Background
Methods
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2: notification prior to arrival of the first operational forces (this means early enough to draw security related consequences).
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1: notification after the arrival of the first operational forces, no threat for the operational forces (this means to late but without consequences for the rescue forces).
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0: threat or damage to the operational forces (this means to late with significant and negative consequences for the rescue forces).
General Characteristics | Data | Assessment |
---|---|---|
Date | 2016.07.18 | descriptive |
Weekday and time of day | Monday 09:14 pm | descriptive |
Bank holiday | no | descriptive |
Weather (rain, snow etc.) | 20 °C, cloudy dry | descriptive |
Place of incident - rural area or city? | City of Wuerzburg (130.000 inhabitants) | descriptive |
Number of hospitals in the area (radius 50 km) | 16 | descriptive |
Number of local trauma centers? | 4 | descriptive |
Number of regional trauma centers? | 3 | descriptive |
Number of national trauma centers? | 1 | descriptive |
Is there a written concept for Mass Casualty Incidents for the emergency medical services in place?
|
yes
|
See lessons learned
|
Is there a written and coherent concept for dealing with mass killing incidents/life threatening mass casualty incidents
|
yes
|
See lessons learned
|
Total number of casualties | 8 | descriptive |
Number of casualties classified as T1/RED in medical triage | 4 | descriptive |
Number of casualties classified as T2/YELLOW in medical triage | 1 | descriptive |
Number of casualties classified as T3/GREEN in medical triage | 1 | descriptive |
Number of casualties classified as T4/BLACK in medical triage | 1 | descriptive |
Number of hospitalised casualties | 6 | descriptive |
Number of casualties deceased on site | 1 (the offender) | descriptive |
Number of uninjured people who have been affected by the event | 15 | descriptive |
Mission related data | Data | Assessment |
---|---|---|
At what time was it noticed that this was a life threatening incident for the rescue services? (Δt from first emergency call to notification of life threatening situation) | 09:20 pm Δt: 6 min | Result: 2 2: prior to arrival of the first operational forces 1: after the arrival of the first operational forces, no threat to the operational forces 0: threat or damage to the operational forces |
Did first notification of the incident happen through police, rescue headquarter or operational forces on scene? | Police headquarter | descriptive |
Δ t from notification until communication between rescue headquarter and police headquarter | Δt: 0 min | Result: 2 2: prior to arrival of the first operational forces 1: after the arrival of the first operational forces, no threat to the operational forces 0: threat or damage to the operational forces |
Δ t from alarm until successful notification of all operational forces about life threatening situation | Δt: 0 min | Result: 2 2: prior to arrival of the first operational forces 1: after the arrival of the first operational forces, no threat to the operational forces 0: threat or damage to the operational forces |
Δ t from alarm until arrival on scene of the first operational forces | Δt: 7 min | Result: 2 2: within the help period 1: outside the help period due to incident circumstances 0: outside the help period without justification |
Δ t from arrival on scene until first understanding of the situation and report to the rescue headquarter | Δt: 1 min | Result: 2 2: immediate information 1: delayed information 0: no information |
Δ t from arrival of the first operational forces until the first assessment and tactical decision | unknown | |
Δ t from arrival of the mission commander until first assessment of situation and planning of the mission | Δt: 10 min | Result: 2 2: immediate 1: delayed 0: no assessment and planning |
Δt from first notification of a life threatening situation until threat cessation | Δt: 106 min | descriptive |
Use of guns? Use of thrusting weapons (knife etc.)? | Knife and axe | descriptive |
Use of explosive agents i.e. Improvised Explosive Devices? | no | descriptive |
Abuse of vehicles (truck/car)? | no | descriptive |
Chemical, biological, radio-nuclear threats (CBRN) | no | descriptive |
Any other imminent danger? | no | descriptive |
Total time of mission (in minutes) | 245 min | descriptive |
Static situation (no change in circumstances such as mobile offenders, changing threats and growing number of casualties)? | No | descriptive |
Dynamic situation (change in circumstances such as mobile offenders, changing threats and growing number of casualties)? | yes | descriptive |
Combination of static and dynamic situation? | no | descriptive |
Multisite attack? | no | descriptive |
Alarm Procedure | Data | Assessment |
---|---|---|
Δ t from first emergency call until use of buzzword (i.e. terror, rampage, life-threatening situation) | Δt: 4 min | Result: 2 2: immediate 1: delayed 0: no |
Δt from first emergency call until first alarm | Δt: 4 min | Result: 2 2: immediate 1: delayed 0: no |
Δ t from first alarm until rescue forces report operational readiness | Δt: 20 min | descriptive |
Δ t from operational readiness until arrival of the rescue forces on scene | Δt: 10 min | descriptive |
Was there enough manpower at the rescue headquarter (dispatch center) at the start of the operation | No | descriptive |
Has the rescue headquarter an alarm system of additional recruitment in place if needed | yes | descriptive |
If there was a lack of forces in the rescue headquarter: Δ t from first notification until full recruitment | Δt: 30 min | descriptive |
Organization of scene (Arrangement of the area) | Data | Assessment |
---|---|---|
Was there a structured organization of the scene during the operation?
| Yes |
Result: 1
1: Yes
0: No
See lessons learned
|
If so, who coordinated the organization of the scene (police forces and/or rescue forces)? | Rescue Headquarter | descriptive |
Δ t from first alarm until arrangement of the area | Δ t: 0 Minutes | Result: 2 2: prior to arrival of the first operational forces 1: after the arrival of the first operational forces, no threat for the operational forces 0: threat or damage to the operational forces |
What was the arrangement of the area? | Yes: Damage sector Deployment sector On–site Command post | descriptive |
Was the arrangement of the area adequate for life threatening incidents (e.g. unsafe and safe zones, safe assembling areas) | No, due to the dynamic situation the deployment (EMS) sector was located in the unsafe zone. |
Result: 0
2: adequate
1: not adequate, no threat for the operational forces
0: potential threat or damage to the operational forces
See lessons learned
|
Did everyone know (police forces and rescue forces) about the organization of the scene?
Was the organization of the scene applied successfully?
|
Yes!
No: due to ambigous information
|
See lessons learned
|
Δ t from first alarm until a deployment sector was planned | Δ t: 0 Minutes | |
Distance (*in meters) between the deployment sector to the unsafe zone | 0 m | Result: 0 1: sufficient 0: insufficient |
Distance* between the on-site command post to the unsafe zone | 500 m | Result: 1 1: sufficient 0: insufficient |
Was a triage area established? | no | |
If so - distance* between triage area and unsafe zone? (secured perimeter) | not applicable | |
Was there an assembling area (casualty gathering point) established | no | |
If so – distance * between assembling area (casualty gathering point) and unsafe zone? | not applicable | |
Was there a zone-related stepwise medical treatment concept according to the principals of Tactical Combat Casualty Care (care under fire, tactical field care, tactical evacuation care) established? | No, the full medical care was provided in the unsafe area | descriptive |
Was an assembly area for uninjured people, who have been affected by the event, established? | yes | descriptive |
If so - distance* between the assembly area and unsafe zone? | 2000 m | Result: 0 1: sufficient 0: insufficient |
Mission strategy and tactics | Data | Assesment |
---|---|---|
Which mission strategy i.e. “Clear up the scene”- was applied? |
No terror related strategy was applied. A mission strategy for mass casualty incidents was applied.
|
See lessons learned
|
Which tactical plan of action was chosen?
For example:
Fastest transport to hospitals of the patients with Triage Category T1/RED?
|
Basically the mission strategy for mass casualty incidents was applied. There was an ongoing threat, so swift evacuation of the patients with triage category I/RED was the most important tactical decision
|
See lessons learned
|
At what time were tactical consequences drawn? | unknown | |
Who drew them? | Subsection Commander of the “subsection damage” | Descriptive |
Δ t from arrival of the first rescue services on scene until a tactical plan of action was fully implemented? | Unknown | |
Coordinated tactical decisions drawn by police, emergency medical services and fire brigade? | Yes |
Incident Command System/Line of Command | Data | Assessment |
---|---|---|
Was an incident command system established? | Yes | Result: 1 1: yes 0: no |
Did the incident commander in chief (medical) have influence on the course of action during the mission?
|
Partly
|
Result: 1
2: complete
1: partly
0: none (see lessons learned)
|
Did the command processes work adequately?
|
Partly
|
Result: 1
2: complete
1: partly
0: none (see lessons learned)
|
Did the incident commander in chief (medical) always have adequate information for repeated re-evaluation and understaning of the situation (continuous flux of reports)?
|
No
|
Result: 0
2: always
1: sometimes
0: never (see lessons learned)
|
Did the incident commander in chief (medical) have influence on the course of action during the mission | Partly | Result: 1 2: complete 1: partly 0: none |
Did the incident commander in chief (medical) have control of the subsection commanders?
|
Partly
|
Result: 1
2: complete
1: partly
0: none (see lessons learned)
|
Was a functioning resource management established? | Yes | Descriptive |
Communication | Data | Assesment |
---|---|---|
Was there a previously defined communication infrastructure between the rescue headquarter and the police headquarter? | No | Result: 0 1: present 0 not present |
Which communication system was used? | Radio and telephone | Descriptive |
Was a communication plan established before the mission started? | No | Result: 0 1: yes 0: no |
Was the plan applied? | Not applicable | |
Was there a regular and structured re-evaluation of the situation for the incident commander in chief throughout the different mission phases (continuous report flux)
|
no
|
See lessons learned
|
If so, where the results recorded in a timely and structured method (mission diary/ map of incident site)? | no | Result: 0 1: yes 0: no |
Was an infrastructure for communication between medical services, police and fire services established?
|
no
|
See lessons learned
|
Did police, medical services and fire services communicate regularly and effectively with each other? | Yes: the subsection commanders No: The incident commanders in chief | 1 2: yes 1: partly 0: no |
If so, which communication infrastructure was used? | Mobile telephone | Descriptive |
Triage | Data | Assessment |
---|---|---|
Was a triage algorithm used? | No specific algorithm was used. | Result: 0 2: the trained standard algorithm 1: any arbitrary algorithm, 0: no algorithm |
If so, which triage algorithm was used? | Not applicable The standard triage algorithm in Bavaria is mStART. It was not deployed by the rescue forces. | |
Δ t from arrival of first rescue services on scene until the start of triage? | Unknown | 2: immediate 1:delayed 0: no triage |
Who was responsible for the triage? | Emergency medical services | descriptive |
Where life saving measures delivered during the first triage cycle? | Yes | descriptive |
Δ t from arrival of first rescue services on scene and communication of primary triage result to the rescue headquarter | Δ t: 8 min | descriptive |
Were casualties treated according to triage priorities? | Yes | Result: 2 2: yes, completely 1: yes, partly 0: no |
Were casualties allocated to hospital according to triage priority? | Yes | Result: 2 2: yes, completely 1: yes, partly 0: no |
Casualty Care | Data | Assessment |
---|---|---|
Was medical care based on damage control principals? | No, there was complete resuscitative care provided | descriptive |
Was there a stepwise care provision according to the different sectors (unsafe sector: “Care under fire”; semi-safe sector: “Tactical Field Care”; safe sector: “Tactical Evacuation Care”? | No, the medical care was provided in the unsafe area (due to the circumstances explained above) | descriptive |
Were there any delays in medical care due to safety issues such as threats to rescuers? | no | descriptive |
If so, how long did it take until the last casualty had received medical care? | descriptive | |
Δ t from first emergency call until transport of the first casualty with triage category T1/RED to hospital | Δ t: 38 min | descriptive |
Δ t from first emergency call until transport of the first casualty with triage category T2/YELLOW to hospital | Δ t:41 min | descriptive |
Δ t from first emergency call until transport of the first casualty with triage category T3/GREEN to hospital | unknown | descriptive |
Δ t from first emergency call until arrival of the first patient with category T1/RED in hospital | Δ t: 48 min | descriptive |
Δ t from first emergency call until arrival of the first casualty with category T2/YELLOW in hospital | unknown | descriptive |
Δ t from first emergency call until arrival of the first casualty with category T3/GREEN in hospital | Δ t: 77 min | descriptive |
Δ t from first emergency call until transport of the last casualty with categoryT1/ RED to hospital | Δ t: 80 min | descriptive |
Δ t from first emergency call until transport of the last casualty with category T2/YELLOW to hospital | none | descriptive |
Δ t from first emergency call until transport of the last casualty with category T3/GREEN to hospital | none | descriptive |
Δ t from first emergency call until arrival of the last casualty with category T1/RED in hospital | Δ t: 79 min | descriptive |
Δ t from first emergency call until arrival of the last casualty with category T2/YELLOW in hospital | none | descriptive |
Δ t from first emergency call until arrival of the last casualty with category T3/GREEN in hospital | none | descriptive |
Δ t from first emergency call until last casualty found | Δ t:36 min | descriptive |
Δ t from first emergency call until identification of all casualties | Δ t:106 min | descriptive |
Documentation | Data | Assessment |
---|---|---|
How were the triage results documented? | EMS (Emergency medical service) Protocol | descriptive |
How was the casualty registration documented? | Computer based protocol | descriptive |
Δ t from first alarm until full identification of casualties and involved parties documented | Δ t: 106 min | |
Were injury report cards used? | Yes | Results: 0 2: for all patients 1: some patients 0: No cards were used |
Was the documentation complete? | No | Results: 0 1: complete 0: incomplete |
Rescue Forces | Data | Assessment |
---|---|---|
Was there an adequate casualties / operational force ratio at any point during the mission | yes | Result: 1 1: yes 0: no |
If so, was this adequate ratio lost again at some point (too many rescue forces)? | Yes, many of the rescue service forces were kept in reserve as a multisite attack was initially anticipated | |
Δ t from first emergency call until adequate ratio was reached | Δ t: 26 min | Result: 2 2: fast 1: with delay 0: never |
Were staff reservoirs built up? | yes | |
Was a structured replacement of the operational forces necessary? | no | descriptive |
Were the operational forces in concrete danger at any point? | yes | descriptive |
Were members of the operational forces injured during the mission | no | Result: 1 1: no 0: yes |
Hospitals | Data | Assessment |
---|---|---|
Δ t from first notification/alerting of the hospitals until arrival of the first casualty | Hospital 1: Δ t = 36 min Hospital 2: Δ t = 36 min Hospital 1: Δ t = 36 min | descriptive |
Do the hospitals have plans in place? | Hospital 1: yes Hospital 2: yes Hospital 1: yes | Result: 2 2: all 1: partly 0: none |
Were the emergency plans activated? | Hospital 1: no Hospital 2: no Hospital 1: no | descriptive |
Were the emergency plans successfully applied? | not applicable | |
When was the rescue headquarter informed about the capacity of the hospitals to receive and treat casualties? Δ t from first notification until capacity information | Hospital 1: 6 min Hospital 2: 5 min Hospital 3: 5 min | Result: 2 2: immediately 1: delayed 0: never |
Ratio between announced to actually delivered causalities | Hospital 1: 4/4 Hospital 2: 1/1 Hospital 3: 1/1 | descriptive |
Adequate allocation and distribution of causalities? | yes | Result: 2 2: yes - all 1: yes - partly 0: none |
Number of self-referred casualties | zero | descriptive |
Did the hospitals have a strategy in place to deal with life threatening mass casualty incidents? | Hospital 1: no Hospital 2: no Hospital 3: no | Result: 0 1: yes 0: no |
Psychosocial emergency care | Data | Assessment |
---|---|---|
Δ t from first alarm to deployment of the psychosocial emergency services | Δ t: 7 min | Result: 2 2: early 1: late 0: never |
Was the psychosocial emergency care coordinated through police and medical service? | yes | descriptive |
Was psychosocial emergency care offered during the days after the incident? | yes | descriptive |
Was psychosocial emergency care offered to rescue forces during the days after the incident? | yes | descriptive |
Was psychosocial emergency care offered to affected people during the days after the incident? | yes | descriptive |
Was there a felt/real hazard to the rescue forces at any point? | yes | descriptive |
How many casualties did receive psychosocial support? | none | descriptive |
How many uninjured affected people did receive psychosocial support? | 20 | descriptive |
How many members of the rescue forces did receive psychosocial support? | 67 | descriptive |
Results
Category: General Characteristics (Table 1)
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Is there a written concept for mass casualty incidents for the EMS?
-
Is there a written and comprehensive concept for dealing with life threatening incidents?
Problem Identified
Lesson learned 1
Category: Mission related data (Table 2 )
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When was it noticed that this was a life threatening situation for the operational forces? (Δ t from first alarm to notification)
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Δ t from notification until communication between medical rescue control centre and police control centre
-
Δ t from alarm until successful notification of all operational forces about life threatening situation
Problem identified
Lesson learned 2
Category: Organization of the scene (arrangement of the area) (Table 4)
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Was there a structured organization of the scene during the operation?
-
Was the organization of the scene adequate for life threatening incidents (e.g. unsafe and safe sectors, safe assembling areas?)
-
Did everyone know (police forces and operational medical forces) about the organization of the scene?Was the organization of the scene applied successfully?
Problem identified
Lesson learned 3
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Establishment of a common access route to the incident area used by police, firearm services and emergency medical services.
-
Establishment of a common arrangement of the area especially a common and safe deployment sector.
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Establishment of a common on-site command post.
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The incident area should be divided into an unsafe, semi - safe and safe zone with different modes of action within these zones.
Category: Mission strategy and tactics (Table 5)
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Which strategy i.e. “Clear up the scene”- was applied?
-
Which tactical plan of action was chosen?
Problem identified
Lesson learned 4
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Are there comprehensive management plans in place?
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Are these plans well known and well trained?
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Are there common drill and training possibilities?
-
Are there clear mission goals and strategies?
-
Is there stockpiling of the equipment and material?
-
Is this equipment and material readily available?
Category: Incident command system and communication (Tables 6, 7)
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Did the command processes work adequately?
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Did the incident commander in chief (medical) always have adequate information for repeated reevaluation and understanding of the situation (continuous flux of reports)?
-
Did the incident commander in chief (medical) have control of the subsection commanders?
-
Was there a regular and structured re-evaluation of the situation for the incident commander in chief throughout the different mission phases?
-
Was an infrastructure for communication between medical services, police and fire services established?
Problem Identified
Lesson learned 5
Discussion
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Lack of a common triage system
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Delayed access to patients due to security issues
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Communication breakdown
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The establishment of a national triage system.
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A better system for cooperating with the police forces in order to get quicker access to casualties.
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The improvement of the communication systems.
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Management of Uncertainties
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Management of Victims
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Management of Teams
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Communication
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The handling of war weapon injuries
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The implementation of the preclinical concept
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The handling of trauma in children
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The reaction to chemical weapons
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The assault on hospitals
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Medical treatment “Care under fire”
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Triage in hospital
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Terror attacks in rural areas
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The casualty identification approach
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Psychosocial emergency care provision
Limitations
“Response bundle”
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High priority communication between the police control center and the rescue control center via defined communication channels for the best understanding of the situation.
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Immediate definition of a coordinated and harmonised course of action by police forces and all other rescue services.
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For the first responders: Give immediate report to the control centre
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Arrangement of the area and management of the scene – definition and communication of the unsafe zone, definition and communication of casualty collection points, triage area (semi-safe zone) and safe treatment area (safe zone)
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Establishment of command and control structures
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Secure Communication
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Early Involvement of hospitals
Police Forces:
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Immediate threat diffusion
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Immediate estimation and communication of expected casualty numbers to the rescue forces
-
Start casualty treatment and evacuation from the unsafe zone to the semi-safe and safe zones - act as evacuation flow accelerator
Rescue forces:
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Establishment of triage and treatment area in the semi-safe zone
-
Fast triage
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Immediate treatment of potentially survivable life-threatening injuries (exsanguination, airway obstruction, tension pneumothorax) during initial resuscitation
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Identification of casualties with life-threatening non-controllable bleeding
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Prioritised and immediate transport of those “Priority 1” patients to nearby hospitals
“Preparedness bundle”
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Establishment of common (police and rescue forces) sense about mission goals
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Usage of a common language
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Common drill and training
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Predefinition of secured communication channels
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Stockpiling of medical equipment to treat penetrating bleeding injuries
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Stockpiling of transport equipment to maintain evacuation flow
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Secure communication technologies
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Prepare for uncommon threats (e.g. biological and chemical weapons)
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Prepare for children in mass casualty incidents
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Development of a common sense (police and rescue forces) about mission goals
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Definition of mission goals and strategy
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Managing the scene
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Command and Control structures
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Communication training between different disciplines
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Basic knowledge and understanding of different mission tactics
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Basic skills-training for the treatment of life threatening bleeding injuries
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Managing the evacuation flow