Blast-Related Injuries from Terrorism: An International Perspective

SPECIAL CONTRIBUTION

BLAST-RELATED INJURIES FROM TERRORISM: AN INTERNATIONAL PERSPECTIVE

E. Brooke Lerner, Robert E. O’Connor, Richard Schwartz, Kathryn Brinsfield, Isaac Ashkenazi,Linda C. Degutis, Jean-Philippe Dionne, Stephen Hines, Simon Hunter,

Gerard O’Reilly, Richard W. Sattin

ABSTRACT

Terrorism using conventional weapons and explosive devicesis a likely scenario and occurs almost daily somewhere inthe world. Caring for those injured from explosive devicesis a major concern for acute injury care providers. Learningfrom nations that have experienced conventional weapon at-tacks on their civilian population is critical to improving pre-paredness worldwide. In September 2005, a multidisciplinarymeeting of blast-related injury experts was convened includ-ing representatives from eight countries with experience re-sponding to terrorist bombings (Australia, Colombia, Iraq,Israel, United Kingdom, Spain, Saudi Arabia, and Turkey).This article describes these experiences and provides a sum-mary of common findings that can be used by others inpreparing for and responding to civilian casualties result-ing from the detonation of explosive devices. Key words:terrorism; disaster preparedness; blast; trauma and injury;emergency medical services; international medicine.

PREHOSPITAL EMERGENCY CARE 2007;11:137–153

INTRODUCTION

Terrorism is a real and constant threat throughout theworld. Although preparedness in the United States has

Received October 19, 2006, from the University of Rochester,Rochester, NY (EBL); Christiana Care Health System, Newark, DE(REO); Medical College of Georgia, Augusta, GA (RS); Boston Uni-versity School of Medicine, Boston, MA (KB); Israel Defense Forces,Israel (IA); Yale University, New Haven, CT (LCD); Med-Eng SystemsInc., Ottawa, Canada (JPD); London Ambulance Service NHS Trust,London, UK (SH); Queen Alexandra Hospital, Portsmouth, UK (SH);Alfred Emergency and Trauma Centre, Melbourne, Australia (GO);and Centers for Disease Control and Prevention, Atlanta, GA (RWS).Revision received December 11, 2006; accepted for publication De-cember 12, 2006.

EBL is currently with the Medical College of Wisconsin. RWS is cur-rently with the Medical College of Georgia.

Address correspondence and reprint requests to: E. Brooke Lerner,PhD, Department of Emergency Medicine, Medical College ofWisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226. e-mail:[email protected]

doi: 10.1080/10903120701204714

focused predominately on the threat of radiation, chem-ical, and biological weapons, terrorism using conven-tional weapons and explosive devices is a far morelikely scenario and occurs almost daily somewhere inthe world. Caring for those injured from explosive de-vices remains a real and ongoing concern for acute in-jury care providers throughout the world. Many coun-tries, including the United States, still struggle to be in aposition of true preparedness for responding to injuriescaused by the detonation of explosive devices.

The impact of such an event on an already frag-ile, overburdened, and underfunded (or nonexistent)response system will likely be catastrophic. Learn-ing from nations that have experienced conventionalweapon attacks on their civilian population is criticalto improving preparedness worldwide.

To this end, in September 2005, the National As-sociation of Emergency Medical Services Physicians(NAEMSP) supported by the Centers for Disease Con-trol and Prevention convened a meeting of blast-relatedinjury experts (Appendix 1) in Nice, France. These mul-tidisciplinary experts included representatives fromeight countries with experience responding to terror-ist bombings and treating the casualties that resultedfrom the detonation of explosive devices among civil-ian populations. The following is a description of theirexperiences and a summary of common findings thatcan be used by others in preparing for and respondingto civilian casualties resulting from the detonation ofexplosive devices.

THE DISASTER PARADIGM

The Disaster Paradigm can be applied to all types ofmass casualty disasters and was selected as our frame-work for describing the medical response to blast-related injuries. The Disaster Paradigm is an all-hazardsmnemonic used in the American Medical Association’sNational Disaster Life Support programs.1 The Disas-ter Paradigm uses the word disaster to illustrate the

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138 PREHOSPITAL EMERGENCY CARE APRIL/JUNE 2007 VOLUME 11 / NUMBER 2

essential components of a disaster response: Detection,Incident Command, Scene Security and Safety, AssessHazards, Support, Triage/Treatment, Evacuation, andRecovery.

Detection is the process of recognition that a situationwill overwhelm the resources available to the provideron scene or at a health care facility. Although the detec-tion of a conventional disaster such as the September 11,2001 terrorist attacks or a terrorist bombing is a straight-forward process, the detection of the scope of the attackand the communication of the situation and responsewill likely unfold over time.

Incident command refers to the command structurethat is initiated once an incident is detected. In theUnited States, the Incident Command System has be-come the standard command structure owing to theHomeland Security Presidential Directive that createdthe National Incident Management System. This sys-tem uses and expands the Incident Command Systemto allow for the early coordination of all assets and todelineate clear lines of authority. It provides for dif-ferent command and control schemes depending onthe size, scope, and jurisdictions involved in an event.There is also a Hospital Emergency Incident CommandSystem, which is being widely used to improve the co-ordination, command, and control within hospitals. Itis also important to note that other command structuresare being used successfully in other countries. For ex-ample, the United Kingdom, Australia, and NATO usethe Major Incident Medical Management and Supportsystem.

Scene security and safety refers to assessing and en-suring the immediate safety and security of the incidentscene. In the prehospital setting, this may require theuse of public safety, fire/rescue, and other assets to en-sure the safety of the providers before entry. Following ablast, scene responders must consider the possibility ofsecondary explosions or coordinated attacks as poten-tial safety threats. In the hospital setting, prearrangedprotocols must be in place to “lockdown” hospitals,provide ingress and egress corridors for patients andstaff, and allow for the activation of secondary treat-ment facilities for minimally injured patients.

Assess hazards refers to first responders and first re-ceivers assessing for potential hazards in all disaster sit-uations. This is done in a variety of ways and dependson the scenario. For example, with a terrorist bombing,providers must be aware of potential threats such assecondary explosive devices, as well as other hazardsthat may have been created by the explosion. This couldinclude the use of a “dirty bomb” for radiation disper-sal or the dispersion of biological or chemical agents.The medical provider must be aware of these hazardsand be prepared to address them.

Depending on the assessment of the hazards and thenumber of victims expected, the providers must de-termine the Support that is required to respond to the

disaster. Support may include but is not limited to ad-ditional hospitals, additional ambulance units, medicaldirection, hazardous materials teams, fire/rescue, pub-lic safety, emergency management agencies, mortuary,logistical support, and additional local, state, and fed-eral resources as needed.

Triage/Treatment refers to selecting the multiple ex-isting triage systems that will be used. There is littlescientific evidence to validate the efficacy or effective-ness of any of these systems. A simple and standardizedtriage system should be used to avoid confusion. As wegain experience with the treatment of blast-related in-jury, evidence-based treatment protocols need to be de-veloped to minimize patient mortality and morbidity.

Evacuation is a complex process in a disaster and in-volves the prehospital emergency medical system aswell as evacuation of patients from an affected healthcare facility. The evacuation phase should also includethe management of families of the disaster casualtiesincluding reunification.

Recovery is a multifaceted process that begins withthe onset of the disaster but may last many years. Animportant component of recovery is the psychologicalrecovery of victims, responders, and others affected bythe disaster. Recovery also includes the return of infras-tructure and economic considerations. This includesensuring public health such as providing clean waterand sanitation.

INCIDENT SUMMARIES: REPORTS OF SINGLE

INCIDENTS

Bali, Indonesia (The Australian Perspective)

On October 12, 2002, a suicide bomber detonated him-self inside a Bali nightclub. Moments later, as peoplepoured into the street, a van parked outside a neighbor-ing nightclub exploded.2 The van contained 1,000 kg ofchlorates, but because of a manufacturing error, it ex-ploded at only one-tenth of its potential power.3 In total,202 people were killed and many more were injured.4

Many of the injured were taken to the Sanglah GeneralHospital in Bali. Among the injured, many were for-eign nationals, predominantly Australian. Therefore,the Australian Air Force airlifted 66 of the most seri-ously injured Australians to the Royal Darwin Hospi-tal in Darwin, Australia, approximately 1084 miles fromBali.5 Darwin is the closest major Australian city to Baliwith a tertiary referral hospital.6

Detection

Initial reports from the scene were limited but widelydisseminated, primarily by foreign nationals using cel-lular telephones. An initial impediment to widespreaddisaster response activation in Australia was that de-tails of the disaster were limited and often misleading.

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Brooke Lerner et al. BLAST-RELATED INJURIES 139

This was because informants were inexperienced va-cationers attempting to assess the disaster scene. Al-though initial communications seemed effective, muchinformation bypassed disaster relief organizers and in-stead went directly to friends and family members ofwitnesses. Subsequently, ongoing information was alsodispersed through extensive coverage by the interna-tional media.

The incident occurred at 23:08 Bali time. By about02:00 Bali time, the Defence Ministry and AustralianDefence Force had been informed, and two Air Forceplanes were placed on notice and configured foraeromedical evacuation. It is of interest that the firstreport of the incident at the Royal Darwin Hospital wasfrom a patient who had escaped the scene and gone im-mediately to the airport, catching the next commercialflight to Darwin.6 On landing, he went directly to thehospital for treatment of his injuries and informed staffof the bombing.

Incident Command

In Australia, the states ordinarily have the primary re-sponsibility for coordinating disaster management ac-tivities. In general, federal government assistance isprovided to states for preparation activities. States alsohave the option, during an incident, to request that theAustralian Defence Force augment their health and se-curity resources. The remote location of this incidentrequired a local response involving Indonesian lawenforcement and local volunteers and a very distantresponse largely coordinated by the Australian gov-ernment through the Australian Defence Force. Initialevacuation resulted in many of the injured being di-rected to Sanglah General Hospital, which was 20 min-utes by taxi from the bomb site and 40 minutes from theairport. Although many volunteers provided medicalcare and assistance at the hospital, efforts to coordinatea multinational relief effort had to go through the Aus-tralian embassy and required Indonesian governmentclearance.

The bomb site was distant relative to Darwin, de-laying the response. Following a meeting of the Aus-tralian government task force, the first of five aeromed-ical evacuation (C130) planes left for Bali from Sydney(approximately 2875 miles away) about 9 hours afterthe blast. This plane carried some medical and nursingstaff, plus limited medical supplies. On a fuel stop inDarwin, additional staff and supplies were acquired.Waiting on a national response, with the AustralianDefence Force responding from Sydney, resources inDarwin, including aircraft with experienced personnel,were initially underused. It took more than 16 hours toget experienced health personnel from Australia to thevictims, and more than 24 hours had elapsed before themore seriously injured patients arrived in Darwin. Al-though delays due to distance and foreign diplomacy

could have potentially impacted negatively on patientoutcomes, it certainly allowed the receiving hospitalsto be very well prepared. The Royal Darwin Hospitalwas designated as the sole initial receiving hospital forthe Bali victims.6

With the arrival of Australian Defence Force stafffrom the Royal Darwin Hospital on the first plane toBali, the flow of information to the hospital improvedconsiderably.6 Nevertheless, details of patient numbersand injury severity were not received until the initial ar-rival of patients.

Scene Security and Safety

Initially, scene security was lacking. Bystanders pro-vided the initial scene response, so the area of the blastwas not cordoned off, and there was an active firewith an ongoing risk of further explosion. Survivorswalked or were carried out by friends and volunteersand were directed to Sanglah General Hospital. The In-donesian police subsequently responded to the sceneand provided security at the bomb site for forensic pur-poses. They also acted as an escort for all AustralianDefence Force movements between the hospital andthe aeromedical staging facility at the airport.

Assess Hazards

At the incident site, there was significant difficultyin assessing hazards because many nationalities wereaffected, and in many cases the removal of victimsbypassed scene triage. Some of the problems arose be-cause many different languages were native to the vic-tims and because persons tend to self- segregate. Therewas the potential for further hazards at the scene, enroute to the hospital, at the hospital, and en route to theairport.

In a broader sense, there were additional hazards pe-culiar to the fact that the responders for this group ofpatients were foreign nationals. The evacuation pro-cess created the potential for the entry and exit of for-eign nationals via unauthorized routes both in Bali andAustralia. Considerable diplomacy was needed to over-come this issue. Similarly, the transport distances cre-ated considerable risk for both patients and crew giventhe long flight hours and the potential complicationsarising during flight.

Support

Early in the morning on Sunday, October 13, a medi-cal evacuation team was organized to fly from Sydneyto Darwin to Bali to assist in evacuating injured peo-ple. Several teams of doctors, nurses, and medical as-sistants, both from Sydney and Darwin, traveled to Bali.Medical equipment, including a large quantity of burndressings, analgesics, and intravenous fluids, was alsosent.

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Large aircraft were needed to transport medicalequipment and personnel to Bali because of the longdistance. Supply gaps in medical equipment and skilledhuman resources were inherently less forgiving be-cause aircraft arrival was sporadic and limited storagecapacity was available. During the 16 hours before thearrival of the first dedicated aircraft, initial care wasdependent on the hard work of the Sanglah GeneralHospital staff and mostly inexperienced volunteers.

At the Royal Darwin Hospital, the 24-hour delay tothe first patient’s arrival allowed considerable surgecapacity to be identified. Among other measures ini-tiated, 600 staff members were recalled to the hos-pital. Despite the local media informing the commu-nity of the situation, there was no decrease in thenumber of regular emergency department visits.6 Oncethe Royal Darwin Hospital was ready to receive pa-tients from Bali, it was an additional 8 hours beforethe first planeload of patients arrived.6 This providedenough time for group tutorials to be held while staffawaited the arrival of the first patients. These tutorialscovered burn dressing, escharotomies, and fluid andairway management.

Triage/Treatment

The initial triage and treatment at the actual bomb sitewas not organized, making it victim- and volunteer-dependent. At the Sanglah General Hospital, intra-venous cannulae were placed and wound dressingswere applied, with some intravenous fluid administra-tion. There was minimal analgesia. Two patients wereintubated and 20 escharotomies were performed.

When the Australian Defence Force contingent ar-rived in Bali, part of the medical team went to theSanglah General Hospital, which was a 40-minute drivefrom the airport.6 Once they arrived, triage was re-peated, followed by additional resuscitation and astaged movement of the seriously injured to the air-port. At that point, there was no need to use the ex-pectant or palliative care triage category because sur-vivors had largely declared themselves. Analgesia wasthe main adjunct available to the Australian DefenceForce staff, in addition to their medical expertise. At thehospital, there was little oxygen available, and few me-chanical ventilators were available (personal commu-nication, Sue Winter, MD, Alfred Hospital, Melbourne).

The remaining members of the Australian DefenceForce medical evacuation team prepared an Aeromedi-cal Staging Facility, situated in a hangar on the airfield.The seriously injured were escorted to this facility fromthe hospital, and retriaged for evacuation to the RoyalDarwin Hospital.5 The severity of injury in these pa-tients was high as 28 of the 61 patients arriving at theRoyal Darwin Hospital had an Injury Severity Scoregreater than 15, and 15 patients ultimately requiredinvasive ventilation. The full range of blast injury se-

quelae were seen in these patients, including severeburns, missile injuries from shrapnel, limb injuries, andpressure wave injuries to ears, lung, and bowel (per-sonal communication, Kerrie Jones, MD, Royal DarwinHospital).

Hundreds of people who were able to extricate them-selves from the scene went to the airport to try to getseats on outbound flights to Australia; many had obvi-ous burns and shrapnel injuries.7 Qantas Airlines antic-ipated the need to fly injured passengers and sent med-ical personnel to Bali. These physicians and paramedicsflew with the passengers on the first commercial flightsout and set up a treatment area in the departure loungefor those waiting for later flights.7 None of these causal-ities were in critical condition because they were all ableto ambulate to the airport. However, many passengersattempted to conceal their injuries because they falselybelieved they might be refused transport if their injurieswere identified.7

Evacuation

Five injured patients were transported by private jetto Perth just prior to the arrival of the Australian De-fence Force C-130.5 Another 61 seriously injured pa-tients were transported from the Sanglah General Hos-pital to the aeromedical staging facility and then evac-uated via five separate flights to the Royal DarwinHospital.5 The first plane arrived at the Royal DarwinHospital at about 01:30 hours (Darwin time) and the lastat about 17:00, on October 14. The C-130 Hercules air-crafts were capable of transporting up to 30 stretcheredpatients. On the first flight, there were 15 patients; twowere in critical condition. During the flight, one patientdied, despite aggressive attempts at resuscitation.5 Af-ter arrival in Darwin, it was determined that many ofthe patients would need to be further evacuated to themajor national burn centers throughout Australia, afterevaluation and stabilization in Darwin. Over 16 hours,35 patients were transferred to the burn centers in theirhome state.5

Issues related to evacuation included the difficultyin maintaining optimal fluid status and normothermia.Communication and documentation were difficult be-cause of the haste of the evacuation. This event had anunprecedented reliance on air evacuation. Sustained airevacuations are greatly limited by the planes’ capacityand lack of flexibility in flight plans and schedules. Pi-lot hours can be an unanticipated rate-limiting feature.That is, marginal increases in flight cycle time may haveconsiderable effects on pilot availability.6

Commercial flights to Australia transported the walk-ing injured who had made their way to the airport.Triage tags were used to identify patients during theflight by placing the tags so that they protruded fromthe top of patients’ seats.7 Doctors and paramedicson these flights and in the departure lounge assessed

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individual patients and documented injuries and treat-ments that were to be instituted during the flight on thetriage tags. Because these patients were all stable, thetraditional triage system was abandoned; instead, thehighest priority tags were assigned to patients withburns, dehydration, or multiple injuries; middle prior-ity was assigned to those with injuries that were stable,but had potential for deterioration; and low prioritywas assigned to patients with emotional stress or mi-nor injuries.7

Recovery

Because of the number of dead and the remotenessof the site, forensics and positive identification wereproblematic.3,4 Delayed posttraumatic stress includedemotional trauma and survivor guilt. The Royal Dar-win Hospital experienced good recovery due to ade-quate preparation time and the ability to disperse manyof the critically ill to other hospitals.

London, England

On July 7, 2005, four suicide bombers struck three un-derground trains and a public bus. The trains werebombed simultaneously, and the bus was struck ap-proximately an hour later. The attacks killed 52 peopleand injured over 700.8

Detection

Because of the nature of the underground train attacks,there were no calls to the emergency medical servicesfrom direct witnesses or passengers. Calls from the pub-lic were received from the stations at both ends of thetunnel. In 27 minutes, the British Transit Police andLondon Fire Brigade received five calls. Most of theinformation, over 20 calls, came from different agencyemployees reporting in through their central commu-nication system, not through the emergency responsedispatch system. Further, initial reports stated there hadbeen an incident but did not report it as a bombing be-cause the bombing occurred in the tunnel where directcommunication was not possible. Initial reports had in-dicated a power surge was the cause of the explosions.Emergency calls regarding the bus bomb were initiallyvague; it was unclear whether one or two busses wereinvolved.

Incident Command

London public safety uses the Major Incident Medi-cal Management and Support Triage System by des-ignating different zones of command: Bronze, Silver,and Gold.9 Bronze Commanders from the fire, police,and emergency medical service agencies worked to-gether at each scene, and each directly reported to their

Silver commanders. Silver commanders were in thefield, managing the overall scene. Gold commandersremained in an office-type setting and coordinated theoverall response.

Command was hampered by a lack of backup com-munication. The written disaster plan relied heavilyon cellular telephone communication as a secondarybackup to crowded radio channels. As predicted, thecellular phone lines became jammed. The City DisasterPlan had called for the general public’s access to thecellular towers to be limited, but in this real event, itbecame apparent that the time needed to change eachtower to relay only appropriate calls was too long, andmany of the responding crews did not have the appro-priately programmed phones. In the end, crews had touse runners and hand signals to make up the commu-nication shortfalls.


The protocol for scene security involved the creationof an inner cordon, an outer cordon, and a traffic cor-don. Only rescue vehicles and certified personnel werepermitted in the inner cordon; the outer cordon wasused as a barrier, and only those with valid forms ofidentification were allowed inside. The traffic cordonwas for public rerouting so the ingress and egress path-ways remained open for response vehicles. These cor-dons were meant to deter secondary devices and self-activating staff and ambulances. Unfortunately, therewere still many volunteers pretending to be doctors andself-dispatched medical staff. The scenes were noted tohave numerous hazards for responders, particularly theunderground train that was bombed between stations.

Assess Hazards

London has a multiagency assessment team that worksacross agencies to determine if there are radiological orchemical threats at the scene of a bombing. This teamarrived promptly at the first bombing site and was ableto determine that there were no additional hazards.With four near simultaneous bombings, there were notenough teams to respond to each site at once. One groupof aeromedical doctors remarked that in the future, theywill carry their own basic detection equipment to ruleout hazards in a similar situation.10 In response to con-cerns like these, all frontline EMS staff are being issuedwith personal radiation detectors.

Support

Over 101 ambulances from London and 41 ambulancesfrom other sources were used in the response. In addi-tion, 150 voluntary ambulances also responded. Over40 doctors, mainly including those who trained reg-ularly with the EMS and aeromedical systems, wereused.10

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Triage/Treatment

Patients triaged green, or walking wounded, weremoved to emergency treatment centers that werestaffed by EMS personnel and EMS physicians. Threeschools and two hotels were used as treatment cen-ters; these locations were preidentified, and necessaryequipment was permanently stored in supervisor vehi-cles so that they could be opened immediately. Greenpatients were not tagged because of a shortage of triagetags. If these patients were found to have minor injuriesand no ruptured tympanic membranes (because of thecontroversial belief that this is associated with primaryblast injury), they were discharged directly from thesecenters after a period of observation.

Few patients received cervical spine immobilization.Red and yellow patients and those determined immedi-ately to need specialist care were transported to hospi-tals. However, it was noted that some patients changedthe color of their tag by removing the tag from its plas-tic sleeve and refolding it, presumably so they wouldbe transported sooner.

Hospital treatment limited the use of radiographs andcomputed tomography scans per standing protocol.Immediate radiographs were limited to the chest andpelvis, and immediate computed tomography scanswere limited to the head. Most patients were observedin hospital. Of note, one patient who went into cardiacarrest in transit from Kings Cross was resuscitated andlived to discharge.10

Evacuation

Evacuation from the blast site was accomplished by acombination of EMS, physician, and fire personnel. Inparticular, medical teams participated in evacuation ofthose patients who had been entrapped. Lockey et al.reported that two patients required sedation with ke-tamine to facilitate rescue.10 Four hundred four patientswere moved to eight hospitals by ambulance and bus.Bus transportation was used for those with less urgentinjuries. Police and medical staff, with the appropriateequipment and communication devices, staffed eachbus. Seven hundred seventy-five patients were treatedon scene. Many patients with minor injuries who livedoutside of London presented to doctors in their home-towns. These patients felt that their injuries were minorand returned to their homes outside London after theexplosion. They then reported to their local emergencydepartment for care.

Recovery

Extra vehicles were placed in the field for several daysafter the incident, and extra management personnelstayed on duty for 2 months. This was done to en-sure that EMS providers were well taken care of andnot overly stressed by the incident. The extra vehicles

were obtained by using staff and vehicles from neigh-boring ambulance services. Health checks were offeredto all ambulance staff. In addition, senior staff mem-bers called the homes of all employees after the eventto check on the welfare of both themselves and theirfamilies.

Madrid, Spain

On March 11, 2004, 10 bombs exploded on four busyearly-morning commuter trains in Madrid, Spain. It hasbeen estimated that approximately 700 people were oneach of these trains.11 The attack resulted in 191 fatalitiesand approximately 2,000 injuries.

Detection

At 7:36 am, the first 112 call, the emergency access num-ber in Spain, was received. Eight seconds later the sec-ond explosion was reported. Three minutes after thefirst call, at 07:39, the third explosion was reported.The third and fourth explosions occurred geographi-cally close to each other, and callers did not report theseas separate incidents because a curve in the tracks keptthem from seeing each other. Therefore, it was not untilemergency units actually arrived at the scene that it wasdiscovered that there had actually been four separateexplosion sites.12

On March 11, the dispatch center received 23000 tele-phone calls; their typical daily average is about9000 calls. They received 167 calls reporting the inci-dent and about 5661 calls asking for information. OnMarch 12, the center handled about 14766 telephonecalls; 2,466 of those were for information about the in-cident. To keep the dispatch center operations runningsmoothly, the center set up a procedure for transfer-ring calls from inquiring relatives to a special team thatwould take down their information. This contact infor-mation was then relayed to a team of psychologists,who would contact the relatives with further informa-tion. Calls from the media and others asking for generalinformation were routed to another special team of op-erators. They also recorded some information and wereable to simply transfer some callers to that recording forinformation. Finally, some hospitals were able to faxinformation on fatalities and injuries. This informationwas entered into a computer system that was then usedby several different government agencies and was alsoposted on the Internet for public information.12

The incident was classified as “extraordinary” underMadrid’s emergency plan, which rates the seriousnessand scope of an incident. That is, the incident was ratedas a “3” on a scale from zero to 4.12

Support

There were four different response sites. In total,6,000 people were involved in the response, including

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2,300 from law enforcement, 500 from fire, 380 socialworkers, 200 psychologists, and 102 employees fromthe dispatch center. Apparatus sent to the scene in-cluded 40 fire vehicles 300 law enforcement vehicles,and 260 ambulances.12

Triage/Treatment

At the Atocha scene, 115 patients were treated, andwithin 1 hour and 15 minutes all of them had beentransported. At the Tellez Street scene, the train doorswere closed at the time of the explosion, so few victimson the train survived for treatment. However, at thatscene EMS treated 165 persons and within 2 hours and25 minutes all of them had been transported.12 Therewere 177 immediate deaths across all of the scenes,976 people were transported to area emergency depart-ments, 250 were treated and released in the field, and204 were treated by a primary care provider. Of thosewho were transported to the hospital, 509 were admit-ted, and 83 were in critical condition. Finally, there werenine additional deaths in the few hours after arrival atthe hospital, and five victims died a few days later, fora total of 191 deaths.11

Evacuation

There was initially a great deal of overtriage of patientsto hospitals. This caused some chaos at the hospitalsthemselves. Further, there was unequal distribution ofpatients between the hospitals and poor communica-tion from the explosion sites to the hospitals. In thehospitals, there were deficiencies in security, identifica-tion of patients, record keeping, and initially there wereissues with handling family members. There had beenno prior hospital simulations to practice hospital leveldisaster response.11

Recovery

After the response had concluded, there was a tremen-dous outpouring of grief and sympathy. Millions of cit-izens assembled in Madrid’s streets to show the worldthey would not be threatened or terrorized, creatinganother incident for the city’s emergency services.12

Riyadh, Saudi Arabia

On May 12, 2003, witnesses reported seeing attackersshoot their way into three gated and guarded hous-ing compounds in the Saudi Arabia capital, Riyadh.Once inside their respective complexes, the nine at-tackers detonated vehicles laden with explosives. Theexplosions decimated homes and apartments in threehousing compounds. A guard at one of the hous-ing compounds told al-Watan newspaper that sevencars exploded there, all apparently carrying suicide

bombers. The explosions created significant damageto the buildings including shearing off their facades,destroyed vehicles, and left large craters.

Detection

Reports of gunfire and explosions came into the policeand EMS communication centers shortly before mid-night, local time. EMS then notified the Civil DefenseAuthority who activated the local disaster plan. Within30 minutes of first notification, police arrived at the hos-pital with the first shooting victims. Shortly after that,the first victims from the explosions arrived.

Incident Command (at the Hospital)

Once notification and activation of EMS and hospitalofficials had occurred, the hospital disaster plan wasput in place. Disaster responsibilities were delineatedand the command center was established. No com-mand center was used in the initial phase; instead,triage teams reported to the emergency department re-ception area, and the clerical staff activated disastercharts. Extra staff were recruited from the personnelpool and asked to report to the emergency department.Current patients were moved to other parts of the hos-pital to increase capacity in the emergency department.Contact with the emergency medical service communi-cation center was maintained.


Police cars and ambulances were seen rushing to theexplosion site. Hundreds of antiriot police and mem-bers of the elite National Guard converged on the scene,leading compound residents to safety and sealing offthe area. National Guard military police secured thescene. Only personnel with disaster passes were per-mitted access, and key personnel wore identificationjackets.

Assess Hazards

As with any bombing, there was substantial concernthat secondary devices had been placed at the sceneand that additional shooters might still be in the vicinityof the bombings. Crowd control became a problem bothat the scene and at the receiving hospital. There werealso problems with identification of personnel and teamleaders. Manpower in the emergency department wasoverwhelmed. The triage area became overwhelmed,and they had trouble processing the arrival of regularpatients who had not been involved in the blast inci-dent. Communication lines were jammed, and mediasupport through the information desk became a hugeburden on already scarce resources.

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Support

A command center for communications had to be estab-lished. Personnel and key leaders had to be identified.The patient-tracking system was used to follow victimsof the event. A patient discharge area was required todecompress patient flow at various areas of the hos-pital. Manpower and equipment needs had to be met,and media support was required.

Triage/Treatment

There were 34 people killed and 194 injured during theattack. Nearly all of the victims were triaged from thescene to local hospitals.

Evacuation

Victims were evacuated from the three sites to separatetriage areas. From there, transportation to the hospitalwas conducted by using police escort to assure safety.

Recovery

On the May 13, the U.S. Department of State issued atravel warning that called for nonessential U. S. citizenemployees to leave Saudi Arabia.

INCIDENT SUMMARIES: REPORTS FROM

COUNTRIES WITH FREQUENT INCIDENTS

Colombia

Located along the northern edge of South America,Colombia is rich in natural resources including theAmazon forest and coastlines on both the Pacific Oceanand Caribbean Sea. The country’s population of an esti-mated 45 million people has experienced an enormousimpact from political strife and terrorism.

Detection

Terrorism has become a commonplace activity withinColombia. The cause of the terrorism in Colombia ismultifactorial and has roots in its active drug trade. Alarge proportion of attacks come from rebel groupssuch as the Revolutionary Armed Forces of Colombia(FARC) for advancement of its political agenda as wellas from acts of extortion. The FARC has been waging itswar against the government for four decades.13 Duringthe 1960s, there were a total of 31 deaths associated withacts of terrorism. This number has steadily escalatedwith over 1,500 deaths from terrorism in the 4-year pe-riod 2000–2004. Trauma has become the leading causeof death in the country with over 40,000 violent deathsover the past decade.14 Children are often targeted, andan estimated 800 people disappear each year without

explanation. Explosive devices have become one of thepreferred weapons of terrorism in Colombia. Commondevices include car bombs and explosives planted inareas of high population density. Military munitions,such as mortar attacks, also have been used. It is disturb-ing that a recent trend has included the use of “neck-lace bombs” for extortion of ransom. These bombs areplaced around a victim’s neck and detonated remotelyif a ransom is not paid.15

Incident Command and Scene Security and Safety

Because of the frequent conflicts between rebel forcesand government troops, scene safety is a major con-cern. Responders do not enter a scene without securityfrom government troops to ensure the safety of the re-sponders. The government forces have a lead role in theinitial response.

Assess Hazards

The threat of sniper fire and secondary devices areconstant hazards for the responders to these terroristevents.

Support

A combined response involving the military, fire res-cue, EMS, are dedicated hospital response teams arerequired to respond to these incidents.

Triage/Treatment

Triage is provided at the incident site, and patients aretriaged into a four-level triage system where Red =Immediate, Yellow = Delayed, Green = Minimal, andBlack = Expectant. The Simple Triage and Rapid Treat-ment (START) triage system is widely taught as a triagetool. Combined injuries with burns and penetratingtrauma are commonly seen in Colombia.

Evacuation

The EMS system is not fully developed, and transporttimes may be extensive especially from rural areas. Sev-eral hospitals have established response units that cango to the scene of the incident to provide medical careon-site. Many of these units have physician support toprovide on-scene care.

Recovery

New initiatives for training the medical community torespond to blast injury have been developed and arebeing implemented. Continued training and improve-ments in prehospital care are needed for an optimalresponse to injuries of this nature.

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Iraq

Following the United States-led invasion into Iraq inMarch 2003, a strong insurgency has developed thatis actively attacking military and civilian targets. Cur-rently, terrorist bombings are a daily occurrence inIraq. Although the U.S. military has taken considerablelosses, there are no good estimates for the Iraqi civil-ian losses. In May 2005, the United States military lost70 soldiers. During this same time, a noted news organi-zation estimated that over 700 Iraqis had been killed.16

The toll from this insurgency has been heavy on boththe military and civilian populations. In this conflict,there has been a 14% improvement in the survival ofinjured military casualties compared with the Vietnamconflict. It is currently unknown what is responsible forthis improved survival rate. It is known that new injurypatterns are being seen as a result of terrorist bombingtactics and improvements in protective equipment.17

Detection

In Iraq, terrorist attacks have taken several forms. Im-provised explosive devices, vehicle-borne explosive de-vices, and suicide bombers are commonly used meth-ods of attack. The majority of casualties have been theU.S. or Iraqi military. However, a considerable num-ber of civilians and enemy prisoners of war have alsobeen injured. These attacks have become almost a dailyoccurrence in Iraq, and one military physician reportshaving participated in over 800 operative cases fromterrorist bombings in a 6-month period. Many victimshave been children who may be injured in an attack orwho may pick up unexploded ordnance.18

Incident Command and Scene Security and Safety

The command structure is a military command struc-ture and follows a military chain of command. The U.S.and Iraqi military forces provide scene security.

Assess Hazards

Many improvised explosive devices are placed in a waythat draws troops into the open for sniper fire and forthe detonation of secondary devices. Any vehicle trans-portation represents a risk of attack and military andcivilians must be alert for potential threats while trav-eling within Iraq. Many of the improvised weapons aremade from unexploded military munitions that are con-verted to an improvised explosive device with the useof “homemade” detonation systems.

Support

The U.S. military uses its own casevac and medivac sys-tem as well as its own tactical support. The Iraqi civilianhospitals and EMS system are much more limited.

Triage/Treatment

In the military hospitals, triage is completed by us-ing the four-level U.S. military triage system. This sys-tem uses four different categories: Immediate (red), De-layed (yellow), Minimal (green), and Expectant (black).Triage categories are marked on the casualty’s foreheadwith a permanent marker. The use of the expectant cat-egory is being used more often as the number of casu-alties increase. The use of this category was thought tohave saved several immediately salvageable patientsby conserving resources that would have been con-sumed by patients with little chance of survival. Triageis considered a continual process, and patients maychange categories as they move through the health caresystem.

Patients are transported via military vehicles by bothground and air. Most of the transport times are short.However, very little prehospital care is provided enroute. The prehospital care provided largely consistsof dressing or tourniquet application for external hem-orrhage. Prehospital use of tourniquets was thought tobe lifesaving in several cases. Patients often arrive atthe hospital hypothermic and acidotic.

Surgical subspecialists, such as urologists or obstetri-cians, often do triage at the hospital. Emergency depart-ment beds are a precious commodity, and patients needto be rapidly resuscitated and moved from the emer-gency department to the operating room, intensive careunit, or floor as soon as possible to make room for in-coming casualties. Likewise, surgeons and operatingrooms are also in short supply, and “damage control”procedures are needed to open up operating rooms assoon as possible. Patient tracking is managed by usinga dry erase board. Patients are given sequential num-bers, and the patient’s location is tracked by using thenumbers on the board.

The wounds seen are very different from woundsseen in typical civilian practice, and altered resusci-tation protocols are needed. Massive tissue loss andextremity injuries with vascular injury are very com-mon. A predominance of extremity wounds was notedbecause of body armour and helmets protecting vitalareas. Patients with hypotension are resuscitated to asystolic blood pressure of 90 and a urine output of 1mL/kg/hr. Donated whole blood has commonly beenused for transfusion with excellent results. Head, chest,and abdominal injuries take priority over the treatmentof extremity wounds even when the extremity woundsappear more significant. Patients with significant hem-orrhage are treated with recombinant factor seven withgood anecdotal success. This treatment is not availablein the Iraqi civilian hospitals.

Wide surgical debridement of wounds is used, andthe importance of serial wound washouts and de-layed primary closure is emphasized. The use of thewound VAC©R (vacuum-assisted closure) was also veryeffective for postoperative care. All patients receive

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prophylactic antibiotics as soon as possible on arrival.External fixation of fractures is commonly done as wellas the use of temporary vascular shunts until defini-tive care can be provided. Liberal use of fasciotomywas thought to be limb saving, and primary amputa-tion was needed for all fractures associated with majorneurovascular injury and/or major tissue loss. Vascularrepairs below the knee have demonstrated a very highfailure rate in blast injury patients. Burns with a greaterthan 40% body surface area also have been found tohave a very low incidence of survival in this setting.Liberal use of escharotomies for circumferential burnsappears to be beneficial. These need to be initiated earlybefore there is evidence of decreased perfusion.

Evacuation

Patients are transported to the hospitals via military ve-hicle or aircraft. U.S. casualties are stabilized in theaterand then evacuated to U.S. military hospitals in Europe.Iraqi casualties have been transported by the militaryand initially treated in military facilities as well as beingtransported by civilian EMS to civilian hospitals.

Recovery

U.S. casualties are evacuated back to the United Statesonce stabilized in Europe. The casualties have accessto extensive reconstructive surgical capabilities as wellas rehabilitation and prosthetics. The Iraqi populationdoes not have access to these intensive medical re-sources. This lack of services and prosthetics is a ma-jor long-term problem for the civilian population. Thepsychological effect of this conflict for the military andcivilian population also will likely be significant.

Israel

In the last 5 years, more than 1000 Israeli citizens havebeen killed and more than 7000 injured in terroristsattacks ranging from shootings to suicide bombings.Seventy percent of those killed or injured were civil-ians. Most Israeli bombings have been suicide bomb-ings, meaning that they are limited to the amount ofexplosives that can be carried by a single person. Tomeet this challenge, Israel has created and maintainedan elaborate emergency response system.

Detection

Although many disaster preparedness leaders considerfirst responders to be health care practitioners, police,and/or fire brigades, in Israel lay-bystanders are con-sidered frontline first responders. Lay-bystanders pro-vide initial reports from the scene by using cellular tele-phones, and they are the first to search, rescue, give

medical assistance, and evacuate victims to hospitals.Public participation has been one of the cornerstonesof Israeli defensive measures against terrorism in thedomestic arena. They believe that the education andtraining of the community as frontline first respondersare critical for prompt detection, reporting, and searchand rescue during a terror event.

Much of Israel’s success in preventing terrorist bomb-ings has been attributed to public awareness. Citizenswho were able to alert the police before bombs wentoff have discovered the majority of explosive devicesplaced in public sites. It is believed that the main rea-sons for this high level of public awareness has been thepublic’s experience with terrorist events and their per-sonal identification with the struggle against terrorism.

The Israeli experience with suicide bombings hasbeen that they are multidimensional and unpredictable,can lead to secondary events, and strain personal andorganizational resources. The very nature of an at-tack disrupts the operation of their response. Fur-ther, the rate of suicide attacks has increased becausethey are effective, easy to accomplish, inexpensive, getwidespread media coverage, and there is no need foran escape plan.

Incident Command

Local or regional resources can manage conventionalweapon events, and incident command is the responsi-bility of the local police and ambulance service. For un-conventional incidents, such as mega-terror or weaponof mass destruction events, Home Front Command,part of the Israeli Defense Forces, is responsible forpreparedness and incident management. Home FrontCommand is composed of a national command with sixregional commands. They are responsible for planning,supervising exercises, and monitoring the prepared-ness of organizations that respond to high-consequenceattacks. These organizations include the medical sys-tem, police, fire brigades, municipalities, transporta-tion, and others. Home Front Command also coordi-nates intelligence for these agencies. Health care assetsreceive notification of credible terrorist threats, allow-ing them to increase staff in response to a threat. TheIsraeli government finances any extra staffing that isactivated in response to a credible threat.

A terrorist incident in an urban area is usually re-ported first to the ambulance service or police, whoimmediately distribute the report of the attack to otheragencies on a predetermined distribution list, includingHome Front Command and the Israeli Defense Forces.Following a preliminary assessment of the nature ofthe incident and its apparent scope, commanders at theIsraeli Defense Forces will determine whether to ac-tivate Home Front Command resources. Home FrontCommand has the capacity to send emergency medicaland search and rescue units to the site.

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At any scene, two perimeters of command are set up.An inner-perimeter command post is set up at the site ofthe incident and controls rescue and medical activities,detection of chemical substances, deactivation of explo-sive devices, preliminary triage, and evacuation to hos-pitals. A second outer-perimeter command post, whichensures the sealing off of the affected area and controlsall contacts with other organizations, politicians, mil-itary, police, municipal authorities, media, and publiccommunication, is also set up.


Although Home Front Command allows for account-ability and integration, the need for personnel pre-paredness is stressed. Personnel need to be physicallyprepared, with the correct level of physical fitness, per-sonal protective equipment, and vaccinations, and theyneed to be mentally prepared to respond to a terroristevent. Mental preparation includes believing that anattack is possible and being action oriented.

Leaders have been identified and a common lexicon isused for communication. Training is continuous, flex-ible, and creative. Even in this area with an ongoingthreat of and actual experience with terrorist blasts,there is a need for joint exercises and training. Israelcontinuously operates a set of drills and full-scale exer-cises on a three-year cycle.

Assess Hazards

In Israel, concern for secondary devices is high and thesafety of providers is paramount. Israel has hazardsassessment teams that are part of the first responders.The teams are available in every terrorist event and areresponsible for detecting any chemical or radiologicalthreats at the scene of the bombing.

In Israel, first responders’ self-protection is con-sidered critical for responders to act effectively andnot become victims themselves. All medical responsepersonnel are issued mechanical protection suchas chest shields and full body protection from allhazards. First responders are also vaccinated againstbiological threats. After the incident, all responders areoffered professional assistance, including appropriatepsychological assistance, debriefing, and alternatework assignments.

Support

Definitive and clear communication with the public ismaintained during any incident. This communicationprovides simple direction to the public on what hashappened and what is expected of them. They havefound that these messages work best when profession-als rather than politicians give them.

Triage/Treatment

The method of triage in Israel is based on the princi-ples of the Simple Triage and Rapid Treatment (START)Plan. Injured victims are categorized into one of threegroups: immediate care, delayed care, and unsalvage-able. The Israeli ambulance service uses colors to de-note the different triage categories: red tags (priority 1)indicate immediate care, yellow tags (priority 2) indi-cate delayed care, and black tags indicate unsalvage-able patients. To this system they have also added bluetags to identify children and gray tags for combinedinjury such as conventional blast and chemical burns.Following a mass casualty incident, walking victimsare automatically triaged for delayed care. For others,categorization is based on vital signs.

Within minutes of a terrorist attack, Home FrontCommand notifies leaders of major hospitals of thelocation and nature of the attack. The hospitals gothrough a rapid transformation to ready themselvesfor casualties. They also tend to mobilize staff fromsurrounding hospitals as well. This strategy is used tobalance hospital resources with needs, while avoidingbottlenecks in treatment.

Evacuation

Israel has refined its response through a series of lessonslearned and implemented a response protocol that max-imizes their capabilities. They report a response time toa bombing of seconds and their response is flexible andcoordinated. All victims are evacuated in 20 minutesin a scoop and run fashion, with minimal treatment onscene. Alert command structures are present 24 hoursa day, 7 days a week allowing for central coordination.

Ambulances, private cars, public transportation, andhelicopters are used for patient evacuation. The pres-ence of military forces at terrorist events may be a fac-tor in the increased use of helicopter evacuation duringterrorist events. All helicopters used for medical evac-uation in Israel belong to the Air Force; the militaryhas a higher level of awareness and expertise in usingthem for evacuation than emergency medical servicefield providers. In addition, helicopters are used forsecondary triage to bring patients to a hospital withthe appropriate resources for their injuries.

Recovery

Israel has developed a change in its culture wherebypublic servants and the general public are in a constantstate of vigilance.

Turkey (Two Sample Incidents)

Cesme is a seaside resort approximately 80 km from thecity of Izmir in Turkey but located within its district. On

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Sunday, July 10, 2005, a fragmentation bomb explodedin a trash bin in the main square of Cesme. There were21 people injured as a result of the explosion.

Kusadasi is about 90 km from the city of Izmir butis in a different district of Turkey. On Saturday, July16, 2005, a timed or remote-controlled bomb explodedinside a minibus that was occupied by a driver and16 passengers. There were 12 people injured and 4 im-mediate fatalities.

Detection

Cesme: One minute after the blast, the police informedthe ambulance service that a bombing had occurred.Three ambulances stationed in Cesme were immedi-ately dispatched to the site, and three additional am-bulances were requested from the city of Izmir. Theonly hospital in Cesme was immediately notified of thebombing. This hospital has only 25 patient beds, so anadditional four hospitals in Izmir were also notified toprepare for casualties to arrive.

Kusadasi: The ambulance service in Izmir was im-mediately notified of the bombing in Kusadasi, but noextra ambulances were requested. Patients were trans-ported to hospitals without any prior notification to thehospitals.

Incident Command

Cesme: The physician on the first ambulance to arriveat the scene assumed the role of incident manager. Halfan hour later the main medical incident manager forthe ambulance service arrived and took over command.This physician coordinated the ambulance response in-cluding treatment and transport. He also oversaw hos-pital retriage, registration, and reporting and organizedother hospitals.

Kusadasi: There was no medical incident manager inKusadası . This created a weak point in the responseand led to a chaotic environment.


To minimize the number of people at the site, fire andpolice responders cordoned off the bombing area inboth incidents.

Assess Hazards

At neither incident were any additional hazards iden-tified. In Cesme, metal fragments were included in thebomb.

Support

Cesme: Sunday is considered a holiday so doctors hadto be called to come to the Cesme State Hospital, and

more ambulances had to be requested from Izmir. Fur-ther four hospitals in Izmir were told to prepare forpatients.

Kusadasi: It was not until late in the incident thathospitals in Izmir were told to prepare for the incident.Further, because most of the passengers in the minibuswere British, the British Consulate was called and theMilitary Air Force prepared transportation for the vic-tims to England.

Triage/Treatment

Cesme: A physician who staffed the ambulance did thefirst triage at the scene. He triaged 2 patients as red, 11as yellow, and 8 as green. No treatment was providedat the scene.

Kusadasi: There was no real triage at the scene inKusadası . Two patients were transported to a state-runhospital, four to a private hospital, and seven to a hos-pital in Izmir.

Evacuation

Cesme: Five ambulances transported all of the patientsfrom the scene to the single hospital in Cesme. Oncethey arrived at the hospital, the patients were retriagedand four were transported to Izmir within 30 minutes ofthe incident. An additional 9 were transported to Izmirlater, while the remaining 10 patients were observed inthe Cesme hospital.

Kusadasi: Ambulances and other vehicles trans-ported victims from the scene to the hospital inKusadasi. Kusadası ’s private and municipal ambu-lances transported five victims to one hospital in Izmirwithout prior notification.

Recovery

Cesme: Everything was physically under control by ap-proximately 2 hours after the incident occurred. Foren-sic reports were prepared for causalities and the policewere informed. Finally, to prevent further psychologi-cal impact, the media were supervised.

Kusadasi: The media were informed continuously.Communication was provided to the British Consulate.The treatment of casualties in the hospitals was fol-lowed closely. The Turkish Government paid all ofthe expenses for treatment and military air ambulancetransport. Psychological support was provided to thepatients’ families.

PARTICIPANT DISCUSSION: COMMONALITIES

AMONG THE INCIDENTS

Detection

The number of emergency access number (e. g.,9-1-1) calls to notify responders that an explosion had

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occurred did not initially overwhelm the dispatchsystems in any of the reported incidents. However,in many cases, some of these calls misled dispatchersas to the nature and/or location of the explosion. Forinstance, in Madrid, callers reported a single explosionin a location where there actually had been two becausethe sites were close together and a bend in the trackskept callers from seeing each of them. It was not untilresponders arrived at the scene that they realizedthat there were two separate explosion sites. Further,in London, the subway explosions were not initiallyreported as an explosion because they occurred in thetunnels rather than a station and communication fromthe tunnel was not possible.

For most of the incidents, after the initial notificationof the central dispatching agency that an event hadoccurred and initial dispatch of responders, the generalcommunication systems quickly became overwhelmedand jammed. However, many systems and organi-zations quickly discovered the importance of havingways to transfer callers to people who were not partof the emergency response system. For example, inRiyadh, media calls to the hospital were transferred toa media liaison outside of the emergency department.In the dispatch center in Madrid, calls from friendsand family were transferred to a separate informationservice, while allowing normal emergency dispatchoperations to continue throughout the event and forthe next several days.

The initial response was rapid for scene providersat all incidents, but communication to the emergencydepartment of the size and complexity of the incidentwas limited in many cases. For example, in Riyadh,emergency department staff treated a guard who wasshot when terrorists attempted to gain entry to one ofthe compounds. Emergency department staff did notknow the guard was shot in a failed attempt to thwartthe bombing. Therefore, the staff devoted most of theirresources to resuscitating the guard rather than prepar-ing for the additional casualties that would arrive as aresult of the bombing.

The media were considered a powerful resource indisseminating information during a disaster. In thesereal-world examples, there was no clear example oftheir effective use as a means of information dissem-ination to the general public. In Darwin, Australia, themedia assisted local authorities by requesting that peo-ple limit their use of the emergency department, but thisrequest seemed to be largely ignored because the num-bers of regular emergency department patients did notchange during the course of the event. Alternatively,in Israel the media relays messages from authorities tothe public, and it was thought that they have also beensuccessful in working with the media to educate thegeneral public on prevention. This education has beencredited with thwarting attempted terrorist bombings.It is clear that the media should be included in pre-

event planning if it is to participate effectively duringan event.

Incident Command

Good leadership at all levels was needed to ensure op-timal response to a blast incident, including a definedchain of command. Designation of specific areas for re-sponse (e.g., staging area, media area) was common tonearly all sites. Predesignation of roles for individualleaders was also common, as well as the need for thecontrol of traffic, including ambulance staging and themaintenance of lanes for ambulance arrival and depar-ture from the scene. Several methods were used for in-cident command, but all shared these components (i.e.,defined roles and responsibilities, chain of command,and staging areas).

Nevertheless, methods of incident command werehighly variable. For example, in the United Kingdomand Australia, the Major Incident Medical Managementand Support system is used. These different modelsappeared to be effective at the sites that used them,particularly in the locations where they were regularlydrilled and practiced. For example, England uses theconcept of “triage Tuesday” where incident commandis practiced throughout the normal working day on anypatient requesting assistance that day. It was also clearthat improvisation at the time of the incident did notwork and that a political layer must be integrated intothe command process.


All sites found that there was a need to move peo-ple away from the scene particularly in large incidentsinvolving walking wounded. Directing the walkingwounded away from the scene to a triage or staging areawithout swamping the local emergency services wasimportant but complex, because they could walk awayfrom the response system entirely and not be trackedfor follow-up. For example, in London those with mi-nor injuries went home and waited until the eveningto go to their local hospital for care, making it hard totrack all of the victims.

Rescuers need to secure the incident site under a va-riety of scenarios. Monitoring who comes to the site tominimize the possibility of a secondary attack was con-sidered critical at all sites. Many people who are notpart of the formal response system will feel a need torespond, “to help out,” and to locate loved ones. Scenesecurity must ensure that those people are who theysay they are and are not a threat to the scene. Thisissue affects both the scene of the incident itself andthe hospitals that receive victims. Many locations hadpreplanned systems for identification and verificationof key personnel. However, several reported that thesesystems broke down for a variety of reasons. One reason

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was that personnel did not have their identificationbadges at the time of the incident, and security guardsfaced with a person they knew and normally workedwith would have trouble sending them away. A sec-ond reason was that the sheer emotion of the situationmade it very difficult to maintain order and systems ofverification.

Assess Hazards

Although no incident was specifically described wherea secondary device or “dirty bomb” was used againstresponders, most incidents described providers as be-ing alert and aware of the possibility of a secondary de-vice that might harm them. In locations where bomb-ings are common, providers are vigilant in regard toprotecting themselves from secondary devices. Specifi-cally, in Iraq and Colombia there is the added worrythat the explosives were intended to draw responsepersonnel into snipers’ line of fire. In some locations,these providers would not respond without appropri-ate security accompanying them. Most locations hadspecial teams dedicated to ensuring that secondarydevices were not present at the scene. Most partici-pants thought that responders to the scene must en-sure that patients transported to health care facilitiesdo not pose a risk to those facilities due to biologicalor chemical contamination or the carrying of explosivedevices.

Support

Additional trained human resources were needed forall incidents, but they were needed in a controlled man-ner. Many speakers stated that it took time to recall staffand that they needed to consider how to maintain sys-tems for hours and days after the initial incident, notjust meeting the initial demand. These issues of solicit-ing and maintaining manpower are difficult and mustbe included in preincident plans.

Self-deployment of medical volunteers and their ve-hicles was an issue at most sites and was discouraged.This issue can persist for several days after the event aspeople and equipment continue to arrive in response tothe event. The potential security risk of unknown vol-unteers further complicated self-deployment and madeit even more important to discourage this practice. For-mal systems for including volunteers in the responsedeveloped prior to an incident were advocated (e. g.,identification badges and staging areas). Ideally, such asystem should stage unsolicited volunteers away fromthe scene, but in a state of readiness should their ser-vices be required. In identifying volunteers, informa-tion on the volunteer must be recorded and maintainedin the event that follow-up becomes necessary. Thiswould be important, for example, if it was later de-termined that a biological agent had also been released

and providers needed to be recalled for vaccination ortreatment.

Inexperienced bystander volunteers may be useful.Some presenters thought it was possible and usefulto integrate lay-volunteer providers into the response,even those who had not been trained in formal disas-ter response. For example, in the Bali nightclub bomb-ing, bystander lay-rescuers were effective and use-ful in assisting responders. Disaster management mayinclude plans for specially trained nonmedical commu-nity members, such as taxi drivers, to formally partici-pate in initial incident response. However, the formal-ized use of “improvised providers” must be consideredin preincident planning and training.

Patient-tracking systems were needed for all ofthese incidents, particularly for tracking the minimallywounded. These systems needed to include methodsfor controlling self-triage to nearby facilities, which,during many events, became overwhelmed by walkingwounded as well as for assisting friends and familiesin locating their loved ones.

Triage/Treatment

In most locations initial triage was done by the vic-tims themselves along with bystanders as they movedaway from the scene and attempted to assist and getcare for friends and loved ones. In some cases, thisoverwhelmed the closest hospital and may have dis-tracted providers from triaging appropriately (e.g.,“you have to help my friend now!”). Further, childrenand those victims with boisterous advocates may havebeen triaged to a higher level than necessary. It is im-portant to prepare providers for these types of issuesprior to an incident, because it may not be in the bestinterest of the response to rectify these inaccuracies inthe field. For example, in Israel a bystander placed apatient with minor but visually alarming injuries in anambulance. Rather than having a confrontation at thescene, which may have looked unfavorable if coveredby the media and caused undue stress at the scene, theproviders transported this patient and an appropriatelytriaged patient simultaneously.

Informing the walking wounded where to go for im-mediate assistance allowed responders to move thesepeople away from the scene and kept them from over-whelming the nearest hospital. That is, by telling thewalking wounded where to go for immediate aid, itkept them from independently deciding where theyshould go. In England, these locations are identifiedduring pre-event planning, so that locations can quicklybe identified and readied to receive victims. However,some victims still went directly to their homes ratherthan seeking care. This could be problematic if thesepeople needed follow-up care, such as in the case of a bi-ological agent release. A patient tracking and documen-tation system is needed to ensure that these patients are

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not lost, but little information was available on the fea-sibility of such systems.

Although specific triage systems varied greatly be-tween locations, the principles were similar. The lo-cations that used and practiced their system regu-larly appeared to perform better during an actualincident compared to the locations that had not hadsuch experiences. Further, there needed to be some formof central coordination, where the big picture of theresponse could be monitored and assistance providedwith appropriate deployment and procurement of as-sets. This was particularly true when there were multi-ple events in a single location. The first events tended toreceive the most resources depleting their availabilityfor subsequent events.

Triage/assessment needed to be conducted continu-ally throughout the healthcare process (i.e., from thescene through discharge home) for the reported in-cidents. Particular attention was needed at potentialhealth care bottlenecks, such as radiology or operat-ing rooms, to get patients appropriately triaged andto maintain resources. Although care of the bombingvictims was the primary focus of the medical staff, reg-ular patients still arrived at the treatment facilities andneeded to receive care.

Depending on the location of the incident and thenumber of people involved, resources can become over-whelmed to the point of denying care to victims who areunlikely to survive (i.e., those triaged as expectant). Thisis a difficult and controversial decision, but these inci-dents illustrate that the definition of expectant cannotbe universal across all situations. It will change as re-sources change. In a resource-rich environment, it maynot need to be used at all. All triage systems include ex-pectant as a category, but participants thought that per-haps there is a need for more detail to be given to healthcare providers on the use of this controversial category.

Evacuation

Local ambulance providers largely coordinated imme-diate evacuation of patients from the bombing scene.The success of these evacuations was dependant oncentral coordination of patient movement. One of themost important means for ensuring rapid and appro-priate movement of patients was to maintain phys-ical pathways for entry to and exit from the scene.Further, communication with receiving hospitals wasidentified as critical. In many cases, hospitals were notaware that they were going to receive patients andthus were not prepared to respond appropriately to thepatients

Nontraditional vehicles, such as buses, were used tomove many patients with minor injuries from blast sitesto hospitals. However, if this type of transport is used,it was stressed that it is important to provide clear di-rections to the vehicle operators so they go to the ap-

propriate destination. One situation was described ofa bus that began to let passengers off at their housesas it made its way to the hospital. It is also importantto place appropriate medical staff with equipment onthe vehicle so that they can deal with any emergenciesthat might arise and reassure the patients that they arebeing appropriately monitored.

In many cases, terrorist bombings occurred in remotetourist communities in developing countries. This com-plicated the response because local hospitals did nothave the resources to attend to all the causalities, andpatients needed to be stabilized and moved to largerhospitals that were some distance away. For example,in Cesme, Turkey, many patients needed to be trans-ported to larger hospitals in Izmir after stabilization,which was 80 Km away.

Another complication was that incidents in resorttowns typically involved foreign nationals. This createda situation in which governmental agencies needed tobe involved in the response and arrangements neededto be made to move patients back to their home coun-tries, which may have required specialty transport ser-vices depending on the nature of the injuries and thecare required during transport.

Recovery

Recovery involves ensuring the mental and physicalwell-being of staff, patients, and families after an event.In many cases, staff involved in the events had sometype of personal relationship to the incident. For exam-ple, in Riyadh, the housing complex that was bombedwas home for many of the hospital staff. Therefore, careneeds to be taken to ensure the well-being of staff sothat the health care system can continue to functiononce the incident has concluded. A second example oc-curred after the London subway bombing; where theambulance service executed a detailed plan of recoveryfor their employees. Senior management put extra ve-hicles in service for 48 hours to decrease workloads andhad extra management on hand at all times for 2 monthsfollowing the event. They offered all staff health checksand called each staff member at home to verify that theyand their families were unharmed and did not needfollow-up services. In addition to physical health, themental health of victims and providers should be as-sessed and problems treated. It was thought that caremust be taken to ensure that appropriate mental healthresources are available to all patients.

Colombia and Israel, as countries that experience reg-ular bombings, talked of recovery in a different context;they thought that there was a need for a change in cul-ture. They advocated that communities needed to bemore watchful and on guard, and in some sense, ex-pectant of the next bombing.

Finally, based on the presentations, there appears tobe a clear need for collection of usable data for analysis

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and future planning and preparation. To accomplishthis, data elements useful for sharing with other or-ganizations and nations must be identified and stan-dard definitions developed. As one example, there isno uniform definition of “blast lung.” These data couldalso be used to develop evidence-based standards forresponse and treatment.

An important component of recovery is informingthe general public of the extent of the event, wherethey can receive assistance if needed, whether there arecontinued risks and how to mitigate them. Althoughit was agreed that primary prevention was beyond thescope of this meeting, participants thought that the im-portance of community awareness and notifying au-thorities if something seemed out of the norm wasimportant to emphasize. It is unknown if improvedcommunity vigilance could have thwarted the eventsdescribed, but it is important for community mem-bers to understand how their awareness can assist inprevention.

CONCLUSION

This report provides an initial framework for learninglessons from the experiences of others in regard to theemergency response to a blast incident. However, nu-merous questions remain which can only be answeredby additional research and policy development. Thereis a need for identification of best practices in responseto a blast incident and for a research agenda to guideresearch priorities.

The need for scientific research includes the organi-zational response to an incident and the actual responseand treatment that are provided to specific patients. Or-ganizational systems of command and control, such asthe United States Incident Management System and theMajor Incident Medical Management and Support sys-tem, need to be compared and studied to optimize re-sponse. Controversial areas for response and treatmentof individual patients include among other things thedecisions for early fasciotomy in blast victims, as wellas the impact of rapid hydration in combination injuriessuch as burns and blast lung.

In the area of policy, bombing of foreign nationalstested political policies between nations and demon-strated a lack of formal agreement in the areas of evac-uation and repatriation. This lack of agreement mayhave hampered initial evacuation and recovery. For-mal policy development between countries with pop-ular tourist areas might be useful for facilitating betterinternational cooperation.

Finally, there is a need for standardized definitionsand data across nations so that the experiences of onenation can be used in the preparedness planning of an-other. Standards that include data elements, clinical vo-

cabularies, and coding systems that convey informationabout the nature, severity, treatment, and outcomes ofinjuries need to be developed. Systems that facilitatethe sharing of information between nations need to becreated.

The findings and conclusions in this report are those of the authorsand do not necessarily represent the views of the Centers for DiseaseControl and Prevention.

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APPENDIX 1. Meeting Participants List

Mona Al Somali, RNKing Fahad National Guard HospitalKingdom of Saudi Arabia RiyadhEmergency Department

Jeffrey Arnold, MDMedical DirectorYale New Haven Center for Emergency Preparedness and Disaster

Response

Isaac AshkenaziHead of Medical Services and SuppliesMedical Corps—Israel Defense Forces

Bob BaileySenior AdvisorDivision of Injury ResponseNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention

Laureano Quintero BarreraMedical Director, University HospitalCali, ColombiaSalamander Foundation

Kathryn Brinsfield, MD, MPH, FACEPAssociate Professor, Emergency MedicineBoston University School of MedicineMedical Director, Homeland Security, Boston EMS

Jean-Claude DeslandesEditor-in-ChiefUrgence Practique

Linda C. Degutis, DrPH, MSNAssociate Professor of Surgery (Emergency Medicine) & Public

HealthResearch Director, Emergency MedicineDirector, Yale Center for Public Health PreparednessYale University

Jean-Philippe Dionne, PhD., P.Eng.Research Engineering ManagerMed-Eng Systems Inc.

Dionisio Herrera Guibert, M.D., F.M. S., M. A.E., PhDChairTEPHINETNation al Center of EpidemiologyInstitute of Public Health Carlos III

Stephen Hines BSc(Hons) Dip IMC RCS EdParamedic Training OfficerLondon Ambulance Service NHS TrustDepartment of Education & Development

Simon Hunter, FRCS(Ed) FFAEMLt. Col RAMCDefence Medical ServicesConsultant in Emergency MedicineAccident and Emergency DepartmentQueen Alexandra HospitalPortsmouthUnited Kingdom

E. Brooke Lerner, PhD.Assistant ProfessorDepartment of Emergency Medicine andDepartment of Community and Preventive MedicineUniversity of Rochester

APPENDIX 1. Meeting Participants List (Continued)

Robert O’Connor, MD, MPHProfessor of Emergency MedicineDirector of Education and ResearchChristiana Care Health SystemNewark, DE

Gerard O’Reilly, MBBS, FACEM, Grad Cert Clinical Trials, MPHEmergency PhysicianAlfred Emergency and Trauma Centre

Jackie ReidyNursing Supervisor King Fahad Nation Guard HospitalKingdom of Saudi Arabia RiyadhEmergency Department

Scott Sasser, M.D.IPA, Division of Injury ResponseNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention

Richard W. Sattin, M.D., F. A. C.P.Associate Director for ScienceDivision of Injury ResponseNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention

Richard B. Schwartz, MD, FACEPChair, Department of Emergency MedicineMedical College of Georgia

M. Turhan Sofuoglu, M.D.Deputy Health DirectorPresident of Association of Emergency Ambulance Physicians

Bradley K. Woods, M.D.MAJ, M. CGeneral SurgeryChief, Combined Surgical ClinicIrwin Army Community Hospital

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Documents

Blast-Related Injuries from Terrorism: An International Perspective