Terrorist Bombings Lessons Learned by ula13878

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									                                 General Sessions
                      Terrorists Bombings: Lessons Learned
               Saturday, February 5, 2005         3:30pm ~ 4:30pm




    Terrorist Bombings:
     Lessons Learned
    Health Data for Disaster and Emergency Response

                          Catherine Y. Lee, MPH
                        Research Analyst, Consultant
              International Disaster Management Conference
                              February 5 2004

                                 Emory University
                              School of Public Health
                     Dept Environmental & Occupational Health
                                School of Medicine
                            Dept Emergency Medicine




                             Goal                               “Analysis of past bombing disasters reveals
                                                                  definite patterns of injury and mortality,
     Survey terrorist bombing                                    which provide the opportunity to plan and
                                                                          prepare for future events.
  tactics and how they influence
         patterns of injury.
                                                                The most important means of preparing for
                                                                    the large casualty loads of bombing
                                                                  disasters is to understand the patterns of
     Analyzed primarily for the medical                         injuries and logistical problems that result.”
       and public health community
                                                                                    Eric Frykberg, MD, FACS




                   Objectives
• Present data on frequency and types of
  terrorist bombings
• Present methods to glean information
  (maybe applied principles) from terrorist
  bombings
• Analyze specific incidents




                                                                                                                 1
                                       General Sessions
                            Terrorists Bombings: Lessons Learned
                     Saturday, February 5, 2005         3:30pm ~ 4:30pm




                                                        Lee, Davis, Noji, Peleg 2003-2004                                                    FBI. Terrorism in the United States. 1999




                                                                                                        Some Background




                                                    FBI. Terrorism in the United States. 1999




              Epidemiology Shift                                                                      1996 Leibovici, Gofrit
       Sandia, China, Sweden, Russia: Man and Blast Injury
1950                                                                                            “The characteristic injury patterns from
                                                                                                 bombings have been thoroughly
1970   IRA: Hospital Experience, Civilian Blast Injuries                                         discussed in the literature. However,
       Epidemiology Started Here                                                                 bombing incidents are prone to be highly
                                                                                                 variable concerning scene settings, victim
        suicide                                                                                  populations, and explosive charge
        bombing                                                                                  properties, including weight and chemical
                                                                                                 structure. Thus, a comparative analysis of
1990   Israel: Mix of factors that influence pattern of trauma                                   injuries inflicted in different bombing
                                                                                                 incidents may be biased.”
2004   Global: Complex Tactics: different influences different                                                       Leibovici, D., Gofrit, O.N., Stein, M., Shapira, S.C., Noga, Y., Herti,
                                                                                                                     R.J., Shenier, J. Blast Injuries: Bus Versus Open-Air Bombings – A
       bombings                                                                                                      Comparative Study of Injuries in Survivors of Open-Air Versus
                                                                                                                     Confined-Space Explosions. Journal of Trauma, 1996, 41 (6): 1030-
                                                                                                                     1035
                                        …and non-English studies




                                                                                                                                                                                               2
                              General Sessions
                   Terrorists Bombings: Lessons Learned
            Saturday, February 5, 2005         3:30pm ~ 4:30pm


     2003 Halpern, Arnold
                                                                                                                      HOST

“ Further information about whether a
 vehicle delivery system was used (e.g.,
 car, truck, plane), explosion setting
 (open-air or confined-space), and
 explosion sequela (structural collapse or
 structural fire) helps establish a “quick
 and dirty” estimate of the initial need for                                                           ENVIRONMENT                 AGENT
 ED resources”
                    Halpern, P., Tsai, M., Arnold, JL., Stok, E., Ersoy, G. Mass-Casualty,
                    Terrorist Bombings: Implications for Emergency Department and Hospital
                    Emergency Response (Part II). Prehospital Disaster Medicine, July –
                    September 2003.                                                                    Epidemiologic Triangle




                                                                                                                                       Arnold, J., Halpern, P., Tsai, M.,
                                   Eric Frykberg, “Medical Management of Disasters and                                                 Smithline.H. Mass Casualty Terrorist
                                   Terrorism, How can we cope? J Trauma. 2002;53:201–212.                                              Bombings: A Comparison of Outcomes by
                                                                                                                                       Bombing Type. Annals Em Med. Feb
                                                                                                                                       2004, 43 (2)




                                                                                             Small and Frequent           “Traditional”: Solo


                                                                                               Open                       Structural             Explosive Type
                                                                                                                                                 Quantity
                                                                                                                  +                              Delivery Method
                Tactics                                                                                                                          Epicenter
                                                                                                               Confined                          People in Vicinity
                                                                                                                                                 Time of Day
                                                                                             Suicide Bombing                                     Etc…




                                                                                                    Complex Tactical Bombing
                                                                                                                                      …Other Considerations




                                                                                                                                                                               3
                                        General Sessions
                             Terrorists Bombings: Lessons Learned
                      Saturday, February 5, 2005         3:30pm ~ 4:30pm


     Catastrophic but rare




                                                            Increasing mortality
                 Complex Tactics


                                                                                                                                         Tactic 1
                             Traditional-Solo
                                                                                           Small Bombings, High Frequency
                                            Small IED, LE




     Increasing frequency




                             Profile                                                                                                            Open
•   Small IEDs                                                                     • Expression of “free field” (or something
•   HE or LE                                                                         like it)
•   Simple logistics, ease of coordination                                           – Friedlander waveform

•   Not high profile targets, symbolic                                             • Few obstacles and hindrances
•   Open spaces                                                                    • Free movement of blast wave
•   Confined space                                                                 • Grassy park, parking lot, open




                                                                                                                                                       Atlanta

                                                                                    100%                                                   7 penetrating
                                                                                     90%                                                   wounds

                                                                                     80%                                                              70%                       5: closed/open fx
                                                                                                                                                                                skull, facial skeleton
                                                                                     70%
                                                                                     60%                                                                                          50%                  3 Strains & Sprains
                                                                                     50%
                                                                                     40%                                                                                                          30%                        1 case of Heart
                                                                                     30%                                                                                                                                     Attack

                                                                                     20%                                                                                                                                                    10%
                                                                                     10%
                                                                                      0%
                                                                                           pulmonary


                                                                                                       Bowel


                                                                                                               Tympanic




                                                                                                                                                                                                   Traumatic


                                                                                                                                                                                                               Nerve palsy


                                                                                                                                                                                                                               Crush injuries
                                                                                                                                         Concussion




                                                                                                                                                                     Bruises,
                                                                                                                          Ocular globe




                                                                                                                                                       Penetrating




                                                                                                                                                                                    Closed/Open




                                                                                                                                                                                                                                                  CVD related


                                                                                                                                                                                                                                                                other




                                                                                    0.0% Critical
                                                                                    0.9% Immediate




                                                                                                                                                                                                                                                                        4
                                        General Sessions
                             Terrorists Bombings: Lessons Learned
                      Saturday, February 5, 2005         3:30pm ~ 4:30pm




                  Victoria Station                   Secondary Injuries Common
• Several kilograms of Semtex in a litter bin      • Regardless of terrorist bombing type, most
• 30 treated at Westminster Hospital                 common, most of the time
• Majority of injuries caused by shrapnel          • Data from Madrid shows otherwise
                                                     (complex bombing)
      Incidents of Injuries
      Soft Tissue Injuries    32
      Open fx                 13
      Neurovascular           7
      Traumatic Amputation    2
      Perforated Organs       4
      Bone fx                 5
      No Burns




                      Glass Hazard


  Secondary Blast
  injury agents:
  Bomb canister pieces
  Glass shards
  Particulate Matter
  Secondary missiles




                                                                                                  5
                                     General Sessions
                          Terrorists Bombings: Lessons Learned
                   Saturday, February 5, 2005         3:30pm ~ 4:30pm


           Small IEDs, LE/HE                                                                                      Soho 1999
                                                                                          • “Nail Bomb Spree”
                                                                                          • 2 DOS, 1 DIH
                                                                                          • 18 admitted, 9 critical




                                                                                                 United Kingdom – London, England
                                                                                                 British Broadcasting Company (BBC)
                                                                                                              3/24/2001




                                                                                            0 fatalities              1 non-fatality wounded        0% mortality
                                                  Courtesy: Battlefield Wounds, John R.
 Land Mine amputation                             Mechtel, RN, MSN – DMRTI                  Blast Epicenter: open-space, parked street in front of main entrance
                                                                                            Bomb-characteristics: HE Secondary (Semtex), IED/Stationary in Trunk




             United Kingdom – England
             Brick Lane, White Chapel                                                                              Confined
                     4/24/1999
                                                                                          • Small dimensional space, tight and limited
                                                                                            movement
                                                                                            – Bus, Small Bar, Store, Bathroom
                                                                                          • Reflecting surfaces
                                                                                          • Magnifies incident 2 – 9 times
                                                                                            – Primary
0 fatalities              6 non-fatality wounded   0% mortality                             – Energized, Secondary
Blast Epicenter: open-space, parked street
Bomb-characteristics: HE Secondary (Semtex), IED/Stationary in Trunk                      • Small amount HE needed




                                                                                                                                                                   6
                  General Sessions
       Terrorists Bombings: Lessons Learned
Saturday, February 5, 2005         3:30pm ~ 4:30pm




                                                                          Confined Space, 6 kg of high explosive
                                                                          10.3% Critical
                                                                          5.2% Immediate


                                                     C.Y.Lee 1 Apr 2004
      Source: www.mfa.il.gov; suicide bombing May 18, 2003, Jerusalem                                       Used in Lee, CY. Development and Application of the BDI Scale. Emory University May 2003.




                                                                              Type of Injury                                                                                           Cases

                                                                              Pulmonary barotrauma: “Blast Lung Syndrome”                                                                 11
                                                                              Other chest traumas including hemothorax, pneumothorax, pulmonary                                            7
                                                                              contusion hemorrhage, A-V fistulas, airway epithelial damage, aspiration
                                                                              pneumonitis
                                                                              Bowel perforation                                                                                            2
                                                                              Other abdominal traumas including hemothorax, pneumothorax, pulmonary                                        6
                                                                              contusion and hemorrhage, AV fistulas, airway epithelial damage
                                                                              Tympanic membrane perforation                                                                               22

                                                                              Penetrating ballistic fragmentation wound                                                                    9

                                                                              Brain/Head Trauma                                                                                            4

                                                                              Lacerations and foreign body penetration to the eyes                                                         5

                                                                              Bruises, contusions, abrasions by blunt trauma                                                               2

                                                                              Organ lacerations                                                                                           20

                                                                              Closed and open fractures to other bones                                                                    10

                                                                              Traumatic amputations of limbs                                                                               1

                                                                              Burns                                                                                                        5
                                                                              Total patients data collected for                                                                           29
                                                     C.Y.Lee 1 Apr 2004
                                                                                                            Lee, CY. Development and Application of the BDI Scale. Emory University May 2003.




                                                                                                     Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J
                                                                                                     Trauma, 1983, 23 (11): 955-967




                                                                                                                                                                                                        7
                                       General Sessions
                            Terrorists Bombings: Lessons Learned
                     Saturday, February 5, 2005         3:30pm ~ 4:30pm


                               Cooper
• “Tavern in the Town”: 11 dead, 89 injured
• “Mulberry Bush”: 10 dead, 30 injured

   Data from 42 total admitted from all hospitals that received:
   Serious soft tissue damage                                    22
   Burns                                                         23
   Fractures                                                     13
   Eye Damage                                                    13
   Blast Lung                                                    3
   TM Perf.                                                      17
                     Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J
                     Trauma, 1983, 23 (11): 955-967




                                 Mellor




                                                                                                                  Celander, H., Clemedson, JH., et al. A Study on the Relation between Duration of a
                                                                                                                  Shock Wave and the Severity of the Blast Injury Produced by it. Acta Phys Scandinav.,
                                                                                                                  Vol 33, 1954.




                                                                                                                                            17%                   52%                  12%                 9%




                                                                                                                    Kahana, T., Hiss, J. Trauma and Identification of Victims of Suicidal Terrorism in Israel. Mil
                                                                                                                    Med, 165: 11: 889, 2000




                                                                                                                                                                                                                     8
                                     General Sessions
                          Terrorists Bombings: Lessons Learned
                   Saturday, February 5, 2005         3:30pm ~ 4:30pm


                                                                                                                                                        La Belle
                       La Belle                100%
                                                90%
                                                80%

•   Confined Space, 10 lbs of high explosive    70%
                                                60%                                     53%

•   4% Critical                                 50%
                                                40%
                                                                                                                                         29%
•   1% Immediate (2/261)                        30%
                                                20%                                                                                                          15%
                                                                                                                                                                                                                                   20%
                                                                                                                                                                                               10%
                                                                     5%
•   300 in club before blast                    10%
                                                0%
                                                                                                                                                        1%




                                                                                        membrane (ear
                                                      barotraumas,




                                                                                                        Ocular globe




                                                                                                                        Concussion




                                                                                                                                          Penetrating




                                                                                                                                                                                                                                                          CVD related
                                                                                                                                                                           fracture to skull




                                                                                                                                                                                                                     Nerve palsy




                                                                                                                                                                                                                                         Crush injuries
                                                                                                                                                             contusions,




                                                                                                                                                                                                     amputation of




                                                                                                                                                                                                                                                                        other
                                                                          perforation




                                                                                                                                                                             Closed/Open
                                                       pulmonary




                                                                                                                                                                                                      Traumatic
                                                                                                                                                              Bruises,
                                                                                                                                            ballistic
                                                                                          Tympanic
                                                                            Bowel




                                                                                                          rupture
•   80 Americans treated:
    –   16 cases of flash burns
    –   TM perf
    –   Lacerations, penetrating wounds
    –   Abrasions, contusions


                                                                                                                                     Lee, CY. Development and Application of the BDI Scale. Emory University May 2003.




                                                                                                                                      Profile
                                                  •         Single vehicle IED
                                                  •         Close to buildings
                        Tactic 2                  •         More time to plan and coordinate
                                                  •         Structures
                Larger, Stereotypical             •         Symbolic targets
                     Bombings




                                                                                                                       Vehicle IEDs




                                                                                                                                                                                                                                                                                9
                                General Sessions
                     Terrorists Bombings: Lessons Learned
              Saturday, February 5, 2005         3:30pm ~ 4:30pm




                Old Bailey                          More Serious Injuries
• St. Bartholomew’s Hospital 3 min away        – 7 minor injuries, loss of consciousness;
  from bombing                                   emotional shock requiring sedation
• Of 154 patients:                             – 3 severe lacerations (non-vital organs)
  – 59 minor abrasions and lacerations         – 3 major vascular injuries, all due to
  – 24 eye injuries                              shrapnel
  – 52 requiring suturing from shrapnel,       – 3 fractures
    discharged home
• 19 admitted




                                                              Beirut
                                           •   Estimated 6 Ton TNT Equivalent HE
                                           •   Complete Structural Collapse
                                           •   37% Critical (7/19)
                                           •   68% Immediate




                                                                                            10
                                General Sessions
                     Terrorists Bombings: Lessons Learned
              Saturday, February 5, 2005         3:30pm ~ 4:30pm


         Injuries from Beirut                                                                                                                                Number of Injury Types Among Admitted Survivors of the Beirut Bombing

                                                                                                              100%

• Among 85 survivors of 112 (234 DOS)                                                                         90%

                                                                                                              80%                                                                                              73%
• 19 Critical injured survivors, ISS > 15                                                                     70%

                                                                                                              60%
                                                                                                                                                                                                                                                                    51%
  – 62 Soft Tissue injuries *most all bomb injuries                                                           50%


    are secondary injuries                                                                                    40%

                                                                                                              30%
                                                                                                                                                                                            33%
                                                                                                                                                                                                                                             29%
                                                                                                                                                                                                                                                22%
  – 43 Bone fractures                                                                                         20%                   16%
                                                                                                                                                        6%                                                                   6% 5%
                                                                                                                                                                                                                                                                                          11%
                                                                                                                                                                                                                                                                                                         6%
                                                                                                              10%
                                                                                                                     1%                                                                                   4%                                                                                                  1%
  – 37 Head injuries, 4 deaths                                                                                 0%




                                                                                                                                                             membrane (ear




                                                                                                                                                                                                               Penetrating




                                                                                                                                                                                                                                                                                                                               CVD related
                                                                                                                     barotraumas,




                                                                                                                                                                             Ocular globe




                                                                                                                                                                                             Concussion




                                                                                                                                                                                                                                                                                           Nerve palsy




                                                                                                                                                                                                                                                                                                              Crush injuries
                                                                                                                                                                                                                                                fracture to skull
                                                                                                                                                                                                                               contusions,




                                                                                                                                                                                                                                                                          amputation of




                                                                                                                                                                                                                                                                                                                                             other
                                                                                                                                          perforation




                                                                                                                                                                                                                                                  Closed/Open
                                                                                                                      pulmonary




                                                                                                                                                                                                                                                                           Traumatic
                                                                                                                                                                                                                                Bruises,
                                                                                                                                                                                                                 ballistic
                                                                                                                                                               Tympanic
                                                                                                                                            Bowel




                                                                                                                                                                               rupture
  – 15 Chest Trauma, 2 deaths
  – 5 Burns, 2 deaths
  – 5 Abd trauma
  – 5 Eye injuries
  – 9 Peripheral Nerve injuries




                                                                                                                                                                                                               Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the
                       FEMA 426- Reference Manual to Mitigate Potential Terrorist Attacks Against Buildings                                                                                                    Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387




                                                                                                                                                              OKC Fatal Injuries
                                                                                                              • 122 Multiple Trauma
                                                                                                                         – Multi-system, multi-dimensional injuries, constellation
                                                                                                                           of 1˚, 2 ˚, 3 ˚, 4 ˚ types
                                                                                                                         – Like “Patient 4” AMIA we just saw
                                                                                                              •      24 Head Trauma
                                                                                                              •      13 Chest Trauma
                                                                                                              •      3 Head & Neck Trauma
                                                                                                              •      3 Traumatic shock
                  Frykberg, ER. Medical Management of Disaster and Mass Casualties from Terrorist
                                                                                                              •      2 Fractures cervical spine
                  Bombings: How can we cope? J Trauma2002;53:201–212.


                  Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the
                  Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387




                                                                                                                                                                                                                                                                                                                                                     11
                                                                       General Sessions
                                                            Terrorists Bombings: Lessons Learned
                                                     Saturday, February 5, 2005         3:30pm ~ 4:30pm

                                                                                        AMIA

100%
                                                                                                                                                                                                           AMIA Most Severe Injuries
90%
80%
70%                                                                                                                                                                                                    • 4 patients out of 17 admitted with major injuries,
60%
50%
                                                                                                                                                                                                         died after ICU admission:
                                                                                                                        41%
40%
                                                                                                            29%                                                29%
                                                                                                                                                                                                       • Patient 1
30%
20%
      18%                                                                                             18%                                                                                                 – Crush syndrome; compartment syndrome both legs
    12%
10%      6%                                                        6%                                                            6%                                              6%                    • Patient 2
 0%
                                                                                                                                                                                                          – Cardiogenic shock, pre-existing medical condition




                                                                                                                                                 Nerve palsy
                      perforation




                                                                                                            fracture to skull


                                                                                                                                amputation of
                                    membrane (ear

                                                    Ocular globe



                                                                   Concussion


                                                                                Penetrating




                                                                                                                                                                                 CVD related


                                                                                                                                                                                               other
       barotraumas,




                                                                                              contusions,




                                                                                                                                                                Crush injuries
                                                                                                              Closed/Open
        pulmonary




                                                                                               Bruises,




                                                                                                                                 Traumatic
                                                                                 ballistic
                        Bowel


                                      Tympanic




                                                      rupture




                                                                                                                                                                                                       • Patient 3
                                                                                                                                                                                                          – Abdominal pain complaints, liver laceration, found outside
                                                                                                                                                                                                            the building, no external soft tissue lesion detected
 Structural bombing, About 1 Ton TNT equivalence                                                                                                                                                       • Patient 4
 29% Critical                                                                                                                                                                                             – Hepatic laceration, bowel microperforation, traumatic arm
 29% Immediate                                                                                                                                                                                              amputation, blast lung




                                                                                                                                                                                                                                                                                                    C.Y.Lee 1 Apr 2004




          Latin America – Caracas, Venezuela
       Spanish and Colombian Diplomatic Missions
                       2/25/2003




  0 fatalities         4 non-fatality wounded                                                                                                   0% mortality
  Blast Epicenter: outside embassy
  Bomb-characteristics: HE using C-4
                                                                                                                                                                                                                                   Arnold, J., Halpern, P., Tsai, M., Smithline.H. Mass Casualty Terrorist Bombings:
                                                                                                                                                                                                                                   A Comparison of Outcomes by Bombing Type. Annals Em Med. Feb 2004, 43 (2)




                                                                                                                                                                                                                                                                                                                         12
                       General Sessions
            Terrorists Bombings: Lessons Learned
     Saturday, February 5, 2005         3:30pm ~ 4:30pm


                         S      19%                                                                                          S               23%
                         C      4%                                                                                           C               16%
                         O      4%                                                                                           O               8%




                                      % Critical Mortality = # who died (in hospital) / # Critical x 100%




                                                                        Texas City
                                                         April 17, 1947 - cargo munitions ship explodes

                                      Explosives         Kiloton equivalent        Radius of Damage                          Key Injuries
                                      2.3 kT AN          1.6 kt TNT-Equivalent     1000 ft - Almost all 560                  Primary Cause of
                                                                                   dead and 800                              Damage and Injury
                                                                                   hospitalized; 2000ft;                     was the blast (blast
                                                                                   3000 ft damage still                      wave, blast wind),
         Tactic 4                                                                  seen up to 10,000 ft
                                                                                   (1.8 mi)
                                                                                                                             missiles, fire, tidal
                                                                                                                             wave (10 ft high)
                                                                                   out
                                      Casualties         Additional Information
                                      5,000 dead and     •    Within a 1,000-foot radius, all will be killed or injured.
Catastrophic, Rare Explosions         injured;
                                      3,500 non-fatal    •
                                                              33% DOS, 50% seriously injured, 17% less injured
                                                              Low death rate among hospitalized survivors (6.25% DIH of admitted) and
                                      injuries;               fewer serious burns that anticipated
        Not terrorism                 800 hospitalized
                                      (16% of total
                                                         •    Thick cloud of black smoke and vapor from soot and chemicals

                                      casualties);
  Industrial and commercial           560 killed, or
                                      missing and

     Massive destruction              presumed Dead

                                                                                    Blocker, V., Blocker, TG. The Texas City Disaster, a Survey of 3000 casualties
                                                                                    1949. American J Surgery




                                                                                                                                                                     13
                                                   General Sessions
                                        Terrorists Bombings: Lessons Learned
                                 Saturday, February 5, 2005         3:30pm ~ 4:30pm


                                           Halifax                                                                           “At approximately 9:05, Halifax was changed forever. The Mont Blanc
                                                                                                                             erupted into a tower of blazing light which consumed almost a cubic mile
                                                                                                                             of air. A hail of red-hot steel rained down on the cities of Halifax and
                                                                                                                             Dartmouth, remains of the Mont Blanc.
Nova Scotia 12/16/1917 – cargo vessel collided into munitions cargo ship
                                                                                                                             For an instant, the bottom of the harbor was visible. A colossal tidal wave
Explosives             Kiloton equivalent              Radius of Damage                 Key Injuries                         was created by the blast, and it hurled itself upon the shores of the harbor.
                                                                                                                             Smokestacks were obliterated, buildings were wrenched from their
200 tons TNT,          2.9 kt                          2 mi severe, up to 4             Amputations; Ocular                  foundations, and wooden houses were completely annihilated. Beyond
2300 tons picric                                       miles critical, up to 50         rupture, possibly more               the flames, the shear force of the explosion toppled stoves, setting homes
acid, 35 tons                                          miles extended; Blast            (undocumented)                       alight. The intense heat caused small whirlwinds or cyclones to form in
Benzyl on its deck,                                    heard up to 207 mi                                                    the air around the harbor, wrecking even more destruction.
61 tons gun cotton.                                    away
Casualties             Additional Information                                                                                The heart-shaking underground rumble was followed a few seconds later
                                                                                                                             by the terrifying crash of breaking glass and splintering wood all over
1900 dead, several •          Smoke stack consumed cubic mi height; colossal tidal wave created by                           the city, as windows were shattered and doors forced by the terrific air
hundred missing    •          blast; buildings were wrenched from foundations, wooden houses                                 blast. There was not a pane of glass left fully intact left in the city from
                   •          annihilated; intense heat caused small whirlwinds or cyclones;                                 at least 50 miles. The impact of the explosion was so severe the barrel of
                              underground                                                                                    one of the cannons landed three and a half miles away. Part of an anchor,
                       •      rumble was followed a few seconds later by the terrifying crash of                             weighing over half a ton, flew two miles in the opposite direction. The blast
                              breaking                                                                                       could be heard and felt from places as far away as Truro, PEI and Cape
                       •      glass and splintering wood all over the city; not a pane of glass left fully                   Breton, which is at least 207 miles north-east of Halifax.
                       •      intact left in the city from at least 50 miles.
                       •      Thick cloud of black smoke and vapor from soot and chemicals                                   For 10 minutes after the explosion a dark mushroom cloud started
                                                                                                                             raining a black oily soot, the unconsumed carbon of the explosives. It
                                                                                                                             blackened clothing, almost like liquid tar, ruining housewives linen. It
                                                                                                                             blackened face and bodies of all it fell on. It penetrated clothing to the skin
                                                                                                                             and coated the ruins of the houses, until the snow and the rainstorms washed
                                                        Explosion In Halifax Harbour.December 6, 1917 Materials From                                                           Explosion In Halifax Harbour.December 6, 1917 Materials From
                                                        Halifax Public Libraries, www.halifax.library.ns.ca                  it away.”                                         Halifax Public Libraries, www.halifax.library.ns.ca




                                     Henderson                                                                                                     Port of Chicago
                 May 4, 1988 – 2 explosions at rocket fuel plant
                                                                                                                       •   The S.S. E.A. Bryan, a new                              •    Explosive:      Cargo of 1,750 tons
Explosives                 Kiloton equivalent             Radius of Damage                  Key Injuries                   Liberty class cargo ship, and the                            (1.75 kt) of TNT-eq munitions
8.5 million lbs. of        250 ton TNT explosive          •     Immediate1.5 mi             Flying broken glass,           adjacent railcars exploded at                           •    Est. range: 1.58 kt – 2.14 kt TNT-eq.)
the finished               burst = 1 kt nuclear air       •     3 mi                        some lacerations               10:19 PM while being loaded with
ammonium                   burst                          •     7 mi                                                       munitions and bombs.                                    •    Key Injury data
perchlorate; several                                      •     10 mi                                                  •   At the time of the explosion, there                     •     710 dead and injured
thousand 55-gallon                                                                                                         were                                                    •    390 non-fatal injuries – most
plastic drums                                                                                                               – 1,780 tons of high-explosives                             superficial glass injuries
Casualties                 Additional Information                                                                              (HE)                                                •    3 survivors with minor injuries within a
                                                                                                                                                                                        building at 1,000 feet                -
2 lives, injured           smoke rose on the thermal column to an altitude of several thousand feet and                     – and 200 tons of low-
approximately 372          was spotted almost 100 miles away; Witnesses reported that this explosion                           explosives (LE) (smokeless                          •    54% of survivor injuries were around
                                                                                                                                                                                        the eyes
people including 15        created a visible shock wave coming toward them across the ground on the 2nd                        gunpowder) within the Bryan,
firefighters               explosion; several cases of respiratory irritation were reported in a small                         and                                                 •    320 killed, or missing and presumed
                           community approximately 30 miles downwind; 200 – 300 patients presented                                                                                      dead
                                                                                                                            – another 150 tons of HE and 20                        •    100% killed within 1,000 feet
                           themselves to hospitals as "walking wounded."; Emergency room facilities were                       tons of LE on adjacent pier.
                           taxed by the numbers but not the severity of the injuries several cases of                                                                              •    81 only bodies recovered, of these 30
                           respiratory irritation were reported in a small community approximately 30 miles                                                                             where identified
                           downwind;




                                                                                                                                              Complex Bombing
                                                                                                                           Integration of different types of explosives,
                                                                                                                           weights, and devices, combined to
                                          Tactic 3                                                                         explode in different patterns temporally
                                                                                                                           and spatially upon various populations
                                                                                                                           including civilians and military personnel,
             Complex Bombings, Current Day                                                                                 in different locations and environments.
                        Combo of Tactics
                  Varying time coordination and
                            complexity




                                                                                                                                                                                                                                              14
                                      General Sessions
                           Terrorists Bombings: Lessons Learned
                    Saturday, February 5, 2005         3:30pm ~ 4:30pm


Small and Frequent                “Traditional”: Solo
                                                                                                       Early Days
  Open                             Structural                             Explosive Type
                                                                          Quantity
                         +                                                Delivery Method
                                                                          Epicenter
                    Confined                                              People in Vicinity
                                                                          Time of Day
Suicide Bombing                                                           Etc…




       Complex Tactical Bombing
                                                             …Other Considerations




                      Africa – Kenya
                  U.S Embassy in Nairobi                                                             Suicide Bombing
                         8/7/1998




   213 fatalities     5000 non-fatality wounded    4.1% mortality**
   Blast Epicenter: ramp leading to underground parking garage
                                                                                                                              Emmanuel, Israel July 16, 2002
   Bomb-characteristics: Semtex or RDX, ANFO, Compressed Gas




                                      Used with Permission, Kobi Peleg                                        Used with Permission, Kobi Peleg
                                      Director, Center for Trauma and Emergency Medicine                      Director, Center for Trauma and Emergency Medicine
                                      Gertner Institute, Sheba Medical Center, Israel                         Gertner Institute, Sheba Medical Center, Israel
                                      Former Director Medical Training, Israeli Home Front Command            Former Director Medical Training, Israeli Home Front Command
                                      Israeli Defense Forces (IDF),                                           Israeli Defense Forces (IDF),




                                                                                                                                                                             15
                                        General Sessions
                             Terrorists Bombings: Lessons Learned
                      Saturday, February 5, 2005         3:30pm ~ 4:30pm

                Africa – Mombassa, Kenya
                      Paradise Hotel
                        11/28/2002




  16 fatalities        80 non-fatality wounded      16.7% mortality
  Blast Epicenter: drove into ground floor atrium
  Bomb-characteristics: Suicide/Car Bomb, HE




             Riyadh May 12 2003                                                            Morocco May 16 2003
• 4 Bombings in quick                                                               • 42 killed including 13 bombers, 100 injured
  succession
• Combination of SHB and                                                            • 24 DOS
  vehicle bombs
                                                                                    • 100 patrons estimated in the Café el
• 34 dead, 190 injured
• Most casualties from the Al
                                                                                      Spana at time of bombing (9 pm)
  Hamra compound                                                                    • Blast at club responsible for most
• “Commando Op”                                                                       casualties
                                                                                    • Explosion in rear outside dining area




                                                               C.Y.Lee 1 Apr 2004                                           C.Y.Lee 1 Apr 2004




                                                                                                                                                 16
                                General Sessions
                     Terrorists Bombings: Lessons Learned
              Saturday, February 5, 2005         3:30pm ~ 4:30pm


                                                                            Moscow Jul 5 2003
                                                               •   Type of Bombing: Open space
                                                               •   Type of IED: 3 SHB (0.5 – 1 kg HE)
                                                               •   Attack Tactic: Multiple
                                                               •   Targeted Population: Teenagers, Young People
                                                               •   Targeted Event: “Krylya” Rock Festival
                                                               •   (Disaster) Impact:
                                                                   – 20 dead
                                                                   – Emphasizes Chechens activity
                                                                   – Trend to target young people, crowds




                                                                             MOSCOW Metro Train DEC 5 2003
                                                                        745AM, Up to 41 DOS, 2 possible SHB with UXO,
                                                                        problems in rescue, 1st suicide train bombing (before
                                          C.Y.Lee 1 Apr 2004
                                                                        Madrid)




       Casualties and Injuries                                               Rescue Challenges
• DOS 70% (31/44) of total fatalities                          •   Friday morning rush hour
• critical mortality 9% (13 of 148)                            •   trapped many severely injured inside
• not unlike the 6% critical mortality reported                •   under overturned train carriage
  from bombings in Israel                                      •   encumbered by a
                                                                   – snarl of electrical wires
• occupied primarily by college students
                                                                   – Cables
• 16 to 68 years old                                               – and overhead fires
• force ejected several occupants
• Up to 148 victims were admitted
• 50 were treated for minor physical injuries                                             “The Suicide Bombing of the Mineralnye Vody Train: A Case Study in Using Open Source Information
                                                                                          (OSINF) for Open Source Health Intelligence (OSHINT)”. Lee, Davis, Noji

  and released




                                                                                                                                                                                             17
                                    General Sessions
                         Terrorists Bombings: Lessons Learned
                  Saturday, February 5, 2005         3:30pm ~ 4:30pm



     “Terrorists also exploit some European
      countries’ liberal asylum laws; open land
      borders; and weaknesses in their
      investigative, prosecutorial, and
      procedural processes while using these
      countries as operational staging areas for
      international terrorist attacks. “



                GAO COMBATING TERRORISM
                Interagency Framework and Agency Programs to Address the Overseas Threat




            Madrid March 2004                                                                                     Sequence of Events
                                                                                                      7:39 a.m. – 3 backpacks loaded with explosives blow up on
•   10 Explosions                                                                                        a commuter train in Madrid's Atocha station.
•    -
    15 m  inute Span,
                                                                                                      7:44 a.m.– 4 backpack bombs explode on a commuter
•   Started at 7:39 AM                                                                                  train entering Atocha station.
•   28 – 33 lb high explosive
•   Backpack, 13 Bombs                                                                                7:49 a.m. – 1 Backpack bomb explodes as a commuter
                                                                                                         train enters Santa Eugenia train station, nine miles from
•   192 Dead                                                                                             Atocha.
•   Approx. 1400 Wounded
                                                                                                      7:54 a.m. – 2 bombs explode on double-decker commuter
                                                                                                         train in El Pozo station, six miles from Atocha.

                                                                                                      10 a.m. – Police carry out controlled explosions of 3 booby-
                                                                                                        trap backpack bombs – two in Atocha, one in El Pozo.
                                                                                                                      Source: Associated Press, “Timeline for Madrid commuter train bombings”, Mar 11, 2004, San Diego-Union Tribune,
                                                                                                                      signon SanDiego.com




        Madrid Casualty Figures                                                                               Madrid Severe Injuries
•   Number of victims: 1430                                                                           1º: Blast injuries (explosion): 56%.
•   Primary care: 204 (14%)                                                                           2º: Penetrating injuries (shrapnel): 50%.
•   Prehospital care: 250 (17%)                                                                       3º: Blunt trauma (ejection): 53%.
•   Admitted to any Hospital: 976 (68%)                                                               4º: Burn injuries (flash burns): 31%?
•   Total number of deaths: 192 (13%)


                                                                                                                                               DO NOT QUOTE, DO NOT REPRODUCE: Property of Dr. Gonzalo
                                  DO NOT QUOTE, DO NOT REPRODUCE: Property of Dr. Gonzalo                                                       Hernández Martínez, May 2004, Presentation at Arona, Novara
                                 Hernández Martínez, May 2004, Presentation at Arona, Novara Italy,                                                               Italy, May 2004, EMDM
                                                         May 2004, EMDM                                                                                          Presented with permission
                                                     Presented with permission




                                                                                                                                                                                                                                        18
                                General Sessions
                     Terrorists Bombings: Lessons Learned
              Saturday, February 5, 2005         3:30pm ~ 4:30pm


                                                                         Aug 24 2004
                                                                  2 Planes Downed 90 Killed
                                                                                     • Female suicide
                                                                                       bombers
                                                                                     • Both planes service
                                                                                          - y ide
                                                                                              -
                                                                                       side b s
                                                                                     • Hexogen, would have
                                                                                       only taken a few
                                                                                       pounds, fuselage



           “250 Perish as 13 Blasts Rock India”




                                   • 156 children killed
                                   • 26 hostage takers
                                   • 700 wounded
                                   •
                                   •
                                     448 hospitalized
                                     Including 248 children
                                                                        Incendiaries
                                   • 69 serious
                                   • Weapons hidden in floor
                                     while under construction
                                     day before
                                   • Most killed from explosion
                                   • Mines and booby traps,
                                     bolts




               Incendiaries                                              Hipercor
• Burns
• Respiratory problems to T3
• Common materials in public
• Less technological skill to craft
• Post-disaster, possibly more time
  consuming to mortuary system
• Doesn’t have to be terrorist
• Daily drills with arsons and fires
                                                                             Gomez Morell, PA., Naif, F.E, et al. Burns caused by terrorist bombing of the
                                                                             Department store Hipercor in Barcelona, Part I. Burns (1990), 16 (6): 423-425




                                                                                                                                                             19
                                   General Sessions
                        Terrorists Bombings: Lessons Learned
                 Saturday, February 5, 2005         3:30pm ~ 4:30pm


            Hipercor Injuries                                                 Compared to HE
• Amonal – “Napalm Like” compound
                                                                  Victoria Station Incidents of Injuries
• 66 injured, 21 DOS due to burns and                             Soft Tissue Injuries                     32
  asphyxia                                                        Open fx                                  13
• 45 Injured, 24 admitted to burn center                          Neurovascular                            7
  – 9 Burns >65% BSA                                              Traumatic Amputation                     2
  – 9 Burns 20 – 65%                                              Perforated Organs                        4
  – 2 Burns < 20%                                                 Bone fx                                  5
• 17 into surgery                                                 Burns                                    0

• 3 DIH due to extensive burns, smoke
  inhalation, ARDS




           Deagu, SOUTH KOREA Feb 18 2003
      10AM, 120 DOS, incineration, major hurdles to rescue,
      including entrapment inside once fire started




      Casualties and Injuries                                        Emergency Complications
• 182 dead, 340 missing and presumed                          • Fire crippled communication system
  dead                                                        • Subway officials couldn’t warn 2nd train
• 2 subway trains                                             • Station control center cut off electricity
• Fire engulfed one 6-car train, spread to the                • black out, no sprinkler system
  next train which had pulled into station few                • Most victims in this 2nd train
  minutes later                                               • Conductor fled without opening doors,
• Most bodies unidentifiable, charred                           victims trapped
• Burned, trampled, suffocated to death                       • “Toxic Gas”




                                                                                                                20
                                     General Sessions
                          Terrorists Bombings: Lessons Learned
                   Saturday, February 5, 2005         3:30pm ~ 4:30pm




                                                                      MOSCOW Metro Subway Feb 6 2004
                                                                 8:40AM, 39 DOS, 2 possible SHB carrying briefcases,
                                                                 rescuers could not open doors for 30 min, get to injured




                                                                 How is it useful to you?




  August 8 2004 Russia Subway




                      Usefulness
• Immediate
  – T3, T2, T1 distribution over time and severity
  – Specialists
• Intermediate
  – O.R, O.R time
  – ICU admissions
  – Length of Stay
• Long-Term
  – Rehabilitation time
  – Injuries
                                                     Closed space = structural                  Used with Permission, Kobi Peleg
  – Possible “at risk” population                                                               Director, Center for Trauma and Emergency Medicine
                                                                                                Gertner Institute, Sheba Medical Center, Israel
                                                                                                Former Director Medical Training, Israeli Home Front Command
                                                                                                Israeli Defense Forces (IDF),




                                                                                                                                                               21
                               General Sessions
                    Terrorists Bombings: Lessons Learned
             Saturday, February 5, 2005         3:30pm ~ 4:30pm


            Future Needs
• More multidisciplinary cross over
• Trauma community active with public
  health
• Modeling?
• Runs into same issue as bioterrorism
• Epidemiology (the HUMINT of public
  health) versus modeling




                                                  References and
                                                 Recommendations




       Thanks for your Time
               Catherine Y. Lee, MPH
                     Atlanta, GA
                   Washington DC
            Email: clee9@sph.emory.edu
             catherineylee@hotmail.com




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