The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001.
Methods
PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018.
Results
Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied.
Conclusions
The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.
Introduction
Background
The emergency management of terrorist attacks has been one of the prominent topics in disaster and emergency medicine before the SARS-CoV-2 pandemic. The most recent attacks have shown that this particular threat is still present and highly relevant today [1‐4]. The idea of “stopping the dying as well as the killing”, which has been coined by Park et al. after the London Bridge and Borough Market attacks in 2017, emphasizes the urgent need to focus on emergency management and early medical and surgical intervention [5].
Rescue systems and hospitals must prepare themselves to manage terrorist attacks in order to save as many lives as possible and to return rescue forces from the missions unscathed. As it is impossible to conduct prospective, high-quality scientific studies, the definition of these medical and tactical strategies relies on the analysis of real incidents and the lessons learned derived from them. After the Paris terror attacks in 2015 for example, important publications, describing the events of the night of the 13th of November 2015, were published [6, 7]. Two publications, one by the French Health Ministry and one by Carli et al., about the “Parisian night of terror” have gone a step further and have clearly described the lessons learned from these attacks [8, 9]. Importantly, experts agree on the importance of the scientific and systematic evaluation of the most recent terror attacks [10]. Challen et al. proved the existence of a large body of literature on the topic in 2012 already, but questioned its validity and generalisability. The authors based their conclusion on a review, which focused on emergency planning for any kind of disaster [11].
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More than ever, the principle applies, that the preparation for extraordinary disastrous incidents is the decisive prerequisite for successful management. The lack of preparedness for the SARS-CoV-2 pandemic has taught modern society this lesson.
With the aim to identify and systematically report the lessons learned from terrorist attacks as an important basis for preparation, we conducted the presented systematic review of the literature.
Materials and methods
Study design and search strategy
This is a systematic review of the literature with the focus on lessons learned from terror attacks. A comprehensive literature search was performed to identify articles reporting medical and surgical management of terrorist attacks and lessons learned derived from them. PubMed was used as database. The first search term concentrated on terrorism, the second on medical/surgical management and the third on evaluation and lessons learned. Adapted PRISMA guidelines were used and all articles were checked and reported against its checklist [12].
The search terms were formulated as an advanced search in PubMed in the following way: Search: ((Terror* OR Terror* Attack* OR Terrorism* OR Mass Casult* Incident* OR Mass Shooting* OR Suicide Attack* OR Suicide Bomb* OR Rampage* OR Amok*) AND (Prehospital* Care* OR Emergenc* Medical* Service* OR Emergenc* Service* OR Emergenc* Care* OR Rescue Mission* OR Triage* OR Disaster* Management* OR First* Respon*)) AND (Lesson* Learn* OR Quality Indicator* OR Evaluation* OR Analysis* OR Review* OR Report* OR Deficit* OR Problem*).
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Eligibility criteria and study selection
Time frame: The attack on the World Trade Centre in New York, the Pentagon in Arlington, and the crash of a hijacked airliner in 2001 is considered the event that brought international terrorism onto the world stage with the beginning of the new millennium. The attacks have been documented and analysed in great detail. For this reason, this analysis starts in 2001 and ends with the terrorist attacks in London and Manchester in 2017. The search history was extended to the year 2018.
Included countries: Terrorism is a worldwide phenomenon. Attempting to evaluate the data of all terrorist attacks that have occurred since 2001 seems impossible due to the extremely high number. The work therefore focuses mainly on Western-oriented democracies, for which a terrorist attack is still a relatively rare event and whose infrastructure and emergency services recently had to adapt to this challenge. The Organization for Economic Cooperation and Development (OECD)—countries therefore represent a reasonable selection of countries for this study.
Exclusion criteria:
1.
Articles reporting mass casualty incidents without a terroristic background
2.
Personal reports without any clear defined lessons learned
3.
Articles dealing exclusively with chemical, biological, radiological and nuclear (CBRN) terrorism
4.
Articles dealing with a narrow point of view and only dealing with specific types of injuries such as burns or psychiatry
5.
Articles not written in English.
Articles dealing exclusively with chemical, biological, radiological and nuclear terrorism (CBRN-attacks) were excluded from the literature-search. The reason for this is the large number of special problems and issues associated with this type of incident. To address this adequately, a separate literature search would be necessary.
Data abstraction
The lessons learned from each included article were extracted according to the inclusion and exclusion criteria. Duplicated data was excluded. As expected, there was a vast number of individual lessons learned. To summarize the results, it was imperative to divide them into categories. As a basis for developing the categories existing systems were used. The reporting system of Fattah et al. defines 6 categories, but these were not sufficient to represent all types of lessons learned [13]. Wurmb et al. had recently developed 13 clusters of quality indicators [14], some of which we were able to adopt. However, both systems focused on categories that serve to describe the overall setting of a rescue mission and were therefore not fully suitable for clustering lessons learned. Finally these 15 categories were used for clustering the lessons learned:
Preparedness/planning/training
Tactics/organisation/logistics
Medical treatment and Injuries
Equipment and supplies
Staffing
Command
Communication
Zoning and safety scene
Triage
Patient flow and distribution
Team spirit
Role Understanding
Cooperation and multidisciplinary approach
Psychiatric support
Record keeping
After defining the categories, the lessons learned were assigned to them. Where applicable, the lessons learned were divided into “pre-incident”, “during incident” and “post-incident” within the different categories.
Results
The extended PubMed Search yielded 1635 articles out of which 1434 articles were excluded on title selection only. The abstracts of the remaining 201 articles were evaluated and finally 68 articles were included in the analysis (Fig. 1).
Fig. 1
Process to identify the articles included in the systematic review
×
To evaluate the quality of the included studies, the PRISMA evaluation was used and all articles were checked and reported against its checklist and then rated as either high quality (HQ), acceptable quality (AQ) or low quality (LQ) paper (Table 1) [12].
Table 1
Overview of all included articles with PRISMA evaluation
HQ high quality, AQ acceptable quality, LQ low quality, USA United States of America, UK United Kingdom
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A total of 616 lessons learned were assigned to the 15 categories. If a lesson matched more than one category, it was assigned to all matching categories. Therefore, multiple entries occur in some cases. Table 2 shows the distribution of categories across all included articles, while Fig. 2 shows the number of articles in which each category appears. In this figure, the publications are assigned to the respective categories. This provides an overview of the number of articles dealing with each category. An overview of the distribution over time is later given in Fig. 3. Lessons learned within the category “tactics/organisation/logistics” were mentioned most frequently, while the category “team spirit” was ranked last in this list.
Table 2
Distribution of the 15 clusters across all included articles
1—Tactics/organization/logistics, 2—Communication, 3—Preparedness/planning/training 4—Triage, 5—Patient flow and distribution, 6—Cooperation/multi-disciplinary approach, 7—Command, 8—Staffing, 9—Medical treatment and type of injuries, 10—Equipment/supplies, 11—Zoning/scene safety, 12—Psych support, 13—Record keeping, 14—Role understanding, 15—Team spirit
Fig. 2
Number of articles mentioning each of the 15 categories
Fig. 3
Categories of lessons learned from terror attacks—development since 2001
×
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To obtain a graphical overview over the entire study period, the frequency with which the categories were mentioned per year were colour-coded and presented in a matrix (Fig. 3).
A summary of all lessons learned assigned to the 15 categories can be found in Table 3.
Table 3
lessons learned assigned to the 15 overwhelming categories
Lessons learned
Tactics/organization/logistics
Pre-incident
1
Offer a detailed manual for potential terror attacks
2
Need for having a solid disaster plan for each hospital
3
Have a national standard for major incidents and a preparedness concept/disaster response plan
4
Adequate trauma centre concepts on national level
5
Use trauma guidelines
6
Conduct updated disaster plans/drills
7
Active pre-planned protocols—pre hospital protocol + hospital protocol
8
All hospitals should be included in contingency planning
9
Do not base disaster plan on average surge rates
10
Standardisation in hospital incident planning
11
Have an emergency plan for preparedness
12
Use standard Protocols but keep flexibility
13
Establishment of various anti-terror contingency plans (hijack/bombing/shooting)
14
Mini disasters as basis for escalation (flu season)
15
Crisis management based on knowledge and data collection
During the incident
16
Activate contingency/emergency plans soon
17
Organisation of trauma teams that stay with a patient
18
Cancellation of all elective surgery/discharge of all non-urgent patients
19
Establish a public information centre close to hospital
20
Alert all hospitals
21
Prehospital and hospital coordination + communication is necessary
22
Crowd control is important
23
Maximise surge capacity
24
Distance to hospital site is major distribution factor
25
Evacuation of the less critically ill to further away hospitals
26
Importance of controlled access to hospitals
27
Avoid main gate syndrome—overwhelmed resources at the closest hospital
28
Avoid overcrowding in the ER
29
Activation of white plan—all hospitals/all staff/empty beds → no shortage
30
Recruit help from outside early on
31
Do not forget flexibility
32
Combination of civil defence and emergency medical services
33
Designated treatment area
34
Rapid scene clearance—highly organised und efficient
35
Flexibility across incident sites/hospitals
36
Vehicle coordination and rapid accumulation
37
Set principles rather than fixed protocols to allow for flexibility
38
Importance of quick evacuation
39
Ambulance stacking area to allow access and reduce traffic jam
40
Important to declare major incident as soon as possible
41
Manage uncertainties and scene
42
Coordination of rescue—especially HEMS
43
Rapid logistical response
44
Divide emergency response into stages break into smaller parts
45
Adaptation of decisions taken
46
Early decision by incidence commander needed
47
No headquarter at frontline
48
Peri-incident intensive care management—forward deployment
49
Critical mortality is reduced by rapid advanced major incident management
50
Use ICU staff for resuscitation and triage
51
Four step approach to terror attacks: analysis of scenario; description of capabilities, analysis of gaps, development of operational framework
52
Experienced personnel should treat patient and not take on organisation
53
Empty hospital immediately
54
Focus on increasing bed capacity especially ICU beds
55
Constant update on resources and surge limitation of all hospitals
56
Trauma leaders must be aware of bed capacities
57
Combined activation of major incident plans (all EMS services)
58
Early activation of surge capacity
59
Crucial interaction/communication between hospital/police/municipalities
60
Fullback structures but flexibility and improvisation important
61
Tactical management—get an overview and do not get stuck in details
62
Prehospital damage control—military concepts in civilian setting
63
Regional resource mobilisation vital
64
Have a plan but use continuous reassessment and modification of response strategy
65
Use METHANE to assess incident
66
Clear escalation plan
67
Coordination and collaboration should be planned and practised at intra/inter-regional, multiagency and multiprofessional levels
68
Improved forensic management
69
Logistic is important for operational strategic roles
70
Maintaining access to other emergencies MI/stroke, etc.
71
Gradual De-escalation – part of contingency plan
72
Issue: recognition of situational aspect and severity + complexity—evolving risk
73
Cockpit view due to HEMS—helpful in big sweep of casualties
74
Limited mobilisation at remote hospitals
75
Incident commander appoints: liaison officer; public information officer; personnel officer; logistics officer; data officer; medical command officer; patient/family information officer
76
“ABCD response”: assess incident size and severity, alert backup personnel, perform initial casualty care, and provide definitive treatment
77
Authority and command structure—two command posts—administrational vs medical management
78
Med Students used as runners
79
Tape fixed with name/specialty
80
Delays should be expected
81
Disruption in transport—lengthens rescue effort
82
Guidelines on biochemical warfare
83
Structural organisation important
84
Clear and well-structured coordination
85
Management of uninjured survivors and relatives—good communication
86
Development of operational framework
87
Assessment and re-evaluation of disaster plans
88
ED as epicentre
89
Most senior emergency physician directs traffic/surgeons overseas area—triage not by most senior personnel
90
Volunteer surges difficult to manage but can be helpful
91
Need to increase morgue facilities
92
Improved alert system
93
Clear communication, organization and decision making skills
94
Robust and simple organisation and command
Post-incident
95
Clinical representation at strategic level to facilitate cooperation between networks/regions
96
Support from neighbouring regions during terror
97
Develop a network of capacities and capabilities which is constantly updated
98
Gaps in provision of rehab services—acute phase vs long term phase
99
Access to legal and financial support for victims
100
Importance of evaluation and improvement of emergency plans
101
Analysis based on past incidences
102
Early debriefing
103
Quickest possible return to normality
104
Quick return to normality—ongoing care for normal patients
Lessons learned
Communication
Pre-incident
1
Terror awareness—train the public—communicate
2
Establish Improved alert system
3
Public engagement and empowerment—communication and teaching
4
Clear communication, organization and decision making skills
During the incident
6
Delays in communication should be expected
7
Radio Equipment vital as often all other communication lines lost
8
Importance of reliable information
9
Effective intra-hospital communication
10
Constant update on resources and limitation of all hospitals
11
Better communication between disaster agencies
12
Importance of communication between different rescue teams
13
Identification vests help communication and command structures—clear roles
14
Intra and interhospital communication is important
15
Importance of public communication centre
16
Communication between disaster scene/EMS and hospital is often big problem
17
Use of protected phone lines and walkie-talkies
18
Early information/communication from site to assess severity
19
Early on radio/bleep system—later use of mobile phones possible
20
Clear, well-structured communication and coordination
21
Increase supplies through early communication with vendors
22
Bleeps and cable phones as cell service is often unreliable
23
Multiple scenes create difficult command and communication problems
24
Communication between rescue services is vitally important
25
Do not solely rely on mobile phones—danger of collapse
26
Establish a public information centre close to hospital
27
Use robust communication methods
28
Communication lines often fail—be prepared
29
Management of uninjured survivors and relatives—good communication
30
Concentrate initially on relaying as much information as possible
31
Important information: (1) the nature of the event (2) the estimated number and severity of casualties; (3) the exact location of the event; (4) the primary routes of approach and evacuation; (5) estimated time of arrival at the nearest hospital
32
Use megaphones if adequate
33
Turn off all non-critical mobile cell phones during terror event (government implementation)
34
Communication centre for relatives
35
No media inside hospital—media centre set up
36
Importance of communication mechanisms during terror
37
Communication with public—use of media
38
Good telecommunication system—with backup options
39
Create database of victims/casualties
40
Importance of communication/coordination between incident site and hospitals
41
Importance of even distribution between hospitals—communication
42
Early press briefings to stop hysteria
43
Communication failure will always happen
44
Good care despite communication failure—hence senior well-trained personnel
45
Communication-use of standardised operational terms
46
Good in-hospital communication between specialties
47
Decision making without all information—lack of communication unavoidable
48
Public Reassurance through good communication
49
Restricted internet access to avoid breakage
50
Communication with relatives
51
Better communication of patient information between prehospital and hospital setting
52
Communication channel between police, EMS and hospitals
53
Public relations and communication
54
Readiness of hospitals—good communication and preparation
55
Mutual communication systems
56
Better Integration of operators of different rescue chains + communication
57
Provide patient lists to police to ease communication/information gathering for relatives
58
Importance of patient hand over communication
59
Effective communication—improve information sharing
60
Sharing of corporate knowledge—communication of information
61
Good communication and situational awareness—use liaison officers
62
Media policy and communication—robust and well informed
63
Consider radio control mechanisms
64
Confidentiality when it comes to communication with media
65
Security and privacy issues when it comes to media communication
66
Quick and clear communication with relatives—to avoid information gathering via social media
Lessons learned
Preparedness/planning/training
Pre-incident
1
Practise/drill—important!
2
Terror awareness—train the public
3
Trained prehospital personnel is a crucial factor
4
Update disaster plans—train them
5
Different sort of drills to prepare (manager drills/full scale drills)
6
Training is most important
7
Have and follow a pre-existing plan—based on experience
8
Thorough good quality preparation
9
Good prehospital care systems improve survival
10
Training of triage to reduce over and under triage
11
Debrief early and in a structured way
12
Preparation for incidents and injury types
13
Be prepared: have 1–3 months supply of surgical disposables
14
All hospitals should be included in contingency planning
15
All hospitals should be prepared to act as evacuation hospital—drills and training
16
Importance of damage control concepts—training
17
Cancellation of all elective surgical procedure
18
Emptying of ICU and wards
19
Importance of planning, coordination, training, financial support and well equipped medical services
20
Clear out hospital during latent phase
21
Have a major incident plan—have it rehearsed
22
Analysis based on past incidences
23
Analysis of gaps between scenario and response needed
Have an emergency plan even if not a level one trauma centre
27
Rehearsal of emergency plan
28
Every hospital should be prepared for a major incident with terrorist background -solid emergency plans in situ
29
Importance of thorough analysis and short fallings
30
Good mix between planning and improvisation
31
A major incident plan is necessary—on a local as well as regional level
32
Meticulous planning
33
Extensive education
34
Regular review of the contingency plans
35
Emergency and disaster preparation and planning is crucial
36
All hospitals should be ATLS trained and have major incident drills
37
Regional major incident plan to help allocate resources
38
Have and activate contingency plans soon
39
Be prepared for uncertainty and unsafe environment
40
Having experience best preparation for next incident
41
Training saves lives
42
Drills based on past experiences
43
Teaching/training/education—best preparation
44
Disaster training best preparation for reality—systematic multidisciplinary training/drills
45
Train for new pattern of injuries
46
Readiness of hospitals—good communication and preparation
47
Public engagement and empowerment—communication and teaching
48
Staff training in combat medicine—cooperation with the military
49
Greater investment, integration, standardisation of disaster medicine
51
Multidisciplinary training—including police/fire service
52
Monthly multidisciplinary trauma training
53
Train the public/police in first aid/bleeding control
54
Importance of evaluation and improvement of emergency plans
55
Emergency preparedness based on planning/training/learning
56
Competence through continuous planning/training/drills
57
Cooperation: teaching of medical staff by military
58
Teaching of trauma management to med students
59
Therapy of paediatric cases—training is essential
60
Anticipation and planning—Plan Blanc obligatory
61
Awareness of tactical threat—idea of hazardous area response team
62
Training in trauma management
63
Planning and training—the value of organised learning
64
National process for debriefing and lessons learned
65
Regional standards for training
Lessons learned
Command
During the incident
1
Strict command and control structures with designated hierarchy
2
Establish incident command system/centre—this is important
3
Early command and control structure—be prepared to rebuild
4
Avoid improvisation in command structure
5
Identification vests help communication and command structures—clear roles
6
Most senior medical officer = commander
7
Prompt and vigorous leadership
8
Civil defence coordinates and has overall command—clear structure
9
Importance of chain of command
10
Command structures—medical director vs administrative director
11
Incident commander appoints: liaison officer; public information officer; personnel officer; logistics officer; data officer; medical command officer; patient/family information officer
12
Chain of command: most senior official from all important specialties plus hospital admin
13
Multiple scenes create difficult command and communication problems
14
Have experienced decision maker
15
Command and control—regular trauma meetings
16
Importance of EMS command centre
17
Accept chaos phase—command structures will follow
18
Importance of local command structures—most senior official = commander in chief
19
Communication/cooperation between managers of different EMS
20
Work within established command and control structures
21
Clear distinction between command/control and casualty treatment
22
Lead by senior clinicians
23
Effective decision making—command is crucial
24
Command structures need to be robust
25
EMS command structures are vital
26
Dual command—ambulance/tactical commander vs medical commander
27
Command and control vs collaboration—both important
28
Flexible leadership
29
Leadership through ER physicians
30
Central Command—Health emergencies crisis management centre
31
Central command in hospital—director of medical operations
32
Good crisis management/command important
33
Multidisciplinary management
34
Clear communication, organization and decision making skills vital
35
Robust and simple organisation and command
36
Crisis management based on knowledge and data collection
37
Solid command structures and leadership based on experience and knowledge
38
Tactical management—get an overview and do not get stuck in details
39
Leadership/coordination through experienced healthcare professionals
40
Tactical command post in safe zone
Lessons learned
Triage
Pre-incident
1
Establish national triage guidelines
2
Improve triage skills
3
Reproducible triage standards
4
Triage according to three ECHO—coloured cards
5
Casualty disposition framework with an effective enhanced triage process
During the incident
6
Priority is quick triage, evacuation and transport to hospital
7
Establish casualty collection points/triage simple and early
8
Multiple triage areas—staff with freelancers
9
Coloured tags for triage
10
Use START system—simple triage rapid treatment
11
Doctors not deployed in red zone -triage in safe zone
12
Triage by most senior personnel
13
In-hospital triage according to ATLS
14
Systematic planning for triage, stabilisation and evacuation to hospital through chain of treatment stations
15
Triage at a distant site to disaster
16
Importance of triage—good triager—absolute authority
17
Deploy small medical teams for 2nd triage
18
Senior general surgeon triages at hospital entrance
19
Triage on arrival at hospital entrance as prehospital triage not necessarily reliable
20
Rapid primary triage—evacuation of the critical ill to nearest hospital (evacuation hospital) for stabilisation
21
Beware of undertriage
22
Importance of triage at incident site
23
Importance of retriage at hospital
24
Importance of triage concepts in general—avoid undertriage
25
Primary in-hospital survey through surgeons and anaesthetists
26
Diligence in triage
27
Large amount of over triage—no negative consequences/overtriage does not kill
Rapid primary survey and triage—delay of secondary survey
33
Most senior emergency physician directs traffic/surgeons overseas area—triage not by most senior personnel
34
Prehospital as well as hospital triage is vitally important
35
Importance of good primary triage
36
Frequent reassessment and triage
37
Quick triage—scoop and run—repeated triage at hospital
38
Quick effective good basic triage—reduction of overtriage
39
Improved triage through physician/paramedic teams
40
Enough equipment but mainly quick triage and transport
41
Deliberate overtriage
42
Directed quick patient flow to relieve triage area
43
Inadequate triage results in critically injured patients—retriage is vital
44
Outside triage area—not in hospital
45
Triage: absolute vs relative emergencies
46
Crisis teams to organise triage
47
Continuous retriage—similar triage system preclinical and in hospital
48
Triage outside hot zone—no therapy in hot zone if not trained
49
Most important triage point: able to walk vs not able to walk
Lessons learned
Staffing
Pre-incident
1
Deploy trained prehospital personnel
2
Staff imprints lessons from mini-disasters and use this experience
3
Establishment of human resource pools—especially with volunteers
4
Too few nurses—improve incentives
5
Description of relevant capabilities of the medical system
6
Staff training in combat medicine—cooperation with the military
7
Up-to-date list of available staffing important
During the incident
8
Descale as soon as possible → rest time for staff
9
Staff Safety is a major concern
10
Freelancers are important but difficult to manage
11
Multiple triage areas—possible staffing with freelancers
12
Quick response—increase staffing as soon as possible
13
Maximal increase of staffing needed—most important factor
14
Forward deployment of anaesthetist—allows for continuity of care
15
Relieve staff after 8–12 h for breaks
16
Optimise utilisation of manpower and supplies
17
Primary survey through surgeons and anaesthetists
18
ED staffed with nurse/doctor combo at each bed
19
Gather information and personnel during latent phase
20
Helicopters to transport staff and equipment
21
Triple: anaesthetist trauma surgeon abdominal surgery lead assessment and allocation to definite care
22
Efficient staff allocation
23
Pre hospital physicians useful
24
Using tags for triage—no resuscitation efforts until enough staffing
25
Train core of nurses in emergency medicine skills
26
Different specialties (ENT/psych) needed
27
Spread out teams to attend more patients
28
Too much staff available in ER—overcrowding
29
Good care despite communication failure—hence senior well trained personnel
30
Triage by senior medical officers
31
Keep track of staff showing up
32
Keep personnel in reserve/on standby
33
Experienced staff is vitally important
34
Surge in equipment and staff vital
35
Safety of personnel—idea of SWAT paramedics—therapy under fire
36
Increase blood bank staff
37
Photography staff/service to document injury
Post-incident
38
Follow up on personnel—psychological and physiological
Lessons learned
Patient flow and distribution
Pre-incident
1
Large number of mildly injured patients need to be expected and swiftly dealt with
2
Provide enough equipment but tailor to quick triage and transport
During the incident
3
Majority of survivors are self-rescuer
4
Establish safe way for self-rescuer/non invalid patients
5
Increase ICU capacity move patients and unlock new areas
6
Patient flow—division between different hospital to avoid overload/right patient to the right hospital
7
Fast forward casualty flow
8
Coordinated distribution of casualties to hospitals
9
Log of most severely injured patients and their whereabouts
10
Quick redistribution of patients to clear ER for new ones
11
Use recovery room for monitoring unstable patient
12
Second wave of patient transfer between hospitals to avoid resource overstretching
13
Misdistribution between hospitals is a huge problem
14
Unidirectional patient flow—quick emptying of ED—one way pathway of care
15
Walking wounded redirected to satellite areas
16
Early evaluation of patients by senior doctors—early estimation of ICU capacity/operating capacity needed
17
Transport off ICU patients to different hospitals needs to be thought of
18
Rapid removal from critically ill patients out of an unsafe environment
19
Transferring patients rapidly to definite care—rapid scene clearance
20
Consider the need for secondary transport (interhospital)
21
Distinction between circle 1 and circle 2 hospitals—direction of casualties accordingly
22
Quick evacuation of casualties—if stable enough severely injured patients to trauma hospitals
23
ED as epicentre—clear ED quick
24
Establish different treatment areas: fast track, psychiatric, major trauma, etc.
25
Primary evacuation of mildly injured patients to distant hospitals
26
Treat patient in level 2 trauma centres and only transfer if necessary to level 1 trauma centres
27
Divert non urgent patients to hospitals further away from incident site
28
Survivor reception centres to alleviate hospitals
29
Primary and balanced distribution between hospitals
30
Timely evacuation out of unsafe zone
31
Overload of patients at close by hospitals is huge problem
32
Fast track route for minor injuries
33
Patient flow—evacuation to cold zones
34
Directed quick patient flow to relieve triage area
35
Secondary patient flow according to capacity and specialty
36
Relocation of current patients
37
Cooperation between hospitals and trauma centres—recognise your limits and transfer
38
Tourniquet use und quick transfer to definite care
39
Track patients through hospital is a difficult task
40
Casualty clearing station—part of patient flow
41
Casualty disposition framework with an effective enhanced triage process
42
Safe transfer and handover of existing patients
Lessons learned
Cooperation and multidisciplinary approach
Pre-incident
1
Common goal is an important benefit
2
Cross organisational planning important
3
Communication channel between police, EMS and hospitals
4
Staff training in combat medicine—cooperation with the military
5
Awareness of tactical threat—idea of hazardous area response team
6
Sharing of corporate knowledge—communication of information
7
Clinical representation at strategic level to facilitate cooperation between networks/regions
8
Simultaneous search/rescue/treatment
During the incident
9
Better communication between disaster agencies is important
10
Importance of communication between different rescue teams
11
Especially trauma patients need teamwork and good cooperation (surgery/anaesthetic)
12
Cooperation of the entire medical system—prehospital as well as hospital
13
Increase supplies through early communication with vendors
14
Collaboration with police to deliver supplies
15
Police command centre within hospital
16
Chain of command: most senior official from all important specialties plus hospital admin
17
Communication between rescue services vitally important
18
Good teamwork is crucial
19
Triple: anaesthetist, trauma surgeon abdominal surgeon lead assessment and allocation to definite care
20
Multidisciplinary meetings
21
Most senior emergency physician directs traffic/surgeons overseas area—triage not by most senior personnel
22
Flexibility of services important—interaction/cooperation important
23
Possibility for emergency services to cooperate and communicate
24
Combined activation of major incident plans (all EMS services)
25
Joint field command post
26
Cooperation and communication between hospitals and all emergency services
27
Dual surgical command-triage
28
Cooperation between police and EMS
29
Methodical multidisciplinary care delivery
31
Good cooperation/collaboration between services is vital
32
Good interdisciplinary cooperation is vital
30
Command and control vs collaboration—both important
33
Multidisciplinary care saves lives
34
Cooperation between EMS and police/fire services
35
Multidisciplinary training—including police/fire service
36
Multi-professional networks/interaction including mental health
37
Cooperation between hospitals and trauma centres—recognise your limits and transfer
38
Crucial interaction/communication between hospital/police/municipalities
39
Provide patient lists to police to ease communication/information gathering for relatives
40
Good communication between incident site and hospital
41
Law enforcement medical commander—cross over between specialties/cooperation
42
Cooperation between civilian rescue teams and military
43
Good communication and situational awareness—use liaison officers
44
Coordination and collaboration should be planned and practised at intra/inter-regional, multiagency and multiprofessional levels
45
Support from neighbouring regions during terror
Lessons learned
Equipment and supplies
Pre-incident
1
Functioning equipment is vitally important (broadband internet)
2
Constant resource evaluation
3
Combat medical care—reduced level of treatment per patient due to resource insufficiencies
4
Need for appropriate equipment + supplies
5
Increase supply of available blood products
6
Mobile multiple casualty carts and disaster supply carts with equipment are helpful
7
Increase supplies through early communication with vendors
8
Assess Need for chemical and radiological monitors
9
Description of relevant capabilities of medical system
10
Provide megaphones
11
Provide protective personal equipment
12
Install mobile mass casualty vehicles with additional supplies
13
Increase and storage of supplies
14
Supply chains need to be reliable/organised well
15
Regional major incident plan to help allocate resources
During the incident
16
Restrict laboratory and radiology testing
17
Protection of medical assets
18
Increase equipment—prep minor OR for major casualties
19
Rapid primary triage—only evacuation of the critical ill to nearest hospital (evacuation hospital) for stabilisation—to avoid resource overstretching
20
Second wave of patient transfer to avoid resource overstretching
21
Optimise utilisation of manpower and supplies
22
Collaboration with police to deliver supplies
23
Helicopters to transport staff and equipment
24
Basic equipment important and needed
25
Use of radio systems
26
Basic first aid kits on buses/trains
27
Allocation of resources difficult especially with multiple incidents
28
Enough equipment but mainly quick triage and transport
29
More advanced equipment including CBRN
30
Allocate resources to correct diagnosis
31
Extensive use of tourniquet
32
Challenge of technology-equipment may fail
33
Back up resources—mobilise equipment and staff
34
Use of clotting devices/tourniquet
35
Surge capacity in equipment and staff is vital
36
Avoid main gate syndrome—overwhelmed resources at the closest hospital
37
Regional resource mobilisation is vital
Lessons learned
Medical treatment + type of injury
Pre-incident
1
Use critical mortality rate as indicator for assessing medical care
2
Terror attack cause different/specific injury patterns
3
Except many blast injuries
4
Average ISS Score of ICU admission
5
Professional abilities are important
6
Train for new pattern of injuries
7
Medical management and knowledge vitally important
8
Stop the bleeding—tourniquet use—train as basic first aid
9
Integration of TCCC to ATLS
10
Improve therapy of paediatric cases—training
During the incident
11
Evacuate patients as soon as possible
12
Rapid treatment is important
13
Use START system—simple triage rapid treatment
14
Combat medical care—reduced level of treatment per patient due to resource insufficiencies
15
Early aggressive resuscitation predicts survival
16
Available surgical capacity needs to be increased
17
Restrict laboratory and radiology testing—minimal investigations
18
Only damage control surgery—the rest must wait
19
Medical treatment dependent on type of attack
20
Rapid provision of definite care
21
Therapy according to ATLS guidelines
22
Predominance of minor injuries during terrorist bombings (secondary/tertiary blast effect) and worried well patients
23
Critical injury appears roughly in 1/3rd of the cases
24
Blast injury results often in immediate death—if not there is often a combination with ear injury
25
Only 5% ISS > 15; 2% ISS > 25
26
Main injuries: blunt trauma, blast injury, penetrating wounds, burns
27
Rapid removal from critically ill patients out of an unsafe environment—scoop and run Therapy
28
Damage control treatment and mind set to increase surge capacity
29
Using tags for on scene triage—no resuscitation efforts until enough staffing
30
Treat patient in level 2 trauma centres and only transfer if necessary to level 1 trauma centres
31
Damage control treatment—no provision of individual definite care
32
Use ATLS/PHLTS standards
33
Use tactical combat casualty care + haemorrhage control
34
Roughly 10% suffer major injury
35
Schedule operations according to urgency
36
Extensive use of tourniquet
37
Offer immediate access to OR
38
Patient therapy/flow: tourniquet use und quick transfer to definite care
39
Safety vitally important—extent of therapy based on situational safety
Lessons learned
Zoning and scene safety
Pre-incident
1
Full personal protective equipment and knowledge of the prehospital environment helpful
2
Beware of hospitals being soft targets
3
Safety of personnel—idea of SWAT paramedics—therapy under fire
4
Awareness of tactical threat—idea of hazardous area response team
During the incident
5
Security at all hospital entrances—consider immediate lockdown
6
Simultaneous search/rescue/treatment—beware of security risks of this concept
7
Scene safety and scene control—beware of loss of rescue personnel—safety first
8
Beware second hit principle—protect trained personnel
9
Establish a safe way for self-rescuer
11
Safety of staff paramount
12
Rapid removal from critically ill patients out of an unsafe environment
13
Scene safety—important but huge problem hence rapid evacuation
14
Awareness for explosive devices being carried into hospital
10
Doctors not in red zone—triage in safe zone
15
Continuous assessment of scene safety
16
Safety first—triage/command outside danger zone
17
Manage uncertainties and scene
18
Evacuation problematics due to scene and geographical environment
19
Importance of scene safety and terror control
20
Scene safety—secondary attack/collapsing buildings/explosive Device
21
Conventional rescue teams out of danger zone
22
Operating capacity within on scene dressing station-tactical physicians as concept
23
Scene safety—zoning (exclusion zone)
24
Scene safety: develop best compromise btw safety of responders, immediate care and fast extraction
25
Triage outside hot zone—no therapy in hot zone if not trained
26
Tactical command post in safe zone
27
Scene safety cannot be guaranteed
28
Safety vitally important—extent of therapy based on situational safety
29
Challenges of being in the hot zone—multifaceted and continuously evolving
30
Recognition of situational aspect and severity + complexity—evolving risk
Lessons learned
Psychiatric support
Post-incident
1
Early psychiatric help is important
2
Site for acute stress disorder therapy needed
3
Good psychological support is necessary and important
4
Importance of post-traumatic stress disorder treatment groups
6
Do not underestimate the psychological and physical effects on health care workers
7
Psychological support for emergency services/healthcare worker/staff
8
Debriefing as stress relief
9
Psychiatric support before discharge for all patients
10
Psychological support for mildly injured patients
11
Set up survivor groups/psychological support
13
Psychological support to reduce long term impact of terrorism
14
Establishment of mental health counselling for staff
15
Psychiatric illness as hazard for emergency personnel
16
Establish psychological support centre
17
Low PTSD with good preparation, debriefing and high role clarity
18
Psychological follow up for staff and patients
19
Multiprofessional networks/interaction inclusive Mental Health
20
Everyone should be seen by psychiatric experts
21
Psychological care—Increase psychological support short and long term
22
1/3 of victims develop post traumatic stress disorder (PTSB)
23
Psychological support—informal and formal Treatment
24
Improve bereavement support
25
Psychological first aid approach including self help
26
Bereavement nurses—24/7 access in the first 48 h
27
Monitor high risk groups of PTSD
Lessons learned
Record keeping
Pre-incident
1
Create database of victims/casualties
2
Identification difficulties of victims—improve documentation to allow quicker identification
3
Improvement in identification: INTERPOL Disaster Victim Identification Standard
4
Standardised documentation at regional level/need for national casualty identification system
5
Patient identification difficult task—standardized identification and documentation systems
During the incident
6
Written documentation strapped to patient
7
Early start of data collection
8
Good record keeping is essential
9
Lead agency to solely deal with record keeping
10
Importance of data collection of casualties at the scene
11
Importance of documentation—which patient has already been triaged
12
Better communication of patient information between prehospital and hospital setting
13
Detailed documentation of the disaster operation
14
Crisis management based on knowledge and data collection
15
Track patients through hospital—this is a difficult task
16
Photography staff/service to document injury
17
Importance of patient identification to allow for family reunification/bereavement
Lessons learned
Role understanding
1
Clear identification methods of roles—tags/vests—helps communication and command structures
2
Dedicated roles with clear defined duties during event—command and control physician; discharge/ patient flow organiser; ED supervisor
3
Assigned roles in disaster plan
4
Flexibility but clear roles
5
Know your capabilities/professional role
6
Low post traumatic stress disorder with good preparation, debriefing and high role clarity
7
Clear defined roles help to give security and confidence and improve outcome
Lessons learned
Team spirit
1
Keep team spirit up
2
Form coalition to keep up spirit and improve
3
Staff solidarity and professionalism vital
4
Public engagement and empowerment—communication and teaching
5
Professionalism and team spirit important for success
6
Mutual support important
Discussion
This systematic review is the first of its kind to review the vast amount of literature dealing with lessons learned from terror attacks. It thus contributes to a better understanding of the consequences of terror attacks since 2001. It also brings order to the multitude of defined lessons learned and allows for an overview of all the important findings.
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Our data has shown that, despite the difference in attacks, countries, social and political systems and casualties involved, many of the lessons learned and issues identified are similar. Important to note was the fact that time of article release did not relate to content. Many articles written after the London attacks in 2005 formulated similar if not the same lessons learned as articles written in 2017 about Utoya [36, 52]. This is a major point of concern as it indicates, that despite the knowledge about the issues and the existence of already developed, excellent concepts [56, 79, 80], their successful implementation and continuous improvements seem to be lacking.
One of these well-developed concepts, the Tactical Combat Casualty Care (TCCC), began as a special operations medical research programme in 1996 and is now an integral part of the US Army's trauma care [79]. The Committee on TCCC, which was established in 2001, ensures that the TCCC guidelines are regularly updated [79]. Many of the lessons learned listed in our review are an integral part of these guidelines and are addressed with concrete options for action. For Example, the principles of Tactical Evacuation Care provide detailed instructions on the management of casualties under the special conditions of evacuation from a danger zone [81]. Moreover, the lack of knowledge on how to deal with injuries caused by firearms or explosive devices, which was mentioned in many articles, could be remedied by a consistent integration of the TCCC guidelines into the training and drills of emergency service staff.
Another concept that deals with the management of terrorist attacks and mass shootings is the Medical Disaster Preparedness Concept “THREAT”, which was published after the Hartford Consensus Conference in 2013 [56]. The authors defined seven deficits as lessons learned and recommended concrete measures to address them. These lessons were included in our review and were mentioned in one form or the other in many of the articles. The defined THREAT concept components were:
T: Threat suppression
H: Haemorrhage control
RE: Rapid extraction to safety
A: Assessment by medical providers
T: Transport to definitive care.
Consistent implementation of these points in training and practice would be an important step towards improving preparation for terror attacks.
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A good example of the successful implementation of an interprofessional concept is the 3 Echo concept (Enter, Evaluate, Evacuate) [80]. It was developed and introduced with the goal to optimize the management of mass shooting incidents. At the beginning of concept development stood the identification of deficits. Those deficits correspond to those that we found in the presented systematic review. The introduction of the concept in training and practice has led to successful management of a mass shooting event in Minneapolis, Minnesota, USA in 2012 [80]. This outlines once again the importance of translating lessons learned into concrete concepts, to integrate them into the training and to practice them regularly in interprofessional drills. Just as the 3 Echo concept is based on interprofessional cooperation, the Joint Emergency Services Interoperability Principles (JESIP) project is also based on this principle [82]. It is the standard in Great Britain for the interprofessional cooperation of emergency services in major emergencies or disasters. Through simple instructions and a clear concept, both the aspect of planning and preparation as well as the concrete management of operations are taken care of [82].
In interpreting the lessons learned in this systematic review, the question arises whether they are specific to terrorist attacks. Our review deals exclusively with lessons learned from terrorist attacks. Other publications, however, systematically addressed the management of terrorist and non-terrorist mass shootings and disasters. Turner et al. reported the results of a systematic review of the literature on prehospital management of mass casualty civilian shootings [83]. The authors identified the need for integration of tactical emergency medical services, improved cross-service education on effective haemorrhage control, the need for early and effective triage by senior clinicians and the need for regular mass casualty incident simulations [83] as key topics. Those correspond congruently with the lessons learned from terrorist attacks that were found and presented in this systematic review.
Hugelius et al. performed a review study and identified five challenges when managing mass casualty incidents or disaster situations [84]. These were “to identify the situation and deal with uncertainty”, “to balance the mismatch between contingency plan and reality”, “to establish functional crisis organisation”, “to adapt the medical response to actual and overall situation” and “to ensure a resilient response” [84]. The authors included 20 articles, of which 5 articles dealt with terror and mass shooting (including the terror attacks in Paris and Utoya). Although only 25% of the included articles dealt with terrorist attacks, the lessons learned are again very comparable to the results of this systematic review.
Challen et al. published the results from a scoping review in 2012 [11]. The authors stated that “although a large body of literature exists, its validity and generalisability is unclear” [11]. They concluded that the type and structure of evidence that would be of most value for emergency planners and policymakers has yet to be identified. If trying to summarise the development since that statement it can be assumed that on one hand sound concepts have been developed and implemented. On the other hand however, the lessons learned in recent terror attacks still emphasize similar issues as compared to those from the beginning of the analysis in 2001, showing that there is still work to be done. It should be mentioned at this point, that there was a federal conducted evaluation process in Germany after the European terror attacks in 2015/2016. The lessons learned were published in 2020 by Wurmb et al. and were very comparable to those of this systematic review [85]. Furthermore the terror and disaster surgical care (TDSC®) course was developed in 2017 by the Deployment, Disaster, Tactical Surgery Working Group of the German Trauma Society to enhance the preparation of hospitals to manage mass casualty incidents related to terror attacks [86]. Finally it is important to mention, that hospitals and rescue systems must prepare not only for terrorist attacks, but also for a wide spectrum of disasters. Ultimately, this is the key to increased resilience and successful mission management.
Limitations
This systematic review has several limitations. Due to the vast amount of information only PubMed was used as a source. From the authors' point of view, this is a formal disadvantage, but it does not change the significance of the study as in contrast to the question of therapy effectiveness or the comparison of two forms of therapy, the aim here is to systematically present lessons learned. To get even more information, the data search could have been extended to other databases (e.g. Cochrane Library, Web of science) and the grey literature. Given the number of included articles, it is questionable whether this would have significantly changed the central message of the study. It is even possible that this would have made a systematic presentation and discussion even more difficult. CBRN attacks have been excluded from the research. The reason for that was that many special aspects have to be taken into account in these attacks. Nevertheless CBRN attacks are an important topic, which would need further exploration in the future. The restriction to OECD countries certainly causes a special view on the lessons learned and is thus also a source of bias. However, the aim was to look specifically at countries where terror attacks are a rather rare event and rescue forces and hospitals are often unfamiliar with managing these challenges. Special injury patterns associated with terror attacks were not considered. This reduces the overall spectrum of included articles, but from the authors' point of view, a consideration of these would have exceeded the scope of this review.
Conclusion
The first thing that stands out is that most lessons learned followed a certain pattern which repeated itself over the entire time frame considered in the systematic review. It can be assumed that in many cases it is therefore less a matter of lessons learned than of lessons identified. Although sound concepts exist, they do not seem to be sufficiently implemented in training and practice. This clearly shows that the improvement process has not yet been completed and a great deal of work still needs to be done. The important practical consequence is to implement the lessons identified in training and preparation. This is mandatory to save as many victims of terrorist attacks as possible, to protect rescue forces from harm and to prepare hospitals and public health at the best possible level.
Declarations
Conflict of interest
The authors have no conflicts of interest to declare that are relevant to the content of this article.
Availability of data and materials
Not applicable.
Code availability
Not applicable.
Ethics approval
Not applicable.
Consent to participate
Not applicable.
Consent for publication
Not applicable.
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