How to stop the dying, as well as the killing, in a terrorist attackBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m298 (Published 30 January 2020) Cite this as: BMJ 2020;368:m298
All rapid responses
The military medical response of the French Gendarmerie to a terrorist event : description of an original model
We read your essay about the improvement of the medical response during a terrorist attack in United Kingdom  with a great attention. As you pointed out, one of the solutions for enhancing this response is the adoption of a standard military practice. As an example, your essay described the one adopted by the RAID (Recherche, Assistance, Intervention, Dissuasion), the French National Police Special Intervention Unit (SIU). To go further into the discussion, we would like to expose you another model, the one chosen by the French Gendarmerie in association with the French Military Health Service (FMHS). The French Gendarmerie is a military institution within the French Home Office. It maintains a strong military culture and deploys its service members in French overseas operations. The FMHS has developed during the Afghan conflict a standardized method of war injuries management . The aim is to provide on the battlefield, a « hot » and also a « warm » zone, the life-saving intervention at the right time.
As all French soldiers, the gendarmes are trained in the first level of forward combat casualty care (Sauvetage au Combat de niveau 1, SC1) . Simple care procedures can be carried by the first responders : survival positioning, use of tactical tourniquets and haemostatic gauzes, lung injuries management.
In case of a terrorist event, the Gendarmerie engages its SIU : the GIGN (Groupe d’Intervention de la Gendarmerie Nationale). Each quick reaction platoon is deployed with its own tactical emergency medical team. It is composed of one military physician and one military nurse, from the FMHS. This procedure was developed in 1994, following the famous assault in Marignane, during an air-hijacking . It's a direct application of the French tradition of forward medicalization. The medical pair applies care adapted to the situation, if necessary under fire. It can also provide high-technical medical cares such as airways management, digital thoracotomy or initiate a damage control resuscitation strategy, including the use of vasopressors agents and anti-fibrinolytic treatments. This is the third level of forward combat casualty care (Sauvetage au Combat de niveau 3, SC3) .
Moreover, the medical pair can rely on health-qualified GIGN’s operators, trained on the second level of forward combat casualty care (Sauvetage au Combat de niveau 2, SC2) . A SC2 trained operator can perform a tourniquet assessment, use intraosseous access, and manage airways and respiratory status (cricothyroidotomy and pneumothorax decompression). He is also trained into tactical triage and can organize a « casualty nest ».
As the RAID's medical officer, in case of massive shooting event, the GIGN's military physician improves the evacuation maneuver, in close cooperation with the police commanders. But, he also has at his disposal a team with a large range of medical and paramedical abilities. The physician's training in crew resource management allows him to organize an early and suitable prehospital medical response. While supervizing the actions of SC2 and SC3 personals, thanks to his experience in military triage, he can coordinate the evacuations of the patients to the medical support zone, via protected corridors. In case of severe injuries or trapped tactical situation, he can optimize intensive cares. All GIGN's operators involved speak the same tactical language, whether they are police officer or medical officer. These procedures are reviewed weekly during training sessions in which the medical pair is associated. However, the military culture of the GIGN medical officer keeps him in mind that the priority is combat action. This corresponds to the « SAFE » (Stop the burning process, Assess the scene, Free of danger for you, Evaluate) of the « SAFE MARCHE RYAN » mnemonic . The neutralization of the terrorist is the only way to stop the casualties and limit the disorganization of the civilian prehospital emergency medical system.
This adaptation of military procedures was also developed by the military physicians of the Paris Fire Brigade. During the terrorist attacks of Paris in 2015, they put into practice the teachings of forward combat casualty care . Used daily in French overseas operations, it's also annually updated, based on the FMHS' experience  : use of ultrasounds, early transfusion strategy (with lyophilized plasma or whole-blood ), early multimodal analgesia , chemical threat  or advanced haemostatic techniques as REBOA .
This spirit of « Civil Defense Service » is shared with our partners of the French national Health system . Since 2016, the FMHS organized a dedicated course of damage control for terrorist attack victims for the parisian prehospital medical teams. This program will soon be broadcasted for all the civilian emergency medical services . Its aim is to propose a dedicated program to mass training in damage control, by providing a standard of care. Thus, a real and coherent continuum of care will unite all stakeholders in a terrorist crisis.
In case of a terrorist attack, the GIGN deploys an original, standardized and adaptative medical response. It's the same as the one deployed by the FMHS overseas, with the French Armed Forces, because, at last, the enemy is the same.
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Competing interests: No competing interests