11 march 2004 madrid bombings a prehospital analysis alfredo serrano moraza, m.d. maría jesús...
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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
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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