Public Health Analysis of Bombing Events in the US

Bobby Kapur, M.D., M.P.H.
Associate Professor of Medicine & Pediatrics
Associate Chief for Academic Affairs
Section of Emergency Medicine
Bombing Events in the US:
Public Health Analysis and
Acute Management

Bombing Events & Blast Injuries 1

Objectives
• Definitions
• Recent global historical perspectives
• US bombings epidemiology
• Pre-Hospital Care response
• Acute hospital management

Definitions: Terrorism

Bombing Events & Blast Injuries
“A policy intended to strike with terror those against
whom it is adopted; the employment of methods of
intimidation; the fact of terrorising or condition of
being terrorised."
The Oxford English Dictionary
5

U.S Federal Criminal Code
“(A) involve acts dangerous to human life that are a
violation of the criminal laws of the United States or
of any State (B) appear to be intended: to intimidate
or coerce a civilian population, or to influence the
policy of a government by intimidation or coercion,
or to affect the conduct of a government by mass
destruction, assassination, or kidnapping…”
United States Code Title 18, Part I, Chapter 113B, Section 2331
6

Medical Definition
“The intentional use of violence - real or threatened-
against one or more non-combatants and/or those
services essential for or protective of their health,
resulting in adverse health effects in those
immediately affected and their community, ranging
from a loss of well-being or security to injury, illness,
or death.”
“A Proposed Universal Medical and Public Health Definition of Terrorism.” Prehosp Disast Med. 2003;18(2):47-
52.
7

Medical Codes
National Center for Health Statistics at the CDC has developed
within the WHO’s International Classification of Diseases,
Tenth Revision (ICD-10) terrorism-related codes:
• *U01-*U02 for mortality due to assault (homicide) for
terrorism,
• *U03 for mortality due to intentional self harm (suicide) for
terrorism
• E979 for morbidity due to terrorism
• E999.1 for late effect of injury due to terrorism
8

Madrid, Spain: March 11, 2004

1. Mitsubishi Triumph mobile phone
2. Copper detonator
3. Explosives (8-12kg)
4. Metal fragments
Madrid Train Bombings: March 11, 2004
7:37 am - 7:40 am
• 10 bombs explode in 4 commuter trains in downtown Madrid
• 3 undetonated bombs found later
• Explosive material: Dynamite (used in construction)

• EMS: 291 ambulances mobilized
• 112 Call center: >20,000 calls
• Injuries: >1,800
• Deaths: 191
12

Gutierrez de Caballos JP,
Fuentes FT, Diaz DP, Sanchez
MS, Llorente CM, Sanz JEG.
Casualties treated at the
closest hospital in the Madrid,
March 11, terrorist bombings.
Crit Care Med
2005;33(1):S107-S112.
13

Key Pre-Hospital Care Logistical Issues
• Mobile phones and radios: do not work underground
• Minor injuries or uninjured evacuated 1st : delayed
evacuation of seriously injured
• Scene safety: possibility of structural collapse or
secondary devices
• Going “back to normal”: difficult for pre-hospital and
emergency services
14

Key Hospital Logistical Interventions
• Cancel all elective surgeries
• Transfer stable patients out of ED and ICU
• Triage of patients by senior physicians
• Use of FAST to quickly diagnose abdominal trauma
Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the
closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med. 2005;33(1):S107-S112.
15

Global Experiences

Blast Injuries. The Lancet, Volume 374, Issue 9687, 2009, 405 – 415.

Europe: UK IRA Bombings 1970-1980s

Middle East: Israel

Middle East: Beirut

Africa: Kenya & Tanzania Embassies 1998

International Terrorism & Bombing Events
• Change in the targets and materials used in
bombing events
• Increased sophistication and planning of events
• Greater coordination among terrorists
22

US Experiences

The U.S. Experience
World Trade Center 1993 Oklahoma City 1995 Atlanta Olympics 1996
25

The U.S. Experience
World Trade Center 9/11 Pentagon 9/11
26

The U.S. Experience?
• Few large-scale events or Endemic problem?
• Domestic or International issue?
• Impact of bombing events on medical and public
health institutions?
• How the U.S. data on bombings can improve planning
and response for future events?
No longitudinal data on bombing events in the US
27

Bombing Events: Impact Issues
• Incidents
• Injuries & Deaths
• Etiology (Motives)
• Location (Targets)
• Materials

ATF Designations for Bombing Events
Explosive: Chemical compound or mixture with a primary
purpose to function by explosion
Incendiary: Device made of an inflammable or ignitable liquid
Premature: Bombing event, either explosive or incendiary, that
occurs when the device functions prior to placement on a target
Attempted: Incident where the device, either explosive or
incendiary, is placed against a target and fails to function or is
made safe before detonation
30

Type of Bombing Incident Incidents (%) Injuries (%) Deaths (%)
Actual Bombings 28,529 (79.0) 5,931 (100.0) 699 (100.0)
Explosive 21,237 (58.8) 4,056 (68.4) 386 (55.2)
Incendiary 6,185 (17.1) 579 (9.8) 139 (19.9)
Premature 1,107 (3.1) 1,296 (21.8) 174 (24.9)
Attempted Bombings 7,581 (21.0) 0 (0.0) 0 (0.0)
Explosive 5,616 (15.6) 0 (0.0) 0 (0.0)
Incendiary 1,965 (5.4) 0 (0.0) 0 (0.0)
Total 36,110 (100.0) 5,931 (100.0) 699 (100.0)
U.S. Bombing Incidents from 1983-2002
32

Number of Explosive and Incendiary
Bombing Events from 1983-2002
0
500
1000
1500
2000
2500
1983 1985 1987 1989 1991 1993 1995 1997 1999 2001
Numberofincidents
Year
33

Number of Attempted and Premature
Bombing Events from 1983-2002
0
100
200
300
400
500
600
700
800
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Numberofincidents
YearNumber Attempted
Number Premature
34

Etiology of Bombing Event ATF Definition
Attempted homicide or Homicide Intent to kill another individual or group of individuals
Suicide Intent to kill oneself
Vandalism Intent to cause property damage
Revenge Intent to respond to a prior action of another individual or group
Protest Intent to gain publicity or support for a protest group
Labor-related Intent to impact a labor dispute
Extortion Intent to receive goods or services from another individual or
group
Excitement Intent to observe the effects of a bombing event
Domestic violence Intent to cause injury or death to a partner
Insurance fraud Intent to make insurance claims from the bombing event
Intimidation Intent to frighten another individual or group without injury or
death
35

Etiology of Bombing Injuries Explosive (%) Incendiary (%) Premature (%)
Determined 2,483 (61.2) 359 (62.0) 296 (22.8)
Attempted homicide 1,810 (44.6) 42 (7.3) 9 (0.7)
Suicide 44 (1.1) 3 (0.5) 0 (0.0)
Vandalism 398 (9.8) 35 (6.0) 206 (15.9)
Revenge 209 (5.2) 132 (22.8) 33 (2.5)
Protest 30 (0.7) 22 (3.8) 4 (0.3)
Labor-related 24 (0.5) 8 (1.4) 1 (0.1)
Extortion 29 (0.7) 113 (19.5) 4 (0.3)
Excitement 20 (0.5) 4 (0.7) 32 (2.5)
Domestic violence 19 (0.5) 0 (0.0) 7 (0.5)
Insurance fraud 0 (0.0) 0 (0.0) 0 (0.0)
Intimidation 0 (0.0) 0 (0.0) 0 (0.0)
Undetermined 1,573 (38.8) 220 (38.0) 1,000 (77.2)
Total 4,056 (100.0) 579 (100.0) 1,296 (100.0)
36

Etiology of Bombing Deaths Explosive (%) Incendiary (%) Premature (%)
Determined 363 (94.0) 129 (92.8) 75 (43.1)
Homicide 268 (69.4) 69 (49.6) 10 (5.7)
Suicide 53 (13.7) 3 (2.2) 1 (0.6)
Vandalism 10 (2.6) 3 (2.2) 54 (31.0)
Revenge 14 (3.6) 40 (28.8) 5 (2.9)
Protest 0 (0.0) 0 (0.0) 0 (0.0)
Labor-related 0 (0.0) 0 (0.0) 0 (0.0)
Extortion 1 (0.3) 1 (0.7) 1 (0.6)
Excitement 1 (0.3) 0 (0.0) 3 (1.7)
Domestic violence 13 (3.4) 3 (2.2) 0 (0.0)
Insurance fraud 3 (0.8) 3 (2.2) 1 (0.6)
Intimidation 0 (0.0) 7 (5.0) 0 (0.0)
Undetermined 23 (6.0) 10 (7.2) 99 (56.9)
Total 386 (100.0) 139 (100.0) 174 (100.0)
37

Target Institution Type Institution Subtype
Residential Single family Structure, Condominium,
Apartment
Commercial Bank/ATM, Bar/Restaurant, Hotel/Motel,
Independent food store, Manufacturing plant,
Shopping center/Mall, Warehouse
Governmental Local, State, Federal, Foreign, Military
Educational School, College/University
Transportation Airport, Bus/Train terminal, Port, Railway,
Subway
Mailbox Residential, Commercial
Vehicle Residential, Commercial
38

Target Institution Type Incidents (%) Injuries (%) Deaths (%)
Determined 32,849 (91.0) 5,081 (85.7) 680 (97.3)
Residential 10,465 (29.0) 1,866 (31.5) 388 (55.5)
Commercial 5,151 (14.3) 1,740 (29.3) 74 (10.6)
Governmental 1,596 (4.4) 756 (12.7) 178 (25.5)
Educational 1,847 (5.1) 464 (7.8) 3 (0.4)
Transportation 723 (2.0) 79 (1.3) 7 (1.0)
Mailbox 7,404 (20.5) 75 (1.3) 2 (0.3)
Vehicle 5,663 (15.7) 101 (1.7) 28 (4.0)
Undetermined 3,261 (9.0) 850 (14.3) 19 (2.7)
Total 36,110 (100.0) 5,931 (100.0) 699 (100.0)
39

Bombing Materials
• Ammonium nitrate
• Black powder (gunpowder)
• Smokeless powder
• C-4 (RDX “research development explosive”)
• Dynamite
• TNT
• Match heads
• Pyrotechnic mixes
40

Type of Material Injuries (%) Deaths (%)
Determined 4,050 (68.3) 595 (85.1)
Nitrate-based fertilizers 1,586 (26.7) 181 (25.9)
Smokeless powder 818 (13.8) 114 (16.3)
Inflammable liquids 579 (9.8) 139 (19.9)
Black powder 526 (8.9) 47 (6.7)
Pyrotechnics 232 (3.9) 18 (2.6)
Dynamite 161 (2.7) 90 (12.9)
Match heads 139 (2.3) 2 (0.3)
C-4 5 (0.1) 1 (0.1)
TNT 4 (0.1) 3 (0.4)
Undetermined 1,881 (31.7) 104 (14.9)
Total 5,931 (100.0) 699 (100.0)
41

Terrorism and Bombing Events:
Global or Local Problem for US Population?
• 1996 to 2002: 925 international terrorist events
involving U.S citizens
• Bombing events: 776 (84%)
• 1992 to 2002: more bombing injuries & deaths in the
U.S. than terrorist injuries & deaths of U.S. citizens
internationally
42

Analysis
• Access
• Internet
• Panic & Instability
• Public health focus: Bombing events vs.
“N/B/C” events?

Pre-Hospital Care & Bombing Events

Pre-Hospital Care Systems and
Bombing Events
• Classic models usually do not occur: 75% of patients will not
interact with the EMS system
• Classic system of triage, triage classifications, triage tags,
flow points, and treatment areas only applies to a one-sided or
one-dimensional scene
• Ambulances transport patients to nearest facility:
–Rapid turn around time
–Instructed to take critical patients to nearest facility
–Roads may be impassable except to a few hospitals
–May not know route to outlying hospitals
–Nearest hospitals may delay closure during disasters
45

U.S Bombings: Pre-Hospital Care Data
Event Hospital Data
Injuries (*Total)
Deaths EMS
Oklahoma City
1995
434 (592) 167 90 (20.7%)
Atlanta
Olympics 1996
111 1 111 (100.0%)
WTC 9/11 1,103 (7,250) 2,749 282 (25.5%)
Pentagon 9/11 106 189 93 (87.7%)
46

• Initiate fundamental resuscitation protocols:
 Airway
 Breathing
 Circulation
• Address blast injuries
• Attempt to gather basic epidemiologic data from scene
Pre-Hospital Management of Bombing Victims
47

Primary
Blast lung injury (pulmonary barotrauma)
TM rupture and middle ear damage
Abdominal hemorrhage and perforation
Globe rupture
Concussion (TBI without physical signs of head injury)
Secondary
Penetrating ballistic (fragmentation) or blunt injuries
Eye penetration (can be occult)
Tertiary
Fracture and traumatic amputation
Closed and open brain injury
Quaternary
Burns (flash, partial, and full thickness), Crush injuries
Asthma or COPD (from dust, smoke, or toxic fumes)
Angina, Hyperglycemia, Hypertension
Blast Injuries
http://www.bt.cdc.gov/masscasualties/explosions.asp
48

No Pre-Hospital Care Protocol for Bombing Injuries

51
Pre-hospital Care Blast Injuries Algorithm
Initial evaluation:
Airway, Breathing, Circulation
Primary Blast Injuries
Secondary Blast Injuries
Assess Lungs, TM’s, Abdomen
O2, IV access, Monitor
Tertiary Blast Injuries
Quaternary Blast Injuries
Assess Soft tissue injuries, Eyes
Apply dressings
Assess Fractures, Head injuries
Splint fractures
Assess Burns, Crush injuries,
Exacerbations of Chronic diseases

52
Initial evaluation:
Airway
Breathing
Circulation
Primary Blast
Injuries
Lungs TM’s Abdomen
Non-rebreather
mask
Monitor
*Thoracentesis
Avoid probing ear
Continuous
assessment
Eye
Cover ruptured
globe
Brain
Monitor
neurological
status

53
Initial evaluation:
Soft Tissue Injuries Eye
Apply sterile dressings
Do not remove fragments
Cover globe
Do not remove fragments

54
Initial evaluation:
Fractures Amputations Head Injuries
Apply splints
Cover open wounds
Hemostasis
Cover and transport amputated
part
Apply dressing to open injuries
Monitor neuro status

55
Initial evaluation:
Quaternary Blast Injuries
Burns Crush Injuries Chronic Disease Exacerbations
Cover with sterile dressing
IVF
IVF
NRM, Albuterol
NTG for chest pain

Acute Hospital Management
of Bombing Injuries

57Bombing Events & Blast Injuries
Gutierrez de Caballos JP,
Fuentes FT, Diaz DP, Sanchez
MS, Llorente CM, Sanz JEG.
Casualties treated at the
closest hospital in the Madrid,
March 11, terrorist bombings.
Crit Care Med
2005;33(1):S107-S112.
57

Management of Bombing Injuries
Primary Survey
Secondary Survey
Blast Lung
Injury
Soft Tissue &
Bone Injuries
Eye & Ear
Injuries
Abdominal
Injuries
Head
Injuries
Burns
CXR X-rays
CK, Electrolytes
T&S
Visual Acuity
Corneal Exam
CT Face?
FAST US
CT A/P
T&S
CT Head Electrolytes
High flow O2
Chest Tube?
Abx & Tetanus
Wound Care
Ophtho? Nuerosurg? IVF
Serial Exams & Observation
OR as needed

Blast Injuries. N Engl J Med.2005;352:1335-42.

60Bombing Events & Blast Injuries
Tympanic Membrane Evaluation:
Indicator of Internal Blast Injuries
Otoscopic Exam of
Tympanic
Membrane
Rupture
Observe O2
saturation
for 6-8 hrs
Intact
Discharge
Decreased O2
Admit for further
care
Normal O2
Discharge with
warnings
Otoscopic Exam of
Tympanic
Membrane
Rupture
Admit and
anticipate
further injuries
Intact
Treat injuries
No obvious injuries present Injuries present
DePalma RG, Champion HR, Hodgson MJ. Current Concepts:
Blast injuries. N Engl J Med. 2005;352(13): 1335-1342.
Blast Injuries. N Engl J Med.2005;352:1335-42.

Summary
• Urban areas around the world face the risk of bombing
events
• US citizens are at more risk of domestic bombing
events than international events
• Local jurisdictions (hospitals, EMS, fire, police)
should be prepared for both explosive and incendiary
blast events
• Pre-hospital and Emergency Department management
of blast injuries should be implemented in an
algorithm manner
61
Kapur@bcm.edu

Public Health Analysis of Bombing Events in the US

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