EMS and Suicide Bombings - Some Potentially Deadly Considerations

During the past few decades there have been numerous terrorist attacks in countries throughout the world. Shrines, churches, tourist and resort areas and other targets that were once considered off-limits no longer enjoy that status. And major public venues such as transportation hubs, sports arenas, and banks as well as other financial buildings have been threatened with or actually experienced violence.  Finally, police uniforms and other emergency-responder clothing, various types of equipment, and even ambulances and other vehicles not usually arousing suspicion have been used in devious ways to wreak devastation and cause public alarm. 

From the viewpoint of a terrorist group, or a mentally deranged individual, a suicide bombing can be one of the most efficient and effective ways to successfully penetrate a target, cause numerous deaths and injuries, and generate publicity. It is now a relatively quiet week when the nation’s 24/7 news channels do not broadcast scenes of chaos and destruction caused by terrorist bombings on buses and in theaters and restaurants – mostly overseas (so far).

Nonetheless, for U.S. responders the important unanswered question is this:  How much havoc, economic and political, would a similar attack cause in the United States, particularly if the attack occurred in a movie theater or shopping mall? 

There is no clear or easy answer to that question. In the last few years much greater emphasis has been placed on training pre-hospital providers to respond to incidents involving the use of weapons of mass destruction (WMDs). The same cannot be said, however, of other smaller-scale, yet just as devastating, acts of violence. In addition, and despite the escalation of terrorist acts – and the emigration of such attacks to cities and countries outside of the Middle East – some U.S. EMS (emergency medical services) agencies and other first-responder organizations still seem to believe that similar suicide attacks would be, if not impossible, very unlikely in the United States itself.

Nonetheless, prudence and common sense dictate that all EMS providers, emergency managers, and other first responders need at least a basic level of awareness about such distinctly devastating incidents. 

Hard Facts and Visible Shortcomings

Any analysis of potential suicide-attack scenarios must necessarily start with the most likely targets. Suicide bombers customarily select targets the destruction of which would have a significant impact on the community – either psychologically, because of the type of target attacked, or in the actual number of victims killed or injured.  These targets can be classified as either “hard” or “soft.”  One example of a hard target is an area – such as a military base, an airport, or a power station – in which access (to at least some areas) is fully or partially restricted and some level of constant security is not only in place but also fairly visible.  The term soft target refers to an area or building where access is relatively easy and the target is not as well guarded or secure as a hard target. 

Soft targets also are usually designed for and/or encourage public gatherings and large crowds: shopping malls, outdoor cafes and restaurants, and both schools and churches, to cite the most obvious examples. Special events such as movie premieres, football playoffs, graduation ceremonies, and political inaugurations also are particularly attractive to the would-be terrorist. 

EMS providers must not mistakenly think that they are immune from harm because they are on the scene – after a mass-casualty incident has occurred – to help. Terrorists have learned how to use “secondary devices” to kill or injure those in the first wave of responders – firefighters, policemen, EMS technicians, and hazmat specialists included.  The demoralizing impact on the public of seeing emergency-services responders rendered useless and helpless is, in fact, often a primary goal of terrorists and not merely an extra added attraction.

The use of lethal secondary devices is not unknown in the United States. The abortion clinic bombings in Atlanta, as well as the World Trade Center attacks in September 2001, saw this tactic employed.  It cannot be stressed strongly enough that responders must be not only totally aware of their surroundings at all times but also particularly suspicious of objects (an errant briefcase, for example) and/or people who seem to be “out of place.”  The urge to rush in to assist those injured must therefore be tempered with judicious restraint based on the scenario encountered. Events such as these should be cleared by public-safety agencies before EMS technicians and other responders are allowed to enter.  If such clearance cannot be provided (for any of several acceptable reasons) then, just as in hazmat incidents, patients should be brought to an area known to be “clean.” 

Triage: When, Where, and How

The utilization of a standardized but simple triage system such as START (Simple Triage and Rapid Transport) should be mandated to sort and transport patients on a priority basis.  The START process can be taught quickly to non-medical responders at the scene and would facilitate the concentration of EMS personnel in positions that require more training. 

This is important because other traditional first responders – policemen and firefighters, for example – will probably not be available to assist in triage because they will have other operational responsibilities. These and other circumstances might therefore sometimes necessitate the use of bystanders to assist in the triage process.  

It is important to remember that triage should always be conducted outside the hazard area.  When necessary, patients should be evacuated to a triage point by law-enforcement or tactical personnel, and then managed by EMS staff.  Only lifesaving procedures – e.g., airway management and hemorrhage control – should be performed on scene; all other supportive measures – starting the IV process, splinting, etc. – are carried out when and/or while the victims are en route to a hospital.  

When Operational Realities Intrude

To ensure a reasonable measure of success in responding to a suicide bombing, the EMS branch manager and the director of the communications center must both take into consideration several critical factors.  The EMS branch manager should always have in his or her possession a Field Operations Guide (preferably in checklist form), a well-marked identification vest, interoperations-capable communications equipment, and, possibly, a megaphone. (Although the megaphone has traditionally been used in the United States only by police agencies, it has also proved to be effective when used by Israeli EMS in dealing with a concentrated incident in which there are a large number of patients and responders.)  As the event progresses, the EMS branch manager must also remember to provide periodic status updates to the communications center.

The communications center director should have his/her own checklist, of course, to quickly identify the resources available, where those resources will be coming from, and the contact information and notification prioritization required for administrators, agencies, hospitals, and numerous other organizations and individuals.  The checklists should be in place well prior to the start of an incident – at all times, in other words. 

An initial over-dispatch of resources – i.e., providing more resources than are expected to be needed – has been proven to be effective.  It is always better, and easier, to cancel responding units than to have to order more. Implementing dedicated MC communication channels – either by having responders switch to a specific radio frequency or by connecting specified groups through a trunk system – not only will allow regular EMS system traffic to continue without interfering with incident operations but also will facilitate the coordination of patient distribution and notifications to hospitals and other healthcare facilities. Of course, there should always be a supervisor/manager on duty in the communications center. 

Unique Challenges, a Diversity of Circumstances

In light of some of the unique challenges involved in responding to a suicide bombing, there are — in addition to clinical considerations – several strategies that progressive EMS systems should be aware of when developing the policies needed for a full and flexible response to a bombing incident, if and when it happens.  Following are a few considerations, relevant to the subject areas indicated, that should be kept in mind when developing those strategies:

Flexibility – For various reasons, suicide bombings may not always lend themselves to standard triage techniques.  Adaptation to the situation might sometimes require, therefore, moving everyone who is capable of relocating to an alternate site and then assessing the degrees of injury suffered. The flexibility factor also encompasses recognizing the need to tailor standard response methods to the events unique to a bombing incident and not trying to make the incident fit a predetermined mold. 

Controlled Response – It is well established that some suicide bombing scenes cannot be deemed safe simply because of the presence of law-enforcement officials.  Responders have been targeted in the past with secondary devices, both in the United States and overseas, and it is critically important that pre-hospital providers think about that potentially huge problem well in advance.  EMS providers should not rush into a scene just because there are people injured, or perhaps even dying. Those in charge at an incident scene must therefore quickly designate perimeter staging areas for EMS personnel and their equipment at various distances from the epicenter of the disaster scene.

Understanding and Utilizing the Incident Command System – In addition to those in medical-operation positions, EMS staff must not only thoroughly understand the Incident Command System but also should be involved in a Unified Command Structure – along with the law-enforcement and firefighting personnel at the scene. For that reason, the designation of an EMS Safety Officer is of paramount importance; as a corollary, he or she must have the authority needed to immediately cease EMS operations, if need be, and order personnel and other resources to retreat to the previously mentioned perimeter staging areas. 

Tactical EMTs/Medics – If the responding EMS agency or organization has a special-operations division or group, the members of that group also should be involved in the pre-planning process.  Tactical training prepares providers for the need to rapidly extricate patients – even prior to stabilization, if and when necessary. 

The Use of Regional, State, or Federal Resources – On-scene decision makers must consider the need for additional assets as early in the process as possible, if only because it may well take more time than anticipated to get those assets to the incident scene.  More specifically, the decision makers should: (a) identify the request pathways needed and build them into response plans; and (b) Try to determine in advance what additional resources might be available and how they can be used – both immediately and to meet longer-term needs. (The additional personnel assets needed might well include Urban Search and Rescue teams, Disaster Medical Assistance teams, and/or Disaster Mortuary teams.)

To briefly recap: The basic realities have changed.  The U.S. emergency-response community was jolted into a sudden awareness of its numerous vulnerabilities by the terrorist attacks of 11 September 2001. But that much-needed “wake-up call” should have occurred well before the 9/11 attacks. Numerous acts of terrorism and tactical ultra-violence had been carried out on U.S. soil in the years prior to 9/11; there were even more attacks on U.S. allies overseas, though. EMS agencies must change, in lockstep with the nation’s public-safety agencies, and embrace a new attitude of constant and continuing preparedness. Developing the protocols needed to respond to a suicide bombing is but one facet, albeit a vitally important one, of this new mindset. 

Raphael Barishansky

Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, he is a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations. His most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.



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