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The existence of terrorism is not new but sitting back and thinking it is something that happens overseas is an indulgence that we no longer can afford. The FBI defines terrorism as "the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives." Recently, we witnessed domestic terrorist attacks involving the use of explosives, some of them with hidden secondary devices intended to injure and/or kill responders.
From 1990 to 1995, there were 15,790 criminal bombing incidents in the United States. The result was 355 people killed, 3,176 injured and $659.1 million in damage, according to the FBI's Explosives Unit/Bomb Data Center. Usual targets of these bombings are locations with a specific focus such as mass gatherings, structures with particular distinctions (government buildings, abortion clinics, physical plants with political tenants and centers of commerce). In each of these instances, the common denominator is the potential for a high-impact event, significant casualties and a requirement for a multi-agency response.
An alarming trend that involves the use of secondary or additional perimeter devices has been noted of late. Although this is a technique common in military operations, as emergency response personnel we have not really taken into account this anti-personnel maneuver and how it will directly affect our scene safety and choreography strategies.
When a bombing occurs, the public has a belief that the emergency response community can and will respond in a professional and appropriate manner. Consistent with the sheer existence of an emergency response agency, a community bond and public trust are promulgated whereby the community expects us to prevent or rescue them from these events.
By the use of secondary devices, the net result is the neutralization of the emergency response organization's ability to achieve its mandate of scene stabilization and assistance to the community. The failure to meet this public mandate also plays into the hands of the sponsoring or perpetrating individual(s)/organization(s) by demonstrating the alleged vulnerability and impotence of the government in this case, emergency responders to protect themselves or the public.
A prime example of the risk exposure from secondary devices can be seen examining the Atlanta abortion clinic bombing. A secondary device was detonated on the periphery and resulted in the injury of six people. For an EMS or fire department response, this problem exposes our membership to potentially devastating injuries, complicates scene management due to responders injured or killed, and escalates the victim count, requiring the commitment of additional resources at the scene to manage the events.
Scene Safety & Operations
As with any other emergency response, the first step required for a safe and effective management of the event is to implement the incident management system (IMS). All agencies should have an adequate understanding of IMS and how to implement it, as well as their response roles and responsibilities.
Clearly, EMS providers should be concerned with the location, extrication, triage, treatment and transportation of the injured. An explosion site is not the place for "freelancing." Location of additional devices and crowd control is the responsibility of law enforcement agencies. Implementation of the IMS process with a good member accountability system is key to avoidance of the above cited problems.
While enroute to the scene, units should ask the dispatch center to relay any pertinent information about the event. This should include but is not limited to the staging area, numbers of patients, suspected device vs. actual explosion, command post location and whether radio traffic has been cleared for the area. If the clearance for radio transmissions at the site cannot be determined, then it should be assumed that transmissions are prohibited.
Responding units should give on-scene signals a few blocks out and conduct all communications face to face or by using runners. Some explosive devices are rigged to detonate via RF exposure. Contact with the communications center will need to occur via hardwire telephone until the permission for radio transmissions from the scene can be obtained from an ordnance disposal team or bomb squad.
Upon arrival, conduct triage of the victims. Have all patients who can walk immediately move to a designated area away from the blast site. Be alert for anything unusual metal tabs on fingers or possible explosive devices affixed to victims' bodies, for example. If you suspect that anything found is unusual, step back and notify law enforcement personnel.
EMS personnel operating at the scene of a criminal explosion must use discretion when cutting the garment of a patient and attempt to preserve evidence, not destroy it. Actions such as cutting clothing away from shrapnel holes, not through them, will significantly assist those charged with the investigatory and evidence-collection process. Also, don't discard or dispose of articles of clothing or other items, for they too may be required by law enforcement agencies. In the event that an item is grossly contaminated due to bloodborne pathogen exposure, red bag it and place a vouchering tag on it, listing the owner and contents.
The flow of information from the command post must be guaranteed. If it is not, issues such as secondary devices may be announced and a delay in advising EMS and fire personnel can occur. It is paramount for your IMS that a liaison position be established early to ensure proper agency representation and access to timely information.
Should a secondary device be confirmed or believed in the area, a decision to transition medical operations to a "load and go" scenario may be required. Use of rapid immobilization techniques and rapid patient evacuation from the area must take place. This maneuver, although medically less desirable for the patient, will assist in limiting the risk exposure to victims and responders.
Until the scene is stable and secure, flexibility in your incident management is strongly encouraged. Keep the big picture in view; do not fall victim to tunnel vision . Always reassess the scene for emerging hazard and safety issues and operational effectiveness. Sometimes, the less obvious threats are the most dangerous. Be aware of downed electrical wires, potential structural collapses or the smell of gas.
When confronted with an explosion, you may find that there will be numerous injuries. Many injuries will appear moderate to minor but a full assessment will be required to properly reach a presumptive diagnosis.
Generally, injuries are related to a direct exposure to the blast or result from the panic that ensues post-blast. In the latter, you may find numerous minor injuries ranging from lacerations to soft-tissue injuries. As witnessed with past explosions, a subsequent panic among the crowd sets in and in the haste to "get out of Dodge," the victims fall and some get trampled or receive lacerations.
Those directly related to a blast exposure experience injuries that range from multiple trauma injuries to possible hearing loss (ruptured eardrums). The presumptive diagnosis of the multi-trauma patient is clinically easy. Do not readily dismiss a patient complaining of hearing loss as minor. The overpressure waves generated by a blast can cause fatal injuries and critical organ damage. Internal injuries can include significant damage to tethered organs and head wounds. Most patients with ruptured eardrums at the scene of an explosion require in-depth evaluation and most likely will spend at least 24 hours at a hospital for observation.
Another medical phenomenon is acoustical trauma. The patient externally may appear to be intact but is in a high level of distress. The body has sustained a significant pressure blow that has resulted in a massive shifting of thoracic organs (medestinal shift). These patients will require immediate airway support, possible chest decompression and rapid transportation to a trauma center for surgical intervention in order to save their lives. It should be noted that these patients, no matter how aggressive treatment is, usually have a high mortality rate.
For more information, contact a local emergency ordnance disposal team or bomb squad. Information is also available from the U.S. Bureau of Alcohol, Tobacco and Firearms (ATF) and FBI field offices.
Paul M. Maniscalco is a deputy chief/ paramedic with the FDNY Bureau of EMS. He is past president of the National Association of EMTs and is an adjunct faculty member of the National Fire Academy in Emmitsburg, MD. John D. Sinclair is assistant chief/paramedic with Central Pierce Fire & Rescue in Tacoma, WA. He is the International Association of Fire Chiefs (IAFC) EMS Section secretary and an adjunct faculty member of the National Fire Academy.