Terrorist Bombing Case Studies

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Terrorist Bombing Case Studies

• Robert Feldman, MD FAAEM
• Cook County Bureau of Health Services

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Scenarios

• Pipe Bomb
• Suicide Bomber
• Vehicle Bomb
• Combined attack
• NBC

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Centennial Park Bombing
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27 July 1996

• 055 There is a bomb in Centennial Park. You
  have 30 minutes.
• Knapsack found, moved
• People evacuated in an orderly fashion
• 0125 Bomb detonates

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Centennial Park Bombing
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Centennial Park Bombing
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Bomb Scene
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Centennial Park - Device
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Centennial Park Bombing
Eric Rudolph
Richard Jewell
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Centennial Park Bombing

• Victims
• Injuries
• Hospitals

Feliciano et al, Am J Surg 1998176538-43.
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Victims

• 111 victims ( 1 MI)
• 96 evacuated within 30 minutes to 4 nearby
  hospitals
• All patients evacuated within 32 minutes by 30
  EMS units
• No formal triage at park

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Hospitals

• Level I Trauma Center
• Grady Memorial
• 3 Urban Community Hospitals
• Crawford Long
• Piedmont
• Georgia Baptist
• Outlying facilities

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Injuries

• Of the 96 patients evacuated to the 4 downtown
  hospitals
• 24 (25) required admission
• If there had been more casualties, the
  over-triage to the closest hospitals would have
  been problematic

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Injuries

• All injuries were due to shrapnel (secondary)
• No primary or tertiary injuries

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Incident Features -Pre-Detonation

• 5 years of planning
• Pre-positioning of resources for Olympic events
• Prior warning
• Partial evacuation
• Repositioning of device

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Incident Features - Post-Detonation

• Adequate resources quickly on-scene
• Rapid evacuation of victims (32 min)
• Excellent communications
• Surgeons in ER before patients
• Overstaffing
• More physicians than patients in Grady ER

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Incident Features - Post-Detonation

• No blast injuries or burns
• Only 1 direct fatality

Alice Hawthorne, 44
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Chicago Tribune - 18 April 2005
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Park Hotel - Netanya, IsraelMarch 22, 2002

• Enclosed hotel banquet hall
• 250 people attending Passover seder
• Many elderly
• Doors windows closed

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Suicide Bomb - 1930

• Charge 8-10kg triacetone triperoxide (TATP)
• Embedded with several hundred steel balls (3-7 mm)

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TATP 2g
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Blast Effects - Confined Space
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Suicide Bomb - Victims

• 250 people in hotel dining room
• 164 victims
• 73 PTSD only (44 of victims)
• 91 bodily injury (56 of victims)
• Mean age 65
• 20 dead at scene (22 of injured)
• 71 alive on arrival at hospitals (78 of injured)

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• Blast site
• Dead at scene
• DOA
• In-hospital death

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Suicide Bomb - Victims

• 71 alive on arrival at hospitals
• 2 Level II trauma, 1 community
• 2 Triage hospitals (1 Level II the community
  hospital)
• 10 died in hospital (2 during initial resus)
• 23 required transfer to Level I trauma center

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Suicide bomb - Injury patterns

• Deceased
• Averaged over 16 pellets
• 90 had head injuries
• 1 traumatic limb amputation

Reuters
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Suicide bomb - Injury patterns

• Early deaths in-hospital (2)
• Penetrating chest injuries
• Diaphragm penetration ? Intra-abdominal injuries
• Death by exsanguination

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Suicide bomb - Injury patterns

• Other wounded (69)
• All severely wounded had penetrating wounds
• 10 minor burns
• 2 major burns (gt30) ? both died
• 3 had blast injury as well as penetrating trauma
• 18 required early intubation

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Suicide bomb - Injury patterns

• Other wounded (69)
• 23 (33) to OR
• 10 laparatomies
• 4 thoracotomies
• 3 craniotomies
• 5 orthopedic
• 2 vascular

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Suicide bomb - Injury patterns

• Injury pattern summary
• Immediate mortality 22
• Severe injuries 45
• In-hospital mortality 14

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Netanya - Lessons Learned

• Blast injury especially evident in immediate
  fatalities
• Severely injured patients suffered hemorrhage
  from blast and shrapnel
• Isolated shrapnel wounds similar to shotgun
  wounds
• Rapid loss of velocity and tissue penetration
  with distance

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Netanya - Lessons Learned

• Entrance wounds often small
• Often no exit wound
• Maintain a high index of suspicion for shrapnel
  injuries!

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Netanya - Lessons Learned

• Wound evaluation
• Stable - CT
• Unstable - whole-body fluoroscopy in OR
• FAST scans helpful
• Do not rule out GI injuries
• DPL

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Netanya - Incident Characteristics

• Confined space
• Indoors
• Sunken area
• Shrapnel
• No structural collapse
• No crush injuries

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Netanya hotel victims
Israeli Ministry of Foreign Affairs
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Oklahoma City - 19 April 1995
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OKC

• 0902 Approx. 4000 lbs. ANFO detonates on north
  side of Murrah Federal Building
• 6.0 on Richter scale
• Heard felt 55 mi. away

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Engineering Analysis, Inc.
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OKC

• 324 buildings damaged
• 10 collapsed
• 14 others condemned

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OKC Bomb Effects
Dallas Morning News
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OKC - Commuications

• Over 1800 calls to 911 within 1st hour
• Incoming call volume overwhelmed switchboards,
  blocking outgoing calls
• Cell phone service overwhelmed
• 27 additional bomb threats that day
• Secondary device scare 1030
• EMS couldnt contact hospitals to assess capacity

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OKC

• Over 22,000 FBI scene IDs issued
• Media counterfeited all IDs, until dot-a-day
  instituted

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OKC

• 168 dead
• 163 in Murrah building
• 19 children
• 2 neighboring buildings
• 1 outside
• 1 rescuer
• 790 injured

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OKC

• Blast effects
• Building collapse

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OKC

• Victims transported by EMS, police, private
  vehicles
• Local hospital staff walked to scene
• One nurse was killed by falling debris

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OKC - Injuries

• Local hospitals 426
• Admitted 82
• Treated released 344
• Private doctors offices 175

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OKC - Injuries
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Impact of Building Collapse
Frykberg, J Trauma 200253201-12.
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OKC - Hazards to Rescuers

• Rescue personnel did not use PPE
• Inhalation hazards
• Similar experience at WTC
• Safe perimeters not established initially
• Volunteer nurse killed by falling debris
• Several others injured due to lack of appropriate
  safety equipment

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OKC - Mental Health

• 19 children killed
• 30 children orphaned
• 219 children lost one parent
• 462 left homeless
• 18,613 people sought counseling by years end

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(No Transcript)
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OKC - Lessons Learned

• Key emergency personnel had recently attended
  training in large-scale disaster management
• Interagency communications are crucial
• Unified command center and structure
• External resources were required
• Youre on your own for 72 hours

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OKC Lessons -

• No defense to an ambush
• You must have plans
• Practice your plans
• Take care of your staff
• Dont think it cant happen to you
• 750 in materials
• 1 billion damage

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OKC - Post-detonation
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Summary Review

• Outdoor detonation
• Indoor detonation
• Large vehicle bomb

Frykberg, J Trauma 200253201-12
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Outdoor vs. Confined Space

• Limits primary (blasts) and tertiary (victim
  thrown)
• Leibovici et al (J Trauma 1996411030-5)
• Jerusalem bombings
• Open-air 7.8 mortality (16/204 casualties)
• Buses 49 mortality (46/93 victims)

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Summary - Triage

• Mass-casualty incident (MCI) vs.
• Disaster

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Triage - MCI

• Medical resources not overwhelmed
• Over-triage to closest hospitals and trauma
  centers can be tolerated

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Triage - Disaster

• On-scene triage is essential
• Over-triage problematic
• Overwhelms facilities
• Delays care for critical patients

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Overtriage vs. Mortality

• Correlation is not causality
• Overtriage will be more prevalent if incident is
  more severe
• Goal is for 50 overtriage, but 75 is common

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Overtriage vs. Mortality

• Must be willing able to redistribute patients
  if facility is overwhelmed
• Must be able to recognize when facility is
  overwhelmed

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Disasters Beware becoming a Boiled Frog
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Bottlenecks

• Patient reception
• Triage
• Imaging
• Laboratories

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Safety

• Bomber may be a victim
• Unexploded ordnance
• Secondary devices
• Dust / inhalation hazards
• NBC contaminants

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Terror-ism

• Plan location for psych casualties
• Patient information
• Families
• Media

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Responder Stress Illness

• Critical Incident Stress Debriefing
• No evidence for efficacy, may be harmful
• PTSD
• OKC - 13 of firefighters
• May affect counselors as well
• Substance Abuse
• Self-medication
• FDNY cases doubled 2003 to 2004

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Responder Stress Illness

• Get staff back to work
• Watch for signs of PTSD
• Avoid stigmatizing PTSD victims

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NBC

• Contaminating agents will greatly multiply
  psychological effect on patients, public, and
  STAFF
• Plan should include screening for ionizing
  radiation

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Prepare!

• Plans without practice - little value
• Plans must be robust (boiled frog)
• Communications must be robust
• Drills are vital