A presentation by Pierre Carli at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Professor Pierre Carli
SAMU de Paris
Hôpital Universitaire Necker Paris
Experiences from the Paris
attacks November 13th 2015

2. No COI to declare

3. Paris November 13 2015
The most severe terrorist
attack in France since WWII
Lessons
Focus on the medical
management

4. SAMU Medical
Regulation Center
15 The French SAMU
system
MICU staffed by Physicians
providing critical care on
scene
Dispatching
Hospital admission
Medical control

5. T = O
T = Min
T = 1h
Definitive care 1h - 2h
Prehospital care for mass casualties in France “Red Plan”
SAMU and Firebrigade
Incident
Advanced Medical Post « PMA »
SICU 1 SICU2
ER 1
ER 2SICU n
MICU
EMS Physicians
Medical
Regulation
Absolute Emergency Relative Emergency
ER n
Deceased
Chief medical officer
“DSM”
Incident Commanding
officer“DOS”
Carli et Al Prehosp Disaster Med 2003, 18 ;98-92

6. The “White Plan” in France
Mass casualties plan for all the hospitals
• The ORSAN organization for
exceptional health situations
• In order to receive :
– Many casualties arriving
spontaneously from the
scene
– Casualties triaged and
managed by the SAMU
medical teams at the
advanced medical post

7. Terrorists attacks
in Paris
1995 - 1996
• Handcraft bombs
• Mono site attacks

8. Evolution of terrorist attacks
NYC , Madrid , London, Mumbay …
Israël , Egypt, Nigeria, Tunisia …
Multisite attacks :
Dedicated plan
Military weapons :
Damage control

9. Prehospital damage control
1. External hemorrhage control
2. Volume loading /vasoconstrictors
3. IV hemostatic agents
4. Airway management /tension
pneumothorax
5. Control of hypothermia
6. Direct admission to Operating
Room notified by SAMU
Tourtier JP and Carli P AFAR V 32, 2013, 520 - 6

10. Friday November 13 2015
The multi site multi modal
terrorist attacks in Paris

11. 9AM Friday November 13th
Exercise «Shooters in the city»
4 groups of shooters 13 different
sites: 66 deaths, 74 AE, 48 RE
Unrealistic ?
12 hours later …

12. 1
2
Le Petit cambodge
Casa Nostra
Bd Voltaire Bataclan
Rue de Charonne
Stade de France
Friday November the 13 th
3 different commandos : multisite attacks
Sector organization
NORTH
SAMU 93
SAMU 94
WEST
SAMU 92
EAST
The multisite plan for terrorist attacks
SAMU
de Paris
21h20
21h25
21h40

13. Stade de France bombings
• North sector of the
multisite “camembert”
plan
• Engagement of the SAMU
of the Paris suburbs
• No MICU from downtown
Paris
Very dangerous situation : 70 000 attendants
French President and multiple VIPs

14. Stade de France
3 kamikaze bombings
• Dead: 3 terrorists +1
• 7 AE 50 RE
• 1 SAMU Physician 1
Firebrigade physician 1
Firebrigade offcier assigned on
duty at the stadium
• 11 medical teams SAMU BSPP
back up
1
2
3
2 1
3
3 Dead 6 AE 11 RE
1 Dead 1 AE 10 RE
31 RE 21h20
21h17
21h45

15. Stade de France bombings
• Terrorists were late and unable to enter the
stadium
• Match was not interrupted
• Stadium was not evacuated
• The bombs exploded in the deserted surroundings
Failure of a potentially major terrorist attacks !

16. 1
6
Sites of the terrorists attacks
EAST sector Paris :
• The café terraces
• The Bataclan theatre

17. 1
7
EAST sector : ParisEAST sector: The Café terraces
Multiples shootings on the pavement outside bars
and restaurants

18. Triage and care on scene
• Many casualties dead on
scene before arrival of
Police or Rescue teams
– Lethal wounds
• Head , chest
• Multiple impacts
• Triage of casualties
• Evacuation by small
groups
Triage tag

19. • Pre hospital damage control by MICU teams
– Control by senior physician of the care protocol and the
time spent on scene
Triage and care on scene
• Absolute emergency
profile
– Isolated penetrating
chest wounds and /or
– abdominal and
inferior limbs injuries

20. Special site : Rue Bichat Le Carillon et le Petit Cambodge
• Few meters from hospital
St Louis
• Spontaneous arrival of
walking casualties or
transported by bystanders
• Stretchers evacuations

21. 2
1
Spontaneous arrival of casualties

22. • Few hundreds meters from hospital
St Antoine
• Patients transported by rescuers to
St Antoine or another designated
hospital after SAMU notification
Rue de Charonne shooting
Involved victims sheltered in Fire Station

23. 2
3
Protection of non injured survivors in 2 nearby fire stations

24. • Street cordoned off by Police and
Army
• Fire fight in the streets nearby the
sites
• Difficult and dangerous access to
victims (bombs ?)
• Evacuation and escape routes
blocked and unsafe
• Terrorist commando still firing and
moving in a car in the area ?
Terraces : A very dangerous
environment
• Commando on the run
• Active street shooters
• Street cordoned of by Police
• Impossible to determine precisely a RED or GREEN zone
• NO advanced medical post only Casualties Collecting Points

25. The Bataclan theater site
Public around 1400 : Hostages taking and shootings during 3 hours
Shooting from the stage by Kamikaze bombers
Escape or extraction of numerous victims in critical condition

26. AMP 1
AMP 2
Shootings
Shootings
Involved victims Absolute Emergency / Relative Emergency
The Bataclan site : Adaptability !
• SAMU 75 and BSPP engaged with nearby departments after clearing of other sites
• Adaptability : implementation of 2 AMP
“Victims nest” Shootings

27. Advanced Medical Post near the Bataclan
AMP AUAMP RE

28. Adavanced Medical Post
Near the Bataclan

29. 2
9
Bataclan AMP for AE
Shooting alert in the AMP

30. 3
0
SAMU headquarters
Medical Regulation
« zonal crisis room »
Increase of the emergency calls
• First hour: 421 %
• All the night: 224 %

31. 3
1
Zonal coordination by SAMU of the 8 SAMU of the region IDF
• MICU capacity:
• 45 MICU teams on the
scenes
• 15 additional MICU kept
in reserve for
• Daily usual activity in
Paris
• Another site and
scability
NORTH
WEST EAST
Major mobilisation of EMTs from Firebrigade BSPP , Red Cross,
Malta order according to the RED PLAN ALPHA

32. MICU OR and post-surgery recovery room
Medical/Surgical
ICU
Summary on paper boards
More than 20 public hospitals APHP and 2 military hospitals mobilised
Medical Zonal regulation : The crisis room during the evening

33. • Reference trauma center
• White plan immediately activated : First victims arrived
very quickly
• New triage at hospital admission:
• AE going straight to post-surgigal unit
• One way progression
• Continuous activity : 1 surgical team (3 specialists) for
each AE
• 10 simultaneous operating rooms, no saturation
• Total: 53 victims, 28 AE, 25 RE
In hospital management: Pitié Salpétrière Hospital

34. Pitié Salpétrière Trauma center
ER and Trauma Unit crisis organization:
Chief Anesthesiologist and Surgeon
BLOC RéservePharmacie-PSL
BLOC RéservePharmacie-PSL
Secondary triage on arrival
ER : Relative Emergency
Recovery room /trauma unit : Absolute Emergency
Victims assigned
to « colour »team
Pr M RAUX Pitié Salpétrière
University Hospital

35. 22:35
1er EU
22:45
10 UA
00:30
9 UA
3:15
6 UA
3:30
2 UA
Casuaties Surge
Arrival at Pitié Salpetrière trauma center
First patient in the SICU End Alert
Pr M RAUX Pitié Salpétrière
University Hospital
• Importance of SAMU medical regulation
to control the hospital casualties surge
• Direct contact between hospitals and
SAMU

36. In hospital management: Saint Louis Hospital
• In one of the shooting zone
• Victims walking in before white plan activation
• Hospital personnel spontaneously came in to help out
• Victim triage in the post-surgical unit
• Major increase in OR availability and operating teams
including help from thoracic surgeons from another hospital
• Teams were never overwhelmed by mass influx of patients
• Total: 26 victims, 11 AE, 15 RE
Haug C, NEJM , 5/12/2015

37. Hirsch et al., Lancet 2015
10.1016/S0140-6736(15)01063-6
Administrative count of
Absolute and Relative
Emergencies
hospitalized in APHP
Military hospitals
Percy et Begin: 18 AE +
34 RE = 52 victims
356 victims hospitalized
Mortality at D7: 1,3 %
No emergency
interhospital transfer
Several hospitals kept in
reserve

38. Psychological emergencies
• « CUMP » Medical and psychological special unit is part of the
plan
• Involved victims transported to one major psychiatric centre :
Hôtel Dieu hospital
• 35 psychiatrics and psychologists
• National back-up of psychiatrists the week after
• Some additional dedicated psych units in city halls !
Complex analysis going beyond trauma care
More than 5000 consultations in 2 weeks

39. Psychological consequences on the SAMU personnel
• Incredible burst of violence
• Very traumatic psychological
context
• First terrorist attack involvement
for many young doctors
• One SAMU physician among the
victims
Dr Stella VERRY
CRRA 15
General Practitioner
Killed in Le Petit Cambodge

40. Many anticipated aspects
were satisfactory
• Mobilization of the different SAMU of the region
• On site medical organization of care and supervision
• Multisite «camembert» strategy
• Anticipation of possible other events with available back up
means
• Several hospitals kept in reserve
• Inter Defence Zone reinforcement and back up activation

41. Many aspects needed
improvement
• Medical team on site protection (new training)
• Ensuring the security of exposed victims on scene (2nd
Bomb?)
• Numerous victims extractions in safe areas during Police
interventions
• Evacuation routes cleared and protected by Police or Army
– Conflict between “damage control” and team safety
• Localisation of multiple small sites scattered during
terrorist getaway and false alarms

42. What have we learned ?
What can we share ?

43. CARLI P , PONS F, et Al The Lancet Published online 7 25,
2017 http://dx.doi.org/10.1016/S0140-6736(17)31590-8
The French emergency medical services after
the Paris and the Nice attacks: what have learnt?

44. Major terrorist attacks in
Europe since 11/2015
• The threat is
increasing
• All Europe is under
attack
• 8 major attacks
since Paris
• Many minor attacks
• Not only the
emblematic cities
but anywhere …
• Thousands of
possible targets
CARLI P , PONS F, et Al The Lancet Published online 7 25,
2017 http://dx.doi.org/10.1016/S0140-6736(17)31590-8
Barcelona Cambrils,
Alcanar
Aug 17-18 2017
Dead 24 (16+8)
152 injured

45. Terrorist Attacks:
A large spectrum from
« low cost attacks »
to sophisticated
multimodal mass
casualties
Individual
stabbing
Car in the crowd
Shooting hand gun
Shooting assault rifle
Truck in the crowd
Multimodal multisite
CBRN
XXX ?
You will never have
the “perfect” plan
Kamikaze bomb
Artisanal bomb

46. Medical response to Terrorism :
You must develop a counter strategy
CAUTION

47. Think differently about your plan
Scalability of
the attacks
The tool box !
ADAPTABILITY

48. Terrorism is not a natural or technological disaster
ISIS Terrorists have a
strategy with precise
targets to
– injure, kill
– spread fear and panic

49. JAMA Surg. Online 2017 Jan 25
“To defeat a network of terrorists, we had to build
a network.” General S. McChrystal in Afghanistan
To minimize preventable deaths from this new
wave of terror, we in medicine must do the same.

50. Importance of training
• As described after the Boston marathon
bombings
• An integrated response Police Rescue Care
to improve survival of casualties
• Drills !

51. Drills
• Before V 13 many
SAMU MICU and
EMT drills
• Indeed !
After V 13 Paris attacks
• Common drills
– Police
– Army
– Rescue
– Prehospital care
• Same interactive scenario

52. Adapt medical
practice to new
victims and a new
environment
Paris November 2015
Coordination
on scene with
Police and
Army

53. But the ultimate lesson of
terrorists attacks is :
Prepare to be surprised
• Terrorism has no limit
• The worst is always possible
–CBRN attacks :
• Clorine, Sarin, mustard gaz
–Children : schools
–Hospitals and health care providers

54. Emergency care and resilience
• Resilience of emergency services
– Broadcasts a positive, non-violent action that
emphasizes the individual
– Opposes the cycle of aggression and repression :
caring the victims and the terrorists
– It encourages the public to get involved to save the
victims
Emergency care organization is the first
step of global resilience

55. Conclusion
• Maximize survival
• Promote resilience
secretariat.pcarli.nck@aphp.fr