Framework for learning lessons for preparing for terrorist events

A multi-disciplinary panel of blast-related injury experts from eight countries that have recently experienced terrorist attacks examined and discussed their emergency medical response to blast events and identified common issues that could be used by others to enhance preparedness.

The represented countries included: Colombia, Indonesia, Iraq, Israel, United Kingdom, United States, Spain, Saudi Arabia, and Turkey. The study was funded by the Centers for Disease Control and Prevention through the National Association of Emergency Medical Service Physicians.

According to lead author, E. Brooke Lerner, Ph.D., assistant professor of emergency medicine at the Medical College, "Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. Our study found that there were a number of commonalities among these terrorist events, even though they occurred in different countries under vastly different circumstances. These commonalities can be used by all nations in their preparedness efforts."

The disaster paradigm-Detection; Incident Command; Scene Security & Safety; Assess Hazards; Support; Triage & Treatment; Evacuation; and Recovery, which can be applied to all types of mass casualty events, was selected as a framework to study responses in these different countries. In each area similarities were found. For example, it was determined that detecting an attack has occurred, such as the Madrid bombings in 2004, was not difficult but frequently the initial reports to the 9-1-1 system were misleading in terms of the scope and location of the event. This could lead to insufficient resources responding to the scene or to providers not taking the appropriate precautions against a secondary device. In discussing incident command and triage, it was found that regions that had a pre-defined command structure and triage guidelines that their providers practiced regularly were able to successfully and quickly respond to events. For example, in London they practice "Triage Tuesdays," where every Tuesday responders triage every patient as if they were involved in a mass casualty event.

An important part of Scene Security is ensuring that people are who they say they are and are not a threat to the responders or bystanders. A hospital that received the bulk of patients from a bombed housing complex in Riyadh, Saudi Arabia, found this was very difficult, since members of the staff were showing up at the hospital without their identification badges leaving security guards to make difficult decisions about who to let in.

Support requires additional trained human resources for all incidents, but they are needed in a controlled manner. Many speakers stated that it took time to recall staff and that they needed to consider how to maintain medical systems for hours and days after the initial incident, not just to meet the initial demand. For example, as the trauma hospital in Darwin, Australia, prepared to receive patients from the Bali, Indonesia, night club explosion, they used the media to ask people not come to the emergency department unless they had a true emergency. However, this request did not significantly decrease the number of patients that came to the emergency department for care.

In considering evacuation, it was important to consider that many terrorist bombings occur in remote tourist communities in developing countries such as Turkey and Indonesia. This complicates the response since hospitals in tourist communities do not typically have the resources to attend to many severely injured casualties. Therefore, patients need to be stabilized and moved to larger hospitals that are some distance away. Another complication is that incidents in resort towns typically involve foreign nationals. This creates a situation where governmental agencies need to be involved in the response and arrangements need to be made to move patients back to their home countries. This may require specialty transport services depending on the nature of the injuries and the care required during transport.

An important component of recovery is informing the general public of the extent of the event, where they can receive assistance if needed, whether there are continued risks and how to mitigate them. Further, community awareness and notifying authorities if something seemed out of the norm was found to be important, particularly by the Israelis who feel that their population is always alert and reports anything that seems suspicious.

"This project provides an initial framework for learning lessons for preparing for terrorist events. However, the next steps are to identify best practices in response to a blast-incident and to develop a research agenda that will guide research priorities," Dr. Lerner says.

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