Deliberate Disasters

It’s a beautiful summer morning. You’re conversing with colleagues in the meeting room of your medical association building, when a deafening explosion occurs nearby. After a stunned silence, cries for help begin to rise up from the street. As several of you make your way outside to survey the damage, you see a bus with its roof peeled off like a sardine can. Discolored bodies are draped over the sides through shattered windows; there is slight movement of other bodies both in and outside of the bus amid splattered blood and body parts. As a physician, you feel a responsibility to help. But how?

This is neither a scene from a scriptwriter’s imagination nor an incident in a war-torn country; it occurred in front of the British Medical Association in downtown London, July 7, 2005. Fourteen mostly retired general practitioners with no equipment, under the leadership of a family practitioner who had air ambulance experience, proceeded to triage the victims of a suicide bombing, providing basic life support (BLS) until advanced care became available. Because of the gridlock caused by multiple simultaneous subway bombings, the first ambulance took 25 minutes to arrive, and the last patient was transported two hours and 20 minutes after the event. The physicians declared one victim dead and ceased resuscitation (a total of 13 persons died at the scene); they assessed the injuries of the remaining victims, attended to airway management, cervical stabilization, applied pressure to bleeding wounds, reduced grossly angulated fractures, and delivered the 15 survivors to the EMS rescue chain in order of descending acuity.

Terrorist Bombings

Terror agents are classified as CBRNE (chemical, biological, radiological, nuclear, or explosive). Although biological agents (BT) dominate our attention when we think of terrorism, conventional explosive attacks are far more likely to occur. In 2005, of 758 terrorist events staged in 45 countries, more than half (399) were bombings, resulting in over 8,000 injuries and over 3,000 deaths. With the exception of the 1984 mass salmonella poisoning in Oregon and the 2001 World Trade Center attack (in which planes were used as incendiary bombs), all terror incidents impacting large numbers of people on U.S. soil have utilized explosive devices (since the early 20th century, seven events causing 2,261 injured and 256 deaths). This should come as no surprise, since bomb materials are readily obtainable and their usage requires little technical finesse. Terrorist bombings present unique challenges:

• Due to the somewhat variable incubation period associated with biological events, there is a gradual upslope to the initial wave of BT patients presenting for care. In contrast, a bombing creates all casualties instantaneously, maximizing surge overload on healthcare systems: Approximately one-half of all bomb victims from an incident will arrive at hospital emergency departments (EDs) within a one-hour window beginning the moment the first patient presents.
• Rescue may be hampered by the inaccessibility of bombing victims (within subway tunnels or collapsed buildings); there may also be concern about secondary explosive charges.
• Bombs can be “laced” with chemical or radiological hazards, not only making rescue operations more dangerous, but complicating treatment of the victims.
• Bomb victims require time-consuming specialized care from highly limited personnel and facilities, i.e., surgeons, operating rooms and teams, surgical ICUs, burn units. Hospitals may also run out of certain supplies, such as blood and external fixators.

Disaster Triage and the START Algorithm

If you arrive at a scene with multiple trauma victims, you may instinctively move first to the most critical patient with the intent of delivering a heroic resuscitation attempt. This is often inappropriate in a mass casualty situation with limited resources, in which the goal is to save as many lives as possible. Excessive time should not be spent on a victim in extremis who has no meaningful chance of survival. The initial goal is to rapidly triage the victims into one of three groups:

1. Those who will survive whether or not they receive immediate care;
2. Those who will die whether or not they receive immediate care;
3. Those who are likely to die without immediate care, but who may survive with it.

When help is in short supply, rescue efforts must be reserved for the last group of patients.
Physiologic criteria alone determine the priority of resuscitation — there are no special categories of patients, such as children, that automatically come first. For example, after a bombing, a pulseless, apneic child in the field without pediatric advanced life support (PALS) capability has a negligible chance of survival; launching into 20 minutes of CPR on this child could deprive other victims of a simple procedure, such as opening a closed airway, that would have made the difference between life and death.

Clearly, clinicians who have not had military training with combat experience will find it extremely difficult to make decisions about patient viability within seconds. To address this problem, the simple triage and rapid treatment (START) algorithm was created to be easy to remember and apply even in stressful situations. For further information on the START system, see www.remm.nlm.gov/radtriage.htm#start.

The Spectrum of Injuries From Bombs

Two caveats: Organs that contain air suffer greater damage than do solid organs, and bombings in enclosed spaces, such as buildings or subway cars, produce more serious trauma than they do outside. Characteristic injuries include the following:

• Blast lung injury (BLI) presents with some combination of dyspnea, hemoptysis, chest pain, hypoxia, wheezing, decreased breath sounds, and hemodynamic instability. The onset of symptoms may be almost immediate or may be delayed up to 48 hours. The chest X-ray often shows a characteristic “butterfly pattern.” Complications include bronchopleural fistula, air embolism, and pneumothorax. Coexisting injuries with conflicting treatment needs sometimes complicate decisions about positive pressure ventilation and fluid management.
• Tympanic membrane (TM) rupture is common, especially with indoor bombings; these injuries may heal spontaneously, but often are associated with sensorineural hearing loss. Communication difficulties may impede initial rescue operations. It is controversial whether the presence or absence of a ruptured TM accurately predicts the likelihood of other serious injuries, so this criterion should not be used to determine the duration of ED observation.
• Hollow viscus injury (blast abdomen) may present with gastrointestinal bleeding, perforation, obstruction, or mesenteric ischemia. The ileocecal region is particularly at risk.
• Concussion may occur even without signs of head trauma; it may mimic post-traumatic stress disorder (PTSD).
• Fractures, traumatic amputations, crush and compartment syndromes, burns.
• Metal projectiles added to bombs cause a wide variety of penetrating injuries and are often the principal cause of death.

Conclusions

While hospitals bear the brunt of the response to a bombing, in many terror incidents the majority of victims self-refer to the nearest or most familiar medical facility, which may be an outpatient clinic. For example, after the 1995 sarin release on Tokyo subways perpetrated by the Aum Shinrikyo cult, about three-quarters of the victims sought medical care on their own, as did over 300 people after the London bombings. The critical shortage of ED beds in the United States is likely to exacerbate overflow to outpatient settings during any mass casualty event: From 1993 to 2003, ED visits increased by 26 percent, while ED beds decreased by 14 percent. After a terror incident, community clinics are particularly likely to be deluged by the “worried well,” who will need accurate assessments and reliable information. Thus, it is important for all physicians, regardless of practice setting, to be able to respond effectively to bombings and other forms of terrorism. In part two I will discuss what you need to know about bombs used to disperse chemical warfare agents or radiation.