A Trial by Medicine
Tactical medicine is a hot topic in Ukraine today, with experts pointing out how crucial it is for a soldier to be assured that he will receive qualified aid in the event of a battle injury. However, emergencies with critical wounds are not restricted to military environments exclusively. Two years ago, Kyiv was not prepared for the shootings in the city’s central square that took away numerous lives. The peaceful city of Paris, unaccustomed to mass gunfire, has become the venue of terrorist attacks for the second time this year.
Tragic events of this scale shake cities to their hearts and call for an immediate response as well as continuous therapy. What may serve as a defensive shield in these cases is medicine. This is when the system goes through a trial, revealing all the cracks and holes. The highest mark it may receive is embodied in the trust of the citizens, in their confidence that come an emergency, they will have access to well-timed qualified medical aid.
PARIS – November 13th, 2015 saw a series of attacks take place in Paris, with around 500 victims. The attacks have been the deadliest on France since World War II and the deadliest in the European Union since the Madrid train bombings in 2004.
Within minutes following the terrorist attacks, Paris municipal authorities applied the so-called “Plan Blanc” (White Plan), a coordinated response offering aid to the shootings victims. It meant getting medical personnel to work, ambulances on the road, and beds readied ahead of the flow of wounded patients pouring into hospitals across the city.
Emergency reaction plans similar to the French “Plan Blanc” are applied in other European countries as well as in the USA. As Dr. Paul Biddinger, who led the emergency department response at Massachusetts General Hospital after the Boston Marathon bombings in 2013, noted in an STAT interview, in both the US and European systems, the same elements are essential for a successful response: a staggered mobilization of staff, an efficient means of command and control, and the ability to detect patients most in need of immediate care, especially when they have life-threatening internal injuries that might not be readily apparent.
Biddinger also stated that terrorist attacks resulting in mass carnage like that in Paris can put to the test competing philosophies of treating patients before they get to the hospital.
One approach calls for a “forward-leaning” response emphasizing immediate treatment at the scene to avoid overburdening the hospital, while the opposing model calls for just stabilizing the wounded at the scene and then taking them to the hospital for a larger share of their care. The former was given preference to following the attacks on November 13th.
The state of emergency in Paris was relieved in the afternoon of November 14th. According to Paris Prosecutor Francois Molina, the death toll had risen to 129 at the time, with another 352 wounded.
As of Saturday afternoon local time, the city’s hospitals had discharged 53 people, but seven hospitals in Paris were still treating 300 people injured in the attacks. Among them, 80 were in absolute critical condition, 177 were in relatively critical condition and 43 others were treated for psychological support, according to The Wall Street Journal.
Alexis Debreil, currently recovering at Hôpital Pitié-Salpêtrière that took in most of Friday’s victims, was shot in the knee at a restaurant, where he was dining that night with some of his friends.
“The first thing I saw was a firecracker. The attackers threw those to cause havoc. Then I saw the silhouette of a man dressed in black with a gun. I shut my mouth, hit the deck and I was hit by a bullet as I was going down,” Alexis told The Wall Street Journal in an interview. “The bullet went straight through my knee and out the other side, I learned afterward.”
He also said people were lying on top of each other on the floor of the restaurant as the bullets rang above. “I know a lady died next to me. At one point I tried to wake her up. I stroked her hair and said, ‘Stay with us, hang in there.’ I know she was alive at that point because I saw her torso move. Then she went completely white and I knew she’d died,” he recounted.
Johan Robert, a 30-year-old patient who had been recovering from a motorcycle accident at the hospital on Friday, witnessed dozens streaming into the emergency ward: “I saw blood everywhere. It was all over the floor and even in the elevator. No one was screaming and no one was running, but there were far, far more people than usual,” said Mr. Robert. “A man who was shot in the back was brought in. Someone else had been shot in both feet.”
“Without thinking about the danger, without hesitation, we all showed up,” Dr. Pashootan told TIME. “This embodied a profession’s resilience in the face of adversity”. On a normal night, only a skeleton crew stays on call at the Saint Louis hospital, but that evening hundreds of doctors and nurses across Paris answered the call of duty.
Philippe Juvin, head of emergency services at the Georges Pompidou hospital in Paris who had worked in conflict zones including Afghanistan, described to The Daily Mail how the gunshot victims had to be rushed to surgery or intensive care after arriving with injuries which he had only seen in conflict zones.
Another doctor, Patrick Pelloux, who was one of the first at the scene of the Charlie Hebdo attack and in A&E on Friday shared with The Guardian his impression that the situation strongly resembled war: “We were treating war wounds made by war weapons, with bullets that go in very fast, that break and burn and send a very strong shockwave so it creates extremely serious injuries".
“The team tried to save a lot of people but there were terrible wounds. Most were aimed to kill, at the head, thorax, abdomen. Others were defensive wounds where people had put their hands up to their face. We tried to save a woman who had nine bullets in her body but she died upon her arrival at hospital.”
KYIV – During the Maidan clashes of February 18th-20th, 2014, when dozens of people dropped dead and hundreds were wounded, first aid was administered without the medical services’ participation. The protesters set up first-aid posts and hospitals to treat the victims.
“When the first hospitals were set up on the Maidan, doctors started arriving, too. A man showed up with two satchels and said: “I’m an anaesthesiologist. I’ve got what I need, I’m ready to work.” Lots of people got together and started working as a team. There was no national coordination plan, just plain self-organization,” recalls Serhii Ryzhkov, deputy commander to Red Cross Emergency Response Groups working on the Maidan during the revolution, currently a “Patriot Defence” tactical medical instructor.
“We were ready to deal with huge workloads, with round-the-clock attendance, but we were not prepared for the events that actually took place. Who would expect mass shootings?! 41 were killed in just an hour! Another 500 received wounds”, says Oleh Musii, National Resistance HQ Medical service coordinator.
The wounded were evacuated under fire by random people. They were genuinely putting their lives at risk, but they still braved the gunfire. The emergency response system was not ready at all. According to Serhii Ryzhkov, there was a lack of ambulances to deliver the casualties to the hospitals. Some of those on spot were reluctant to take the wounded. Protesters had to look for means of negotiating aid. “They didn’t even have proper bandages. I’m not sure anything’s changed over the two years. Let’s take the recent Verkhovna Rada grenade explosion (August 31st, 2015). The victims were put in civilian cars and taken away, that’s it.”
It became evident following the 31st of August that Ukraine lacks systematic coordination. “The biggest issue was the coordination between agencies: the MIA did not inform the Kyiv City Council which was therefore unaware that more ambulances would be needed in proximity of the Verkhovna Rada”, says Dr. Ulana Suprun, Verkhovna Rada Healthcare committee consultant, in her comment on the events near the Ukrainian Parliament on the last day of August, 2015.
“The second issue is that Ukraine does not have a unified dispatch system. In most countries, there is a single telephone number for emergencies, and when a call is received, the police, the firefighters, the ambulances - they all arrive and they all know what to do”, Dr. Suprun adds.
This principle is applied in Sweden. The Regional Coordination Centre is charged with overseeing the activities of all emergency services (ambulances, firefighters, rescue workers), it receives valid data on the local and neighbouring hospitals, road congestion and even weather conditions.
“The Centre is on duty twenty-four hours a day, seven days a week. If necessary, the heads of emergency services as well as the representatives of the local government and the press are summoned here. It has coffee prepared for the visitors, there are even maps showing the nearest hotels, to say nothing of autonomous electricity generators. The entire system is organized in way so that even the inhabitants of the tiniest island off the Western shore of Sweden could rest assured they would receive timely and qualified support, be it by land, air or sea,” says Hlib Bitiukov, senior instructor at “Patriot Defence”, currently on training in Sweden.
Along with the issue of coordination, there is an evident lack in first aid skills. The S.M.A.R.T. course, held by “Patriot Defence” in October, 2015 in cooperation with British experts, revealed that Ukrainian medical personnel did not possess sufficient knowledge to treat trauma effectively in case of emergencies: “Unfortunately, we don’t have the kind of well-structured guidelines our foreign colleagues follow,” says Volodymyr Martsyniv, anaesthesiologist and S.M.A.R.T. trainee in an interview with Voice of America.
Dr. Suprun also stresses the need that other emergency services possess first aid skills as well: “It is usually the police or the firefighters who are the first to arrive at the scene. It is they who administer first aid. It takes a little longer for the paramedics to arrive, thus their task is to offer enhanced, next-level support.”
Whether the Paris emergency system has dealt with the attacks successfully remains to be assessed yet. Still, it is evident that the city’s medical services were up to the task of offering coordinated aid to the 500 victims of the carnage. There’s another question to ask: if a similar situation were to occur, would the Ukrainian system be able to cope? So far, it has only been flunking its tests.