No abstract

Background Terrorism-related incidents that are associated with mass casualties (mass-casualty terrorist incidents) are a medical and organisational challenge for every hospital because of the special injury patterns involved, the time of the incident, the development of the situation, the initial lack of information, the number of injured, and the number of uninjured survivors who self-refer to a hospital. Methods The Terror and Disaster Surgical Care (TDSC®)-Course was developed in order to address mass-casualty terrorist incidents and to provide surgeons with the specialist medical and surgical knowledge and skills required for these special situations. The focus of the TDSC® course is on how to provide surgical care and how to deploy scarce resources in a particular tactical situation in such a way that the number of survivors is maximised. Results The effective management of such a tactical situation must be based on priorities and first and foremost requires the standardised sorting and categorisation of the injured at the hospital. The aim of triage, or the sorting of the injured, is to immediately identify patients with life-threatening injuries in environments with strained resources. The medical management of mass-casualty terrorist incidents requires tactical abbreviated surgical care (TASC) teams that have the skills needed to perform a primary survey and to provide care for casualties who need immediate surgery (triage category 1-T1). Initial fluid therapy should be restrictive (permissive hypotension) unless contraindicated. Clotting products are replaced in a standardised manner on the basis of patient requirements, which are calculated using rapidly available surrogates (blood gas analysis). Blood products can be administered or kept available depending on risks and triage categories. The highest priority should be given to the identification and management of haemodynamically unstable patients who require immediate surgery for injuries associated with bleeding into body cavities (T1 + +). Conclusion The recommendations and approaches described here should be considered as proposals for hospitals to develop standards or modify well-established standards that enable them to prepare themselves successfully for situations (e.g. masscasualty terrorist or shooter incidents) in which their resources are temporarily overwhelmed.

Background and purpose The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training. Material and methods We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019. Results Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events. Conclusion A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

Zusammenfassung Hintergrund Weltweite terroristische Aktivitäten seit „9/11“ und folgend auch im europäischen Raum haben im Rahmen der Bewertung von kritischer Infrastruktur in Deutschland zu einem Umdenken auch hinsichtlich der Sicherheit an und in Kliniken geführt. Ziel der Arbeit Die vorliegende Publikation befasst sich mit der Bewertung vorliegender Konzepte zu Themen wie „Alarmierung“, „Sicherheit“, „Kommunikation“ und „Vorbereitung“ im vorgenannten Kontext. Material und Methoden Anhand einer Literatursichtung sowie einer Umfrage unter den Teilnehmern*innen der 3. Notfallkonferenz der DGU (Deutsche Gesellschaft für Unfallchirurgie) werden diese Thematik und die aktuell vorliegende Situation weiter analysiert und vorgestellt. Ergebnisse Die gewonnenen Daten verdeutlichen, dass ein Großteil der Kliniken zwar über eine Krankenhausalarm- und Einsatzplanung verfügt, jedoch die Frequenz der Aktualisierungen und die innerklinische Kommunikation zur Steigerung der Wahrnehmung eine deutliche Streuung zeigen. Weiterhin verdeutlichen die Ergebnisse eine Heterogenität der vorliegenden innerklinischen Alarmierungskonzepte sowie einen Mangel an Sicherheitskonzepten und Kooperationen mit Sicherheits- und Wachdiensten. Zudem zeigt sich, dass die Thematik einer möglichen CBRN(chemical, biological, radiological, nuclear)-Bedrohung in der Risikoanalyse noch nicht adäquat wahrgenommen wird bzw. umgesetzt ist. Diskussion Zusammenfassend scheint die latente Bedrohung durch terroristische Aktivitäten dazu geführt zu haben, dass sich deutsche Kliniken in der Bewertung als kritische Infrastruktur mit der Thematik „Krankenhausalarm- und Einsatzplanung“ auseinandergesetzt und diese überwiegend auch umgesetzt haben. Allerdings zeigt sich für die nachgeordneten Bereiche und die aus der Alarmplanung ableitbaren Konsequenzen noch nicht die nötige Stringenz, um letztendlich adäquate Reaktionen in diesen besonderen Szenarien im Hinblick auf die Sicherheit in und an deutschen Kliniken zu gewährleisten.

Purpose The threat of terror is omnipresent in Europe and the number of attacks worldwide is increasing. The target of attacks in Europe is usually the civilian population. Incalculable dangerous situations at the scene of the event and severe injury patterns such as complex gunshot and explosion injuries with a high number of highly life-threatening people present rescue forces, emergency physicians and subsequently hospitals with medical, organizational as well as tactical and strategic challenges. The Terror and Disaster Surgical Care (TDSC®) course trains clinical decision-makers to meet these challenges of a TerrorMASCAL in the first 24–48 h. Methods A table-top exercise was developed for the TDSC® course as a decision training tool, which was prospectively evaluated in six courses. The evaluation took place in 3 courses of the version 1.0, in 3 courses in the further developed version 2.0 to different target values like, e.g., the accuracy of the in-hospital triage. Furthermore, 16 TDSC® course instructors were evaluated. Results For the evaluation, n = 360 patient charts for version 1.0 and n = 369 for version 2.0 could be evaluated. Overall, the table-top exercise was found to be suitable for training of internal clinical decision makers. Version 2.0 was also able to depict the action and decision-making paths in a stable and valid manner compared to the previous version 1.0. The evaluation of the instructors also confirmed the further value and improvement of version 2.0. Conclusion With this prospective study, the table-top exercise of the TDSC® course was tested for decision stability and consistency of the participants’ decision paths. This could be proven for the selected target variables, it further showed an improvement of the training situation. A further development of the table-top exercise, in particular also using digital modules, will allow a further optimization. http://www.bundeswehrkrankenhaus-ulm.de