Podcast – Care in the Hot Zone with Claire Park at Tactical Trauma 2024

   I’m going to talk about learning for and from, civilian incidents. But I’m going to include some military experience, my own. I was in the Army for 23 years I’m also the chief investigator on a UK trial looking at learning from terrorist attacks, both the patient data and also interviews with responders to terrorist attacks. But more importantly, nationally and internationally, learning from all of the incidents we’ve had, and particularly conferences like this, where you meet people who work in the same field. There isn’t a lot of published evidence, and I think most of our learning comes from talking to each other.

So just to start setting the scene, I’m going to talk about hot zones. So one of our incidents in the UK that was a hot zone was the London Bridge attack where the attackers, if you don’t know, drove over the bridge, came back again onto the pavement, hitting a lot of pedestrians. Somebody went up and into the water and sadly died. And then they crashed the van they were driving into the corner of the Barrowboy and Banker pub and ran through the market stabbing people until they were outside the Wheat Sheaf pub.

This is a video of the attackers attacking that one of their final victims and the armed police arriving. Some of you will have seen this video before. Just think about putting yourself in the position of a paramedic arriving to what they thought was an RTC on the bridge and they find themselves one road down from this surrounded by people who’ve been stabbed and the next thing they hear is a lot of, shots being fired. You don’t know who’s firing the shots. and you don’t know, What’s going to happen next? Probably, I think, 48 shots were fired something like that. you’ve, once you start hearing that, you don’t know whether you want to stay or go.

 As you could see, the attackers were stabbing with a huge amount of force, and this is a busy Saturday night. It’s 10 o’clock, in the middle of London. That paramedic was around the corner, found himself surrounded by sad patients wondering what to do and at the same time there was some unarmed police, our response police, running down those steps after they’d crashed that van, maybe just a couple of minutes later. Those unarmed police officers, from our interviews with them said they heard a commotion screaming and naturally as a copper you run towards it.

They only had batons to protect each other and they knew that there was a chance a terrorist could come back. They ran down the steps and were faced with multiple casualties, taking it in turns to protect each other with a baton. And at the same time that paramedic on his own found that he had all of these patients, he knew some had died, some were dying. Common sense said I need to get out of here. I don’t know who’s attacking who what’s going on. But at the same time he knew he couldn’t because there were police there and members of the public there. And so he stayed. He knew ambulances weren’t coming and so one of his first patients he put in a police car And that was a 35 year old lady who had multiple stab wounds She arrived at King’s 37 minutes after being injured which was at least 20 minutes before the first casualty left the casualty clearing station. And she had blood given, went straight to theatre after having her chest decompressed, and had 3 litres of blood in her abdomen and 2 litres of blood in her chest. He accelerated her chance of living and got her to hospital alive, and there’s no doubt she wouldn’t have survived if she’d stayed on scene.

We’ll come back to the idea of flow acceleration later on. Going back to the concept of a hot zone. So what actually is a hot zone? London Bridge attack was that area of Borough Market was called a hot zone for 12 to maybe 15 hours. Despite there being no active evidence of a direct threat to life, because they thought there was a fourth attacker.

There were lots of things going on, there were distraction calls, they thought there was another attacker coming from the north side of the bridge. that’s not unusual, anyone that’s read any of the after action reviews from Las Vegas will have read about the thought that there were multiple attackers in other hotels, there were people running down the runway, they thought there was a shooter on the runway.

So in all of these events this sort of thing happens. And as one of the fire officers from Manchester Arena said, when we’re looking at hot zones actually what prevents us going into the hot zone and from treating people in there is calling it a hot zone in the first place. Now sometimes that might be accurate but what actually is a hot zone and if you look at the, certainly the UK definition that we have in our guidelines, it’s a direct threat to life.

And from the policing point of view, they will be looking at somebody actually firing shots or actively attacking people. And obviously if it really is a hot zone, there’s minimal care that can be possible. The concept of care under fire, direct threat care that I don’t need to tell many people about here. and dragging people to cover, maybe chucking them some tourniquets to try and help them while you neutralize the threat. Primarily for police officers for each other in the first instance, but then also for members of the public when they have capacity, once the threat is neutralised or there is no longer a threat in front of them. Just moving on to one of our other incidents, Fishmongers Hall, this was a known attacker. It was someone who was attending a learning together event at Fishmongers Hall. and in fact, there’s a picture of him sat there at the table with one of the victims that he sadly killed. He ran down the stairs and came out of the toilets with knives and started stabbing people and the response was actually a lot of really good things happened in that incident. The bystanders stopped him, tried to treat the people that were injured, as did the police. The reason I mention it, is it’s often quoted as two years after London Bridge, a reason why things are much better, and lots of good things did happen there. The RVP was at the cordon, which allowed face to face communications from the police to the health services that arrived once they’d made it to warm zone. And they made that warm zone decision quite quickly because they had the learning of trying to get people in to save lives and they knew they needed to get health in. They were unsure about the safety of the IED, they’d had an indication from the dog that it was safe, but they weren’t 100% sure, but they decided the distance was enough to get people in to save people that they knew were in cardiac arrest or try to. And as I’ve mentioned, a lot of other things happened and we had critical care in there very quickly.

But it wasn’t an MTA, it was a single attacker who was known to all of the people attending that meeting. He was neutralised fairly rapidly. It wasn’t a London Bridge style attack. I’m not sure that we’ve got past at least having a hot zone for a period of time in a London Bridge style attack again because of the unknowns.

So whose decision is it that it’s hot zone? What risk? That depends on who’s there at the time and who’s making the decision to a certain extent. Some of our researchers also showed that some people suggest that perhaps you may just communicate what the risk is rather than calling a hot zone So this is a response police officer from Manchester Arena who said actually maybe we should have just given people a quick brief. Do you want to go in these are the circumstances? This is what could happen at least give them the option of going in if they want to. And that’s certainly something that we’re thinking in terms of our clinical response to major incident groups that we’re looking at in the UK and considering the idea of a,almost a default to go in unless someone says not to go in as opposed to the other way around.

So what about risk? We all take risk every day when we’re working in pre hospital care. There’s an inherent risk to ourselves. on every, any scene and we make a balanced risk assessment as to whether it’s safe to go in. There’s also the professional risk of the decisions you make about patients. You don’t necessarily think about the inquest on a day to day basis. You think about it in a major incident, but it is always there. And then the psychological risk of the decisions we make. If we decide not to resuscitate someone, that’s a bit easier when there’s one patient and you know that you’ve done everything. It’s much harder when there’s multiple patients, but that psychological impact of going home and knowing you’ve done everything you could, or maybe wondering if you hadn’t, is something that a lot of people suffer from.

So how do we assess risk to ourselves? What risk are we willing to take with patients lives by delaying going in versus our own life by going in?

And I’m not suggesting people should run in without thinking about it, but there’s an argument to think about the idea of the 40 70 rule. That being If you have less than 40% of the information, maybe it’s not enough. But once you get to more than 70%, perhaps you’ve waited too long and you risk decision inertia.

And that’s something that we should avoid in these situations. It’s obviously really easy to look back when it comes to the inquest and you have all of the information. But just a reminder that you’re never going to have all the information when you really need to make that decision.

Obviously, we’ve got to understand the potential risks, have the appropriate PPE to get in there. I’m not suggesting people go in unnecessarily, but I think we have to think about what we’re doing. And the idea of where you’ve got separate emergency services achieving a shared mental model is something that we’ve seen in our research is not always the case, even if everyone’s aiming at the same thing in the end.

And communicating the information and risk has also been a problem. In the UK, we have three separate services on different radio networks, different standard operating procedures, different appetites for risk and understanding of threats and different commanders in charge of them. So that commander is making a decision for the people they put in. And so that is also a consideration that it’s harder to make a decision for someone else than for yourself to go into that zone. And the communication between services has to be face to face because we don’t have radios that allow us to speak to each other on the scene. It only has to go over via the control room and come back.

So there will always be a delay. It was 17 minutes at Fishmonger’s Hall, but that’s probably the quickest it’s going to be from point of injury to getting health care in.

Obviously, everyone has different TEMS models internationally, and there’s a lot of people here that have integrated TEMS teams within their teams.

services and that the benefit I think of clinicians integrated within police teams is such as we’ve seen in incidents like the Bataclan where the RAID doctors went in with the RAID operators. They arrived and six minutes later they were inside the orchestra pit, the doctors triaging the casualties even while the hostages were still being held by the terrorists.

And that comms, that integrated training, all of that does overcome some of the problems of three separate services, but there are different models that work internationally. But thinking about time, and making the most of time, the idea of the death clock.

What we’re trying to do is save people that are potentially savable. And for some casualties, that death clock is really short. For some, they’re unsurvivable, whatever, it’s not going to make a difference. And some will be fine, whatever you do. but for others, they’ve got a death clock that is, that’s ticking.

And that death clock is what we really need to look at, identify the people with one that is ticking, that needs something doing about it, to try and slow it down and get them to hospital alive. And it’s the survivable injuries that we’re most worried about. This is a, this is all cause of, bleeding.

It’s not specifically from terrorist attacks. it’s a graph from John Holcomb’s paper. Looks at a consistent curve of death and patients that are bleeding to death from internal bleeding. And the green star is the opportunity in the pre hospital environment to stop that. The yellow star is the opportunity in the ED and the red star is the opportunity in the operating room.

And I think it’s really interesting to look at that time. Average time to stopping bleeding from point of injury to being in the operating room is 2. 1 hours. That takes into account prepping, draping the patient and getting knife to skin and haemorrhage control. That’s quite a long time when you can’t afford to waste any of that time pre hospitally, particularly when you can’t get a patient out or get into them, we have to really think about that.

 So what can we do to try and stop, slow down, because we can’t always stop that death clock. Initially, triage,but probably more importantly than triage, life saving interventions, and it won’t surprise anyone to know that I’m going to say that 10 second triage is a good recommended triage tool that we’ve developed, that does allow people to have a framework to stop death clock from catastrophic haemorrhage and airway, and also start that flow of casualties, by having the P1s being moved out. Minimising other treatment, so bridging interventions what I mean by that is minimal interventions to just allow us to get casualties out, not anything more until they’re in a place where you can then provide damage control, pre hospital care is what we started to call it in London, but essentially targeted interventions, that allow the patient to get to hospital alive, and it’s not going to be your definitive care. It’s not going to be a full RSI or full chest drain. It might just be a thoracostomy with a chest seal over it, and getting them to definitive care as soon as possible. And those patients that really need something, we’re calling P1 pluses.

 Ten second triage. Briefly, the reason for this, it gives you a framework to approach it. It allows simple questions that ask the end organ effects of the physiology. So you don’t need to measure the physiology. It focuses on the life saving interventions in the blue diamonds.

it includes non compressible haemorrhage as a risk for getting out quickly and needing to be a P1. It doesn’t mean you have to pronounce someone dead in 10 seconds without really thinking about it. and if everyone’s using it, it’s a common language used by everybody.

The bridging interventions I talk about, we’ve published in a paper, but essentially it’s the idea that the only things that are really going to make a difference after that cat hemorrhage and airway are splinting to stop more bleeding from broken limbs, analgesia, because with every step you take, some patients are in pain, it takes you much longer to move them out.

 Getting some form of analgesia or Penthrox, fentanyl lozenges are easy because you don’t need IV access, but you may need IV access to give them decent sedation to splint them properly. And then anything that you really need to do, like,pain relief, IV access for blood or TXA to get them out.

And then, getting that. early critical care decision making forward. Because actually the thing you can’t put into an algorithm is that clinical decision making that we make knowing what is killing someone. You build that over years of experience. So having that senior clinician making the decision about P1 Plus.

Repeated lesson we’ve had is people being carried out on barriers and the lack of stretcher availability. So both at, Manchester Arena and the Bataclan everyone was carried out on barriers and hoardings. That takes a lot more people, is a lot more uncomfortable for the people being carried out.

And in both instances, they’ve commented on not having stretchers, even though they had them maybe outside, they just weren’t used. So we should try to remember that. And carry sheets or simple lightweight stretchers can be flow accelerators, along with the analgesia. again, it’s a bit of a soapbox thing of mine, but we, no one in the UK will give analgesia in the hot zone until you’ve got critical care there at the moment.

So even the police will be doing something else at that point. And then coordination of the evacuation, so directing who needs to go out first, getting a senior clinician maybe to do that with good command and control and using police or fire, as well as maybe bypassing the CCP for your P1 plus patients.

So what about the way forward? What evidence is there about what we should be doing? We do have information available, but it’s not really joined up, certainly in the UK, we don’t have good data sharing on this. especially multi agency, often police are there first, and apart from inquests and inquiries, where all of the witness statements and all of the body worn footage and, CCTV footage is looked at, we don’t have really good data available to tell us all of that information.

We’ve done a systematic review, which is not published yet, but in the process of being submitted, on all of the published data about actual causes of death. What’s actually killing people in these incidents? And there’s only nine papers despite all of the incidents in the world. There’s nine papers that actually tell us about modal mechanism of death from the incidents there. Four firearms papers covering 27 incidents in the US. Two covering blasts, one bladed weapons from Israel. It does actually tell us about one particular patient’s injuries. The Mumbai attack and the Berlin vehicle as a weapon, but it really, most of those are limited to the anatomical location of the injury, they don’t tell us what’s actually killing them, they just say chest, abdomen, pelvis, for instance. They don’t tell us what injury track, what vessel, and the ones that do talk about potentially preventable deaths are mainly the ones from Reed Smith and his group from the U. S., and they do look at chest injuries and identify that potentially there is tension physiology there as a cause, but that’s by exclusion because there was no large vessel injury as opposed to actual post mortems proving that.

We don’t have really good information, sadly even from not that long ago, 7/7 in the UK, post mortems weren’t carried out on our, on the patients. So we only have evidence from external examination of the patients and witness statements that were written at the time. London Bridge,more recent incidents in the UK, this was one of the patients that those police officers who went down the stairs went to in the Borough Bistro, Sebastian.

Sebastian had been talking initially when the members of the public got to him. When the police ran down the stairs and they got to him a few minutes later, he stopped talking, was breathing and then became agonal and they ended up doing CPR on him. They were with him for 14 minutes because they thought ambulance were coming and they didn’t because it was a hot zone.

So they ended up carrying him up to the ambulance. Sebastian had lots of injuries, but Ben Swift, who is his pathologist that gave evidence at the inquest, said he felt that the fatal injury tracks were to his right lung, so to his right middle and lower lobe of his lung. He also had other injuries that just nicked the diaphragm, just nicked the liver, but there was no significant bleeding. He had small bowel injury and some defensive injuries, but again, nothing that he thought was fatal and Ben said if he thought of a pre hospital enhanced care team had been literally next to him at the time, they could have saved him by giving him blood, IV access, decompressing his chest, and putting him off to sleep and ventilating. So clearly in this incident, nine minutes is not very long, but that’s the kind of information we need to know about what we need to do for these people and what we should be doing to save them.

I’m sure a lot of people actually would have seen this picture of Manchester Arena and the volume two looked in depth at the inquiry response to patients that we know about in terms of injuries from there that open source in volume two.

John Atkinson. In terms of his injuries, John was only 28 when he died. He went into cardiac arrest an hour and 16 minutes after being blown up.

And he was in the casualty clearing station at that time. He had compressible injuries. He had penetrating fragments to both of his legs. the muscles, the blood vessels, multiple fractures to both of the legs, which would have been compressible with tournaquets. So that’s really important learning that we know we still are not treating compressible haemorrhage and probably because he didn’t have amputations, I’m guessing people didn’t know that they needed to put tournaquets on his legs.

 Zafi was the other potentially preventable death but this was highly debated with six or seven days of multiple experts looking at it. Her injuries, her named vessel injuries were popliteal arteries bilaterally. She had multiple fractures to her legs.

She did also have some blast lung injury and other injuries which it was debatable about whether she would have survived but potentially had she had earlier haemorrhage control. Again, it was difficult to see because she didn’t have obvious bleeding out. She was bleeding inside her legs. and they felt that she may have survived.

So bringing that brings us onto the question of survivability. And what do we mean by that? There is no guidance on what we mean exactly by how we assess survivability, certainly with patients in the UK in this situation. A recent, report was published in September. by an independent review of forensic pathology in response to a government paper on the Hillsborough, inquests and what the families had to go through, through multiple inquests there and they’ve identified that this all needs to be looked at and we do need some guidance. And we’ve been doing this work as part of our research project, looking at a literature review. The most common definition seems to be that survivable would be based on, it’s almost a two stage question, survivable is based on anatomical injuries. So is that injury survivable in any circumstance with the best treatment? And then the preventable bit would be in the circumstance that you found them. So considering the situation, the comorbidities, their frailty, and available resources. But survival to what is not defined? Are we talking about hospital discharge? Are we talking about 30 days? Are we talking about a year? The terminology also can be potentially impactful for families when you say it’s a preventable death. So we do need to think about what that looks like, and we definitely need our family liaison clinicians to be part of this working group to look at this.

There is a WHO criteria for the categories of preventable, potentially preventable, not preventable, but that’s based on, middle to low income countries, which are probably not appropriate for us in the UK, so those criteria probably need to be modified. But we certainly think they should not just be forensic pathologists, it should include people that see these patients every day. So include pre hospital physicians, emergency physicians, trauma specialists. And the other really important element is the multi agency data. So this is not currently in the UK collected and joined together. Our research project took me two years to get data sharing agreements between police, ambulance and fire just to access all of that data.

And there’s such rich data from the police body worn footage, the CCTV and the bystander reports about what actually happened to patients before we ever got there as healthcare professionals. We really need to be recording that in a better way and sharing it. with the forensic pathology information and with the healthcare information as well.

and that’s what we’re hoping to publish on soon. But just coming back to the element that is probably more important for all of us, is we’re all human. Academic research and knowledge is really important, but ultimately, the thing that’s going to allow us to do our jobs is the human factors. Everybody that gave evidence at the Arena Inquiry described the overwhelming sense of just being hit by the noise, the sounds, the smells, the body parts, and even if you knew what to do, it’s really hard to make yourself do it.

Matthieu Langlois in his book, Medecin du RAID, describes walking into the Bataclan and describes being completely, even though he’s trained for this, and prepared for it, being overwhelmed by what he saw initially having to triage the, I think it was 89 dead from the, 100 alive patients in the orchestra pit.

And he said he really had to get over himself. And for him, speaking to him about it, that’s one of the most important things of this is understanding your behavior, but also that of patients. They had to, in the Bataclan, really engage with patients who’d been lying, pretending to be dead under people who were dead, to get them to get up and walk out, even though they weren’t injured.

So try using more than just your clinical assessment but also your ability to engage with people is really part of that whole. Overcoming the human aspect of it and allowing us to really do our job. Having a framework can help, so something like TST gives you a starting point and almost probably a bias to action to get doing something, we hope, But also authentic rehearsal, so some of the stuff that we’ve done is really getting people to believe that they’re in that environment, it’s still really difficult because, you never really believe that you’re in danger when you know it’s an exercise. But you can certainly believe if someone’s really good at acting, you can believe the emotions of the relative that’s with them. Actually, people that are really sick don’t shout and scream, they’re really quiet. And having that, really authentic behavior and look, the pallor, the sweating, the injury patterns, having to make a decision, this was some police officers deciding whether to go onto a track or not when we had some students playing,very sick patients with agonal breathing, can really make you think about it.

So really reflecting that human impact of every case and rehearsing the emotional response, you know how that might affect your decision making is probably the best that we can do as well as understanding what people go through. It’s the human factors that allow us to do our jobs. Overwhelming nature of these incidents, we can somewhat prepare for anticipate and have flow charts to overcome some of this stuff, but hopefully something to prompt the ability to start doing the basics well and ultimately, hopefully the rest will follow after that.

 Thank you very much.