Major Incidents, Mass Casualty Incidents

Preparing for Vehicle Attacks: Lessons Learned from Berlin, Germany

Issue 6 and Volume 43.

 

Injured persons are treated by first responders and bystanders who provided initial first aid after a terrorist drove a truck into a crowd of people at a Christmas market in Berlin. Photo courtesy Berliner Feuerwehr

It was a cold, dry winter’s evening at a popular Christmas market at Breitscheidplatz in Berlin, Germany on the night of December 19, 2016. With the temperature hovering just above freezing, residents and visitors peacefully drank warm, mulled wine as they huddled around market stalls next to the Kaiser Wilhelm Memorial Church. Nobody noticed the semi-trailer truck, stolen earlier that night, as its driver made his way from the direction of Zoologischer Garten railway station and deliberately drove into the crowd of holiday shoppers in the square outside the church.

The incident, likely a terrorist attack, injured 67 people, many critically, and 12 people were killed. In the year since this attack took place, deliberate attacks where vehicles are used as lethal weapons have increased in frequency and become a disturbing trend.

Last year, vehicles were used as weapons in attacks in cities both large and small, in the U.S. and abroad, including New York City, Barcelona, Charlottesville (Va.), Stockholm, Jerusalem and London—where there were two attacks. Sadly, Germany can now lay claim to experiencing two of these attacks, after the driver of a delivery truck slammed into a crowd of people in the city of Muenster on April 7.

EMS personnel treat injured patients amidst the trail of devastation left behind after a stolen trailer truck plowed through the alleyway of the Christmas market. Photo courtesy Berliner Feuerwehr

Chronology of the Attack

At 8:02 p.m., the semi-trailer truck is deliberately steered into the walkway between the stalls of the Breitscheidplatz Christmas market. The first person to place a call 1-1-2, the European emergency number, reports a traffic accident on the other side of the square.

At 8:04 p.m., acting on the assumption that there’s been a traffic accident and not a deliberate attack, the Berlin Fire Department dispatches one fire truck, one ambulance and one emergency doctor vehicle, providing them with the description for a standard traffic accident.

Additional people calling 1-1-2 describe the event in more detail. Two of the callers, an off-duty rescue service employee and an emergency doctor, try to give dispatchers a clearer picture of the scale of the events unfolding:

“Zoologischer Garten. Mass casualty incident. Several injured. Truck crashed into the Christmas market outside the Waldorf Astoria,” one of them says.

“Budapester Strasse, right?” the emergency dispatcher asks, referring to Budapest Street.

“Exactly. Unfortunately, this isn’t a joke. I’m afraid it’s serious. A truck—a big one—has hit a crowd of people!”

At 8:07 p.m., the Berlin Fire Department dispatches two additional fire trucks, five ambulances, two emergency doctor’s vehicles and one large equipment vehicle carrying extra materials required to treat the injured at large-scale incidents.

Commanding officers of the incident are appointed, and include an organizational chief of EMS, a senior emergency physician and an experienced incident commander.

At 8:09 p.m., the dispatch center changes the description of the alert to “mass casualty incident (MCI). Threat situation—police.” This alerts emergency personnel that there may be an active threat when they arrive on scene, and that they must adjust their tactical approach accordingly.

It takes emergency personnel approximately two minutes to get from the fire station on Rankestrasse (i.e., Rank Street) to the location of the incident at Breitscheidplatz square.

On arrival at the Weltkugelbrunnen (i.e., world fountain), a water feature which is located about 492 feet (150 meters) away from the incident, emergency personnel encounter visitors peacefully drinking mulled wine while visiting the Christmas market.

Other people rush toward them, alerting them that the incident is on the other side of the square.

At 8:11 p.m., emergency personnel arrive on scene, where they see a heavily damaged truck standing in the street.

An initial size-up of the scene, completed by an officer from the Moabit Fire Department, reveals there are many people injured and a high probability of fatalities. He notes the truck’s cargo: a load of steel parts.

The truck had entered the alley between the stalls at a crosswalk, drove about 196 feet (60 meters) through the market, turned to the left and returned onto Budapester Strasse, where it finally came to a halt.

Numerous ambulances, emergency doctor’s vehicles and fire trucks line the road of Budapeter Strasse, which runs parallel to the Christmas market. Photo courtesy Berliner Feuerwehr

Several people are trapped under the truck and show no signs of life. Bystanders had already started providing first aid to those who were injured.

Many of the stalls that form the Christmas market have partially collapsed, and the path between them is still visible. Stall lighting offers only dull illumination of the scene.

Emergency personnel begin identifying the seriously injured, dead and dying. Medical care becomes the top priority.

All firefighters are qualified to provide BLS care at the EMT level, and many are paramedics and able to provide ALS care.

Together with the bystanders already providing first aid, they begin treating injured patients between the market stalls. Triage squads categorize the wounded by marking them with triage tags and then documenting the tags in their logs.

Three lifeless bodies are identified as being trapped under the truck, and rescuers fear more of victims could be buried beneath the partially collapsed stalls.

In addition to the stability of the remaining stalls, emergency personnel also consider the danger posed by gas escaping from cylinders powering the now-damaged food stalls as well as the position of the truck in the poor lighting.

The dispatch center and the on-site incident commanders are also concerned about the possibility of a second strike by additional attackers. In cases where there is still a potential threat, Berlin’s emergency response procedures call for the commander of the fire department and the commander of the police department to meet on the scene and coordinate the ongoing response.

At 8:14 p.m., the dispatch center issues a pre-alert for the emergency service fast- response unit operated by the German Red Cross, a team of off-duty personnel and volunteers qualified to work in emergency services. The dispatch center formally alerts the unit four minutes later.

At 8:20 p.m., 10 additional ambulances and two more emergency doctor’s vehicles are requested by incident command. The alert is initially delayed because of a software problem at the dispatch center.

At 8:23 p.m., additional emergency personnel are dispatched to care for uninjured witnesses, including a consultant from the non-profit organization.

After the attack is confirmed and with the number of victims rising, the dispatch center begins pre-alerting hospitals at 8:25 p.m. and continues this until 8:50 p.m. Additionally, every fire station is informed about the ongoing operation via loudspeaker announcements.

Between 8:28 p.m. and 8:35 p.m., incident command requests six more fire trucks and two command vehicles, as well as emergency psychosocial care for the relatives of those affected, bystanders and emergency personnel who were first on scene. The psychosocial unit treats 60 people by the end of the night.

As the number of fire department resources responding to the incident continues to rise, the voluntary fire department is requested to report for duty. Other off-duty professional firefighters report to their departments, even without being formally alerted.

At 8:30 p.m., the fire department spokesman arrives on site and consults with the incident commander.

At 8:38 p.m.—36 minutes after the incident began—the first patients in triage category 1 are transported to hospitals.

In an ambulance staging area, EMS crews are organized and ready to transport patients as they’re assigned for transport. Photo courtesy Berliner Feuerwehr

Triaged category 1 and 2 patients receive care in a medical tent across from the incident site. Photo courtesy Berliner Feuerwehr

At 8:40 p.m., a fire department spokesman gives the first live interviews to approximately 100 journalists, who are eagerly waiting for more information on two sides behind the police cordon.

At 8:45 p.m., Provincial Fire Protection Director Wilfried Gräfling assumes leadership of incident command.

The technical rescue unit of the Charlottenburg Nord Fire Department is alerted to provide a heavy rescue vehicle and a crane truck at 8:46 p.m. In the course of the operation, the crane truck is used to lift the truck and its trailer, so that the bodies can be recovered.

At 9:05 p.m., the ten more ambulances are dispatched to Breitscheidplatz at the request of incident command.

From 9:10 p.m. to 9:20 p.m., the German Red Cross units arrive on scene. The team consists of an incident commander, the emergency service fast-response unit, the care service and four ambulances. The fast-response unit is initially dispatched to act as reserve emergency personnel, but the team is later called on to treat patients in the Berlin Fire Department’s ambulance bus. The four ambulance crews begin taking care of patients. The care service sets up an emergency shelter for relatives and eyewitnesses in the Waldorf Astoria Hotel.

After consulting with the incident commander, a Berlin Fire Department spokesman answers questions from the many journalists on scene. Photo courtesy Berliner Feuerwehr

By 9:30 p.m.—one hour and 28 minutes into the incident—all patients of the triage category 1 and 2 have been transported to local hospitals. Because many of the ambulances in Berlin have already been dispatched, the control center requests five ambulances from Brandenburg, which then gather at the Charlottenburg Nord fire station and remain on standby.

At 9:37 p.m., the coordination service at the dispatch center alerts the Berlin Fire Department’s post-incident care team (called “Einsatznachsorgeteam”). The Moabit fire station becomes the contact point for emergency personnel.

A fire department spokesman gives more interviews about the operation around 9:55 p.m., after verifying with the numbers of injured, persons affected and fatalities.

At 10:30 p.m., on-site incident command contacts the control center and reports, “The scene of incident is under control.”

All patients in triage category 3 are now being treated in hospitals.

As emergency personnel gradually begin to leave the scene, a loud bang is heard suddenly, just before the end of the operation. The noise is soon attributed to police blowing up an ownerless suitcase at an adjacent crosswalk.

In total, the vehicle attack left 12 people dead and 67 injured, some of them seriously. Most patients had blunt force injuries due to being run over or due to direct impact with the truck.

According to forensics, the deceased were so severely wounded they had no chance to survive. The patients were distributed to 22 hospitals and, by Dec. 22, 30 patients had been discharged.

On Dec. 21, a large debriefing involving 66 emergency service employees took place. A post-incident care team consisting of 23 employees from across Germany stayed on-site to help with post-incident stress management and psychological well-being.

Table 1: Emergency personnel deployed to Christmas market truck attack

Berlin Fire Department

Reserve & Other Emergency Personnel

(153 members deployed)

(including off-duty personnel)

26 ambulances

5 ambulances (Brandenburg EMS)

9 fire trucks (professional)

150 voluntary firefighters

4 emergency doctor’s vechicles

21 fire trucks (voluntary)

2 incident commanders (level B)

8 ambulances (voluntary)

2 incident commanders (level C)

1 command unit (voluntary)

2 mass casualty vehicles

misc. off-duty Berlin Fire Dept. personnel

1 fire truck (voluntary)

15 members of German Red Cross (Berlin-City)

1 heavy rescue vehicle

Other Personnel

1 crane truck

Governing Mayor of Berlin

1 ambulance bus

Senator for the Interior and Sport

1 command unit

State Secretary for the Interior

1 press spokesperson

Senator for Economics, Energy and Enterprises

German Red Cross

Provincial Fire Protection Director

(70 members deployed)

Provincial Fire Protection Deputy Director

4 ambulances

Chief of Police

2 vans with MCI equipment trailer

17 psychosocial emergency care personnel

2 command vehicles

follow-up care team

1 four-stretcher ambulance

 

1 fast-response care unit

 

1 crisis intervention team

 

1 fast-response emergency

 

service unit (partial team)

 

Berlin, Germany

Berlin is the capital of Germany. Its 9,601.4 square feet (893 square meters) are home to approximately 3.53 million people. A hub of commerce and tourism, the city has many international visitors who explore the city alongside citizens using various routes winding through the metropolitan area, including 205.05 miles (330 kilometers) of railway tracks, 186.41 miles (300 kilometers) of streetcar rails, 90.72 miles (146 kilometers) of subway tracks and 47.85 miles (77 kilometers) of highways. The city has a large, centrally located airport, 31 hazardous incident plants, as well as multiple ministries and embassies that pose special challenges for emergency services personnel.

Berlin Fire Department

Founded in 1851, the Berlin Fire Department, referred to in Germany as “Berlin Feuerwehr,” is the oldest professional fire department in Germany. With 3,200 professional firefighters, it’s the country’s largest fire department. Personnel work out of 34 fire stations and the department staffs for 553 operational functions, not including the dispatch center, service units and other back-office services. Every station has at least one fire truck and two ambulances available at all times. In addition, there are 58 voluntary fire departments with a total of approximately 1,400 members—an important resource contributing to the effectiveness of the Berlin Fire Department and are used as a fixed component when operations are planned. The city also has a youth fire department that’s made up of approximately 1,000 members, of which over 200 are female.

EMS in Berlin

In Germany, EMS is referred to as “rettungsdienst” (which in English, literally translates to “rescue service”). ALS care is typically rendered by a specially trained emergency physician called a “notarzt” (i.e., emergency doctor), who arrives on scene in a non-transport vehicle and meets up with mobile ICUs and BLS ambulances on high-acuity scenes, or at incidents that have the possibility of presenting high-acuity patients.

In 2016, Berlin firefighters were dispatched to handle 454,143 calls, of which 374,942 were for EMS—up from 363,599 in 2015, as well as 333,199 in 2014. Due to the large increase in the number of calls each year, the Berlin Fire Department has increased its resources. Since April 10, 2017, 139 emergency vehicles and 24 emergency doctor’s vehicles report for duty on a daily basis to handle EMS calls, an increase of 20 ambulances and four emergency doctor’s vehicles from 2016.

Additionally, an EMS helicopter, Christoph 31, is dispatched for approximately 2,500 calls annually. An intensive care transport helicopter based at the Berlin Emergency Hospital is dispatched about twice daily. The Berlin Fire Department also has two specially equipped stroke vehicles, which include a mobile CT scanner, the latest laboratory technology and telemedicine capabilities.

There are 38 hospitals in Berlin. Of those, six are national hospitals and 17 are regional trauma centers. Basic care is provided by 15 clinics.

Insights & Lessons Learned

The authors spoke to Rolf Erbe, who is in charge of MCI and special operations training at the Berlin Fire and Rescue Academy, about the strengths and weaknesses of the operation as well as lessons learned.

What was your first impression of the incident scene?

Rolf Erbe: For a long time, I thought, or rather hoped, that it was an accident—perhaps a truck driver fell asleep at the wheel. My colleagues thought so too, by the way. It was eerily quiet at the incident scene. No one yelled at all. The many first aiders and my colleagues were highly focused while treating patients on scene. The lights of the stalls were still on and at first glance you didn’t see that the truck had driven over the market, because he steered exactly through the alleyway between the stalls.

What tasks where you assigned to during the incident?

Rolf Erbe: After consultation with the coordination service, I was originally sent to the Hadenbergstrasse to document and assist our press service. I arrived during the early stages of the operation, about 20 minutes after the incident.

There weren’t enough emergency personnel on scene, so I was appointed to triage for the next 30 minutes. During initial screening of patients, I just counted the injured to help us get clear figures.

During the second round, we triaged the injured using the START algorithm. Many of them had already received treatment from my colleagues. After triage was complete, I documented the operation.

What did you learn from your experience counting patients during triage?

Rolf Erbe: In my experience, the number of patients you initially see at a large MCI is half the actual number. I initially counted 25 injured patients in the first round of triage, but we actually treated over 50.

I drew the conclusion that the incident commander has to prepare for this: Always plan for double by utilizing an additional treatment area and reserve personnel, for example. This is something that is also known from different application areas and simply means: Get an overview of the situation and ensure backup.

What else did you learn from triaging patients at this incident?

Rolf Erbe: When there are a high number of patients at an MCI, the first overview has to be done as soon as possible, because it’s crucial for the decisions the incident commander makes and in planning the way the incident will be handled.

The pre-triage system must be well-known by personnel and must actually be used to identify and tag the critically injured in a very short time so that the appropriate resources can be assembled in an enough time to save as many human lives as possible.

What tools or knowledge are critical for emergency services personnel in high-risk situations?

Rolf Erbe: There has to be preplanning that’s specific to high-threat situations, a system for pre-triage should be in place, and there must be training, planning and coordination with other agencies, such as with police.

Equipment usually required for MCIs should be supplemented with enough supplies needed to treat special injury patterns associated with high-risk MCIs or terrorist attacks. There should also be enough supplies for police personnel and bystanders administering first aid.

The topic of safety at such operations is also a concern. I don’t believe that there will ever be complete safety.

As long as there are no concrete indications of danger or threat, we will always do everything we can to save human lives.

What went well?

1. The ability of emergency personnel to mutitask proved very effective. We were constantly assessing the scene for danger while performing the necessary medical measures.

2. The use of tourniquets saves lives. Only after the attacks in Paris did they become a permanent fixture in our equipment.

3. It allowed us to test our concepts, and we concluded that the concepts are good, and that they work.

4. It’s a reminder that although plans of action are important, we have to act on them and follow the plan. Deviation from the standard operating procedure always leads to problems, no matter how good the intentions were. Cancellation and alterations must not happen.

Did anything cause problems for you?

Rolf Erbe: Although the digital radio worked properly, we were surprised to discover that some of the radio devices dialed into one particular radio installation again and again. This led to communication problems. The communication with the control center and with other authorities always had to be verified.

The internal communication at incident scenes is very important but often gets neglected. After an alleged terrorist attack, all emergency personnel want to know, “Am I safe?”

What did you notice about the psychological support and aftercare of personnel?

Rolf Erbe: Care for affected personnel by the psychosocial emergency care (PSNV) went very well. However, we have to improve the care for the relatives and the many first aiders who fell through the cracks.

How did the many deployed emergency crews feel?

Rolf Erbe: Many of my colleagues were asking themselves if they did everything they could possibly do. Forensics gave us the feedback that no patient died because of insufficient treatment or a delayed transport. That was very helpful knowledge in this situation.

What will change in Berlin as a result of this incident?

Rolf Erbe: We’re reviewing the events at all levels, and we will improve in as many areas as possible. For example: We realized that we didn’t bring any materials for bystanders to provide first aid while on scene. Resources were very limited, especially at the beginning. The fire and police departments both get money for equipment and advanced training from the safety package provided by the regional government of Berlin.

We hope to purchase backpacks for our vehicles and for police vehicles that each contain slings and a supply kit for surgical injuries. We also think that this will strengthen cooperation and joint training with other authorities.

What impressed you most?

Rolf Erbe: Many of my colleagues from the professional fire service, the volunteer fire service and administrative personnel who were off-duty reported to their fire stations without being asked in order to provide help and assistance. This support is very important for us. Praise from politicians and the public also helps emergency personnel with their processing of the operation.