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On March 11, 2004, terrorists detonated a series of bombs on four commuter trains heading toward Madrid, Spain. This intricate, well-coordinated act of terror, causing the deaths of 191 people and injuries to over 1,800, is considered the most grievous incident to have occurred in Europe in peacetime. In short order, an urban pre-hospital and hospital system worked through the chaos and confusion to deliver care to the victims, manage the recovery of the dead, and provide solace to loved ones. Despite official declarations that this incident was the handiwork of the ETA, a Basque separatist organization, it was subsequently discovered that Muslim extremists were the actual perpetrators. At the general election in Spain, the conservative government fell, caused in part by the general perception that it attempted to mislead the public about ETA's role. Over the course of time, scores of additional suspects were arrested, and finally, 28 (mostly Moroccan Arabs and Spaniards) were brought to trial. At the trial's conclusion, 21 were convicted and sentenced to terms of up to 43,000 years. Seven were acquitted. The presumed motive behind the attacks was to induce the government to remove its troops from Afghanistan.

In the early morning rush hour of March 11, 2004, at the Acalá de Henares train station (9 miles from Spain's capital), an unknown number of perpetrators placed 13 explosive devices in four commuter trains and made their escape. Each device, concealed in a sports bag or rucksack, contained up to 22 pounds of trinitrotoluene (TNT), shrapnel, and a detonator that was connected to the alarm function of a mobile phone. All four trains were on the same track, with the final destination of Madrid's Atocha Station. Between 7:38 and 7:42 A.M., 10 bomb explosions took place. Three bombs had failed to explode.

On the first train, three bombs (one per car) detonated at Atocha Station; on the second train, four bombs detonated at Tellez Street, 546 yards from Atocha Station; on the third train, two bombs exploded, but two failed to detonate when the train was at El Pozo Station, in southeast Madrid; and on the last train, located at Santa Eugenia Station on the eastern end of Madrid, one bomb detonated.

Emergency Response and Evaluation

The explosions triggered an immediate response from Madrid's Emergency Medical Services. The average response time by agencies such as Servicio de Urgencias Médicas de Madrid (SUMMA), Servicio de Emergencias de la Comunidad de Madrid (SERCAM), Servicio de Asistenza Municipal de Urgenza y Rescate-Protecció Civil (SAMUR-PC), and Cruz Roja Española (CRE) was seven minutes to all sites. Subsequent investigations revealed that 175 deaths were immediate. Of the more than 1,800 injured, a high proportion spontaneously sought treatment at local hospitals or were cared for by the responding EMS agencies. The mean patient evacuation time from all four sites was 99 minutes. Nevertheless, at the Tellez Street site, for nearly an hour, about 10 medics were triaging and treating 150 victims. Similarly, at El Pozo Station, 10 other medics initially assisted 50 victims.

Therefore, a cursory review of response/evacuation times and subsequent death toll is not sufficient to address the efficacy of an EMS response involving a complex, multifocal, simultaneous, high-threat catastrophe. Subsequent in-depth analyses of the prehospital events indicate that there not only was much to praise given the unique circumstances, but there was also much that needed improvement. Positive aspects of the EMS response included rapid response times and evacuation, professional abilities of the responders in extreme circumstances, and the use of the sports pavilion at Tellez Street as a field hospital. Negative aspects of the EMS Response included the lack of common radio channels among the responding agencies, lack of powerful command structure at each site, and an initially poor triage system.

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