Madrid 11-M análisis preliminar respuesta sanitaria prehospitalaria

Presentación del tema: "Madrid 11-M análisis preliminar respuesta sanitaria prehospitalaria"— Transcripción de la presentación:

1 Madrid 11-M 2004 análisis preliminar respuesta sanitaria prehospitalaria
Good afternoon. My name is Alfredo Serrano, emergency physician in Madrid. That day, Madrid sent a silent cry,my friend’s cry, my brother’s cry, my cry, your cry, everybody’s cry. I’m going to show you some points of the preliminary March-11 analysis draft, based in still partial data. Alfredo Serrano Moraza María Jesús Briñas Freire Andrés Pacheco Rodríguez Alejandro Pérez Belleboni

2 Medicina de Catástrofes basada en la evidencia
MeCaBE A. Pacheco, Oct. 2004 “The conscientious, explicit, and judicious use of current best evidence in making decisions about the management of disasters” Badenoch D. Evidence-based Medicine Toolkit. BMJ Books 2002 Jeffrey Arnold, MD Yale New Haven Office for Emergency Preparedness and Disaster Response

3 Metodología MEBE Máximo rigor
Control estricto de las fuentes de información Se nombran SIEMPRE Se indica cuándo la fuente es menos fiable Se indican como estimados los datos no totalmente contrastables Cualquier hipótesis debe resistir su contraste científico Metodología exhaustiva Sólo se utilizan cuando su aportación es crucial no se dispone de datos fiables Whe outline this is a technical document strongly bound to these general principles. Our principal aim is to make some light on some specific lessons from that day. Numerosísimos intervinientes Pendiente recogida metodológica de información hospitalaria

4 Principios generales Abordaje científico Imperativo de respeto
Principios éticos “Aprender de nuestros errores debe tener prioridad sobre la adquisición de nueva información” McIntyre N, Popper K. Br Med J 1983; 287: Sin críticas para los profesionales sanitarios (y otros), voluntarios y público ...para poder crecer Whe outline this is a technical document strongly bound to these general principles. Our principal aim is to make some light on some specific lessons from that day. Sin imágenes crueles de las víctimas ni datos confidenciales Sin luchas internas Sin publicación a la prensa no especializada Manteniendo el apoyo psicológico a pacientes, familiares y amigos

5 NO La emergencia sanitaria termina en la escena La clave
Mientras la emergencia policial y de bomberos, quizá termina en el foco La emergencia sanitaria NO termina en la escena La necesidad de coordinación de camas de críticos tiene impacto en la morbi-mortalidad de los pacientes As you really know, while Police and Fire-Rescue Emergency could, perhaps, finish on focus, EMS Emergency does not finish on scene. This is one of the milestones of mass-casualty incidents (MCI) prehospital assistance. It’s the key for integrated work. After initial units dispatch efforts, this was the preferential Coordination Centre work. Indeed, critical-bed needs coordination has impact on patients morbi-mortality. Up to date, our present data suggest this could happen on March-11.

6 NY 9/11 vs. Madrid 11 de Marzo Casi uno / varios focos
9/11 McKinsey report 9/11 Commission full report Ausencia de informe oficial Casi uno / varios focos Pacientes críticos casi ausentes / sobrecarga Modelo EMT-Parameds. / medicalizado Ausencia de víctimas entre el personal de emergencia Otras SUH etiquetas rojas We begin showing the principal differences between NY 9-11 and Madrid March-11. Our comparison data arise from NY McKinsey’s report. Specially, in March-11 our prehospital system took directly care of more that 500 patients. Hospital registers show 1430 patients assisted in the first 24 hours. The total amount rises to approximately 1900 total patients. In NY 9-11, these patients did NOT arrive at ED Hospitals. Finally, our prehospital model, a more european modelo, is physician-based from the begginnig, with essential changes in prehospital care. Capacidad de respuesta 100 % real operativo extraordinario Máx. total

7 Puntos de intervención
Objetivos ideales Puntos de intervención Trabajo óptimo en los focos Llegada en tiempo Triage prehospitalario medicalizado y estabilización Transporte adecuado en tiempo, medio y modo Promover adecuación hospitalaria del nivel de cuidados Coordinación camas de críticos Prevenir sobrecarga de los SUH Reducir evacuación masiva y Scoop and run y sus consecuencias In this figure we show our ideal aims in global assistance.

8 Colaboración ciudadana
Estuvieron presentes desde el primer minuto Ö Muchas víctimas atendieron a otras Ö Incluso llegaron a hacer torniquetes in situ Ö Sus historias son muy ricas en aspectos técnicos y humanos Ö Evacuación masiva y Scoop and run Ö x Salvaron muchas vidas y, quizá, nuestra imagen Causas Gran número de heridos, algunos muy graves Retraso inicial EMS (cuatro focos) Algunos accesos difíciles Consecuencias Diferencias en datos EMS-SUH (en parte) Transporte no asistido de pts. graves No siempre fue la peor opción Baja mortalidad in itinere (2 pacientes) Citizen’s collaboration was of critical magitude, even from the begginning. They were present from the first minute. Someone traveled in the same train. Some others were next to the focus. Gardeners, Security personnel and other City workers helped as hard as they can, even until physical and psychological extenuation. Many victims cared for the other ones. Many of them refused care in benefit of more severe wounded people. They were responsible for the Scoop and run, with variable consequences. Only two people died in car transport. A police car, arrived in the first minutes at Santa Eugenia, loaded four critical patients. One of them arrived dead at ED because of an exanguinating femoral section. The other one, a pregnant young woman, survived for ten minutes. An emergency cessarean procedure could save her baby but only for one hour. However, most of critical patients arrived at ED by this way needed initial advanced inhospital care. In our actual job, we’r trying to know if scooped patients were the least critical ISS scores in every focus, or perhaps there were some other factors for scoop as unconsciousness, heavy weight, or so. Citizens really saved a lot of lives and, perhaps, our image. They really contributed to accelerate care and evacuation. Madrid, I love you (Forges). Diferencias en el ISS ?

9 Ciudadanos 2

10 Activación 1 Unidades sanitarias
Dos servicios diferentes – dos Centros de Coordinación diferentes x SUMMA 112 Hora punta y de relevo: doble guardia Muchas unidades sin camilla (ej: coches rápidos) x No sistema de llamada en grupo por cualquier vía (teléf/radio/otros) Ö Se dio preferencia a enviar las unidades x Difícil registro en tiempo real x Ausencia de software específico de catástrofes Más personal – enorme colaboración Incluso personal del Centro Coordinador Quizá mayor confusión en los focos ? Ö x Our analysis begins with call receival and units immediate activation. SUMMA 112 Centre (SCU) work is nowadays subjected to some deficiencies. At 7:39 SCU begin to activate units one by one. This is not a problem in day work, but incoming call overload, the concurrence of four focus and all this work revealed the imperious need of group calls for future incidents. This problem has not been solved, yet. In this scenario, SCU operators gave preference to send units, what disturbed real-time registering tasks. As a consequence, initial activation times were not always exact, and many units’ focus specific register was mistaken. At this time, EMS is double-shifted. This won many many health workers for the job. All available additional personal was sent fo different focus on wheels. Even new teams went to focus by taxi or own cars. SAMUR even doubled workers number. Specially, at focus arrived a lot of units without inside stretcher, what became ambulances a critical factor for casualties evacuation. Ambulancias: factor crítico x

11 Activación 2 Personal no de guardia
Activación variable del personal que no se encuentra de guardia Ö SAMUR tiene protocolo - x difícil de cumplir en tiempo real SUMMA NO tiene protocolo x TV / radio difusión Dependiente de Disponibilidad personal Calles libres/atascadas Favorecido por red de policía y colab. ciudadana x We have no protocol for no-shift activation, what makes this task to be highly variable. Home workers’ recruitment is, then, dependent on external factors, such as TV/radio diffusion, individual availability, clear city ways and so. It was really favoured by police network and citizens collaboration. Many patrols guided health workers who asked for it. Police communications network ordered “open cordon” for particular sanitaries to get into. Many other no-metropolitan polices and firefighters services offered their efforts. Ö La realidad: Todo el personal disponible acudió a ayudar Algunos al Centro Coordinador, otros a los focos

12 x Cuatro focos Uno de los factores más determinantes del resultado
Difícil de prever Las unidades EMS penetraron en zonas calientes EN EVOLUCIÓN Cada foco necesita un análisis individualizado contra toda recomendación académica, sabiéndolo cuando se encontraban prácticamente solas mientras la población hacía lo propio La solución quizá pueda ser difícil Perhaps, the most determinant factor of success was the presence of terrorist attacks on four different and simultaneous focus. In fact, we spent some minutes to discover this reality. In every focus, EMS teams do really penetrate in hot evolutive areas. This was accomplished even against all academic recommendations, they kew. Although this needs a more complex and internal analysis and debriefing work, we think it’s very difficult to solve it, specially when EMS units frequently were almost alone in their areas and lay people also broke security limits. Nevertheless, every focus work needs an individual advanced analysis. We show some data in next slides.

13 De nuevo, telefonía fija en los focos
Comunicaciones SUMMA Radio Teléfono UHF (personal mobile radio) Trunking Fijo (en las bases) x limitado Ö baja saturación Inalámbrico (GSM) Ö x casi al 100 % en los primeros 40 min. Ö red abierta x no walkies x ahora en red cerrada x baja rentabilidad x compartido con CYII De nuevo, telefonía fija en los focos cabinas, bares, etc. Consecuencias Soluciones de fortuna x Difícil asignación de cama x Difícil reenvío-redirección en caso de otro/s foco/s o cambios en los ya conocidos Ö x Frecuentes mensajes por la red Ej: ”A todas las unidades: el Hospital X está saturado...” Ö x de nuevo, telefonía fija en los focos cabinas, bares, etc.

14 Advanced support 18 31 13 8 + 1 Coord. (4-8 coord.) 11 2 mICUS mICUS
Phys + Nurs + 2 EMTs 31 mICUS Phys + Nurs + 1 EMT 8 + 1 Coord. Phys + Nurs + 1 EMT VIR 13 (4-8 coord.) VIR Phys OR Nurs + 1 EMT Phys + 1 EMT usually for home non-emergency medical visit UAD 11 2 Phys + Nurs EMTs + pilot/mechanic HEMS Total approx. 80

15 Basic support 48 conveniated ambulances SERMAS 47 SAMUR ambulances
32 Red Cross ambulances 20 Civil Protection ambulances 3 ambulances from SAMER N private ambulances + more than 100 vehicles (most SAMUR) for logistics and some other services 150 + N ambulances

16 Atocha SAMUR 2+13 8 - SUMMA 4 5 5 mICUs VIR UAD IC organization
Feedback information IC organization Dead 34 Total victims SUMMA/SAMUR 6 deceased in place 12 critical SUMMA 15 critical SAMUR 30 severe wounded Work time approx. 2h 7:49-8:00

17 Atocha 7:39, the first bomb explodes whit the train open-doors in a crowded station. The two bombs were separated for, at least, some seconds. When people in the same train went to help the other ones, then exploded the second bomb, Killing more people. It was horrifc for the first unit to penetrate into an area where everyone ran away from. This is what you could see in Atocha. Although Atocha PMA was placed beside a principal wall, it had to be evacuated. There was inside, at least, one relaxed patient. Some others could be evacuated in a hurry.

18 Santa Eugenia SAMUR 2+1 2 - SUMMA 4+1 - - mICUs VIR UAD
7:50 mICUs VIR UAD SAMUR SUMMA IC organization Dead 17 Total victims 52 SUMMA/SAMUR 4 critical SAMUR 10 severe SAMUR 6 severe SUMMA Work time approx. 1 h 15 min.

19 Santa Eugenia Santa Eugenia, a residential area, is five kilometers far from Madrid, what delayed first assistances. One train passed in a high speed while units were working on focus.

20 El Pozo SAMUR 5 3 - - SUMMA 5 1 1 1 First units: Police, Fire-Rescue
The face of death First units: Police, Fire-Rescue and basic support Heroical citizen support Wild scoop and run Hour ? mICUs VIR UAD Helo SAMUR SUMMA There’s no physic IC 8:50 More units, also Helo 9:00-9:15 There’s another bomb Train evacuated Rescue stopped Dead 67 Total victims 56 SUMMA/SAMUR 4 critical SAMUR 2 critical SUMMA 45 almost unknown ambulances Work time approx. 1 h 15 min.

21 El Pozo Two near bombs exploded into a crowded two-storey train
Inside, almost anyone could save life.

22 Téllez SAMUR 2+6 2 - - SUMMA 4 - 2 - Confussion for ½ hour
Original IC is not available Victims are evacuated to next sports centre SAMUR SUMMA mICUs VIR UAD Helo Dead 64 Total victims 83 perhaps 2 deceased in place ?? 7 critical rest is confusing Work time approx. 2h 25 min.

23 Téllez The most complex. The first ½ hour, there was an enormous confusion. It was thought this was a train accident, and after so, perhaps the same Atocha call. The four bombs’ explosion lifted the train, at least, one meter. The train was walking, and most of the bodys broke the structure and got outside, dead. Alive victims were inside the train. Rescues were very hard. Firefighters used doors to evacuate victims. Some of them died in the first assistance. Near sports centre was used as PMA. We comment the images.

24 Téllez 2

25 Téllez 3

26 Datos hospitalarios Fallecidos Muy graves Críticos Heridos Graves
Altas Leves As you know, these are the official data from the same March-11 night. Datos hospitalarios Consejería de Sanidad 11 de Marzo, 21 h

27 Saturación hospitales más próximos
Robregordo Montejo de la Sierra La Hiruela Acebeda Prádena del Rincón Horcajo Madarcos Braojos Nava- rredonda Puentes Viejas Buitrago Lozoya Gargantilla Berzosa Puebla de la Sierra Robledillo Garganta de los Montes Lozoyuela El Atazar Cervera de Patones El Berrueco La Cabrera Valde- manco Bustarviejo Canencia Rascafría Torrelaguna Caba- nillas Navala- fuente Venturada Miraflores de la Sierra Talamanca de Jarama Valdepié- lagos Soto del Real Colmenar Viejo Manzanares el Real El Vellón Valdetorres del Jarama Collado Mediano Cercedilla Guadarrama cerrada Los Molinos Villalba Hoyo de Tres Cantos San Sebastián de los Reyes Alcobendas Algete Fuentelsaz Valdeolmos Alapardo Ribatejada Valdeavero Fresno de Torote Cobeña Daganzo Meco Camarma Esteruelas Paracuellos Alcalá de Henares Los Santos de la Humosa Anchuelo Santorcaz Torrejón de Ardoz Coslada San Fernando Villalbilla Corpa Pezuela Alameda Valverde Pozuelo del Rey Nuevo Baztán Olmeda de las Fuentes Ambite Villar del Olmo Velilla Rivas- Vaciamadrid Arganda del Rey Campo Real Valdilecha Orusco Carabaña Brea de Tajo Valdaracete Estremera Fuentidueña de Tajo Villarejo de Salvanés Villamanrique Belmonte Tielmes Perales de Tajuña Valdelaguna Chinchón Villaconejos Morata de Aranjuez Ciempozuelos Valdemoro Getafe Pinto Parla Fuenlabrada Leganés Casarrubuelos Serranillos del Valle Móstoles Pozuelo de Alarcón Villamanta Villaviciosa de Odón Navalcarnero Aldea del Fresno Villa del Prado Cadalso de los Vidrios Cenicientos Rozas de Puerto Real Alcorcón Boadilla del Monte Brunete Majadahonda Las Rozas de Madrid Torrelodones Galapagar Valdemaqueda Santa María de la Alameda El Escorial Zarzalejo San Lorenzo de El Escorial Navas del Rey Pelayos de la Presa San Martín de Valdeiglesias Robledo de Chavela Fresne- dillas Navalagamella Valdemorillo Villanueva del Pardillo Villanueva de la Cañada Colme- narejo Quijorna Colmenar de Arroyo Ajalvir Mejorada del Campo Loeches de las Torres Torres de la El Molar Serna Pinilla Valle Ala- me- da Villa- vieja El Álamo Arroyo- molinos Moraleja de Enmedio Batres Cubas de la Sagra Griñón Humanes la Calzada Somosierra Villamantilla Perales Chapi- nería Sevilla la Nueva Velasco San Martín de la Vega de Oreja Titulcia Guadalix Pedrezuela San Agustín Becerril El Boalo Moralzarzal Torre- mocha Gascones Piñuécar Horca juelo Redueña Alpedrete MADRID Madrid Etiquetas rojas 5 17 H Gómez Ulla Doce Oct. Gregorio M. 1 1 14 5 91 15 30 1 But, correctly presented, the reality talks by itself of nearer ED overcrowding. Three nearer hospitals, Gregorio Marañón, Doce de Octubre y Gómez Ulla received 159 red labels. We show some preliminar causes for this in next slide. 38 2 12

28 Diferentes datos EMS-SUH ¿ Por qué ?
Fallecidos # Etiquetas rojas SAMUR 44 – 49* 1 fallecido de camino SUMMA 21* + 20** Asignación al azar* Fallecidos en la escena 14* – 20** Caída de las comunicaciones ? Serv. Urg. Hosp. 233 85-90 143 ? Admisible sub-triage o unidad no disponible transporte básico ? Evacuación masiva ? Diferentes sistemas de clasificación Ej: SUH críticos/muy graves/graves. No etiquetas amarillas Official SAMUR data talk us of patients evacuated in advanced support units. One patient died on the way. Same data of SUMMA patients show they assisted and transported a total advanced amount of patients. On scene estimations and some other data tell us about people deceased. Then, we may have a total red labels of Hospital data register 243 red labels in the first night. The, what’s the reason of these different EMS-ED data? First of all, it’s clear both have different classification systems. Second, all EMS-assisted MCI may have a legitimate sub-triage difference. Or, perhaps, no available unit. In the image on the right, we can see a green-label walking patient who received a craneotomty afterwards. Third point, data collection in focus is not always easy. Fourth, and in some instances, the most important factor –in fact, focus-dependent-, tragedy’s size and some other factors contributed to the existence of a variable people-guided scoop and run evacuation. Difícil recogida de datos en los focos * datos oficiales ** estimado

29 En los IMV urbanos, ¿ son la mayor parte de los heridos evacuados a los hospitales por los SEME ?
47 % global Madrid 11-M 2004 mebe org 38 % et. rojas © Jeffrey Arnold, MD

30 Lecciones aprendidas 80 % fiabilidad
Dos servicios diferentes Un Centro Coordinador y una central de comunicaciones Déficits de infraestructuras Enorme colaboración ciudadana Caída irregular comunicaciones SUMMA Enorme trabajo de Bomberos, Policía y esfuerzos público-privados Déficit de planificación SUMMA Gran trabajo de los SSEE sanitaria Cuatro focos simultáneos Propias del incidente Correcto manejo de la escena SAMUR Gran trabajo Centro Coordinador SUMMA Asignación aleatoria hospital sin confirmación SAMUR Filosofía inadecuada ? Enorme trabajo red hospitalaria Evacuación masiva moderada Y Scoop and run 63 % etiquetas rojas Sobrecarga de críticos de los hospitales más próximos Impacto en morbi-mortalidad ?

31 Muchas gracias Madrid, mis amigos, Madrid, mis hermanos:
No podéis ver mis lágrimas: ya no me quedan pero, ¿podéis oir cómo lloran mis palabras por vosotros? Thank you very much.