Are We Ready for Suicide Bombings?

A call comes over the radio: “EMS 12, EMS 4, Supervisor 1: All units head to the downtown area. We are receiving reports of a possible explosion with an unknown number of injuries.” You start heading toward the business and financial district and are still a few minutes out when you hear a supervisor arrive on scene. He immediately calls for additional units. The background noise from the scene almost drowns out his transmission—it sounds like a large crowd has gathered. A minute later, he is yelling that he wants all units to “step it up” and asks dispatch to have more police respond.

You arrive on scene to find chaos. There are body parts, glass and metal scattered about, and it seems like no one is in charge. Twenty feet or so in front of your rig, you see what you think is a human head on the street. You and your partner make your way to the lobby of a large bank, where the majority of the wounded lie in various states of injury. You are triaging patients when someone grabs you by the arm. You turn to see your supervisor. “It was a suicide bombing,” he tells you. “Police are evacuating the area because of a possible secondary device.”

A suicide bombing can be one of the most efficient and effective ways to penetrate a target, create injuries and generate press coverage. Television news frequently broadcasts scenes of chaos and destruction caused by bombings in buses, theaters and restaurants overseas. What type of impact would a similar event cause in the United States?

While great emphasis has been placed in the last few years on training prehospital providers to respond to incidents involving weapons of mass destruction (WMD), the same cannot be said of training for other, smaller-scale, yet potentially just as devastating acts of violence. Unfortunately, despite the escalation of terrorist acts and the spread of these events to locations outside of the Middle East, some EMS systems in the U.S. still believe “it can’t happen here.” Is your EMS agency ready to respond to a suicide bombing? This article will provide EMS providers and managers with a basic level of awareness about these devastating incidents.

Overview

A suicide bomber is an individual who carries an improvised explosive device (IED) on his person to detonate with the intent of taking his own life, as well as those of bystanders. These persons are dedicated to acting and can choose the time and place they strike. Experience with suicide bombers in the Middle East has demonstrated that their targets can include buses, clubs, restaurants, hospitals, police stations and other public locations where large groups gather. The bomber can be of either gender, and ages have ranged from adult to early adolescence. The IED is designed so that it can be hidden inside clothing, belts, handbags, vests or other easily carried containers. One recent incident involved a bomber who was carrying approximately 15 lbs. of explosives sewn into his underwear.

Targets

Suicide bombers choose targets that have a significant impact psychologically, due to the type of location attacked, or in the actual number of those injured or killed. These targets can be “hard” or “soft” (see Table 1). A hard target is an area with restricted access and some level of consistent security, such as a military base, airport or power station. A soft target is a place or entity that has easy access and is not as well-guarded or secure as a hard target. These are usually areas designed for public congregation, including malls, outdoor cafes, restaurants and schools. Other targets carry particular importance regardless of their security level or accessibility. These can include special events, large public gatherings, houses of worship (all religions) and public transportation (rail, ground and air).

Secondary Devices

A secondary device can be defined as a corresponding IED, usually placed close to a primary device, that is time-delayed to allow for crowds or emergency personnel to respond to the scene of the initial bombing. Secondary devices can be detonated by remote control, explode automatically at a given time or even be triggered by another suicide bomber. EMS providers must not think that they are immune to harm because they are there to help. Secondary devices are often aimed at killing or injuring the first wave of responders, EMS included. The demoralizing impact on the public of seeing emergency service responders made useless and helpless is often a primary goal, and not just a side benefit, to terrorists.

This practice is not unknown in the U.S. Bombings in 1997 at an abortion clinic and a nightclub in Atlanta were followed by secondary explosions; at the former location, seven more people were injured. It can’t be stressed enough that responders must be aware of their surroundings, as well as suspicious objects and individuals. The urge to rush to assist must be tempered with judicious restraint based upon the scenario. Events such as these should be cleared by public-safety agencies before EMS providers are allowed to enter. If they can’t be, then, just as in hazmat incidents, patients should be brought to an area known to be “clean.”

The ICS and Unified Command

The Incident Command System (ICS), with the concept of unified command, has become the U.S. standard for any emergency response requiring multiple disciplines to operate at the same scene. This standard must be tailored slightly, however, if it is to be used in a situation that cannot be made safe enough to allow for normal EMS operations.

Israeli EMS uses a modified ICS with a rapid triage and transport component. Patients within the immediate vicinity of an explosion are removed from the area as quickly as possible, without triage or stabilization. Basically, responders are acting as though there is a secondary device in the area until proven otherwise. Once patients and personnel are safe from danger, traditional care can be given. Using these tactics, Israeli responders have been known to clear 40 or 50 patients from the scene of a suicide bombing in 15–20 minutes without just moving the incident to the hospital. The average time from the report of an explosion to the first unit arriving on scene is 4.6 minutes. The average time until the first transport is initiated is 11.5 minutes, and, on average, the last critical patient can be transported in 30.2 minutes.1

Triage

A simple standardized triage system, such as the START (Simple Triage and Rapid Transport) system, should be used to sort and transport patients on a priority basis. This process can be taught quickly to non-medical responders at the scene, and it allows for the concentration of EMS personnel in positions that require more training. This is important because the traditional first responders—police and fire personnel—will probably not be available to assist, due to other pressing responsibilities. This may necessitate the use of bystanders for the triage function.

Remember that triage should always be conducted outside the hazard area. When necessary, patients should be evacuated to a triage point by law enforcement or tactical personnel and then managed by EMS. Only lifesaving procedures—e.g., airway management and hemorrhage control— should be performed on scene; all other supportive measures—IV establishment, splinting, etc.—can be done en route to the hospital.

Operational Realities

To ensure a measure of success in responding to a suicide bombing, the EMS branch manager and the incident’s communications center personnel must address several critical factors. The EMS branch manager should have a field operations guide (preferably in checklist form), a well-marked identification vest, interoperable communications equipment and, possibly, a megaphone (megaphones have been shown to be effective by Israeli EMS when dealing with a concentrated incident with a multitude of patients and responders). As the event progresses, the EMS branch manager must also remember to give the communications center regular status updates.

The communications center should have its own checklist set up that includes available resources, where those resources will come from, and contact information and notification prioritization for administrators, agencies, hospitals, etc. This must all be in place prior to an incident.

An initial overdispatching of resources has been proven to be an effective tactic. Implementing dedicated MCI communication channels, whether by having responders switch to a specific radio frequency or by establishing groups through a trunk system, will allow for regular EMS system traffic to continue without interfering with incident operations, as well as enabling coordination of patient distribution and hospital notification. Lastly, there should always be a supervisor/manager in the communications center.

Handling the Injured

Victims of suicide bombings can experience all types of traumatic injuries, as well as significant burns. Bomb or blast injuries are identified as primary, secondary or tertiary. Primary injuries are due to the heat and overpressurization generated by the explosion. Overpressurization is caused by the creation of a narrow pressure wave that rapidly moves concentrically away from the detonation’s epicenter, causing a sharp increase and then an equally dramatic decrease in air pressure as it passes. When this wave hits the body, it compresses and then decompresses any air-filled spaces. Based upon the proximity and position of victims to the blast, they can receive life-threatening traumatic injuries to both their respiratory and gastrointestinal systems (e.g., the collapse of the lungs or rupture of the bowels). Adequate oxygenation and ventilation of patients is vital, as is assessing for and addressing tension hemo/pneumothoraces. Care should be taken when providing ventilatory support due to the chance of forcing air embolisms into vascular spaces surrounding damaged lung tissue. However, severely dyspneic patients may need positive-pressure ventilation.

Depending on the strength of the blast, patients may present immediately with signs of shock due to internal damage to organs, or such signs may develop over time. Hollow organs are more susceptible to infection post-injury, whereas solid organs bleed and cause the prompt onset of shock. Thermal burns can be caused by the initial blast. These burns are usually limited, unless an incendiary agent like Napalm was added to the bomb or a source for continued combustion (such as multiple layers of clothing) is present. Again, given the force of the blast wave, closely monitor the patient for burns to the respiratory tract.

Projectiles carried in an explosion can cause secondary injuries, such as ballistic wounds and impalements, that can be just as life-threatening as (or more than) primary injuries. Beyond the device container or casing, some terrorists pack shrapnel like nuts and bolts, ball bearings or nails into their bombs for maximum effect. These projectiles can cause wounds over a large percentage of the body surface and produce significant hemorrhaging. Attempts should be made to remove gross surface contaminants before managing bleeding, but impaled objects must be left in place and stabilized. Also, large areas of tissue damage are more susceptible to infection. Removing any clothing and covering these injuries with clean sheets will help reduce the introduction of further debris and the risk of infection. An additional consideration in suicide bombings is that projectiles may also include the body parts of the bomber.

Tertiary injuries occur when victims are thrown onto the ground or other objects by the blast wave, causing blunt or penetrating trauma. Tertiary injuries are also found in patients caught by the collapse of structures damaged by the blast. While both mechanisms can lead to serious and life-threatening damage to skeletal, nervous and vascular tissue, structural collapses can also require the commitment of additional resources for patient extrication.

The difficulty in addressing patient injuries under these circumstances is that initially, there is no way to ensure complete security for EMS to establish operations. The potential for a secondary device precludes establishing standard patient triage and treatment sectors at or immediately near the scene. Specialized protocols may need to be implemented to handle the sorting and treatment of victims following a suicide bombing. Protocols used by EMS agencies in Israel prohibit CPR at the scene of a bombing. These protocols call for the majority of stabilizing patient treatments to be completed once the patient is en route to the hospital.

Strategies

Given some of these unique challenges, there are several strategies that EMS systems should keep in mind when developing policies for responding to possible suicide bombings. These include:

Flexibility—For various reasons, these events may not lend themselves to standard triage techniques. Adapting to the situation may require moving everyone able to relocate to an alternative site, then assessing their degrees of injury. This flexibility includes recognizing the need to tailor standard response methods to these events and not trying to make such an incident fit a mold.

Security—Security is paramount. A disturbing and important fact to remember is that ambulances and other emergency vehicles have been utilized in other parts of the world to transport both bombers and devices to their potential targets.

Controlled response—It is well established that these scenes cannot be deemed safe just with the presence of police. Responders have been targeted with secondary devices, and it is crucial that prehospital providers plan for this. EMS providers cannot rush into a scene just because there are people hurt. Identify perimeter staging areas at various distances from the scene for EMS personnel and equipment.

Utilization of the Incident Command System—Besides medical operation positions, EMS should be involved in a unified command structure alongside the public-safety and fire entities controlling such a scene. Also, designating an EMS safety officer is paramount. This person should have the authority to immediately end operations and order resources to retreat to a perimeter staging area.

Tactical EMTs/medics—If your EMS system has a special operations division or group, it should be involved in the preplanning process and included in the first wave of responders to a bombing. Tactical training prepares providers to rapidly extricate patients prior to stabilization.

Regional, state or federal resources—Consider additional assets early on, as it takes time to mobilize them. Identify request pathways and build them into your response plans. Think about what resources exist and how they can assist, both immediately and long term. These can include USAR teams and DMATs.

Conclusion

Acts of terrorism and violence had been perpetrated on American citizens for many years prior to 9/11, both here and abroad. As has happened with public safety, EMS systems need to move away from the philosophy of “it can’t happen here” and embrace an attitude of preparedness. Developing protocols for responding to a suicide bombing is but one facet of this.

Another way to reinforce this mind-set among responders is to conduct drills, both tabletops and full exercises, for the suicide-bombing scenario. Finally, there is a definite need for progressive EMS agencies to strengthen relationships and communications with the public-safety entities with which they regularly interact. Anytime there is an alert that causes the public-safety