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 in order to gain insight into current trends in disaster management among Madrid's Emergency Medical Services (EMSs). Thus, the existing emergency planning framework is described, as well as the basic structures of the different EMSs. The attacks are briefly depicted before consideration is given to pre-hospital management. The issues encountered 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.