“It wasn’t a medical miracle—we made our own luck”: lessons from London and Manchester terror attacks
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4309 (Published 19 September 2017) Cite this as: BMJ 2017;358:j4309
- Anne Gulland, freelance journalist, London, UK
- agulland{at}bmj.com
Last week London’s St Mary’s Hospital had to declare a major incident after a terror attack on an Underground train at Parsons Green. The explosion once again highlighted the challenges for doctors and medical teams—hospitals in London and Manchester have already been tested by four major terror attacks in 2017: Westminster Bridge, Manchester Arena, London Bridge, and Finsbury Park mosque.
The Parsons Green victims mainly sustained burns, but each of the attacks have presented different challenges. The Westminster Bridge attacker rammed a vehicle into pedestrians, and most patients brought to hospital had blunt trauma. At London Bridge, the attackers used both a vehicle and knives and many patients presented with stab wounds. In Manchester the attacker detonated a shrapnel loaded device and patients presented with complex, multiorgan injuries.
At a conference at the Royal Society of Medicine in London earlier this month, doctors who treated those patients shared what they have learnt. The NHS was widely praised for its response; however, Duncan Bew, a trauma specialist at King’s College Hospital in south London where many of those injured in the Westminster and London Bridge attacks were treated, told the meeting: “We cannot rest on our laurels. Because we have done well in this incident, it doesn’t mean we’ll do well in the next one.”
Patients present before major incident declarations
Early reports of a terrorist attack often say that a major incident has been declared, giving the impression that some magical switch is flipped and a well oiled emergency plan kicks in.
Malcolm Tunnicliff, clinical director for emergency and acute care at King’s College Hospital NHS Foundation Trust, says the reality is different. The first inkling he got of the Westminster Bridge attack on 22 March was when he was waiting to start a shift in the trust’s emergency helicopter and he heard traffic over the radio about an incident.
“The first patients were a normal trauma call. We were getting very little information—patients were being sent through and we didn’t have a sense of what was going on until about an hour later,” he says.
At the London Bridge incident, which took place just after 10 pm on Saturday 3 June, King’s again received patients before a major incident was declared. In the parlance of the emergency services, police officers “scooped and ran,” picking up two injured colleagues without treating them on the scene. “The first we knew was when police officers were banging on the door of resus,” remembers Tunnicliff.
Susan Beards—a consultant in intensive care and anaesthesia, and medical director at University Hospital of South Manchester NHS Foundation Trust—says there was a delay in the major incident plan being enacted after the bomb at Manchester arena, with patients arriving at the emergency department unexpectedly.
New ways of communication needed
Beards told the conference that staff contact lists were out of date and some staff did not answer their phones because the hospital’s number was listed as “number withheld.”
“The switchboard was inundated with calls from the public, and some staff couldn’t get through. We had an emergency email address for the hospital command and control centre but not many people were aware of it,” she says.
Many of the speakers used WhatsApp, an encrypted instant messaging tool, to communicate with groups of colleagues but were uncertain if they were breaking professional codes. Joshi George, consultant neurosurgeon at Salford Royal NHS Foundation Trust, told the conference that WhatsApp was useful for working out how many staff were needed on the night and who was available.
“It’s not an officially sanctioned form of communication but it worked well on the night. Going forward we need to look at a way of regulating this,” he says. WhatsApp is seen as very secure, with even the government unable to break in to spy on potential suspects.1 However, according to information obtained by The BMJ three doctors were investigated by the General Medical Council between January 2015 and June 2017 for using WhatsApp to discuss work.2
But some forms of communication can be distracting, says Tunnicliff. During the London Bridge attacks staff were inundated with messages from friends, family, and colleagues and were given incorrect information, particularly about reports of a second attack in Vauxhall. “You have to be disciplined. This is where the value of a hospital ambulance liaison officer comes in as they are giving you the correct information,” he says.
Triaging—and re-evaluation—of patients is key
At the scene of a major incident paramedics triage patients according to three categories: patients classified as “P1” have life threatening injuries and need immediate treatment; “P2” patients have serious injuries and need urgent treatment; the P3 category is for walking wounded.
However, says Tunnicliff, a patient can deteriorate or even improve on the journey to hospital. Some of the patients injured during the London Bridge attack had been drinking or taking drugs, adding an extra layer of complexity to diagnosis.
The first patient Tunnicliff saw had been stabbed in the back of the head but because he seemed well had been categorised as P3 and sent to minor injuries. However, after it was discovered that he had an expanding haematoma in the neck he came back to resus for immediate intubation before going to theatre. “Patients won’t be triaged correctly—that’s no one’s failing. That’s just medicine,” he says.
Unlike London, which has trauma centres such as King’s or the Royal London that can cope with all major trauma, Manchester has three hospitals that operate as a collaborative trauma centre. George says: “If you have a chest, abdominal, and brain injury there is no one place where that can be treated. We have three different hospitals that form a collaborative trauma centre. That’s a problem, particularly when you have injuries from shrapnel. Shrapnel does not respect tissue boundaries,” he said.
George paid tribute to the paramedic crews. “It was testament to their ability that we had very few secondary transfers. They triaged very well because they knew which injuries could be treated in which hospital. We only had four secondary transfers, and in the next few months we will be looking at those particular patients to see what we could have improved on,” he said.
Chris Moran, national clinical director for trauma for NHS England and professor of orthopaedic trauma surgery at Nottingham University Hospital, said that in future it might be better to triage patients into just two categories: walking and lying wounded. “The situation is dynamic and repeated evaluation is essential. P2 can become P1 very quickly,” he said.
Do you need to return to business as usual so quickly?
The night after the London Bridge attack, King’s had eight major trauma calls, including a patient with an unstable neck fracture and a rupture of the spleen. Rebecca Bott, a general surgery registrar at King’s, who was on call on the night of the attack, points out: “Ongoing trauma doesn’t stop because there has been a major incident.”
But some doctors feel their hospitals returned to business as usual too quickly. At Salford the major incident alert was stepped down the day after the bombing, but George believes that the hospital should have cancelled all elective operations for the next two weeks.
“It might even take three to four weeks to know for sure that you have finished all the operating that needs to be done. We underestimated the impact the incident would have on the normal service,” he says.
Beards told the conference that in her trust 139 hours of additional operations were performed after the Manchester attack—equivalent to an extra two weeks of operating time. Her trust cancelled 78 elective cases.
Moran urged hospitals not to declare a major incident over too quickly.
“People think because the scene has been cleared and all casualties have left that means a major incident is over. The ambulance service can begin to step down, but for hospitals the incident is nowhere near finished. Hospitals take a huge hit during these events—they should have a divert on for 10 days and take local cases only.
“Do you have to continue business as usual? Couldn’t St George’s take on some cases for King’s?” he asked.
The buzz is normal: be proud of your performance
The London Evening Standard newspaper3 described the survival of all 48 patients from the London Bridge attack as a “medical miracle”—something Bew disputes. “That’s a wonderful thing to hear, but I don’t think it’s true. In lots of ways we made our own luck,” he said.
The hospital is well prepared for major incidents, and treating patients with penetrating injuries is, unfortunately, a fact of life in south east London since 30-50% of patients presenting to the emergency department on any given day have stab wounds. Some 27% of patients self present so the hospital is used to people arriving unexpectedly and can respond quickly.
Tunnicliff says that getting a buzz from working in a major incident is not something to be ashamed of. “It’s not bad to feel energised—it’s almost what we’re trained to do. We’re delivering a response to an event that is not ordinary. All of those involved with emergency services and ongoing care should feel energised and good about what they’re doing. Some of our staff find that difficult to cope with,” he says.
Bott describes working on the London Bridge incident as “massively rewarding. It’s energising and it does give you a buzz,” she says.
Police offer essential first aid in the first instance
Getting to trauma patients quickly is crucial, but if that patient is in the “hot zone” paramedics will not be able to get to them. The hot zone is where the terror incident is ongoing and where firearms officers are, in the terminology, attempting to “neutralise” the suspect(s), often with “lethal force.” Police officers are allowed into the hot zone but paramedics are not.
In France, doctors accompany special forces, but Cressida Dick, commissioner of the Metropolitan Police, told the conference this was unlikely to happen in the UK. Instead, she emphasises the advanced first aid skills of police officers. “Our officers all receive a high level of first aid training and are trained to work in chaotic and disordered places.
“The same officers who neutralise the threat, within split seconds are trying to save that person’s life. I’m very proud of what they did in those dreadful incidents in London,” she says.
Doctor’s eye view: “It was a horrible shift, but an inspiring shift”
Owen King first realised something was happening at Manchester Arena at about 11 pm. The specialist registrar in anaesthesia was taking a break from his shift and flicking through social media when he read the first reports of an incident.
About an hour later, a major incident was declared at University Hospital of South Manchester, and staff were told to expect between 10 and 20 casualties. They did not know the nature of the incident—was it a crush or a crash at the nearby railway station? King and colleagues started to prepare the theatres and call in as many people as possible. “We were a bit like a sports team before a big match: we were running through our pre-game rituals, checking our kit,” he says.
When the first patient arrived King, four years into his specialist training, was the most senior anaesthetist in the department—something that was beginning to worry him. The paramedics looked like they had been through hell, he says. “It wasn’t until later that I understood why.”
His first patient was conscious and the image of her dirty, tear streaked cheeks remains with him. “Her injuries were strange—like little holes. It was shrapnel flying through her limbs but at the time I had no idea. She also had skin and tissue stuck to her that didn’t belong to her,” he says.
He remembers the surgeon pulling hexagonal fragments from the patient’s body and swearing as he found more terrible injuries. He remembers the scrub nurse crying. “Everyone was on edge, everyone was scared but everyone got on with the job,” he says.
“It was an exhausting night. I had nothing left and by morning I was running on adrenaline. It’s still very hard to talk about. It was a horrible shift, but it was also a very inspiring shift.”
Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.