that despite the existence of many researches in this sense, only 3 apps contained in them are accessible. "TRIAGIST" does not allow the entry of an unidentified user, "Major Trauma Triage Tool" presents negative comments from users who have used it and "ESITriage" lacks updates to improve its performance.

Development of the Aerial Remote Triage System using drones in mass casualty scenarios: A survey of international experts

The use of drones for triage in mass-casualty incidents has recently emerged as a promising technology. However, there is no triage system specifically adapted to a remote usage. Our study aimed to develop a remote triage procedure using drones. The research was performed in three stages: literature review, the development of a remote triage algorithm using drones and evaluation of the algorithm by experts. Qualitative synthesis and the calculation of content validity ratios were done to achieve the Aerial Remote Triage System. This algorithm assesses (in this order): major bleeding, walking, consciousness and signs of life; and then classify the injured people into several priority categories: priority 1 (red), priority 2 (yellow), priority 3 (green) and priority * (violet). It includes the possibility to indicate save-living interventions to injured people and bystanders, like the compression of bleeding injuries or the adoption of the recovery position. The Aerial Remote Triage System may be a useful way to perform triage by drone in complex emergencies when it is difficult to access to the scene due to physical, chemical or biological risks.

Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review

AIMS AND OBJECTIVES

The aim of review was to describe and synthesise the evidence on the use of tourniquets to control haemorrhages, summarising both civilian and military use.

BACKGROUND

Trauma-related haemorrhage constitutes one of the most preventable deaths among injured patients, particularly in multi-casualty incidents and disasters. In this context, safe instruments such as tourniquets are essential to help healthcare professionals to minimise loss of life and maximise patient recovery.

DESIGN AND METHODS

An integrative review was conducted in Medline, Nursing & Allied Health Premium, and Health & Medical Collection, using published data until March 2021 and following the PRISMA guidelines.

RESULTS

A total of 25 articles were included. Evidence has been synthesised to understand the use of different types of tourniquets, environment of application, indication for their placement and potential complications associated with tourniquet placement.

CONCLUSIONS

Commercial tourniquets such as Combat Application Tourniquet or Emergency Tourniquet models are a valuable and safe instrument for haemorrhage control in both military and civilian out-of-hospital care settings. Nurses, as part of emergency teams, and other professionals should be aware that there is a possibility of adverse complications, but they are directly proportional to the time of tourniquet placement and generally temporary. In addition, national and international guidelines ensure the need for all civilian emergency services to be equipped with these devices, as well as for the training of healthcare professionals and first responders in their use.

RELEVANCE TO CLINICAL PRACTICE

Despite the lack of complications in the use of tourniquets in these cases, their use has been a matter of debate for decades. In this sense, this review yields up-to-date guidelines in the use of tourniquets, their recommendations and their significance among professionals to manage complicated situations.