BY ART ANDRES
The Federal Bureau of Investigation (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.” (28 CFR, Section 0.85) All too often we find ourselves thinking it will never happen in my town or someone else will assume the role of protector for my community. Terrorist acts in the world continue to increase, with explosive devices and high-velocity firearms as the weapons of choice. A resolute group of people with available resources to execute scandalous acts is a challenge most Americans can never imagine, but we need only to look at cities such as Madrid, Spain, and London, United Kingdom, to understand the impact explosives detonated in densely populated areas will have on emergency services. How would we address incidents caused by an adversary that will stop at nothing to achieve the objective of instilling fear and terror into our society?
The fire service responds to countless emergencies on a daily basis, but rarely do we face situations that involve explosives. The National Fire Protection Association (NFPA) reports that there are between 10,000 and 12,000 firework-related emergency room visits every year. The majority of these wounds involve hand and facial injuries. The 2005 study identified unsupervised school-age children as the highest risk category and attributed it to nearly 50 percent of all injuries. The highest rate of injury relative to the general population was for ages 10 to 14, which accounted for nearly three times the risk of the rest of society.1
Although the firework injuries identified in the NFPA study relate to commercially manufactured fireworks, improvised explosive devices (IEDs) are often developed using fireworks. The FBI Bomb Data Center released data from the 10-year period from 1988 to 1997 that analyzed the number of bomb-related fatalities and injuries resulting from bombing incidents.2 The FBI reported 17,579 bombings, 427 related deaths, and 4,063 injuries in the United States in that time. The potential for a terrorist-related bombing event is a threat to every nation and poses unique challenges from mass casualties to panicked crowds. In the United States, this threat requires a broadening of existing skills.
IMPROVISED EXPLOSIVE DEVICES
Currently, the number-one cause of U.S. military fatalities (approximately 60 percent) in Iraq and Afghanistan result from IEDs, according to Department of Defense statistics. A majority of terrorist acts in the world involve explosives, and nearly all groups have vowed to keep attacking American targets in an attempt to kill, destroy, or instill panic. Bombers are varied in their reasons for creating IEDs but often choose targets based on political, religious, or personal motivations.3
IEDs range from a simple Molotov cocktail to pipe bombs and large vehicle bombs. The components required to build an explosive or destructive device are readily available to most members of society and are relatively inexpensive. Pyrotechnic powders from fireworks, black powder, and smokeless powders are several examples of readily available materials used for the assembly of IEDs and account for 54 percent of all explosive materials, according to the Bureau of Alcohol, Tobacco and Firearms (ATF).4 When combined with a sealed container and triggering mechanism, they create a very effective IED. Construction was once a matter of experimentation; currently, resources for bomb makers abound, including libraries, gun shops, television, and the Internet.
BLAST INJURIES
Car accidents, shootings, and stabbings all present unique traumatic injuries routinely treated by emergency responders, but the characteristics of a blast injury will challenge even the most seasoned prehospital care provider. A blast will always have three distinctive qualities: a rapid release of heat, sound, and pressure (photo 1). Blast waves create (as seen in this photo) a single spherically expanding pulse of gas at a high temperature and pressure. The pressure wave will dissipate the farther it travels away from the explosion, but the transfer and duration of overpressure, combined with the mass of a person’s body and orientation to the explosion, will create internal injuries not commonly seen.
 (1) A blast has three qualities: a rapid release of heat, sound, and pressure. [Photos courtesy of Ontario (CA) Fire Department Arson/Bomb.] |
Injury occurs from the sudden increase in air pressure as it passes through the body. Solid organs are largely unaffected, but hollow (i.e., gas-filled) organs such as the lungs and bowel sustain greater injury because of tearing of the tissue at the gas interface (where hollow meets solid). Loose, poorly supported tissues are displaced beyond their elastic limit, especially the lungs, and quickly fill with blood. (3) Why is this scenario unique?
When the number of injured victims on-scene overwhelms responding resources, emergency responders triage to provide immediate care to the most severely injured. We commonly ask those who can walk to separate themselves, thereby leaving the critically injured to be treated immediately. The delayed or walking wounded are left for later assessment when resources become available. Depending on the proximity to the blast, a victim may present without outward clinical signs of blunt trauma and yet have significant internal injuries. The alveoli may have torn as the pressure wave passed through the body, causing the lungs to fill with blood. This is commonly referred to as “blast lung.”5 Consider anyone exposed to an explosion and complaining of chest tightness or respiratory distress as critically injured. Respiratory distress associated with a blast can be fatal and should be treated immediately. Many of these patients might initially be bypassed for those with more obvious signs of external injuriesbleeding, broken bones, or soft tissues injuries.
SHEAR INJURIES
Pressure from a blast can also create shear injuries to soft tissue, causing avulsions, amputations, and fractures (photo 2). The positive pressure wave will also displace objects that may become impaled in victims. These injuries should be treated like commonly seen penetrating wounds.
 (2) Injury from an M-80. |
HEAT RELEASE
The heat release will cause burns normally seen only with direct flame impingement (photo 3). The heat is attributed to the explosive material’s being released during the exothermic reaction. The patient’s final hospital destination should be a trauma center capable of treating the burns relating to the blast.
RESPONSE
IEDs vary in size and construction. A small package can be just as deadly as a large vehicle bomb and should be treated as an immediate threat to rescuers and the public. Complacency has caused many fire injuries. While responding to time-sensitive urgent situations, such as structure fires, we tend not to stop and develop detailed plans prior to taking action. We rely on standard operating procedures and prior training to effectively mitigate the emergency.
Hazmat responses are a type of emergency very similar to bomb-related incidents. Like a suspicious package, hazmat scenes involve many unknowns and call for development of an organized plan prior to taking action. Do not assume the threat is not real or the danger is minimal based on the size of a package. All fire personnel should be able to address the three primary objectives without specialized training or equipment. First, always provide for the safety of your crew and the public. Second, isolate the suspicious package with appropriate safety perimeters, and notify the appropriate authorities (bomb squad). Bomb technicians have a common saying, “If you can see the bomb, the bomb can see you.” Evacuate the immediate areas according to local protocols. Table 1 presents rules of thumb for evacuation.
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Many injuries have resulted from curious personnel who did not believe the threat was significant. IEDs can be initiated by a victim (or firefighter), on time delay, or be detonated remotely. An individual may be watching from a distant location to determine the perfect time to set off a destructive device. We can only hope that the time is not when a firefighter is standing immediately over the package.
The fire service has seldom been a target of outside violence. Large-scale incidents are the exception, not the norm. We should look to other countries currently experiencing regular violent behavior to anticipate future trends in our communities. Terrorist groups have created secondary explosions aimed specifically at injuring rescuers. Do not become complacent while operating at explosive incidents. Remember, scene safety is paramount when approaching any incident. Always have a heightened sense of awareness during the operation.
The following is an example of a routine response that could have had a tragic outcome. Firefighters responded to a private residence after an explosion was heard and found a victim bleeding in the bathroom. Firefighter/paramedics treated the patient on-scene and transported him to the emergency department in an ambulance. It was only when a nurse removed his pants to place him in a gown that the weapons were discovered (photo 4). The firefighters and ambulance crew had placed themselves at risk by believing the damage had already occurred and there was no further threat.
 (4) These items were removed from the clothing of an individual who had an IED explode in his hand while in his home. |
Explosions generate large numbers of walking wounded. It will be difficult to control a large group of people with an emotional involvement or panic and fear. Some will search for medical attention on their own at local medical facilities, but many will approach the first emergency responder they find, making it difficult to maintain scene control. The Centers for Disease Control and Prevention (CDC) predicts half of all initial casualties would seek medical care over a one-hour period at the closest hospitals.6 This may be useful to predict the demand for care and resources. Emergency departments may quickly become overcrowded while responders attempt to find appropriate medical facilities for the severely injured. As seen in the Madrid bombing, the wounded with the ability to walk without assistance will self-evacuate to local hospitals, causing a large surge. (6) The closest hospitals after the Madrid bombing received 272 patients in 21⁄2 hours.
Large gatherings of people have been favorite terrorist targets across the world. In the United States, incidents at schools in Jonesboro, AR; Columbine, CO; and Blacksburg, VA (Virginia Tech University), are examples of the terror distraught individuals can create on a school campus. Imagine a well-thought-out and refined plan set in motion by an organized terrorist group. The Beslan (Russia) school siege of September 2004 was one such incident. Chechen separatists took 1,200 children and adults hostage, using approximately 66 pounds of explosives consisting of more than 100 IEDs. The result was the deaths of 334 civilians, including 186 schoolchildren.7
Firefighters and emergency responders not only are public servants but also hold the front line in homeland security. The public we serve expects exceptional performance while we make decisions and implement specific action plans. We can never let our guard down or fall into the trap of believing that we will never be a target. Identify locations in your response area that may be threatened, and preplan how to prevent attacks while addressing concerns that may arise if a terrorist were successful. Fire prevention is without question a foundational function of the service we provide.
Almost every fire department is involved with building plan checks, adopting universal fire codes, and community fire prevention programs. Preventing terrorist attacks is similar to fire prevention in that it is accomplished through intelligence gathering, threat assessments, and proactive activities aimed at deterrence. Emergency action plans developed in collaboration with the fire service, local law enforcement, transportation providers, and local hospitals will assist in mitigating a blast-related incident.
Keep in mind the following: The injuries associated with a blast differ in many aspects from normal traumatic wounds. Victims may have been exposed to a pressure wave that caused significant internal injuries even though there are no external signs of trauma. Anticipate critically injured victims who are able to ambulate and will quickly overwhelm local emergency rooms. Be vigilant with respect to scene safety and potential threats in an effort to avoid becoming a victim of a secondary explosion.
Do not become complacent. We must always protect those who place their trust in us while also keeping ourselves out of harm’s way.
References
1. “The Alliance to Stop Consumer Fireworks Aims To Prevent Injury and Fire,” NFPA Journal, May/June 2005.
2. FBI Bomb Data Center General Information Bulletin 97-1, U. S. Department of Justice, Washington, DC, 1997.
Fireworks, NFPA Fire Analysis & Research, April 2007.
3. http://www.cdc.gov/masstrauma/preparedness/primer.htm/.
4. ATF Evaluation & Inspections Report I-2005-005, March 2005.
5. “Blast Injuries,” Eric Lavonas, MD, FACEP, eMedicine.com, 2007.
6. “In a Moment’s Notice: Surge Capacity in Terrorist Bombings,” CDC Mass Casualties, November 7, 2007.
7. Giduck, John. Terror at Beslan: A Russian Tragedy with Lessons for America’s Schools, First Edition. Archangel Group Inc., 2005.
“Radical Islam’s War Against the West,” Obsession, documentary, 2006. DVD released September 11, 2007. Wayne Kopping, director; Raphael Shore, producer; Trinity Home Entertainment.
ART ANDRES, a 14-year veteran of the fire service, is a captain on one of the busiest medic engines in the Ontario (CA) Fire Department, where he has served for the past 12 years. He has been a paramedic for 18 years while working in a regional trauma center as a flight paramedic and an instructor in various communities. He serves as the paramedic representative on the State EMS for Children Committee and the Emergency Medical Care Committee for San Bernardino County. He is a certified bomb technician and regularly speaks on blast injuries to emergency responders.
