Until recently, we did not think of terrorism or terrorist acts as “our problem.” The World Trade Center bombing in New York City, the destruction of the Federal Building in Oklahoma City and the explosion at Centennial Park in Atlanta during the Olympics brought it home. The reality is that terrorism is a threat anywhere and at any time.
When terrorism strikes, it is highly likely that local EMS providers will be first on the scene. The challenge will be to deal with many victims — each one with injuries characteristic of the effects of either a bomb blast itself or the consequences of structural collapse caused by an explosion.
In a recent satellite video conference, “The Medical Effects of Terrorism” sponsored by the U.S. Department of Veterans Affairs, Dr. Michael Olinger, chief of Emergency Medical Services at the Trauma Center at Methodist Hospital of Indiana in Indianapolis, offered an overview of the medical results of terrorist bomb explosions. Olinger is also medical team manager of the Federal Emergency Management Agency (FEMA) Indiana Urban Search and Rescue (USAR) Task Force 1 and was on the scene during the rescues in Oklahoma City.
“An explosion causes injuries by three main mechanisms,” Olinger said. “The resultant injuries are termed primary, secondary and tertiary blast injuries.”
Olinger described primary blast injuries as those due to the direct effects of the blast wave. This blast wave travels away from the point of explosion at a velocity of 6,000 to 18,000 mph, creating pressures of hundreds of thousands of pounds per square inch. Victims subjected to the direct effect of a primary blast are almost always killed outright. The blast overpressure ruptures lungs or causes air embolisms by forcing air into the blood stream. Those few who do survive present a condition commonly referred to as “Blast Lung.”
“While the exact mechanism of these injuries is debated, clinically they are identical to the pulmonary contusions we routinely see following blunt chest trauma, and the treatment is essentially the same,” said Olinger.
Secondary blast injuries are caused by pieces of buildings or other debris striking victims at enormous speed and force. “Secondary blast injuries are the major cause of death and injury in terrorist bombings,” said Olinger. “They range in severity from simple lacerations to traumatic amputation of extremities, to devastating wounds.”
Based on his experiences in Oklahoma City, Olinger noted some typical patterns of secondary blast injuries. “Clothing offers considerable protection,” he said. “The most common sites of injury are the unprotected head and neck, followed by the extremities.” He also said that penetrating wounds to the eye are common secondary blast injuries.
Olinger cautioned that any laceration following a blast should be suspected of containing a foreign body until proven otherwise. “Because of the irregular shape and poor ballistics of bomb debris, they transfer large amounts of kinetic energy to the tissues, and foreign bodies are often embedded deep in bone or tissue,” he said.
He urged liberal use of X-rays, MRIs and other imaging technology in evaluating bombing victims. For field EMS personnel, this means transporting patients with perhaps minor wounds who might be treated and released from the scene under other circumstances.
Tertiary blast injuries are deceleration injuries that occur when the victim is thrown around by the blast and strikes a wall, the ground or another fixed object.
“Tertiary blast injuries are no different than the injuries we see daily in our trauma centers from falls and motor vehicle accident,” Olinger said. “These injuries include closed head trauma, fractures of solid organs, notably the spleen and the liver, and long bone and pelvic fractures.”
Olinger also cautioned that a careful search must be made around a large perimeter following a bomb blast, because some tertiary blast victims may be hurled hundreds of yards from the blast site and missed during the initial size-up.
The other effect of a bombing is the collapse of a building, greatly increasing the number of fatalities.
“The majority of these victims die almost instantly from massive internal injuries and head injuries as tons of steel and concrete crash down on them,” Olinger said. But he added that when buildings collapse, void spaces may be created and victims entombed. They will die of thirst or exposure if not rescued within a window of several days.
Olinger noted there are reports of victims who survived for days, only to die within hours of being rescued. Those who don’t die immediately often die later of renal failure. Olinger said this phenomenon is called “Crush Syndrome” and he described it as the combined effect of the release of potassium and other toxins into the bloodstream by the death of crushed muscle cells, and shock caused by fluid loss and profound vascular system changes as a result of parts of the body being crushed by debris.
Terrorism is an unfortunate reality of our lives and times. While we can’t prevent it entirely, preparation, awareness and training can go a long way toward easing the impact of the consequences when the unthinkable becomes reality.
Rich Adams, a Firehouse® contributing editor, is a volunteer EMT with the Bethesda-Chevy Chase Rescue Squad in Montgomery County, MD. He operates RDA Associates Inc., a public safety video production and consulting firm in Silver Spring, MD.
