David Pariente, left, and Yonathan Freund are doctors in the emergency department at the Pitie-Salpetriere hospital near the location of one of the Nov. 13 terrorist attacks in Paris.
On the Friday of the Paris terrorist attacks, Yonathan Freund was taking a 10-minute coffee break in his office above the emergency room when a call came in.
Freund picked up the phone.
The hospital had been contacted by SAMU, the French emergency medical services, a nurse told him. Mass shootings had occurred at several sites across the city, and things didn't look good: As many as 200 people had been hurt, many of them gravely. How many patients could Freund, an attending physician in the emergency room of Pitie-Salpetriere, a major Parisian teaching hospital, accommodate?
Freund blew the caller off.
"OK, OK," he remembered saying, a little impatiently. "Thank you very much, but I've got work to do. Goodbye."
As Freund suspected, the call was part of a drill - one of the exercises that have become more common over the past two years as the threat of terrorism has increased - and Freund was having a busy day. He hung up, finished his coffee and went back downstairs to the ER, where patients with pressing problems such as chest pains and sprained ankles were awaiting his care.
Less than 12 hours later, on a relatively quiet Friday evening in the ER, Freund's colleague David Pariente received a similar call. The SAMU was reporting mass shootings and suicide bombings at several sites. Only this time it was real.
As the scale and severity of the attacks became clear, the director of the Assistance Publique-Hopitaux de Paris (APHP), a network of public hospitals in Paris, took an unprecedented step: He activated the city's Plan Blanc, or White Plan, mobilizing all 40 hospitals to call in extra staff members and free up resources by emptying beds and canceling nonessential procedures. A further goal of the citywide coordination was to avoid over-staffing the initial response; some doctors and nurses needed to be fresh to treat patients the following morning. Freund, 35, who lives near the site of the drive-by attacks in the streets, was among them.
At Pitie-Salpetriere, Pariente and his colleagues began putting Plan Blanc into action.
He and three other attending ER physicians sent some patients home and divided the facility in two, setting aside one half to receive the bloodied and traumatized young men and women who began to arrive: the first one in a car who had superficial wounds on her scalp. The next via Uber, with a bullet lodged in his abdomen. For the rest of the night, damaged bodies were delivered in ambulance after ambulance, sometimes four in each vehicle, leaving a red wake on the white linoleum floor that led into the building.
"I was walking on the blood," said Pariente, 39. "I didn't realize it. I was looking ahead of me all the time."
The two phone calls - the first an exercise and the second alerting physicians to attacks that would leave 130 dead and more than 350 wounded - reflect the realities of a city that has been preparing its medical services to provide a coordinated response to events that seemed at once unthinkable and inevitable.
"Everyone knew. Everyone knew something would happen," said Pariente, looking back. There was a heightened sense of risk, he said, with a bomb scare closing the nearby Gare de Lyon station that very Friday afternoon.
"The question," Freund said, "was not if, but when."
The French response was highly centralized and drew on practices that differ from U.S. emergency services. Using protocols adapted from the military, the SAMU sent physicians to the field, setting up triage centers close to the sites of the attacks, where they could treat patients on the spot before dispatching them to a hospital where specialists would be on hand to treat their particular injuries.
The patients wore colored signs around their necks:
Red marked the most critically wounded, who were admitted directly to resuscitation units and often were moved swiftly into surgery.
Yellow was for those who needed immediate treatment in the ER.
Green was for patients who could be sent home with instructions to check in at an ER within 24 hours.
Pariente doesn't remember seeing any green labels that night. Out of the 100 victims who were assigned red labels, 28 were sent to Pitie-Salpetriere's resuscitation unit, while 27 went to the ER. The hospital, which usually has only one operating room open overnight, was able to staff 10 from late Friday until 6 a.m. Saturday.
Physicians in Paris rarely treat gunshot wounds. "Not one a day. Not one a week," Freund said. And the mass shootings that have plagued U.S. campuses are unheard of. But French trauma surgeons have had a growing awareness, heightened by January's fatal attacks on the satirical magazine Charlie Hebdo in Paris, of the need for know-how.
Pariente, who spent six years working in the SAMU, had some familiarity. The patient who arrived by Uber bore in his abdomen an eerie sign of what had already happened - and of the kinds of injuries doctors would face hours later when the police finally rescued the hostages held in the Bataclan concert venue.
Pariente took a look at the man's CT scan, which showed the bullet in his abdomen. It was narrower and longer than any bullet he had seen before. The distinctive shape, he would later learn, of the ammunition from an AK-47.
Such somber realizations were matched by the surprising quiet of the ER.
"There was no agitation," Pariente said. Patients weren't crying. They weren't even speaking, simply answering the questions doctors asked about their medical histories.
When Freund came to work at 5 a.m. to relieve Pariente, following the bloody trail into the ER, he saw his first gunshot wound ever - a fierce red burn line tracing the trajectory of a bullet from its tiny entry point in the skin on the back of a young man's neck across to his right shoulder where its exit had left a jagged hole. Marveling that the man had been spared certain death by one-fifth of an inch, Freund asked about his medical history.
"I had testicular cancer 15 years ago," he said, and had been cured. Not yet 40, he had already dodged two bullets.
Freund found victims who looked at once familiar and as though they had come from a war zone.
"They were all our age," he said, all younger than 40, covered in blood and grime and with their clothes ripped, not only from bullet wounds but from their struggle to escape. Many of them had been enjoying an evening out in the bars and restaurants of the bohemian quarter Freund and his friends like to frequent. "It's our Brooklyn," he said.
About 8 or 9 a.m., a young woman came in with her boyfriend to be treated for burns on her back. She explained very quietly what she thought had happened. An assailant had pointed a gun at her, she said. When the police burst in, he detonated his suicide vest, which exploded into her.
Freund couldn't help but think as he cleaned out the burns that it might be the flesh of the terrorist seared against her skin.
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