Physician Involvement in High-Threat Prehospital Situations: The French Touch.

We read with great interest the contribution from Granholm et al. on the necessary involvement of emergency physicians with the guidelines of tactical medical response ( 1 Granholm F Tin D Ciottone GR. Physician involvement in high-threat prehospital situations. J Emerg Med. 2023; 64 (00–00) Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar ). As the authors reminded us, the French prehospital emergency medicine system integrates appropriately trained tactical physicians into their elite counterterrorism units, such as the RAID (Recherche, Assistance, Intervention, Dissuasion) for the French Police and the GIGN (Groupe d'Intervention de la Gendarmerie Nationale) for the French Gendarmerie ( 2 Service Médical du RAID. Tactical emergency medicine: lessons from Paris marauding terrorist attack. Crit Care. 2016; 20: 37 Crossref PubMed Scopus (18) Google Scholar , 3 Corcostegui SP Galant J Pasquier P et al. Military medical response of the French gendarmerie to terrorist events. BMJ. 2020; 368: m803 Crossref PubMed Scopus (1) Google Scholar ). This choice is notably due to the historical presence of embedded military nurses and physicians within military institutions in charge of the response to terrorist attacks, such as the GIGN or the Paris Fire Brigade ( 4 Lesaffre X Tourtier JP Violin Y et al. Remote damage control during the attacks on Paris: lessons learned by the Paris Fire Brigade and evolutions in the rescue system. J Trauma Acute Care Surg. 2017; 82: S107-S113 Crossref PubMed Scopus (22) Google Scholar ). This integration allows the training of first responders in life-saving procedures and in the concept of preventable deaths (massive bleeding control, pneumothorax, and airways management). Military physicians from the GIGN and the Paris Fire Brigade have benefitted from the experience of the French Military Health Service in recent conflicts during the decade 2000, which led to the standardization of war-wounded management with the SAFE MARCHE RYAN method ( 5 Pasquier P Dubost C Boutonnet M et al. Predeployment training for forward medicalisation in a combat zone: the specific policy of the French Military Health Service. Injury. 2014; 45: 1307-1311 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar ). This forward medicalization training program, particularly adapted for firefighters and gendarmes, allows the implementation of a chain of survival for the gunshot wounded during a terrorist attack, just as French service members do in overseas operations. Moreover, and to improve the integration of its emergency physicians in rescue operations, the Paris Fire Brigade decided several years ago to train its physicians and its fire officers together, each at their level of operational qualification courses. Briefings are shared before carrying out joint exercises, which allows understanding of the stakes and constraints of each part and helps optimize the efficiency of rescue operations. As for the GIGN's physicians and nurses, they all follow the operator's tactical training course. The relevance of these organizational choices can be illustrated in two high-threat prehospital situations that Granholm et al. do not mention: maritime counterterrorism and chemical, biological, radiological, and nuclear (CBRN) attacks.