Page 97 - 2020 JSOM Winter

A Spanish Intentional Mass-Casualty Incidents
Medical Response Model

Delphi Consensus

Guillem Roca, RN* ; Luis Martín, RN ;
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Diego Borraz, RN ; Leticia Serrano, RN ; Barry Lynam, MD 5
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ABSTRACT
The increase in global violence in recent years has changed the These IMCI statistics are alarming not only in the United
paradigm of emergency health care, requiring early medical States; this is an international problem, as highlighted by sim-
response to victims in hostile settings where the usual work ilar incidents in Europe. The attack in Oslo and Utøya Island
cannot be done safely. In Spain, this specific role is provided by (22 July 2011) left 77 dead and 220 wounded. In France, the
the Tactical Environment Medical Support Teams (in Spanish, Charlie Hebdo attack (7 January 2015) left 12 dead and 15
EMAETs). The Victoria I Consensus document defines and wounded; the Bataclan attack (13 November 2015) left 137
recognizes this role, whose main lines of work are the emer- dead and 415 wounded; the attack in Nice (14 July 2016) left
gency medical response to the tactical team and to the victims 87 dead and 458 wounded; and one of the most recent at-
in areas under indirect threat, provided that the tactical op- tacks in Paris (12 May 2018) left 2 dead. The United Kingdom
erators can guarantee their safety. To reinforce the suitability has also suffered from various IMCIs, including the London
of this approach, we submitted the possible outcomes of this Bridge attack (3 June 2017) that left 11 dead and 48 wounded,
response model to a panel of national experts to assess this the Manchester attack (22 May 2017) that left 23 dead and
proposal in the different areas of Spain. The chosen research more than 800 wounded, the London attack (14 August 2018)
design is a conventional Delphi method, based on the con- that left 3 wounded, and yet another attack in London (29
tent of the Victoria I Consensus response model. The panel of November 2019) that left 3 dead. The attacks in Barcelona
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52 expert reviewers from 11 different regions were surveyed and Cambrils, Spain (17 and 18 August 2017), left 15 dead
anonymously; a high degree of accord was recognized when and more than 120 wounded.
the congruence of the responses exceeded 75%. Consensus
agreement was reached in all sections of the survey after two Despite the fact that IMCIs are events with a low probabil-
iterations. Specific contributions and recommendations were ity of occurring, they have a high psychosocial impact and
made to achieve unanimous consensus despite the population important consequences because of the perception of social
and resource differences in the country. Our results suggest vulnerability. An early and proper response can contribute to
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that the EMAET approach is useful in areas with short re- increasing the resilience of those affected. Focusing on this
sponse times. However, in more sparsely populated areas, this reality and following the Hartford Consensus as the major
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may not be feasible, and a more pragmatic response model international reference, new medical directives and opera-
may be suitable. tional responder roles are required, depending on the internal
needs of each emergency service organization. In Spain, this
Keywords: Spanish intentional mass-casualty incidents med- operational medic role is provided by the Tactical Environ-
ical response; global violence; response model; casualty ment Medical Support Teams known as EMAETs (in Spanish,
incidents Equipo Médico de Apoyo al Entorno Táctico). These teams
are defined by the specific training and competencies described
in the Victoria I Consensus report 9,10 and are an adaptation
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of the Tactical Emergency Medical Services (TEMS) and the
Introduction
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Rescue Task Force (RTF) to the Spanish context.
The increase in global violence has been a reality in recent
years. Forty intentional mass casualty incidents (IMCIs) be- The implementation of specific medical response teams must
tween 2014 and 2016, with a total of 92 deaths and 139 inju- always be planned in advance and executed in collaboration
ries, prove this. According to the US Secret Service, in 2017 with the police force. The reason for this is that the EMAETs’
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there were 28 attacks that left 147 dead; in the IMCI in Las main lines of work are the emergency medical response to the
Vegas alone, 58 people died and 869 were injured. In 2018, 27 tactical team and the victims in areas under indirect threat,
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IMCIs took place, causing 85 fatalities and 128 injured, and provided the tactical operators can guarantee their safety. 13–15
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in 2019, 175 IMCIs resulted in 184 deaths and 673 injuries. 4 This operational approach allows for most prevalent critical
*Correspondence to guillemroca@gencat.cat
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1 Mr Roca is a registered nurse in Special Intervention & Support Unit EMS, Catalonia, Spain. Mr Martín is affiliated with the. Spanish Army,
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Almería, Spain. Mr Borraz and Ms Serrano are registered nurses affiliated with the Zaragoza Fire Department, Zaragoza, Spain. Dr Lynam is
affiliated with the Special Intervention & Support Unit EMS, Catalonia, Spain.
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