About deadly knife attacks in public, the scene, teamwork, how to protect, and how to prepare, you can read here:
1. The Deadly Knife Attack in Solingen on August 23rd, 2024
1.1. What Happened?
The Knife Attack
The German city of Solingen near Düsseldorf in North Rhine-Westphalia was celebrating its 650th anniversary when a deadly knife attack happened during an open-air concert on one of the stages. Three people sadly lost their lives, five visitors suffered life-threatening wounds, and three more visitors sustained minor injuries. The perpetrator had deliberately aimed to stab the victims in their necks.
What We Know About the Rescue Work in Solingen
Emergency medical services and the police were both deployed at a large scale. All victims were taken to to the hospital of the city (Städtisches Klinikum Solingen). A police helicopter circled over the city centre. In addtion to the doctors and the paramedics, many crisis intervention teams tended to the visitors who had been severely traumatised.
What Could Be the Next Steps?
Such a brutal assault is a huge shock and our hearts go out to the victims and their relatives. The people who are suffering now will be needing continued help.
From a professional point of view, we need to keep in mind that this was not the first deadly knife attack on German soil and it will not have been the last. Therefore, we should prepare ourselves. It is important, though, that we remain able to feel a zest for life and happiness at large and joyous gatherings at the same time.
1.2. The Subtopics of This Article Have Been Adapted After the Attack
As announced in July, we will deal with hazardous scenes in this article. So shortly after the vicious assault in Solingen, we will focus on knife attacks in public. What can we do to protect ourselves? As lay persons and as professionals?
We will first look at some basic facts about knives as weapons, before turning our attention to the circumstances at the scene of a deadly knife attack and how to handle it whilst working with various teams in the best possible manner. In addition, we will eluciate how to avoid common mistakes and how emergency medicine service providers prepare themselves and their teams.
2. A Few Basic Facts About Knives as Weapons
Knives can be stabbed into any part of the body, and the resulting injuries correspond to the structures which have been hit. Wounds in the thorax may also affect the abdomen and vice versa. If the carotid arteries have been cut open on the neck, the victim may bleed to death within two to three minutes, depending on the size of the damage, additional wounds and any blood thinning medications.
The wound can be deeper than the length of the blade suggests, because tissues can be compressed during the attack. It can also be wider than the width of the blade when the knife has been moved inside the body. Such movements can also cause cone-shaped damages, which are much larger than initially assumed. Sometimes, victims try to grab the knife in an attempt to defend themselves. These attempts often lead to severe injuries to the fingers, including amputations.
Do Not Remove the Knife From the Wound
If the knife is still in the body after an assault, do not pull it out. It might compress major blood vessels and, therefore, prevent the injured from bleeding to death. In this case, the injured should not move if the situation allows. The knife should be fixed in its place, until it can be removed in the operating theatre.
3. The Scene After a Deadly Knife Attack
3.1. Knife Attacks Happen at All Types of Places
No two scenes will look the same. An assault might happen in the open, inside a building, or in another type of confined space. The crime scene can be anywhere where people go about their daily business, shop, or use public transport. An attack can also happen at places where people gather to celebrate special occations, relax, or enjoy entertainment, such as open air concerts.
3.2. People React Differently to a Knife Attack in Public
Many different reactions are possible. In buildings, the majority of people will try to escape through the entrance doors, which can cause obstructions. People may fall and be overrun by others, who are also trying to get out. In the open, most people will also try to run away, be it in panic or deliberately in order to protect themselves. Some will scream and some may behave as if they were entirely frozen.
The victims can be dead or wounded. Some bystanders may do what they can to help them. Others may try to actively prevent oncoming people from entering the crime scene. Usually, many calls reach the emergency call centre.
The reactions also depend on whether the perpetrator is still there or if he or she has fled or has even already been subdued.
You can easily see that it will be demanding to gain an overview of the scene. It will take some time to evaluate how many people there are, how many have been stabbed and how severe the injuries are.
4. The Rescue Operation Is Interdisciplinary Teamwork
It depends on the number of victims whether an emergency is classified as a mass casualty incident, MCI. An MCI usually involves a larger number of victims than the EMS providers in the respective district can handle. In this case, individual treatment of each patient will not be available at first.
As this article cannot replace the careful reading of a detailed textbook, we will highlight the most important principles in this subchapter. We will look at the German system, in which a head emergency physician and an organisational manager (a specially trained paramedic) fulfil clearly defined roles as they coordinate the medical part of the scene management. However, most of the principles discussed here and the common mistakes, which will be elucidated in subchapter 5, may be of interest to most EMS providers.
First of all, EMS personnel should not enter the scene until the police, or even a SWAT unit, has brought it under control.
4.1. First Status Report and Triage
Gaining an Overview
When we arrive at the scene, we take a first look at it whilst we are still in the rescue vehicle. As we are sitting a little elevated, the overview is better. We should deliberatly use these first few seconds, still shielded from the chaos, to take in as many details as possible and to deliver a first status report to the dispatcher.
Once we leave the vehicle, the next steps depend on how many and what type of rescue services are present already. If we are the first to arrive, we start to triage the patients. Whenever another team has arrived first, we will join its members and first listen to their report.
The Triage
The goal of the triage is to gain an overview of how many patients have suffered what type of injury. The triage is not about making a diagnosis or starting treatment. Only life-threatening conditions, such as heavy bleeding or an obstructed airway are addressed with fast and easily to apply measures.
It is our duty as doctors to distinguish the unconscious patients with life-threatening injuries from the dead. Further, we have to determine how many patients have life-threatening injuries ("red/immediate" category) or major injuries whose treatment can be delayed until more rescuers have arrived at the scene ("yellow/delayed" category). The patients in the "green" category are those who can walk. In order to obtain a better view of the entire picture, the patients in the "green" category are asked to walk to a safe space and gather there.
The overall aim is to provide the best help to as many victims as possible until adequate individual care is available again.
4.2. Excellent Coordination Is Vital as More Teams Arrive
As more and more teams arrive at the scene, they need to obtain the necessary information, which has been gathered so far. In addition, they need to know where they should perform what task. In Germany, the head emergency physician and the organisational manager accomplish the coordination together, as far as the medical rescue operations are concerned. They work closely together with the commander of the fire brigade and other parts of the operations management as it is being established at the scene.
The following tasks need to be coordinated (selection):
- determining where the rescue vehicles are to be staged and where helicopters can land
- deciding whether the injured should be brought to one spot and treated there (only at larger scenes)
- assessing how many and what types of rescue teams and services will be needed, including crisis intervention teams, rapid response teams, and technical support, amongst others
- which of the rescue teams will treat which patients
- which ambulance or transport vehicle will take which patients to what hospital
- accurate documentation: a list with at least the patients ´ case numbers and categories, along with who has been taken to which hospital
4.3. Notifying the Hospitals and Patient Transport
Hospitals Often Have Previously Prepared Emergency Plans
As the hospitals have their own emgerncy plans, according to which they have to act, they need to learn about the emergency as early as possible. They should also be informed about the type of injuries. Each hospital can then assess, how many patients it can accept and whether it has to interrupt routine work, including planned operations. It may even have to call in staff who are off duty that day.
Reevaluation and Transport of the Victims
The victims need to be reassessed several times, because their initially assigned category may change. Depending on the number of victims, it has to be decided, whether a certain number of ambulances and helicopters is sufficient or if larger transport vehicles need to be deployed.
It is of utmost importance that the patients, who have suffered life-threatening injuries ("red" category), are taken to the most appropriate hospitals first. Only after all of these patients have been considered, those with major injuries in the "yellow" category will be transported to the most suitable healthcare facility.
All these actions have to be coordinated continuously. Whereas the lead emergency physician decides who will be needing what kind of treatment depending on the type of injury (e. g. to the head and central nervous system, spine, thorax, abdomen, limbs), the organisational manager helps to coordinate which patient will be taken to which of the available hospitals.
When all rescue work at the scene has been done, the head emergency physician, usually in the presence of police officers, examines the dead bodies and issues the preliminary death certifcates.
5. We Need to Avoid These 9 Major Errors
It cannot be stressed enough that the first objective is to help as many victims as possible in the best way. In order to achieve this, we need to act in a coordinated manner and communicate precisely. It is crucial, to avoid the 9 common mistakes compiled in the list below.
- Blockieren wichtiger Wege und anderer Fahrzeuge => alle Fahrzeuge sollten ordentlich an der geeignetsten Stelle geparkt werden.
- Beginn mit der Behandlung der Opfer bevor die Sichtung beendet ist => schwere Verletzungen können übersehen werden.
- Damit beginnen, diejenigen zuerst zu behandeln, die am lautesten schreien => schwerverletzte Patienten könnten die nötige Hilfe zu spät erhalten.
- Patienten mit geringeren Verletzungen zuerst ins Spital bringen => dies könnte Patienten, die als „rot“ klassifiziert wurden, ihr Leben kosten.
- Viele Patienten ins nächstgelegene Spital bringen => dies kann die Einrichtung überfordern.
- Die Spitäler nicht früh alarmieren => diese sollten so früh wie möglich verständigt werden, damit sie ihre Notfallpläne aktivieren können.
- Zum Einsatzort kommen, wenn man nicht im Dienst ist, auch von weiter her => vermeiden Sie dies, da es eine ohnehin schon komplexe Einsatzstelle noch chaotischer macht.
- Teams von anderen Organisationen auseinanderreißen => lassen Sie diese gemeinsam an einer Aufgabe arbeiten.
- Unkoordinierte Kommunikation am Funk => nutzen Sie den richtigen Kanal und behalten Sie standardisierte Formulierungen bei.
6. What Can We Do to Protect Ourselves From Knife Attacks?
Below, we will explore, what lay persons and rescue personnel can do.
Regardless your role, train and maintain your situational awareness. Recognising suspicious behaviour and signs of any escalation early can help to alter the course of events.
6.1. What Everyone Can Do in Case of a Knife Attack
First of all, do not try to act as a hero. Instead, save your own life.
During a deadly knife attack in public, the perpertrators usually hit their victims randomly. Therefore, try to run away, if possible, or to get out of sight immediately and hide. Depending on the type of crime scene, disappear under a table, or behind a car. Remember to keep low, do not show your head, and do not let your mobile phone give away your hiding place. In a building, you can lock the door to the room and place a heavy object behind it.
Do only fight if it is absolutely necessary. If you have to defend yourself, be determined. Try to recruit others to help you. Use any suitable object to hit the attacker. Your aim should not be to "win", but to get out of the situation.
You never know whether the attacker has "only" got one knife or if he or she is carrying another weapon, including a firearm. From a safe distance, you can observe the scene, call for help, try to prevent others from walking towards it, and you can assist the victims if you feel able to do this.
6.2. How Emergency Medical Service Providers Should Act
As we said at the beginning of subchapter 4, medical personnel should not enter any crime scene until it is properly secured. We should always maintain our professional situational awareness and be prepared to leave a scene quickly. For more about how to act in case of violence during a call, please refer to the first article of this series (Subchapter 4.1. "Violence at the Scene").
7. Hope for the Best, but Expect the Worst - Professional Preparations
7.1. Useful Training Courses for EMS Personnel
It is to be expected that the deadly knife attack in Solingen will most likely not have been the last one in Germany as mentioned earlier. Although we seek peace and would love to live in safety, we need to learn how to handle the scene after such an attack and maintain our respective skills. Two internationally standardised courses, which paramedics as well as prehospital emergency physicians can attend, are the so-called Prehospital Trauma Life Support, PHTLS, and Tactical Emergency Casualty Care, TECC, which are offered in many countries around the world.
7.2. Learning All About the Cooperation With the Police and SWAT Units
Large-scale exercises, which include police officers and EMS personnel, are sometimes conducted at major conferences, such as the EMS World Expo. This is the largest EMS conference in the world and it is held annually in alternating cities in the US.
7.3. In Case a Mass Casualty Incident Leaves Us Traumatised
Everyone who works in emergency medicine should learn during his or her training how to detect the signs of post-traumatic stress and how to distinguish it from a post-traumatic stress disorder . EMS agencies usually provide help, starting with specially trained peers, whom can be approached first. It is crucial to understand that it is not shameful to seek help and to ask for it as early as possible.
In remembrance of the victims of the deadly knife attack in Solingen on August 23rd, 2024
8. Another Specially Dedicated Article in September
The article in September will be about a highly topical issue, as well. Be prepared for a special piece, in which we will elucidate some major hazards that most people won´t expect at first glance.
Author: Eva-Maria Schottdorf
Date: August 28th, 2024
On my blog page , I have linked more blog articles for you.
After one year, the articles will be removed from the blog page, updated, augmented and turned into books. You can purchase these directly on the page "A Special CRM Book Series" . The first volume is already waiting there for you.