Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon

 
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Retour d’expérience des attentats
            de Paris

                  Pr. Pierre CARLI

                SAMU de Paris Hôpital Necker
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Le 13 Novembre 2015

• Un attentat multisite multimodal
• Le plus grave en France depuis la seconde
  guerre mondiale : 130 DCD plus de 410 blessés
• Suivi d’une vague d’attentats sans précédent
  en Europe
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Le SAMU de Paris
      Les SAMU d’IDF en première ligne

    19 ans après le dernier
attentat terroriste perpétré à
        Paris en 1996
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
L’attentat terroriste
Une crise particulièrement intense
• Qu’avions nous préparé avant ?
• Qu’avons nous fait pendant ?
• Quels sont les leçons à l’usage de tous les
  responsables
Un parcours de l’événement, de l’urgence à la
résilience ….
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Avant …
La menace terroriste n’est pas
    une surprise complète
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Attentats
terroristes
  à Paris
1995 -1996
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Attentat terroriste de Port Royal à Paris 1996
70 victimes (12 UA 58 UR) et plus de 400 personnels sur place : Rapport
1/4 ou plus … 17 hôpitaux reçoivent les victimes
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Plan Rouge pré hospitalier
                           puis plan NOVI

T=O                                Site
                                                   SMUR
                                                Réanimation
                                                   Triage
T = Minutes

                                                  SAMU
T = Heures (1-2)                                Régulation
                               PMA
Traitement définitif
                               UA       UR             H
                                                     SAU 1

       H      REA 1
                       H   REA 2
                                    H   REA N     SAU N

                                                    H
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
Plan Blanc hospitalier

• Une obligation réglementaire
  pour tous les établissement
  de santé
  – Réponse à un afflux de victimes
  – Ou une situation sanitaire
    exceptionnelle
Retour d'expérience des attentats de Paris - Pr. Pierre CARLI SAMU de Paris Hôpital Necker - LAST retour exp attentat 2018 Lyon
L’hyper terrorisme et les attentats
            multi sites
               • New York 2001

               •Madrid 2004

               • Londres 2005

               • Bombay 2008
Bombay 2008 : attentat multisite et multimodal
• 10 sites d’attaques avec fusillades,
  explosions et prises d’otages :
    –   gare, métro, restaurants, Police, hôtels
        de luxe, hôpital …
• 10 terroristes , plusieurs commandos
• 188 DCD 312 blessés
Un double enjeu
• Adapter nos techniques de soins aux victimes de
  fusillades
  – Principes du « Damage control »
• Mettre en œuvre une stratégie qui permette aux
  équipes médicales de « couvrir » l’ensemble des
  sites et de s’adapter à l’évolution de la crise
  – Le plan attentats multi sites « camembert » du SAMU
  – Articulé avec le Plan Rouge Alpha de la BSPP
« Damage Control » pré hospitalier
Tourtier JP and Carli P , AFAR , 2013, 520 - 6

• Traitements simplifiés
  – Hémorragie externe = Garrot /
     compression
  – Hypotension permissive = Objectif
     conscience +
  – Acide tranexamique = 1g / 20 min
  – Prévention de l’hypothermie
  – O2 et pas d’intubation exsuflation PNO /
     ventilation mécanique
  – Analgésie limitée
• Evacuation vers Bloc pour hémostase dans
  les 60 min
Chaine Médicale de l’Avant
              modifiée pour le « Damage Control »

                                       Impliqués CUMP
                                                                       H
                                                        Grande Noria
                                                         Evacuation

                                                                       H
            TRI
         secouriste

         PRV                     TRI   PMA
 Médicalisation       Petite Noria
  De l’avant          Ramassage

Priorité à l’hémostase chirurgicale des UA instables                   Bloc
    2 exercices de terrain en 2013 et 2014 pour                        Réveil
               préparer une fusillade
                                                            Carli P et Al JEUR 2017
Renfort
                                                          SAMU 95

                              SAMU 93

                                        Vers le 93
          le 92
     Vers                                                            SA
                                                                       MU
                                                                            94
                    2                                Ve
           SAM U9                                      rs
                                                          le
                                                             9   4

                         Stratégie en cas
 Renfort
SAMU 78
                        d’attaque multisite                               Renfort
                                                                        SAMU 77 91
J a n vi er 2 0 1 5

                                                                        1 p oli ci er bl ess é
                                                                        p ar b all e U R V P

                                                                        1 P oli ci er e n A C R
                                                                       + 2 P oli ci er s U R V P
                            11 DC D 4 U A
                         1 d a m a g e c o ntr ol

                                                                  1 U R all o n g é e
                                                                    s ur l e s ol

T o urti er J P … C arli P et Al A m J E m er g M e d 2 0 1 5
Double prise d’otages 9 janvier 2015
• Un type d’intervention
  différent des fusillades
• Le premier multisite IDF

                                      17
Pendant …
Le jour de l’attaque
 La préparation à l’épreuve des
              faits
Le 13 Novembre 2015
L’attaque terroriste multisite et
      multimodale de Paris
Exercice «Tireurs dans la ville » Samu Zonal le
matin du Vendredi 13 Novembre 2015 à 9h30

                            Une répétition 12h avant …
Les sites d’attentat du 13 novembre 2015
■ 21h20 Stade de France : 3
  Kamikazes.
   ■ 21h20 une première explosion
      près de la porte D du Stade de
      France                                  Stade de France

   ■ 21h 30 deuxième explosion près
      de la porte H

   ■ 21h53 troisième explosion
      restaurant Mac Donald                                           Le Petit cambodge

                                          ?
                                                        Casa Nostra
■ 21 h 25, une seconde équipe ouvre                   Bd Voltaire          Bataclan
  le feu sur un bar et un restaurant
  angle rues Bichat et Alibert, dans le                                      Rue de Charonne
  10e arrondissement.

■ À 21 h 40, une troisième équipe
  composée de trois hommes arrive
  au Bataclan et tire sur les
  spectateurs.
                                                            2
                                                            1
Stade de France

• Secteur Nord du
  camembert
• SAMU 93 engagé
• Aucune unité du
  SAMU de Paris

      Une attaque potentiellement majeure
31 UR                       21h20            Stade de France
                    2
        2                            1
                3 DCD 6 UA 11 UR
                                         • Explosion de 3 bombes
                                           kamikaze
                                         • Public 70 000 et VIP
                            21h17        • Dispositif de secours et de
                    1
                                           soins pré positionné
                                           • SAMU   93 BSPP sur place

            21h45
                        3        3
              1 DCD 1 UA 10 UR
Stade de France

•   Les terroristes étaient en retard
•   Le match n’est pas interrompu
•   Le stade n’est pas évacué
•   Les bombes explosent loin de la foule

Echec d’une attaque potentiellement majeure
Les sites « fusillades » = secteur EST

•   Un commando mobile
•   Des cibles au hasard
•   Un bilan très lourd :
     – 40 DCD 32 UA
•   Une diversion … ?

                                              25
Rue Bichat et hôpital Saint Louis
                            ■ Arrivées spontanées à ST Louis
                            ■ Avant toute alerte !

                            ■ Victimes portées par les témoins :
                              UA et UR

                            ■ Brancardage depuis le site d’ UA
                            ■ Adaptation et renforts
                              chirurgicaux ultérieurs
Rue de Charonne
■ Transports à ST Antoine non médicalisés
   mais régulés depuis le terrain adapté au
   service d’orthopédie
■ UA envoyées à la Pitié
■ Mise en sécurité des impliqués dans la
   caserne de la BSPP
Les terraces      : un
                                      • Street cordoned off by Police and
                                        Army
                                 environnement
                                      • Fire fight in thetrès
                                                         streets nearby the
                                        sites
                                 dangereux
                                      • Difficult and dangerous access to
                                 • Commando        en mouvement
                                        victims (bombs ?)
                                      • Evacuation and escape routes
                                 • Tirs dans   les rues
                                        blocked and unsafe
                                 • Rue• barrée    par la Police
                                        Terrorist commando  still firing and
                                            moving in a car in the area ?

• Impossible de délimiter les zones dangereuse
• Pas le temps de formaliser des PMA : Points de rassemblement des
  victimes PRV
Le site du Bataclan

Le point de vue médical
• 21h40 Les 3 kamikazes
                                                     Dans le Bataclan
gence
    fusille la foule depuis la
    scène 80 tués
•   22h Le comissaire de
    garde entre et tue un                                     STA
                                                                 GE
    terroriste
•   22h15 BRI RAID entre
    dans le theatre
•   Assaut final à 0h18

                                                                      Extraction des
                                                                      blessés par les
                                                                      médecins BRI
                                                                      RAID

                                        1rst floor

                                                     Entrée
RAID AFMU 2016 DOI 10.1007/s13341-015-0601-4
La zone rouge du Bataclan
des médecins d’intervention à l’intérieur du Bataclan
  Comandement « Préfet de Police »

                                                         Extraction

               Nid de
              victimes
                PRV

                                                        RAID AFMU 2016 DOI 10.1007/s13341-015-0601-4
Le Bataclan : Le pire des scénarios
• Un concert avec 1500 spectateurs
• 21h40 : 3 terroristes
  – Ouvrent le feu devant puis à l’intérieur du théâtre
  – Exécutent froidement les spectateurs
• 22h00 :
  – Fusillade avec la BAC : un terroriste tué
  – Intervention BRI et RAID
• 0h18 : Assaut et neutralisation des 2 autres
  terroristes retranchés à l’étage
Le site du Bataclan

                ZONE VERTE       ZONE ORANGE              ZONE ROUGE
                                                                   n
                                                            ractio
                                                         Ext
                                       NID DE VICTIMES

                                                n
                                           atio                  BATAC
                                     Eva
                                        cu                            LAN

                     PMA
                      UA

                           AMP
                            UR

   Une adaptation de la chaîne médicale classique
PMA UR   PMA UA

Les PMA du Bataclan
Les PMA du Bataclan
Sécurité sur le terrain :
Danger y compris au PMA en zone protégée

                            3
                            6
SAMU de Paris: La régulation des événements
          en salle de crise zonale

Mise en œuvre des moyens
Alerte : Générale et Inter région (DGS)
Mobilisation : Rappel APHP et Zonal
Coordination avec la BSPP et La
préfecture de Police                 3
                                     7
Répartition des urgences
absolues (UA) et relatives (UR)
dans les hôpitaux de l’APHP

Hôpitaux militaires:
Percy et Begin: 18 UA + 34 UR =
52 blessés

17 hôpitaux APHP et SSA

354 blessés Hospitalisés

Mortalité cohorte APHP à 1
mois : 1,3 %

Pas de transfert secondaire en
urgence
     Hirsch M , Carli P et al., Lancet 2015
Hôpital Saint Louis
• Dans une zone de fusillade

• Arrivée des premières victimes à pieds avant toute alerte

• Retour spontanné des personnels du “quartier”

• Plan blanc auto déclenché : UA en SSPI

• Augmentation majeure du potentiel chirurgical

• Renfort chirugical spécialisé plus tard

• Très forte activité mais pas de saturation: 26 victimes, 11 UA, 15 UR

                                               Haug C, NEJM , 5/12/2015
                                   39
Hôpital Pitié Salpêtrière
• Un des 7 Trauma Center IDF
• Activation très rapide du plan blanc : première
  arrivée spontanée
• Retriage à l’arrivée:
  • Admission immédiate des UA en SSPI
  • Pour chaque UA 1 équipe chirurgien
    anesthésiste
  • 10 blocs activés en simultanné : pas de
    sturation
• Total: 53 victimes, 28 UA, 25 UR
Après …
Les leçons, les progrès
Impact médiatique et politique
  immédiat et très intense !
L’attentat terroriste le plus grave
        survenu en France
Pour les services impliqués :
Une situation à très haut risque
     médiatique et social
  Héros                        De plus en plus déconnectée
                               d’une évaluation objective de
     Victimes                     la réalité technique et
                                      professionnelle

          Incompétents

                Malhonnêtes

                         Coupables !
Les facteurs perturbants
• L’émotion:
  – Des victimes et de leur proches
  – De tout le monde : stupeur suivi du refus de la
    réalité
• Les pseudo – experts médiatiques animateurs
  de controverses
• Les professionnels jaloux, concurrents …
  – Tout ceux qui veulent être sur la photo !
• Les justiciers et les donneurs de leçons
  – Y compris ceux qui n’ont pas faits leur travail
Viewpoint
                                                                                                                                                                                                                                                                                                  De nombreux autres rapports et
The medical response to multisite terrorist attacks in Paris
Martin Hirsch, Pierre Carli, Rémy Nizard, Bruno Riou, Barouyr Baroudjian, Thierry Baubet, Vibol Chhor, Charlotte Chollet-Xemard,
Nicolas Dantchev, Nadia Fleury, Jean-Paul Fontaine, Youri Yordanov, Maurice Raphael, Catherine Paugam Burtz, Antoine Lafont, on behalf of the
health professionals of Assistance Publique-Hôpitaux de Paris (APHP)

Introduction                                                            participated, especially in recent months, in exercises or              Published Online
                                                                                                                                                November 24, 2015
                                                                                                                                                                                                                                                                                                         articles publiés
Friday, Nov 13, 2015. It’s 2130 h when the Assistance                   in updating emergency plans.
                                                                                                                                                http://dx.doi.org/10.1016/
Publique-Hôpitaux de Paris (APHP) is alerted to the                       In this report, we present the prehospital and hospital               S0140-6736(15)01063-6
explosions that have just occurred at the Stade de France,              management of this unprecedented multisite attack in
                                                                                                                                                Assistance Publique-Hôpitaux
a stadium in Saint-Denis just outside Paris. Within                     Paris from the viewpoint of the emergency physician, the                de Paris, Paris, France
20 min, there are shootings at four sites and three bloody              trauma surgeon, and the anaesthesiologist. This is a                    (M Hirsch MsC); SAMU de Paris,
                                                                        testimony on behalf of the health professionals involved
                                                                                                                                                                 NEW ENGLA ND JOURNA L                                                                            MEDICINE
explosions in the capital. At 2140 h, a massacre takes                                                                                          Hôpital Necker-Enfants

place and hundreds of people are held hostage for 3 h in                in the night of Nov 13.                                                    The
                                                                                                                                                Malades, University
                                                                                                                                                Paris-Descartes Paris, France
                                                                                                                                                                                                                                                            of
Bataclan concert hall (figure).                                                                                                                 (Prof P Carli MD); Hôpital
  The emergency medical services (service d’aide médicale               The emergency physician’s perspective                                   Lariboisière, University
d’urgence, SAMU) are immediately mobilised and the                      Triage and prehospital care were the duty of SAMU. In                   Paris-Diderot, Paris, France
                                                                                                                                                (Prof R Nizard MD); Hôpital de
crisis cell at the APHP is opened. The APHP crisis unit                 the minutes that followed the suicide bombing at the                    la Pitié Salpétrière, University
is able to coordinate 40 hospitals, the biggest entity in               Stade de France, the Paris SAMU unit regulatory crisis                  Pierre & Marie Curie, Paris,
Europe with a total of 100 000 health professionals, a                  team began to send out medical workers to the emergency                 France (Prof B Riou MD);
capacity of 22 000 beds, and 200 operating rooms. It is                 sites from all eight units of SAMU in the Paris region and              Hôpital Saint-Louis, Paris,
                                                                                                                                                France (B Baroudjian MD,
very quickly confirmed that the attacks are multiple and                from the Paris fire brigade (Brigade de sapeurs-pompiers                J-P Fontaine MD); Hôpital
that the situation is highly scalable and progressing                   de Paris), alongside rescue workers and police. The                     Avicenne, University Paris 13,
dangerously. These facts led to a first decision: the                   regulatory crisis team was composed of 15 individuals to                Paris, France

                                                                                                                                                                                                                                       Perspective
activation of the “White Plan” (by the APHP Director                    answer the calls, and five physicians. Their mission was                (Prof T Baubet MD); Hôpital
                                                                                                                                                Européen Georges Pompidou,
General) at 2234 h—mobilising all hospitals, recalling                  to organise triage and dispatch mobile units (composed                  Paris, France (V Chhor MD);
staff, and releasing beds to cope with a large influx of                 of a physician, a nurse, and a driver) to the wounded and               Hôpital Henri Mondor, Créteil,
wounded people. The concept of the White Plan was                       to the most appropriate hospitals. As part of the White                 France (C Chollet-Xemard);
developed 20 years ago, but this is the first time that the             Plan and ORSAN (organisation de la réponse du système de                Hôtel Dieu, Paris, France
                                                                                                                                                (N Dantchev MD); Hôpital de la
plan has been activated. It is a big decision, and timing is            santé en situations sanitaires exceptionnelles), 45 medical             Pitié Salpétrière, Paris, France
key: it would lose its effectiveness if taken too late. On the           teams from SAMU and the fire brigade were divided                       (N Fleury MsC); Hôpital
night of Friday Nov 13 to Saturday Nov 14, the activation               between the sites (figure) and 15 were kept in reserve,                 Saint-Antoine, Paris, France
                                                                                                                                                (Y Yordanov MD), Hôpital
of the White Plan had a critical effect. At no time during               since we did not know how and when this nightmare
                                                                                                                                                Bicêtre, Paris, France
the emergency was there a shortage of personnel. During                 would end. This approach avoided early saturation of                    (M Raphael MD); Hôpital
these hours, as the number of victims increased, with a                 services—often, in emergency situations, all the resources              Beaujon, University
sharp increase after the assault was launched inside
the Bataclan, we were able to reassure the public and
                                                                        are focused on the first crisis site, leaving a shortage for
                                                                                                                                                  Report from Paris
                                                                                                                                                Paris-Diderot, Paris, France

government that our abilities matched the demand. And                                                      Stade de France                        Charlotte J. Haug, M.D., Ph.D.
when we felt that it might be necessary to deal with an                                                    (Saint-Denis)

                                                                                                                                                                    “Wea can
influx of severely injured people, two further “reservoir”                                             8 medical teams
capacities were prepared: other hospitals in the area were                                                                                                                   meet after my lecture, at a table, over                                        asked her what was happening,
put on alert, together with some university hospitals,                          Casa Nostra                                                                              drink,” Carl Ogereau told me — that’s                                              and told her that if there was
more distant from Paris, but with the ability to mobilise                     4 medical teams
                                                                                                                                                          Le Petit Cambodge,                                                                                shooting and people were wound-
ten helicopters to organise the transport of the wounded.                                                                                                          “the French way to fight terrorism,” he explained:
                                                                                                                                                          Le Carillon
                                                                                                                                                                                                                                                            ed, the police and the Services
                                                                                                                                                         9   medical teams
These other two reservoirs have not been used, and we                       La Comptoir Voltaire                                                                   refusing to be intimidated. So on Friday evening,                                        d’Aide Médicale Urgente (SAMU),
believe that despite this unprecedented number of                           3 medical teams                                                                                                                                                                 the medical emergency service,
wounded, the available services were far from being                                                                                                               Bataclan
saturated. While hospitals were receiving and directing                                                                                                         15 one
                                                                                                                                                                   medicalweek after the Paris terrorist        It started as an ordinary Friday            would arrive soon. But she
                                                                                                                                                                     teams
patients to specific institutions based on capacity and
                                                                                                                                                                    attack   that left 130 dead and             night, the emergency department             wouldn’t calm down.
                                                                                                                                                              La Belle Equipe
specialty, a psychological support centre was set up.                                                                                                               hundreds injured, Ogereau arrived           full of patients. Saint Louis is a             “The situation was odd, but
                                                                                                                                                                    medical
                                                                                                                                                                 6 on
35 psychiatrists, together with psychologists, nurses, and                                                                                                             his
                                                                                                                                                                      teams motorbike at Café Clochette         specialized hospital, known for its         she was so insistent that in the
volunteers were gathered in a central Paris hospital,                                                                                                               across the street from the Hôpi-            hematology, oncology, urology,              end I just gave her a stretcher,”
Hôtel Dieu. Most of them had played a similar role                                                                                                                  tal Saint Louis. Nearby, we saw             and nephrology services. It treats          Ogereau said. Neighbors or friends
during the attacks against Charlie Hebdo. Most of the                                                                                                               candles and flowers outside Le              burns and does transplantations,            brought in the first victim. The
emergency workers and health professionals working on                                                                                                               Carillon and Le Petit Cambodge,             skin surgery, and plastic and               second came on a stretcher. “And
the evening of Nov 13 had already been involved in                                                                                                                  the restaurants where more than             maxillofacial surgery. It has in-           after that, stretchers, stretchers,
serious crises, were used to working together, and had                  Figure: Map of Paris attacks and prehospital emergency response
                                                                                                                                                                    a dozen young people had been               ternal medicine and support ser-            stretchers, patients, patients, pa-
                                                                                                                                                                    killed and many more severely in-           vices, plus emergency depart-               tients.” The first patient was a
www.thelancet.com Published online November 24, 2015 http://dx.doi.org/10.1016/S0140-6736(15)01063-6                                                                jured 1the previous week. The res-          ment and intensive care units. But          young man who didn’t know he’d
                                                                                                                                                                    taurants are so close to the hospi-         it is not a trauma center. There is         been shot. “He said, ‘I felt some-
                                                                                                                                                                    tal that wounded people escaping            no neurosurgery or orthopedic,              thing bizarre. I have pain. I can’t
                                                                                                                                                                    from the massacre walked to the             thoracic, or vascular surgery.              walk.’ He had two bullets, one in
                                                                                                                                                                    emergency department or were                    Some time around 9:30 p.m.,             the back and one in the leg. The
                                                                                                                                                                    brought there by bystanders.                a colleague ran into the emergen-           second patient was a grandmother
                                                                                                                                                                         Ogereau, the assistant head            cy department, shouting breath-             who had been leaning over her
                                                                                                                                                                    of the emergency department at              lessly that there was shooting              grandson to protect him.”
                                                                                                                                                                    the Hôpital Saint Louis, was in             outside and she needed a stretcher.            When the third patient ar-
                                                                                                                                                                    charge on Friday, November 13.              Ogereau tried to calm her down,             rived, the emergency physicians

                                                                                                                                                                                                                        n engl j med   nejm.org                                              1
                                                                                                                                                                                                     The New England Journal of Medicine
                                                                                                                                                                       Downloaded from nejm.org on December 5, 2015. For personal use only. No other uses without permission.
                                                                                                                                                                                       Copyright © 2015 Massachusetts Medical Society. All rights reserved.

      Commission d’enquête parlementaire , enquête judiciaire en cours …
Adapter la réponse
      d’urgence
           et
Favoriser la résilience
The French emergency medical services after
      Insufficient expertise on war weapons
                                                             French actions
                                                                                      (Continued from previous column)
                                                                                                                                               French actions

                     the Paris and the Nice attacks: what have learnt?
      Expertise transfer from the Military Medical service   Ongoing                  Terrorist attacks in an area with insufficient medical resources
      Training of EMS personels and physicians               Done                     Early activation of distant resources                    Done (regional and
                                                                                      (ie, regional, national,7 or international)              national); to be
      Basic teaching to all medical students                 To be implemented
                                                                                                                                               implemented
      Advanced teaching for anaesthesiologists, surgeons, To be implemented                                                                    (international)
      and emergency physicians during their fellowships
                                                     French actions                                                                             French actions
                                                                                      Identification of the victims
     Prehospital
fficient expertisedamage
                 on war control
                        weapons
                                     4
                                                                                   (Continued from previous column)
                                                                                      New standard operating procedures for victim             Done
      Equipment
 ise transfer    (tourniquet
              from           andMedical
                    the Military dressings) and
                                         service           Done
                                                       Ongoing                     Terrorist  attacks in an area with insufficient medical resources
                                                                                      identification
     prehospital administration of tranexamic acid Done                            Early activation of
 ng of EMS personels and physicians                                                    Reconciliation ofdistant   resources
                                                                                                         the prehospital and hospital           Done (regional and
                                                                                                                                               Done
     Expertise                                                                     (ie,admission
                                                                                       regional, national,    or international)                 national); to be
          to alltransfer from the military medical service
                                                      To be Ongoing
                                                                                                            7
 eaching         medical   students                         implemented                           identification number
     (not to apply to every type of trauma5)                                                                                                    implemented
 ced teaching for anaesthesiologists, surgeons,        To be implemented              Care of the psychological victims                         (international)
     General
mergency     public teaching
          physicians  during their fellowships               Pilot programme
                                                                                      Improve our ability
                                                                                   Identification of theto  care for a high number of
                                                                                                          victims                              Ongoing
     Children
 spital damageas victims
                 controlof ballistic trauma                                          victims over operating
                                                                                                  a longer period to prevent
                                                                                                                          forPTSD
                         4

                                                                                   New standard              procedures       victim            Done
 mentExpertise    transfer
        (tourniquet     andfrom  adult to paediatric
                             dressings)     and      physicians
                                                           Done Ongoing               Conduct clinical trials to test therapeutic
                                                                                   identification                                              Ongoing
 spitalfor
         administration
           specific trainingof tranexamic
                             (ballistic trauma,acid
                                                CBRNE)                                interventionsoftothe
                                                                                                        alleviate and suppress PTSD
                                                                                   Reconciliation           prehospital and hospital            Done
  ise transfer from
       Expertise     the military
                 transfer from themedical   service
                                    paediatric to the Ongoing
                                                          Ongoing                     symptoms
                                                                                   admission identification number
 o apply  to physicians
       adult every type(in
                         of case
                            trauma   5
                                      )
                                 of excess capacity of                                International
                                                                                   Care             medical network
                                                                                        of the psychological        on terrorist attacks
                                                                                                              victims
      paediatric
 al public       hospitals)
           teaching                                    Pilot programme
                                                                                      Expertour
                                                                                   Improve  meetings
                                                                                                abilitytoto
                                                                                                          share
                                                                                                            careexperience
                                                                                                                 for a highand
                                                                                                                            number of          Ongoing
                                                                                                                                                Ongoing
 en as victims ofbetween
     Cooperation  ballisticadult
                            trauma
                                 and paediatric centres      Ongoing               victims over a longer
                                                                                      implementation       period
                                                                                                       of new     to prevent
                                                                                                               measures:      PTSD
                                                                                                                         UK, Spain,
 ise transfer
      Chemicalfrom  adult to paediatric physicians
                 weapons                               Ongoing                        Belgium,
                                                                                   Conduct     Germany,
                                                                                            clinical trialsDenmark,  Israel , USA, and Japan
                                                                                                            to test therapeutic                 Ongoing
ecific training (ballistic trauma, CBRNE)                                          interventions
      Improve our global preparedness                        Ongoing                  Unexpectedtoterrorist
                                                                                                     alleviate  and suppress PTSD
                                                                                                              innovation
 tise transfer from the paediatric to the              Ongoing                     symptoms
       Upgrade ofcase
                  EMS of
                      equipment                              Ongoing                  To be prepared to be surprised  8
                                                                                                                                               Never enough
 physicians  (in          excess capacity of                                       International medical network on terrorist attacks
 atric Health-care
       hospitals) facilities as target                                                                                                         prepared
                                                                                   Expert meetings to share experience and              Ongoing
 ration between    adult andinpaediatric centres plans,
                                                   Ongoing                            The plans “used as a tools box” should authorise Never enough
     Include this possibility  the mass casualties      Ongoing                    implementation of new measures: UK, Spain,
                                                                                      sufficient local or regional autonomy              prepared
      both at the prehospital and hospital levels
 ical weapons                                                                      Belgium, Germany, Denmark, Israel , USA, and Japan
                                                                                     Encourage terrorist
                                                                                   Unexpected  innovationinnovation                            Never enough
     Secure
 ve our     intervention
        global           of medical responders “under
               preparedness                           fire”
                                                Ongoing
                                                                                                                                               prepared
 de ofCooperation
       EMS equipment                             Ongoing
                  between all emergency responders   Done                          To be prepared to be surprised8                            Never enough
     (police, rescuers, and medical responders)   6                                                                                           prepared
 h-care facilities as target                                                         PTSD=post-traumatic stress disorder. EMS=Emergency Medical System.
      Triage on scene   andmass
                            at thecasualties
                                   arrival of plans,
                                              the hospital                         The plans “used asbiological,
                                                                                     CBRNE=chemical,   a tools box”   shouldnuclear,
                                                                                                                 radiological, authorise      Never enough
                                                                                                                                     and explosives.
 e this possibility in the                            Ongoing
                                                                                   sufficient local or regional autonomy                        prepared
 t theExpertise
        prehospital  and  hospital  levels
                transfer from the military medical         Ongoing                   Table: Identified
                                                                                   Encourage           weaknesses during the recent FrenchNever
                                                                                               innovation                                  terrorist attacks1,3
                                                                                                                                                 enough
 e intervention    of medical
      service to civilian ones responders “under fire”
                                                                                     in Europe and proposed solutions                     prepared
 ration  betweenexercises
      Simulation all emergency   responders
                          to improve              Done Ongoing
                                     the whole process
e, rescuers, and medical responders)6                                             PTSD=post-traumatic stress disorder. EMS=Emergency Medical System.
      Analyse existing database (research)
  on scene and at the arrival of the hospital
                                                             Ongoing                          CARLI P , PONS F, et Al The Lancet 2017
                                                                                  CBRNE=chemical, biological, radiological, nuclear, and explosives.
                                                                                      During and after the Paris and Nice attacks, many
  ise transfer from the military medical               Ongoing                         http://dx.doi.org/10.1016/S0140-6736(17)31590-8
                                               (Table continues in next column)
                                                                                    individuals
                                                                                  Table: Identified required
                                                                                                    weaknessespsychological
                                                                                                              during the recentcare,
                                                                                                                                Frenchirrespective     of
                                                                                                                                       terrorist attacks             1,3

 e to civilian ones
                                                                                  inwhether
                                                                                     Europe andthey
                                                                                                  proposed
                                                                                                       hadsolutions
                                                                                                             been wounded physically. These
and paediatric teams); and second to ident
       Major terrorist attacks in                                                      additional preserved resources such as local
                                                                                       available hospitals because of the evo
        Europe since 11/2015                                                           unpredictable nature of terrorist attacks.
                                                                                       strategy is needed, coordinated by experien
Manchester
May 22, 2017
23 dead
                                                              Stockholm
                                                              April 7, 2017
                                                                                    • Vague d’attentats
                                                                                       care professionals, not only on scene but
                                                                                       regional or state level.7
119 injured                                                   5 dead
                                                              14 injured            • Touchant l’Europe
                                                                                         Emergency services must also be prepar
                                                                                       very different scenarios, including attacks wit
                   London
                   March 22, 2017
                                                                                    • 8 attaques
                                                                                       weapons (such as sarin, mustard gas, or c
                                                                                       recently used in the Middle East), and attac
                   6 dead
                   >49 injured
                                                                     Berlin
                                                                     December 19, 2016
                                                                                      majeures depuis
                                                                                       at iconic victims such as children or emer
                                                                                       responders. There is no reason to think tha
                                                                                       will become less violent. However, the rec
                                             Brussels
                                             March 22, 2016
                                                                     12 dead
                                                                     56 injured       Paris
                                                                                       suggest that simple means (such as h
                                                                                       weapons and trucks) can result in a very high
   London
   June 3, 2017
                                             35 dead
                                             340 injured                            • Multiples attaques
                                                                                       victims.1,3 Protecting hospitals against an atta
   11 dead                                                                             new challenge for health-care authorities. H
   48 injured
                                                                                      mineures
                                                                                       facilities are no longer sanctuaries but soft
                                                                                       terrorists.13 Professionals must be responsib
                         Paris
                         November 13, 2015
                                                                                    • Des milliers de
                                                                                       own security; in view of this, timely updated
                                                                                       emphasising protection of hospitals have b
                                                                                      cibles possibles
                         137 dead
                         413 injured                                                   duced in France.14
                                                                                         Exsanguination remains a major problem
                                                                                       attacks using high-velocity war weapons. Eq
                                                                                       all rescuers with tourniquet and haemostat
                                    Nice                                               might be a simple and efficient solution for som
                                    July 14, 2016                                      and a rapid transfer to hospital for immedi
                                    87 dead
                                    458 injured
                                                                                       is another important issue requiring a v
                                                                                       cooperation between actors. We should also b
   Barcelona Cambrils,
   Alcanar                                                                             to observe early deaths due to exsanguination
   Aug 17-18 2017
                                                                  CARLI P , PONS F, etourAl efforts
                                                                                             The Lancet   Published
                                                                                                     and this       online
                                                                                                              must be       7 25, to car
                                                                                                                      explained
   Dead 24 (16+8)                                                 2017 http://dx.doi.org/10.1016/S0140-6736(17)31590-8
                                                                                       and the population. This does not preclu
   152 injured
Le terrorisme n’est pas une simple catastrophe
• Il a des cibles précises
• Une stratégie élaborée
• Kamikaze : Pas de négociation

  Il faut opposer à une stratégie terroriste une autre stratégie
           conçue à sauver le plus possible de victimes
Attaques Terroristes:
                                                XXX ?
 un large spectre depuis
les attaques “Low Cost”                     NRBC

     jusqu’aux mega
 scénarios avec tueries           Multimodal multisite
                                Camion bélier
        de masse        Fusils d’assaut

                                          Bombe Kamikaze
                                  Armes de poing

                             Bombe artisanale
Plaie par   Voiture bélier
arme
blanche
                                                     Vous n’aurez jamais
                                                       le plan parfait !
S’adapter rapidement
• Ne pas essayer d’appliquer à toute
  nouvelle circonstance le plan issu du
  RETEX de l’événement réel ou simulé
  antérieur qu’on a pas su traiter !
• Aucun plan ne sera parfaitement adapté
  à l’attentat terroriste auquel il faut faire
  face

                                                 52
Attention à la dictature du plan !

            CAUTION

Construire une stratégie et apporter une
        réponse opérationnelle
L’adaptabilité est essentielle !

• Les plans ne sont pas la Bible mais la boite à outils de la stratégie à
  opposer à l’attaque terroriste
• Pendant la crise il est nécessaire de prendre des décisions
  opérationnelles et de les faire appliquer
Dispositif ORSAN
            Décrets, arrêtés, circulaires

                                   TEXTES GÉNÉRAUX

                 MINISTÈRE DES AFFAIRES SOCIALES ET DE LA SANTÉ

Décret no 2016-1327 du 6 octobre 2016 relatif à l’organisation de la réponse du système de santé
 (dispositif « ORSAN ») et au réseau national des cellules d’urgence médico-psychologique pour
 la gestion des situations sanitaires exceptionnelles

Une coordination et une complémentarité étroiteNOR : AFSP1617819D

      – ORSAN
   Publics               AMAVI
           concernés : agences          dede la
                                régionales         Santé
                                              santé,  professionnels de santé, établissements de santé, services de
l’Etat.
      – :ORSEC
   Objet                NOVI de
           modalités d’élaboration,      laduSécurité
                                    contenu    dispositif ORSANCivile
                                                                 et son articulation avec le plan départemental de
mobilisation.
   Entrée en vigueur : le texte entre en vigueur le lendemain de sa publication.
1. Kotz D. After double checking records,        2QwMjfM13).                                     story/2013/04/boston-medical-mecca-
         injury toll from bombs reduced to 264. Bos-      3. Kragh JF Jr, Littrel ML, Jones JA, et al.    equipped-for-mass-trauma-90228.html).

                Importance de la préparation
         ton Globe. April 24, 2013:B3.
         2. Gawande A. Why Boston’s hospitals were
         ready. The New Yorker. April 17, 2013 (http://
                                                          Battle casualty survival with emergency tour-
                                                          niquet use to stop limb bleeding. J Emerg
                                                          Med 2011;41:590-7.
                                                                                                          DOI: 10.1056/NEJMp1305480
                                                                                                          Copyright © 2013 Massachusetts Medical Society.

                                                                                        NEJM 2013 368;21
We Fight Like We Train
Eric Goralnick, M.D., and Jonathan Gates, M.D.

         A  s we say in the U.S. Navy, charge of Alpha Pod (one of four       The Boston Public Health
            “We train like we fight, and separate 14-bed pods, all within Commission’s Medical Informa-
        we fight like we train.” In Bos- the larger emergency department tion Center called; BWH would
        ton, we do the same.               [ED]) conducted a scan of our be receiving 8 patients from the
           That was never more evident 55-bed ED. It was full: 47 patients scene. The team initiated Code
   La   devise       de la Navy s’applique aux attentats terroristes
        than at 2:50 p.m. on April 15, in beds, 6 in the hallway, 6 in the Amber, our hospital-wide disaster
        when two explosive devices abrupt- waiting room, and 4 in the tri- response.
• Connaissance organisationnelle et médicale
        ly shattered the 117th Boston age area.                               A senior EM resident who had
  hospitalière et préhospitalière
        Marathon. On Patriot’s Day, the       One floor below the ED, our attended a disaster-management
        day we commemorate the open- perioperative nurse administrator training session in October 2012
• Partage d’informations entre les services de l’état
        ing battle of the Revolutionary reviewed his caseload: 30 of 42 reminded the team to consider
        War in Lexington and Concord, operating rooms (ORs) were ac- the possibility of a hazardous-
• Réalisation d’exercices communs
        Boston was under attack.           tive, with 8 more available for material (HAZMAT) threat.
           Over the past 8 years, Brigham the 4 patients waiting in the pre-  As reports trickled in — that
La nécessité d’utiliser
                              l’expérience militaire
                                et la transposer au
                             contexte de soins civils

• S : Stop the burning
  process
• A : assess the scene
• F : Free danger from you
• E : Evaluate “ABC”
Combat Casualty Care
et Soins en Situation d’insécurité
 • M Massive bleeding control
 • A Airways
 • R Respiration
 • C Shock
 • H Head / hypothermia
 • E Evacuation
   Extraction de victimes par
   des groupes spécialisés
Tourtier JP et Carli P Injury 2016 , 47 , 784
                                                58
Exercice de
Simulation
  Scénario
  interactif
  commun

                    Importance de la
               coordination opérationnelle
                      interservices
Importance de la coordination
             opérationnelle
•   Police
•   Armée
•   SAMU
•   Pompiers , Secouristes

    Souvent organisation complexe avec des
    services « menants » et « concourants »
                 qui changent
Comité de rédaction

Coordination scientifique
Pr Pierre CARLI
Pr François PONS
Coordination de la rédaction
Dr Alain PUIDUPIN
Dr Jean-Marc PHILIPPE
Dr Sergio ALBARELLO

Comité de lecture

Pr Jean-Pierre AUFFRAY
Pr Paul BALANDRAUD
Dr Laurent CAUMON
VIEWPOINT
                           Preparing for the Next Terrorism Attack
                           Lessons From Paris, Brussels, and Boston
                                                                                         JAMA Surg. Online 2017 Jan 25
Eric Goralnick, MD, MS     The most recent spate of brutal terrorist attacks in              Prevention is a critical tool we have in our arsenal
Brigham and Women’s        Nice, Bangladesh, Baghdad, Istanbul, and Orlando high-       against terrorism—but we need a revolution, not an
Hospital, Boston,          lights the need for a more global concerted effort to        evolution in our preparedness strategy.
Massachusetts;
                           gather and share lessons from these events among                  First, we must ensure that valuable lessons from
Harvard Medical
School, Boston,            health care professionals. In June 2016, only a few days     each attack, including interdisciplinary practices, prob-
Massachusetts; and         after the mass shooting in Orlando, health care leaders      lems, and recommendations, are captured and dissemi-
Harvard T. H. Chan         from Paris, Brussels, and Boston gathered to discuss our     nated in a rapid, standardized, academically rigorous af-
School of Public Health,
Boston, Massachusetts.
                           experiences in emergency preparation, response, and          ter-action reporting system. Although there is consensus
                           recovery from each city’s recent terrorist attacks. A con-   in the medical community on the value of sharing best
Frank Van Trimpont,        ference jointly organized by the Paris Descartes Faculty     practices and areas for improvement, the improve-
MD                         of Medicine and Harvard Medical School, followed by          ment of our tactics based on lessons learned is not keep-
European Council of        focus groups in Paris and Brussels, highlighted the par-     ing pace with the increasing need for such information
Disaster Medicine,
Belgium; and Centre        ticular health care challenges of responding to a multi-     sharing. There remain numerous report formats that are
Hospitalier de Wallonie    site terrorist attack; the need for a timely, standard-      tailored to specific organizations and are not amenable
Picarde, Tournai,          ized, academically rigorous approach to after-action         to systematic comparison of practices and their
Belgium.
                           reporting; and the critical role of public engagement.       implications.1 As a result, largely descriptive, anecdotal
                           •    “ Pour vaincre le réseau terroriste en Afghanistan nous avons
                                The lessons gleaned from these attacks are cru-         reports published through various outlets render com-
Pierre Carli, MD
Urgente de Paris                construit un réseau” General S. McChrystal
                           cial, and our understanding of them continues to             pilation of lessons learned impractical. In the aftermath
Hôpital Necker–Enfants     evolve. What is certain is the need for greater invest-      of terrorist events, affected communities are busy bal-
Malades, Paris France;
Assistance Publique
                           •    Pour réduire la mortalité évitable des victimes nous devons faire
                           ment, integration, and standardization of disaster           ancing media inquiries with VIP visits and maintaining
                           medicine curricula and the need to focus on translating      daily operations. They are too busy to adequately di-
Hôpitaux de Paris,              de même en médecine
                           military medical knowledge into civilian practice.           gest experiences and assess better future response.
Paris, France; and Paris
Descartes University,
Paris, France.                      Partageons sans frontière les expériences
                           Although much has been made of the comparison
                           between the European prehospital philosophy of
                                                                                        On the other hand, Israel conducts a structured after-
                                                                                        action review after each mass casualty incident to sup-

                                         d’événements rares et graves !
                           “stay and play” vs the United States “scoop and run”
                           approach, similar themes arose from Boston, Brussels,
                                                                                        port timely, standardized knowledge dissemination.2
                                                                                        A US standard of reporting and analysis is not without
Anticipation des risques
           et bench marking

• Partage international des expériences
  – Utiliser toutes les sources possibles
• Partage des critères d’évaluation
  – Basés sur les résultats médicaux (mortalité,
    morbidité)
  – Indépendants des systèmes d’urgence
• Création de référentiels adaptés
Fusillade au Mercy Hospital de Chicago
            le 19 /11/2018

                        Sécurisation du
                       SAU et des abords
Profiter de l’afflux d’ambulance …
Attentats Terroristes Chimiques
• Le trio gagnant est dans le contexte
  des conflits au moyen orient est
   • Le chlore
   • Le sarin
   • L’ypérite
• A disposition des terroristes ou
  réalisables sur place

                                         66
La réponse médicale
             favorise la résilience
• La Santé est un des premiers facteurs de Résilience
• Elle s’oppose directement à l’objectif du terrorisme,
  répandre la peur et panique , par :
   • La résistance des services d’urgence à la
     désorganisation malgré l’agression et la violence
   • Le maintien de la qualité et de la sécurité des soins
     malgré l’afflux de victimes et l’effet de surprise
   • Le maintien des principes éthiques
                                                     67
Triage and terrorism

                                    PAPER

                                    Second thoughts about who is first: the medical
                                    triage of violent perpetrators and their victims
                                    Azgad Gold,1 Rael D Strous1,2

1
 Beer Yaakov Mental Health          ABSTRACT                                                      dictionary becomes more specific: ‘the assignment
Center, Beer Yaakov, Israel         Extreme intentional and deliberate violence against           of degrees of urgency to wounds or illnesses to
2
 Sackler Faculty of Medicine, Tel
Aviv University, Israel
                                    innocent people, including acts of terror and school          decide the order of treatment of a large number of
                                    shootings, poses various ethical challenges, some related     patients or casualties’. This definition implicitly
Correspondence to
                                    to the practice of medicine. We discuss a dilemma             illustrates the dominance of the conventional
Dr Azgad Gold, Psychiatry, Law      relating to deliberate violence, in this case the aftermath   approach according to which medical attention in
and Ethics Unit, Beer Yaakov        of a terror attack, in which there are multiple injured       emergency situations should be determined based
Mental Health Center, PO Box        individuals, including the terror perpetrator. Normally,      on the degree of urgency (the ‘worst-first’
1, Beer Yaakov 70350, Israel;       the priority of medical treatment is determined based on      approach).
azgad.gold@moh.health.gov.il
                    • Triage et attentat terroriste : Priorité au terroriste
Received 25 February 2016
                                    need. However, in the case of a terror attack, there is
                                    reason to question this. Should the perpetrator of
                                                                                                     It seems to be current consensus that in medical
                                                                                                  emergency situations those with remote or no pro-
Revised 21 July 2016
Accepted 8 August 2016
                      ou à la victime ? Pas de vengeance!
                                    extreme violence receive medical treatment on the scene
                                    before the victims if he or she is designated as the most
                                                                                                  spects of survival are ‘triaged out’ and only those at
                                                                                                  the second stage of severity, with a reasonable like-

29 August 2016      • Le maintien de notre éthique est essentiel !
Published Online First              seriously injured? Or rather, should victims receive
                                    medical care priority if they are also in some life-
                                                                                                  lihood of survival despite their life-threatening
                                                                                                  status, are prioritised for medical attention. Among
                             – Le plus grave d’abord même si cela peut bénéficier
                                    threatening danger, although not at the same level of
                                    severity as the perpetrator? We present two opposing
                                                                                                  this group, the conventional approach holds that
                                                                                                  priority to medical treatment is determined solely
                               parfois aux terroristes /victimes
                                    approaches: the conventional ‘no-exceptions’ approach,        based on need, namely, the level of injury.
                                    which gives priority to the terrorist, and the justice-          The conventional approach (which may be char-
                                    oriented ‘victim first’ approach, which gives priority to      acterised as universal and impersonal) would state
La résilience médicale favorise
                celle du public
• L’action des Services de Santé diffuse une image positive,
  non violente qui privilégie l’individu
• Elle se substitue à l’engrenage de l’agression et de la
  répression                      Don de sang le 16/11/2015
• La société soigne les
   victimes (mais aussi
   les terroristes)
• Elle incite le public à
   s’impliquer pour
   sauver les victimes

                                                          69
Favoriser la résilience du public
• En l’informant :
  – Réseau sociaux
  – Nouveaux média
  – Applications
Favoriser la résilience du public

• En le formant
• Pour apprendre les
  premiers gestes en
  cas d’attaque
Formation et matériel à la
 disposition du public aux
  USA en cas de fusillade
Transformer le public
« cible molle » et victime
potentielle, en un acteur
  de la réponse et de la
         résilience

Application pour
• Localiser
• Guider
• Connecter
les volontaires
Les fleurs ne
suffisent pas …
Il faut une réponse
médicale forte :
• Pour sauver plus
   de vies
• Pour favoriser la
   résilience
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