The 2004 Madrid train bombings: an analysis of pre-hospital management.

The terrorist train bombings in Madrid, Spain, on 11 March 2004 triggered a swift and massive medical response. This paper analyses the pre-hospital response to the attacks to gain insight into current trends in disaster management among Madrid's Emergency Medical Services (EMSs). To this end, the existing emergency planning framework is described, the basic structures of the different EMSs are presented, and the attacks are briefly depicted before consideration is given to pre-hospital management. Finally, an explanation of the main underlying misconceptions in emergency planning and management in Madrid is provided to aid understanding of the origins of some of the problems detected during the response. These are attributable mainly to inappropriate planning rather than to mistakes in field-level decision-making. By contrast, many of the successes are attributable to individual initiatives by frontline medics who compensated for the lack of clear command by senior managers by making adaptive and flexible decisions.