Page 60 - JSOM Spring 2025

the time the conventional prehospital teams received clearance viewed as a breach of the tacit contract between police, cit-
to enter the Bataclan Concert Hall. The teams then discovered izens, and the State. The counterargument was based on the
89 fatalities. 10 need for safety and planning to ensure a safe mission. Embed-
ding paramedics into PTGs supports all-agency planning. The
Owing to the mismatch between the number of casualties and Queensland Ambulance Service Special Operations Response
clinicians within the hot area, the RAID physicians decided Team (SORT) consisted of specially trained paramedics to re-
to manage walking casualties before treating patients with se- spond to high-risk police incidents with the Queensland Po-
vere but accessible injuries. The physicians did not complete lice Service (QPS) Special Emergency Response Team (SERT).
all the concepts of damage control resuscitation, and multiple SORT was responsible for responding to high-threat incidents
casualties did not receive damage control resuscitation. This such as an active armed offender, counter-terrorism responses,
resulted from the mismatch between the number of casualties, and similar taskings (QAS SORT was disbanded in 2010 due
the tactical physicians, and the insufficient medical equipment to political issues). Anecdotal evidence from the QAS SORT
available within the hot area. 10 and QPS SERT partnership showed a significant decrease in
the risk profile of operators and target persons when an all-
These Paris treatments were nothing more than what an Aus- agency plan was developed. If the target person was known to
tralian ACP can do, does daily, and have done for 20 years in the police, the paramedic could make a rudimentary, indirect
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the standard TCCC interventions. This analysis showed that medical assessment from available intelligence. The author
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the higher-level clinical care that physicians or high-acuity para- was involved in several such assessments before tactical action
medics are capable of could not be undertaken in the hot/warm was taken, benefiting the target person’s health. This planning
areas; instead, solid LSI techniques were performed. Analysis time allows higher-trained clinicians to set up in the cold area.
showed that 58% of the total injured (196 casualties) came
from the Bataclan Concert Hall. A total of 262 casualties were Procedures have been developed across the globe to support
triaged during the prehospital phase; 13 (4%) received orotra- medical responders operating in hot areas. SAMU embraced a
cheal intubation and 9 (3%) catecholamine administered. 9 proactive and contemporary mindset to mass violence events
and developed and exercised treatment protocols for such in-
cidents. On the morning of 13 November 2015, SAMU exer-
Results
cised these protocols. An after-action report highlighted that
The value of this case study lies in the significant differences the training received by emergency and medical workers was
in prehospital clinical responses between France and Austra- a key factor in treatment success. Evidence presented by Dr.
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lia. A lessons-learned paper on the Paris attacks acknowledges Langlois and other doctors during the MAI stated that only
the uniqueness of the French prehospital system and highlights experienced physicians or “level 8 consultants” were suitable
that other countries can learn from these attacks. The Parisian to ensure rapid and safe patient flows from threat zones during
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prehospital system is physician-focused, easily allowing the mass violence events. However, Dr. Langlois also acknowl-
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embedding of physicians within the PTGs. It is suggested that edged that a good paramedic is better than a bad physician.
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the skillsets used by RAID physicians are similar to those of Differences between French and Australian services are noted
Australian ACPs, who perform at a very high competency level. here; Australian doctors are rarely solely responsible for pre-
hospital triage, which typically falls to the most senior clinical
Supporting the thesis that higher clinically trained person- paramedic. Lt. Col. Claire Park indicated that only an experi-
nel are best suited to operate in the cold area, conventional enced clinician, typically a doctor, can make triage decisions
prehospital teams can be supervised by an emergency physi- in a tactical environment. However, paramedics routinely
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cian, a procedure also used by RAID. This allows for high- identify the need for LSIs and rapid transport to hospitals in
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quality clinical leadership to a larger cohort of paramedics, normal operations. Throughout MAI, it was emphasized that
as opposed to a few PTG medics within the threat zone. Ex- only doctors were suitable clinicians within a threat zone. This
sanguination remains the primary cause of mortality with raises questions about workplace health and safety, selection,
high-velocity weapons. Tourniquets, hemostatic dressings, and training, and cost benefits of deploying assets correctly.
rapid transport for surgery form a simple and efficient treat-
ment regime. This paradigm casts doubt on the clinical ben- Dr. Thomas Peter Hurst, medical director of London Air Am-
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efits of having the highest-trained paramedics and physicians bulance, stated that a small group of patients (estimated at
within the threat zone. These highly trained clinicians are more less than 1% of all emergency patients) require interventions
beneficial in cold areas, where they have significantly more that core paramedic practice cannot provide. This statement
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time and resources to perform or oversee complex treatments. is more relevant to Australian paramedics, as the London Am-
By the time the scene was declared safe for conventional re- bulance Service is staffed by paramedics with similar skillsets,
sponders, PTGs had extricated all surviving casualties to the training, and education. This supports the rationalization of
cold area. If current Australian protocols were applied to this maintaining physicians within the hospital system during mass
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response, the mortality rate might be higher due to the ther- violence events. Allocating valuable resources for the 1% of
apeutic vacuum created by the staging protocol (waiting in a patients in a mass casualty event can be detrimental to the
safe area for the scene to be cleared). The time taken to wait majority of the injured, already-hospitalized patients and the
for threat neutralization is detrimental to the survival rates of injured self-presenting to hospitals.
casualties with survivable injuries; this is a risk with the Aus-
tralian Ambulance Service’s staging protocols. Dr. Langlois referred to patient flow and reducing stop points
from the scene to the appropriate hospital. The success of the
After-action reports questioned whether the safety of police response was attributed to the rapid clearing of casualties from
was prioritized over civilian safety and if the 2-hour delay in the threat zone to the cold zone, facilitated by RAID physi-
initiating emergency action compromised lives. This could be cians’ rapid triage and operational information sharing with
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58 | JSOM Volume 25, Edition 1 / Spring 2025