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Critical care in the 21st century: preparation, preparation, and preparation

This month in Critical Care we are launching a disaster management themed section, and we hope that the series of articles published in this section will be an important education tool for all of our readers.

Recent history has made us much more aware of disasters, be they natural, accidental, or terrorist driven, and our need to prepare for them has never been greater. The first article in this series, by Turégano-Fuentes and coworkers [1] from the Gregorio Marañón University General Hospital in Madrid, Spain, covers the terrorist bombing that occurred in Madrid in March this year, and is accompanied by a related commentary by Frykburg [2].

Dr Turégano-Fuentes is Chief of General Surgery and the Emergency Department at the Gregoreo Marañón University General Hospital. Turégano-Fuentes and his co-authors, encompassing the fields of neurology, general surgery and intensive care, have combined their experience and expertise to produce a report that covers the logistics, injuries and clinical management of the casualties seen in their hospital after the Madrid bombings, from emergency room to intensive care unit (ICU). We must acknowledge the strength and courage of all those involved in dealing with this event, but we must also learn from them, and it is our hope that this article will help us to do so.

The article provides several important lessons in dealing with a mass casualty situation. It also raises questions that should be considered in the development and implementation of trauma strategies in health care institutions worldwide, such as how does one balance over-triage and under-triage in the hospitals closest to the blast, and just how does one prepare staff for these situations [1, 2]?

Since 9/11 it has been observed that situations resulting in mass injury tend to possess certain similarities with regard to the treatment of patients, and it is generally agreed that better preparation is needed [35]. As well as preparations for dealing with the patients from a logistical and medical viewpoint, we must take into consideration critical incident stress management, not only for the victims but also for the workers involved from across emergency services. One of the most difficult aspects faced by the emergency services is the exposure to sudden, violent death across all age groups [6]. The matter of leadership and team collaboration in the ICU are also important. A recent report by Lingard and colleagues [7] addressed the 'rules' and dynamics of collaboration in ICU teams. Their paper stressed the need to move beyond the rhetoric of cooperation and toward a more grounded understanding of how an ICU team works in daily practice, which could then be utilized in disasters and other crisis situations.

In the coming months we shall commission further articles covering all aspects of disaster management, including SARS, the role of critical care in complex medical operations, educational programmes for intensivists, communication, leadership and victim support, as well as further first-hand experiences in mass casualty situations.



= intensive care unit.


  1. Peral Gutierrez de Ceballos J, Turégano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M, Martin-Llorente C, Guerrero-Sanz JE: 11 March 2004: The terrorist bomb explosions in Madrid, Spain – an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005

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  2. Frykberg ER: Terrorist bombings in Madrid. Crit Care. 2005

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CE, ER and KL are employees of BioMed Central and receive a fixed salary. As editor-in-chief, JLV receives a fixed honorarium from Current Science Ltd, which is part of BioMed Central

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England, C., Lapworth, K., Rahman, E. et al. Critical care in the 21st century: preparation, preparation, and preparation. Crit Care 9, 3 (2004).

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