WEDNESDAY, Aug. 10, 2005 (HealthDay News) -- A vivid picture of what it meant to be a doctor confronted with the carnage of the London terror bombings of July 7 is painted in the austere pages of this week's New England Journal of Medicine.
Physicians also offer some practical advice about management of the physical and psychological consequences of such an attack.
One of the four reports about that bloody day was written by Dr. Peter J.P. Holden, a family doctor in Matlock and an officer of the British Medical Association (BMA).
"A last-minute change of plans at 9 a.m. leaves me working at BMA House, preparing for a meeting," Holden remembered. "This was to prove fateful."
As colleagues gather for a meeting, signs of trouble begin to emerge. Emergency vehicles bustle about; a medical helicopter hovers overhead. "We turn on the television; clearly a major incident is unfolding. A chill runs down my spine. I sat in the same place watching the events of 9/11," Holden wrote.
Then at 9:50, "everything momentarily seems pink. There is an enormous bang. Some of my colleagues have looks of terror on their faces. We can see white smoke and debris raining down in the square."
The association's headquarters is on Tavistock Square, where one of the four bombs planted that day by terrorists tore the roof off a double-decker bus, killing 13 passengers. A total of 56 people died in the four blasts, which were also detonated in underground subway stations.
Holden was one of the doctors who ran to help the survivors of the attack on the bus. He was put in charge of the group.
"I have trained for such a situation for 20 years -- but on the assumption that I would be part of a rescue team, properly dressed, properly equipped and moving with semi-military precision," he wrote. "Instead, I am in shirtsleeves and a pinstripe suit, with no pen and no paper, and I am technically an uninjured victim. All I have is my ID card, surgical gloves and my colleagues' expectation."
Most of them "have not cared for a casualty for 20 years. They accept my instructions without a murmur. Astonishingly, I have established command."
The first job is triage, sorting out the injured who need treatment most, then to "feed patients into the rescue chain in an orderly fashion." Gridlock makes supplies and ambulances slow in arriving, but the job is getting done. By noon, the 15 people being treated in and near the association headquarters are moved to hospitals, in order of clinical priority. Another six injured are reported to be in a nearby hotel; they also are routed to hospitals. "All but one victim who entered BMA House have left alive and in better shape than on arrival," Holden noted.
"I have created a casualty clearing station in the shadow of a memorial to the physicians who served in the Second World War," he wrote. "I hope we did them proud."
The medical lessons of the day are outlined by Drs. Jim Ryan and Hugh Montgomery of University College London. A terrorist attack was expected; "the question, experts said, was not if but when."
But the scope of the attack -- four simultaneous explosions by suicide bombers at different locations, most of them underground -- put enormous pressure on emergency services. And such attacks can be expected in the future, using not only explosives but also biological agents and poison gas, the physicians said.
So there must be coordinated training -- "not restricted to a few experts; many passerby's doctors engaged in casualty care at each of the scenes. Specialists must be trained in new skills, such as extrication, triage and transport." And every city should be prepared for such an attack, providing training and emergency equipment, they said.
The response to the psychological effects of a terrorist attack need not be so swift, notes a commentary by Dr. Simon Wessely, a professor of psychiatry at Kings College London. Controlled trials with people involved in auto accidents and other traumatic experiences have shown that immediate counseling has little or no beneficial effect, he said.
"In general, we often underestimate how people will behave in the face of adversity," Wessely said. Even in the worst situation, being trapped underground in the dark, few people panicked.
Wessely said he was told by a secretary who worked at the university and who was trapped underground by one of the explosions that even when smoke began to pour into the darkened car, most people remained calm. One young man in the car had lost a leg in the explosion; a trainman wrapped his belt around the leg, saving the man's life by preventing blood loss.
Britons have been through this sort of thing before, Wessely noted. He recalled that the novelist Virginia Woolf, who lived at Tavistock Square, came back after the all-clear sounded in October 1940 to find that her home had been destroyed by a German bomb during an air aid. And the Irish Republican Army set off a number of bombs in the city in later decades.
But the July 7 attack was different than those mounted by the IRA, he said. "There was a sense of the rules of the game with the IRA," he said. "They were not intending to kill the maximum number of civilians."
But British civilians can take heart in the fact that the emergency response system worked and worked well, Wessely noted, and they need not be afraid in the future.
"We must be careful to avoid shifting from the language of courage, resilience, and well-earned pride into the language of trauma and victimhood," he wrote. "The bombs made more than enough victims; it is important that we do not inadvertently create more."
More information
For more on terrorism preparedness, visit the U.S. Department of Homeland Security.
