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Organization and Operations Management at the Explosive Incident Scene
DISASTER MEDICINE/BEST PRACTICES FOR MANAGEMENT OF EXPLOSIVE INCIDENTS SUPPLEMENT
Organization and Operations Management at the Explosive Incident Scene Colleen M. Donovan, MD*; Christopher Bryczkowski, MD; Jonathan McCoy, MD; Matthew Tichauer, MD; Robert Eisenstein, MD; Joshua Bucher, MD; Will Chapleau, EMT-P, RN, TNS; Clifton R. Lacy, MD *Corresponding Author. E-mail: [email protected].
0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.09.006
[Ann Emerg Med. 2017;69:S10-S19.] INTRODUCTION The scene of a mass casualty incident is a chaotic, stressful environment. Explosive incident scenes, especially those related to terrorism, add increased levels of fear and potential injury to both civilians and health care providers. They frequently destabilize infrastructure in multiple ways. This article discusses best practices for management of the out-of-hospital explosion scene. The majority of the recommendations are based on expert panel consensus as described in the introductory article. On completion of this article, the reader will have been introduced to several key concepts that may be applied to his or her system in planning for an explosive incident. Because health care and emergency response systems vary considerably from region to region, we do not provide detailed incident plans, but offer a strategic base on which a more specific plan may be built. In the world of disaster management, the Incident Command System is widely used and provides a common language for health care providers. The system is a framework developed to coordinate response to mass casualty incidents. The branches of the Incident Command System are divided into operations, logistics, planning, and finance/ administration. The Federal Emergency Management Agency (FEMA) Incident Command System for emergency medical services (EMS) introduces 6 stages of incident management1: planning and training, initial response, operations, stabilization, demobilization, and termination. We will use these 6 stages in this article as a framework for the discussion of management at the explosive incident scene. Furthermore, the National Incident Management System is a standard approach to disaster management that implements the Incident Command System. It was designed to help integrate and coordinate between all levels of responding, from the municipal government through the S10 Annals of Emergency Medicine
federal government. The Incident Command System is one of the key organizational systems described by the National Incident Management System, which helps appropriate resources through a disaster response. Although it is unnecessary to approach this topic in detail for the purposes of this article, it is important to understand its role in mass casualty incidents.2 PLANNING AND TRAINING When considering the timeline of any time-sensitive event such as an explosion, the preparations leading up to that event will determine how well the system responds. Preparation will also play a critical role in survivor outcomes. Health care systems should engage in “allhazards” planning; that is, they should create a comprehensive plan to cover most disasters. An effective all-hazards response plan encompasses features common to all mass casualty incidents instead of having numerous plans for each threat. Good plans have the flexibility and resilience to adapt to the specific conditions of any given event while dealing with the broader common picture of all events. They should also be scalable, able to handle smallto large-scale events. Past events should be reviewed to identify response pitfalls, hospital resource limitations, and command or control problems that must be prevented. Review of local and regional incidents provides insight into specific issues for each system, whereas review of national and international incidents provides new and innovative solutions to problems. In this way, planning for blast incident response should be conducted in the context of a larger mass casualty incident plan and take into consideration the distinguishing physical characteristics of explosions and blast injuries. Specific plans will vary according to individual situations, but, as discussed below, some general issues are common and critical to successful planning. Volume 69, no. 1s : January 2017
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Exercises “If you’re not ready every day, you’re not going to be ready for game day.”3—Nicole Lurie, MD, MSPH, US Department of Health and Human Services Assistant Secretary for Preparedness and Response. It is very important for all agencies and stakeholders involved in mass casualty incident response to participate in creating an all-hazards response plan. Once that plan has been put in place, it is equally important that all of the players drill or practice the plan before a mass casualty incident. Beware of “paper plan syndrome,” the illusion that preparedness can be accomplished simply by putting a plan on paper without training and practice. Exercises are essential to test and refine plans. They also train responders and hospital staff to execute the plans in an efficient, coordinated manner. The Incident Command System-300 course, offered by FEMA, helps prepare individuals for advanced applications of the Incident Command System. At this level, individuals learn how to integrate National Incident Management System command and management. The course provides training on developing full incident action plans for simulated events. Ideally, providers in a supervisory position who are assisting with planning exercises should take this course.4 Exercises fall into 2 broad categories: discussion and operational. Discussion exercises include seminars, workshops, tabletop exercises, and games or simulations. Operational exercises include drills, functional exercises, and full-scale exercises. Emergency response organizations and hospitals should plan and schedule a combination of exercises over time to ensure readiness to deal with the specific aspects and requirements of explosive events and the injuries they cause. The size and frequency of exercises depend on institutional factors and available resources. The Homeland Security Exercise and Evaluation Program of the US Department of Homeland Security is an excellent source of materials and guidance for planning and conducting exercises (https://www.fema.gov/media-library/assets/ documents/32326). Although frequent exercises are important for putting a response plan into practice, responders and hospitals should incorporate processes and procedures required to deal with explosive incidents into daily routine practices so that they are familiar with them when mass casualty incidents occur. INITIAL RESPONSE Formal explosive incident scene management begins immediately after the incident has been identified and Volume 69, no. 1s : January 2017
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confirmed. As with most emergencies, notification is likely to come as a call from a layperson or witness through an emergency telephone system, such as the public-service answering point 911 system in the United States, Number 112 in Europe, or 000 in Australia. Initially, only partial information will be available: the fact that there has been an explosion, the general vicinity of the incident, and perhaps an estimate of the damage and extent of injury at the scene. This limited initial information can be disseminated through the medical priority dispatch system to responding units, ie, the police department, fire department, and EMS, with basic information to initiate the Incident Command System.1 To extract the most pertinent information from an incident notification, dispatchers should be educated and trained in concise, efficient communication skills. One recommended approach is the creation of explosionrelated scripts, similar to the organized scripts used routinely by emergency dispatchers. Proper scripting allows dispatchers to obtain crucial information and alert first responders that the event may involve special features, hazards, or the need to use specialized responses. The script should include pertinent information that responders need to know to react quickly with the appropriate equipment and supplies. Responders including fire, police, and EMS representatives should be involved in the creation of these scripts. After advising the caller to move a safe distance from the scene, dispatchers may be able to obtain important information, including magnitude of the blast; extent of affected area; potential for chemical, biological, or nuclear exposures; and number and status of victims. Some script examples include the following: What is the extent of the damage (magnitude and area)? How many victims are visible and what appears to be the extent of injury? How many buildings or vehicles appear damaged? Are there downed power lines? Is there power at the scene? Is there fire? Does it appear that gas lines or water lines have been disrupted? Is there smoke? Is there a detectable odor? Is the scene an organized venue, such as a sporting event? (If so, medical response may already be on site. However, prepositioned EMS responders may be among the injured.5,6) Alternatively, because public-service answering points (911 centers) are often overwhelmed with incoming calls during a disaster, a Reverse 911 system can be used to Annals of Emergency Medicine S11
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proactively inform the public. In their 2007 study on public notification of the San Diego wildfires, Neaves et al7 found that 42% of study respondents received their first notification through Reverse 911. Likewise, local hospitals and trauma centers should be proactively notified by 911 or dispatch centers without waiting for detailed damage reports from the scene. Depending on proximity to the event, hospitals may have anywhere from 10 minutes to an hour to implement their mass casualty protocols, including plans for surge capacity and heightened hospital security, before the system is saturated or overwhelmed. Early notification allows hospital teams and resources to be rapidly assembled to provide the best possible patient care when the surge hits. Arrival at the Scene As every out-of-hospital provider learns early in his or her training, on arriving at a scene, the first question the provider should ask is, “Is the scene safe?”8 Situational awareness is critical to the safety of everyone at the incident site. Blast incident scenes are dynamic and pose different threats according to the type and amount of explosive used and the environment or location (open versus enclosed space, underwater, etc) of the explosion.9 Responders must be situationally aware and continually perform scene assessment to ensure their own safety and to report information to the incident command. Until proven otherwise, responders should assume that all blast incidents are deliberate acts and should consider the possibility of secondary events. A secondary event may be another intentionally set device, but it may also be any additional explosions caused by the initial incident. For example, a vehicle bomb may set other nearby vehicles on fire, blow out windows, and cause structural damage, building collapse, and potential chemical or biological contamination. Secondary devices are targeted at incapacitating first responders and subsequently disrupting response efforts to maximize the damage to human life and property.10 They have been used more frequently, to deadly effect. EMS provider safety cannot be overemphasized and must be an overriding priority in scene operations. Casualty management must be understood as secondary to responder safety. EMS providers should approach incident scenes with extreme caution. They should consider waiting until evaluation of potential dangers is performed and issues are fully addressed, regardless of the condition of casualties. According to one source, rescuer fatalities make up to 70% of casualties after confined-space rescue operations. This adds to the casualty load and impairs rescue efforts.11 Although the convention of “scene safety” is widely accepted and practiced, the recent Boston Marathon bombings of April 15, 2013, at first glance seem to S12 Annals of Emergency Medicine
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challenge this concept. During the bombings, 3 spectators were killed and 264 casualties were treated in 27 local hospitals. It has been claimed that there were so few fatalities because bystanders immediately became first responders, not waiting for the area to be declared secure by law enforcement. A secondary explosive device exploded 13 seconds and 210 yards from the initial explosion but did not harm any of the responders to the first blast. Also, because of the nearby medical personnel prepositioned at the finish line, and the geographic proximity to Boston’s trauma centers, it took only 18 minutes to triage, treat, and transport most critically ill “red tag” victims and 45 minutes until the last victim of the blast was transported. No one transported to a hospital died. Although the actions of the rescuers at the 2013 Boston Marathon were indisputably heroic and Boston’s preparations were excellent, many experts observed that the outcomes could have been significantly worse. Boston may have been “fortunate,” or “lucky,” to a certain extent, in that the second device did not cause additional injury, that the incident occurred in close proximity to the finish line and prestaged first responders, and that the scene was located within a few miles of 6 major trauma centers.12,13 The Boston Marathon bystander response, with respect to scene safety, has been the topic of much discussion. Other experiences, such as the 2008 Mumbai terrorist attacks and multiple Israeli incidents, indicate that early bystander action is lifesaving in time-sensitive crises.13,14 Israeli experts, such as Drs. Avraham Rivkind and Isaac Ashkenazi, are strong proponents of the “scoop and run” approach, in which patients are not necessarily triaged on scene but are rapidly transported to a hospital by anyone (bystander, trained medical professional, etc) to ensure that the patient receives definitive care as fast as possible, minimize scene time, and decrease the risk of additional casualties by secondary devices.13,15 Although this recommendation comes from field experts, no formal data currently exist to prove that this lack of triage increases or decreases mortality. Thus, in the initial moments of any given event, the bystander or first responder will have to decide whether the benefit of reaching a victim outweighs the risk of becoming injured and increasing the overall casualty burden. At the very least, it stands to reason that public outreach programs should be included in preparedness planning to educate potential bystander-rescuers. Although the police department, fire department, and specialty teams are responsible for the overall safety at the site, everyone is responsible for maintaining situational awareness. If You See Something, Say Something16 is a public awareness campaign originally used by New York’s Metropolitan Transportation Authority and subsequently licensed to the federal Department of Homeland Security. Volume 69, no. 1s : January 2017
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All responders should be cross trained in response to blast incidents. Police should be trained to administer first aid. EMS should be trained to recognize secondary devices and to make preliminary judgments about structural damage or risk of building collapse. Every responder should be trained in security procedures needed at a blast scene. Personal protective equipment should always be used and may range from standard uniforms, gloves, and closed-toe shoes (level D) to fully encapsulated suits, such as those used with self-contained breathing apparatus gear (level A).17 OPERATIONS AND STABILIZATION Incident Command Considerations Local protocol will determine how the Incident Command System is implemented. In this respect, explosive scenario incident command is no different from a response to any other mass casualty event. Usual practice in most jurisdictions designates the initial responder on the scene as the incident commander, who then transfers command and control to a trained fire department, police department, or EMS incident commander. As noted above, 3 services are typically involved in the initial incident command: the fire service, police and other law enforcement, and EMS. This expands to involve other subject matter experts and support agencies, which may include physicians, nurses, public health, emergency management, and military (National Guard and perhaps active components, if available). Finally, community, volunteers and nongovernment organizations may be involved.6 Incident commanders need to be well trained, including having a thorough understanding of the unique aspects of blast incidents. They must have an awareness of security concerns, transportation requirements, medical supply needs, potential alterations in standards of care, and hospital locations and capabilities. Incident commanders should also have knowledge of all potential personnel who may arrive on scene and must be aware of which and when certain personnel are likely to respond. This includes additional on-duty and off-duty police, fire, and EMS responders (depending on dispatch message, local protocols, and desire to assist by volunteer or other nearby jurisdictions), state agencies, federal agencies (eg, Federal Bureau of Investigation; Bureau of Alcohol, Tobacco, Firearms, and Explosives; FEMA), the news media, and local elected officials. Safety and Security Risk Assessment Generally, police and fire departments are responsible for the organized safety and security risk assessment. As noted above, every blast incident location should be treated as an active criminal or terrorist event. This means Volume 69, no. 1s : January 2017
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that there are many related dangers that must be considered in addition to the initial explosion. EMS providers must be aware of the possibility of active shooters positioned to attack likely treatment points, ambulance staging areas or pickup points, and the incident command post. Secondary bombs may be located in buildings, vehicles, or bags near the initial blast. Particular attention must be paid to cars that appear to be out of place or unattended parcels. False ambulances are an increasingly serious threat. Police should credential all ambulances before they are permitted to enter the perimeter. Parked response vehicles should be locked to prevent bombs from being placed in them while responders are working. All casualty collection points should be routinely checked for secondary devices. Police should establish a detailed perimeter around the incident command post, casualty collection points, ambulance staging areas, and the whole area to limit access in or out by both vehicles and pedestrians. Proper identification of personnel allowed into staging areas is imperative. Casualty collection and triage points should be established a “standoff distance” from the immediate blast area and provide protection from secondary blasts or active shooters. Standoff distance, or range-to-effect distance, is defined by FEMA as the “distance, from the [asset] to [the] nearest point that an explosive device can approach from any side, assuming that all security measures are in place.”18 It is an estimate of the blast radius for a given type and location of an explosive device. Personnel and assets should be maintained at a standoff distance to avoid injury or damage in case a device is detonated. FEMA and the National Counterterrorism Center provide recommendations on standoff distances based on type of explosive.18,19 Large vehicles or other nearby structures may be used to provide physical protection from public view, line of sight from potential “shooter” locations, and secondary bombs. Implementation of these measures will be situation dependent. Cell telephones can be used by perpetrators to detonate secondary devices. Security teams may consider shutting down immediate cell service to the incident site, but only after weighing the negative effect on operations of doing so.6 Alternatively, they may consider using electronic countermeasures, such as limited-range electronic jamming, around the blast site. Teams should be on the alert for perpetrators making videos of the blast incident (or field training exercise) to measure reaction times, to improve technique, or for propaganda. Crowd Control Security teams should remove all curious bystanders from within the perimeter. Police should have a system of Annals of Emergency Medicine S13
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collecting information from potential witnesses or family members (name and contact information) for follow-up by law enforcement. All noncredentialed persons, including volunteers who want to assist, should be kept outside of the incident command location, triage locations, and ambulance staging areas. Responders will likely have to deal with the news media. The Incident Command System is capable of handling the media effectively if established early. This duty can be delegated to the information officer, who should handle all contacts with the press. This allows responders to perform their duties and limits the dissemination of partial or false information. Responders who encounter members of the news media should refer them directly to the information officer and refrain from discussing scene management details.1 Blast incidents can be emotionally catastrophic for family members and responders. EMS providers must be prepared to handle injured patients who are related (parents or children) and uninjured family members who arrive on scene to search for their loved ones. Although not discussed in detail here, experts agree that, because of the heightened emotional sensitivity at mass casualty incidents and at explosive scenes in particular, it is important for law enforcement and EMS teams to discuss and plan how to handle family interactions before an event. Specialty Teams, Decontamination, and Concealed Weapons When an explosive device is suspected, appropriate specialists, such as the bomb squad or SWAT team, should be involved. Bomb technicians should be dispatched to the scene to assist with the search for and safe disposition of secondary devices. As discussed earlier, out-of-hospital medical providers will have to weigh the risks and benefits after initial assessment of the scene to decide whether to enter the damaged area before law enforcement, fire, and structural experts have advised that the scene is secure. The incident commander on scene should coordinate whether and when EMS teams proceed. Decontamination should take place in the open in a fresh-air environment, not downwind of the explosion scene and not upwind of other victims and responders. Safety perimeters and hazard control zones should be established to control movement of individuals and decrease the possibility of further contamination of victims or responders. Hazard control perimeters are divided into hot, warm, and cold zones. Hot zones are the designated regions immediately surrounding hazardous material incidents and are created large enough to prevent any adverse consequences from contact with the hazard. Warm zones are S14 Annals of Emergency Medicine
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designated regions beyond the hot zone for close support functions, decontamination, and access control. Cold zones are designated regions beyond warm zones where incident command and other support functions are staged. Two types of decontamination are established at the blast scene: emergency decontamination for large numbers of patients, using fire department equipment or fire hydrants and hoses; and decontamination trailers or tents with water showers for less urgently needed agent dilution or removal. Special consideration should be given to decontamination for nonambulatory patients. In addition, experience with blast events demonstrates that the majority of ambulatory hazardous material mass casualty incident patients self-evacuate without decontamination in the field. Thus, nearby hospitals must be notified as soon as a concern for potential contamination is raised. Concealed weapons may be a problem. EMS providers are generally not trained to find concealed weapons and should not be responsible for searching for them. They should be aware that some victims may be armed and that some casualties may also be perpetrators, and exercise due caution. Weapons may be discovered coincidentally during the evaluation and triage process. Unless they have been previously trained, EMS providers should not attempt to handle any potential weapons. Protocols should be put in place for EMS providers to notify their law enforcement counterparts that a weapon has been identified and needs to be safely secured. Local Capabilities Incident commanders and EMS providers need to understand the capabilities of local hospitals, including, but not limited to, hospital surge capacity (bed availability in the emergency department [ED], hospital floor, critical care, operating rooms, etc) and treatment capability (trauma centers, burn centers with trauma capability, pediatric centers, etc). This information should be reviewed and frequently updated. EMS and hospital leadership should meet to discuss ways to make this information easily and automatically accessible in the event of a disaster. Equipment Supply and Rehabilitation Ambulances typically have more supplies than they normally need for the patient(s) they are actively transporting. After an explosion, during which resources will be rapidly consumed, EMS teams should consider leaving extra basic life support (BLS) supplies at the scene when they are transporting casualties to hospitals. This also requires making pre-event provisions to resupply ambulances in between transport of patients. Plans should include the staging of a medical supply truck or trailer at Volume 69, no. 1s : January 2017
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the scene. In accordance with review of past explosive incidents, additional supplies anticipated for these events include the following: Skeds and long boards to more easily move casualties from the point of the explosion to the triage area Tourniquets “Blowout” kits (specialized kits for blast events including tourniquets, combat-type hemostatic gauze, and basic airway adjuncts such as nasal airways) Additional pediatric kits Tents Generators and lights for command post and triage areas Bullhorns to communicate with bystanders or walking wounded and as a supplement to radio communications among the responders Operations should not be delayed to set up tents, generators, lights, or supplies unless it is essential to do so for protection of casualties and responders from the elements. Out-of-Hospital Primary Triage Blast injuries will yield multiple casualties who have a high likelihood of severe injury and mortality. As a result, triage must be conducted very early, well, and often. The earliest triage should occur at the place of injury on scene, where patients must be identified as alive, dead, or unlikely to survive (expectant). Patients who are alive are then moved to casualty collecting areas, the location of which should be determined according to the characteristics of the scene. Ideally, collection areas should be placed uphill and upwind from the blast zone because of the continued danger to health care providers from the initial blast and from potential secondary attacks. The minimum safe distance from the blast site will be scenario dependent. Extra care in planning and subsequent training must be taken when staging for response to a potential terrorist act is considered because using standardized locations for collection points may make these areas easy to anticipate and target by terrorists. As noted above, many terrorists have learned to exploit what is known as the “second-hit principle” or a “primary or diversion attack,” which involves attracting first responders by an initial blast and then injuring or incapacitating them with a subsequent attack.20,21 At casualty collection areas, a triage officer coordinates the assignment of triage teams, who then quickly evaluate and determine which patients will likely benefit from immediate intervention(s). Although physician triage officers have been shown to improve triage accuracy, the triage officer may come from a variety of backgrounds, including nursing or EMS.22,23 Because the triage officer cannot simultaneously serve in any other function, physicians may provide more Volume 69, no. 1s : January 2017
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benefit in their traditional direct-care provider roles during times of critically scarce resources.1 Triage Tools One of the most difficult decisions to be made in a mass casualty setting is determining which casualties should receive care and which should not. As a result, several mass casualty triage algorithms have been developed to categorize the severity of injury and optimize outcomes. Methodologies that require extensive observations and multiple points of testing simply do not work in a timeand resource-constrained setting such as a mass casualty incident. Presently, Simple Treatment and Rapid Transport (START) triage, Triage Sieve, and CareFlight Triage are the most used adult triage modalities.24 For example, Boston EMS uses the START triage method and the SMART triage tag system.* The START triage adult algorithm remains perhaps the most widely used mass triage algorithm in North America and has been used at disasters such as the 1995 Oklahoma City bombing and the 1992 and 2001 attacks on the New York City World Trade Center.24-26 The START triage algorithm assigns patient priority according to ability to walk, airway patency, respiratory rate less than or greater than 30 breaths/min, presence of radial pulse or delay in capillary refill, and ability to follow commands. Patients are next stratified into categories: minor, walking wounded (1, green); delayed, not life threatening (2, yellow); immediate, life threatening (3, red); and deceased or expectant care (4, black).27 The Triage Sieve is a widely accepted algorithm in the United Kingdom and Australia, used by EMS, hospital personnel, and the army.28 It focuses on the ability to walk, airway patency, breathing rate less than 10 or greater than 30 breaths/min, and either delay in capillary refill or pulse rate greater than 120 beats/min (depending on whether the environment is dark or cold).26,28 Although both triage modalities start the same, Triage Sieve immediately categorizes patients with a respiratory rate less than 10 breaths/min or pulse rate greater than 120 beats/min as “immediate,” whereas the START algorithm does so only if the patient also has inability to follow commands.24 The CareFlight algorithm assesses the ability to obey commands, the presence of respirations, and the palpability of the radial pulse. The respiratory rate is not assessed in the algorithm, and level of consciousness is assessed first. Because there are no numeric values associated within the *There are many commercially available triage tag systems that aid in patient triage, documentation, and tracking. The SMART Tag is one such system.
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algorithm, it may be appropriate for triaging children as well. CareFlight was used in the aftermath of the Bali nightclub bombing in 2002.24,26,29 A retrospective review found that the START and CareFlight had very similar sensitivities in predicting serious injury (85% versus 82%, respectively), whereas CareFlight triage had better specificity (96% versus 86% for START). Triage Sieve was found to be a poor predictor of identifying injury, with a sensitivity of 45%.26 Although retrospective reviews of these algorithms attempt to test for predictive validity, algorithms such as START have not been studied in real-world conditions.26 Likewise, no triage algorithm has been studied in mass casualty incident events involving biological, chemical, or radiologic agents.24 As a result, although many triage algorithms have been developed, multiple studies continue to demonstrate that the Glasgow Coma Scale motor component and the systolic blood pressure measurement remain the most specific objective values in assessing significant injury.26,30 The Sort-Assess-Lifesaving Interventions-Treatment/ Transport (SALT) triage system was designed to address evidence and efficacy issues noted in previous mass casualty triage systems. A work group was convened by the National Association of EMS Physicians in 2006 and was funded by the Centers for Disease Control and Prevention (CDC). Content experts convened to devise a triage system incorporating a review of the best literature available.31 This triage system was designed according to currently available research, best practice of existing systems, and consensus opinion from the experts involved in the work. The SALT triage system involves a few key components. Patients with obvious life-threatening injuries or apparent unconsciousness require immediate assessment. Lifesaving interventions include major hemorrhage control, opening airway maneuvers, chest decompression, or the consideration of autoinjector antidotes. After these interventions have been performed, if indicated, further assessment is conducted to determine the next level of care for the patient.31 The Model Uniform Core Criteria were created by another work group funded by the CDC to expand on the work from the group that designed the SALT triage system. It involved 4 general categories (general considerations, global sorting, lifesaving interventions, and individual assessment). The work group concluded that these are the minimum elements that all mass casualty incident triage systems must incorporate into their algorithm.32 The Federal Interagency Committee on Emergency Medical Services recommends that all states adopt triage methods that are based on the Model Uniform Core Criteria, such as the SALT triage system.32 S16 Annals of Emergency Medicine
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Under- and Overtriage Although it is important to remember that triage is a dynamic, continuous process in which patients require frequent reassessment, the accuracy of on-scene triage may affect the overall success of the medical response.33 During the initial chaos of a mass casualty event, triaging errors are prone to occur. Undertriage involves incorrectly assigning critically ill victims to delayed categories. Delaying muchneeded medical care to such individuals can lead to devastating consequences, including death.34,35 One way to reduce undertriage may be to assign clinical providers to all delayed-care areas so that they may quickly identify and upgrade deteriorating patients. Given the fact that, under normal circumstances, medical personnel often provide the greatest amount of good for the patient at hand, overuse of resources, or overtriage, becomes an issue that will quickly burden tertiary hospitals in mass casualty incidents. This involves providing immediate care to individuals who do not necessarily require it. Although overtriaging typical, small patient loads poses only economic and administrative strains on hospitals, during mass casualty incidents, it can pose a significant lifethreatening risk.13,22 A large influx of noncritical victims delays rapid identification and direct care of the critically ill. Data from mass casualty bombings, as published by Frykberg and Tepas,34 demonstrate a direct, linear relationship between overtriage rate and the mortality rate of survivors. Computer modeling further shows that quality of care provided is poorer with increasing rates of overtriage, and thus patient load.35 As a result, disaster response should aim to maximize triage accuracy while avoiding both overand undertriage. Realistically, this is difficult to do in a resource-scarce environment, and thus several elements should be implemented to help create an “error-tolerant” system with enough flexibility to account for the inevitable occurrence of some triage error.35 In the out-of-hospital setting, one way to minimize overtriage is to have multiple casualty collection areas, in which noncritical casualties are progressively filtered out and only immediate patients are transported. Continued triage on hospital arrival in the ED and hospital lockdown to prevent nonevent-related walk-ins further aims to minimize this burden. Likewise, continued reassessment of noncritical casualties both in the field and within the hospital for signs of clinical deterioration are of utmost importance in preventing devastating consequences.35 Another key component of out-of-hospital triage is to evenly distribute casualties among several hospitals through a concept known as leapfrogging.36,37 The goal in bypassing the hospital most proximal to the blast zone is to avoid overwhelming one facility, as well as to match patient Volume 69, no. 1s : January 2017
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needs with appropriate hospital-specific resources.35 The closest hospital will likely face the largest volume of selfevacuated walking wounded. Ideally, patients with severe injuries should be transported to trauma centers. Treatment In general, advanced life support (ALS) treatment should not be provided at the scene. Casualties are only to be treated on scene if there is a delay in transporting them to the hospital. While they are en route, ALS treatment may become necessary, but BLS with pain control is paramount. BLS providers should remember that pain control is not limited to medications; patient positioning, splinting, temperature control within the ambulance, blankets, etc, factor in to treating pain within the BLS scope of practice. Again, although EMS or field-trained physicians and nurses may be able to provide excellent triage, the staffing of nonscene trained medical personnel such as physicians and nurses should be avoided. EMS or field-trained physicians and nurses, on the other hand, may be able to provide better triage. Such individuals often provide too much care and prolong field time.35 Patient Tracking Scene patient tracking should be a formal, integrated system with data that include names (if possible), type and extent of injuries, times of assessment and transfer, and disposition, with the name of the receiving facility. A tracking system should also be in place for the walking and mildly wounded because they are difficult to manage and often wander around the scene. It is important to send them to a casualty collection area for further instructions and attempt to prevent them from going to the nearest hospital on their own. As discussed in the above triage section, it is easy to inundate the closest hospital, especially when ambulatory victims self-transport to the nearest facility. Blast injuries may present unique patient flow challenges, with patients often sustaining loss of sight and hearing, impeding effective communication. Instructions should be simple, and signs should be easily understandable. If available, volunteers may be a valuable resource to guide such patients to appropriate locations. Providers should gather contact information (name and contact telephone numbers) for victim tracking and potential law enforcement follow-up. All hospitals in the service area (and optimally, all hospitals in the same region) should use the same patienttracking system. Evidence Collection While providers are on scene, it is important for them to remember that every explosive event is treated by federal, Volume 69, no. 1s : January 2017
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state, and local law enforcement as a deliberate, criminal act until proven otherwise. Evidence collection, although important for law enforcement, should remain secondary to patient care and should not interfere with casualty assessment. Nonetheless, organic debris should be maintained as evidence because it may help identify the type and source of the blast explosion. Procedures should be enforced to maintain chain of custody for evidence gathered at the scene. Police should also gather the names and contact information of uninjured witnesses to the event. If possible, witnesses should be interviewed at the scene, even if briefly, with scheduled follow-up. Transportation Traffic control at the scene is essential. Ambulance and other emergency vehicle ingress and egress must be controlled very early, with staging and pickup areas clearly identified and protected. Ambulances should go to a staging area established by the incident commander until called to pick up patients. Clearing roads to casualty collecting areas and receiving hospitals is of major importance. A recommended approach is the use of contraflow. In this solution, one or more of the lanes inbound to the blast zone is reversed to become an outbound lane (in the direction of the hospital). This serves to reduce traffic and alleviate bottlenecks.38 Explosions may produce large numbers of casualties and create a need to consider nontraditional transportation. The use of buses, vans, and other nontraditional means for transporting patients classified as having minor and delayed triage should be considered. If nontraditional transport is used, medical personnel and supplies should accompany patients during transport to continually triage and reassess their status and provide immediate care if necessary. Safety or security support should also be provided during transport; for example, police escorts for nontraditional vehicles. Nonmedical drivers of nontraditional transportation, such as bus or cab drivers, may not be willing to respond to an explosive incident. In this case, out-of-hospital leadership must identify and routinely train staff members on how to operate a nontraditional vehicle and safely transport their patients with one. As always, planning, training, and exercise are required for effective response. For pediatric patients, a family member should go in the same ambulance with the child if possible. If, however, both parent and child are injured, they should be sent to a trauma center first because sending injured parents along with their children to a children’s hospital may overwhelm the staff at the children’s hospital and result in suboptimal care for the adult casualty. Annals of Emergency Medicine S17
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The organized use of private vehicles should be avoided. Although the Oklahoma City, Iraq, and Israel experiences have demonstrated that private vehicles will be used by individuals before responders arrive, this is done individually. Private vehicles are difficult to identify as authenticated victim transport vehicles and need to be screened for possible delivery of secondary devices. DEMOBILIZATION AND TERMINATION As the scene becomes more stable and casualties are transported to hospitals, the incident commander will gradually release responding units back into general service. When the incident commander is satisfied that all potential casualties have been evacuated from the scene, he or she will terminate the response and compile a final progress report, including patient totals and unit status. In the days after an explosive incident, it is likely that many providers, patients, and family members will be emotionally affected by the event. It is crucial to address the psychological health of anyone involved. Summary Explosions significantly complicate the management of a mass casualty incident scene and require that several additional issues be taken into account. The Incident Command System should be followed and basics such as situational awareness, scene safety, and rapid triage and transport are paramount. Complicating factors, such as secondary devices, concealed weapons, structural integrity, and potential criminal investigation, will affect crowd and scene control. Minimal ALS should be provided on scene. Treatment should focus on strong BLS skills, with a goal of transporting patients to definitive care as quickly and efficiently as possible. The key to optimal scene management lies in routine assessment and reassessment of all-hazards planning, with training and regular exercises that include all involved agencies. Author affiliations: The Departments of Emergency Medicine and Medicine, Rutgers, The State University of New Jersey–Robert Wood Johnson Medical School, New Brunswick, NJ (Donovan, Bryczkowski, McCoy, Tichauer, Eisenstein, Bucher, Lacy); American College of Surgeons, Chicago, IL (Chapleau); and University Center for Disaster Preparedness and Emergency Response at Robert Wood Johnson University Hospital, New Brunswick, NJ (Lacy, Eisenstein, Donovan). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and have provided the following details: funding for this project was provided by a grant to Robert Wood Johnson University Hospital from the Telemedicine and Advanced Technology Research Center (TATRC), US Army Medical
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Research and Materiel Command, under contract number W81XWH0810324. Publication of this Supplement is supported by Robert Wood Johnson University Hospital, New Brunswick, NJ. Military disclaimer: The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of Defense or the US Government.
REFERENCES 1. FEMA. Incident Command System. 2013. Available at: http://www. fema.gov/emergency/nims/IncidentCommandSystem.shtm. Accessed October 3, 2016. 2. Department of Homeland Security. National Incident Management System training program. September 2011. Available at: http://www. fema.gov/pdf/emergency/nims/nims_training_program.pdf. Accessed October 3, 2016. 3. Robert Wood Johnson Foundation. Nicole Lurie: strength needed in time of emergency. 2011. Available at: http://www.rwjf.org/en/cultureof-health/2011/04/nicole-lurie-strength-needed-in-time-ofemergency.html. Accessed October 3, 2016. 4. Department of Homeland Security. National Incident Management System Training Program. 2011. Available at: http://www.fema.gov/ pdf/emergency/nims/nims_training_program.pdf. Accessed October 3, 2016. 5. Friedman FD. Conventional explosions at a mass gathering. In: Ciottone GR, ed. Disaster Medicine. Philadelphia, PA: Elsevier/Mosby; 2006:764-766. 6. Opinion of the Best Practices for Management of Explosive Incidents—Expert Panel. Presented at: Robert Wood Johnson University Hospital; December 22, 2010; New Brunswick, NJ. 7. Neaves TT, Mann SC, Myers LB, et al. Assessing Reverse 911®: a case study of the 2007 San Diego wildfires. J Emerg Manag. 2014;12:315-325. 8. Mistovich JJ, Hafen BQ, Karren KJ, et al. Scene size up. In: Werman HA, ed. Prehospital Emergency Care, 6th ed. Upper Saddle River, NJ: Brady; 2000:128-145. 9. Leibovici D, Gofrit ON, Stein M, et al. Blast injuries: bus versus open-air bombings—a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996;41:1030-1035. 10. Dallas CE, Coule PL, James JJ, et al. Traumatic and explosive events. In: Basic Disaster Life Support Provider Manual, Version 2.6. Chicago, IL: American Medical Association; 2007:3-9:3-33. 11. Frykberg ER. Disaster management. In: Flint L, Meredith JW, Schwab CW, et al, eds. Trauma: Contemporary Principles and Therapy. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:44. 12. Biddinger P. Lessons in emergency preparedness after Boston bombings [transcript]. National Public Radio. May 2, 2013. 13. Ashkenazi I. Blast scene medical management. Keynote lecture presented at: Management of Explosive Incidents: Coordinating Health Care, Emergency Management and Law Enforcement; May 13, 2013; New Brunswick, NJ. 14. Roy N, Kapil V, Subbarao I, et al. Mass casualty response in the 2008 Mumbai terrorist attacks. Disaster Med Public Health Preparedness. 2011;5.4:273-279. 15. Rivkind A. “Scoop and Run” vs “Stay and Play”. 2008. Available at: https://www.oryarok.org.il/webfiles/.../rivkind_or_yarok_dec_2008. Accessed March 22, 2016. 16. Department of Homeland Security. If You See Something, Say Something campaign. 2013. Available at: http://www.dhs.gov/files/ reportincidents/see-something-say-something.shtm. Accessed October 3, 2016. 17. Salomone JP, Pons PT, eds. PHTLS—Pre-Hospital Trauma Life Support, 6th ed. St Louis, MO: Mosby JEMS/Elsevier; 2011.
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18. Department of Homeland Security. Buildings and infrastructure protection series: reference manual to mitigate potential terrorist attacks. 2011. Available at: http://www.dhs.gov/xlibrary/assets/st/stbips-06.pdf. Accessed October 3, 2016. 19. National Counterterrorism Center. Bomb threat stand-off distances. Available at: http://www.nctc.gov/docs/2006_calendar_bomb_stand_ chart.pdf. Accessed October 3, 2016. 20. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201-212. 21. Goh S. Bomb blast mass casualty incidents: initial triage and management of injuries. Singapore Med J. 2009;50:101-105. 22. Frykberg ER. Triage: principles and practice. Scand J Surg. 2005;94:272-278. 23. Champion HR, Sacco WJ, Gainer PS, et al. The effect of medical direction on trauma triage. J Trauma. 1988;28:235-239. 24. Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23.1:3-8. 25. Asaeda G. The day that the START triage system came to a STOP: observations from the World Trade Center disaster. Acad Emerg Med. 2002;9:255-256. 26. Garner A, Lee A, Harrison K, et al. Comparative analysis of multiplecasualty incident triage algorithms. Ann Emerg Med. 2001;38: 541-548. 27. START triage. Simple Triage and Rapid Treatment. Available at: http:// www.start-triage.com. Accessed February 14, 2012. 28. Hodgetts TJ. Triage: A Position Statement. 2001. Available at: http:// ec.europa.eu/echo/files/civil_protection/civil/prote/pdfdocs/ disaster_med_final_2002/d6.pdf. Accessed October 3, 2016.
29. Tran MD, Garner AA, Morrison I, et al. The Bali bombing: civilian aeromedical evacuation. Med J Aust. 2003;179:353-356. 30. Fries GR, McCalla G, Levitt MA, et al. A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting. Ann Emerg Med. 1994;25:885-889. 31. Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;(2 Suppl 1): S25-S34. 32. Federal Interagency Committee on Emergency Medical Services. National implementation of the model uniform core criteria for mass casualty incident triage. 2013. Available at: http://www.ems.gov/ nemsac/dec2013/FICEMS-MUCC-Implementation-Plan.pdf. Accessed October 3, 2016. 33. DePalma RG, Burris DG, Champion HR, et al. Blast injuries. N Engl J Med. 2005;352:1335-1342. 34. Frykberg ER, Tepas JJ. Terrorist bombings: lessons learned from Belfast to Beirut. Ann Surg. 1988;208:569-576. 35. Hirshberg A, Scott BG, Granchi T, et al. How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis. J Trauma. 2005;58:686-695. 36. Jacobs LM, Ramp JM, Breay JM. An emergency medical system approach to disaster planning. J Trauma. 1979;19:157-162. 37. Jacobs LM, Goody M, Sinclair A. The role of a trauma center in disaster management. J Trauma. 1983;23:697-701. 38. Urbina E, Wolshon B. National review of hurricane evacuation plans and policies: a comparison and contrast of state practices. Transportation Res. 2003;37:257-275.
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Organization and Operations Management at the Explosive Incident Scene Colleen M. Donovan, MD*; Christopher Bryczkowski, MD; Jonathan McCoy, MD; Matthew Tichauer, MD; Robert Eisenstein, MD; Joshua Bucher, MD; Will Chapleau, EMT-P, RN, TNS; Clifton R. Lacy, MD *Corresponding Author. E-mail: [email protected].
0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.09.006
[Ann Emerg Med. 2017;69:S10-S19.] INTRODUCTION The scene of a mass casualty incident is a chaotic, stressful environment. Explosive incident scenes, especially those related to terrorism, add increased levels of fear and potential injury to both civilians and health care providers. They frequently destabilize infrastructure in multiple ways. This article discusses best practices for management of the out-of-hospital explosion scene. The majority of the recommendations are based on expert panel consensus as described in the introductory article. On completion of this article, the reader will have been introduced to several key concepts that may be applied to his or her system in planning for an explosive incident. Because health care and emergency response systems vary considerably from region to region, we do not provide detailed incident plans, but offer a strategic base on which a more specific plan may be built. In the world of disaster management, the Incident Command System is widely used and provides a common language for health care providers. The system is a framework developed to coordinate response to mass casualty incidents. The branches of the Incident Command System are divided into operations, logistics, planning, and finance/ administration. The Federal Emergency Management Agency (FEMA) Incident Command System for emergency medical services (EMS) introduces 6 stages of incident management1: planning and training, initial response, operations, stabilization, demobilization, and termination. We will use these 6 stages in this article as a framework for the discussion of management at the explosive incident scene. Furthermore, the National Incident Management System is a standard approach to disaster management that implements the Incident Command System. It was designed to help integrate and coordinate between all levels of responding, from the municipal government through the S10 Annals of Emergency Medicine
federal government. The Incident Command System is one of the key organizational systems described by the National Incident Management System, which helps appropriate resources through a disaster response. Although it is unnecessary to approach this topic in detail for the purposes of this article, it is important to understand its role in mass casualty incidents.2 PLANNING AND TRAINING When considering the timeline of any time-sensitive event such as an explosion, the preparations leading up to that event will determine how well the system responds. Preparation will also play a critical role in survivor outcomes. Health care systems should engage in “allhazards” planning; that is, they should create a comprehensive plan to cover most disasters. An effective all-hazards response plan encompasses features common to all mass casualty incidents instead of having numerous plans for each threat. Good plans have the flexibility and resilience to adapt to the specific conditions of any given event while dealing with the broader common picture of all events. They should also be scalable, able to handle smallto large-scale events. Past events should be reviewed to identify response pitfalls, hospital resource limitations, and command or control problems that must be prevented. Review of local and regional incidents provides insight into specific issues for each system, whereas review of national and international incidents provides new and innovative solutions to problems. In this way, planning for blast incident response should be conducted in the context of a larger mass casualty incident plan and take into consideration the distinguishing physical characteristics of explosions and blast injuries. Specific plans will vary according to individual situations, but, as discussed below, some general issues are common and critical to successful planning. Volume 69, no. 1s : January 2017
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Exercises “If you’re not ready every day, you’re not going to be ready for game day.”3—Nicole Lurie, MD, MSPH, US Department of Health and Human Services Assistant Secretary for Preparedness and Response. It is very important for all agencies and stakeholders involved in mass casualty incident response to participate in creating an all-hazards response plan. Once that plan has been put in place, it is equally important that all of the players drill or practice the plan before a mass casualty incident. Beware of “paper plan syndrome,” the illusion that preparedness can be accomplished simply by putting a plan on paper without training and practice. Exercises are essential to test and refine plans. They also train responders and hospital staff to execute the plans in an efficient, coordinated manner. The Incident Command System-300 course, offered by FEMA, helps prepare individuals for advanced applications of the Incident Command System. At this level, individuals learn how to integrate National Incident Management System command and management. The course provides training on developing full incident action plans for simulated events. Ideally, providers in a supervisory position who are assisting with planning exercises should take this course.4 Exercises fall into 2 broad categories: discussion and operational. Discussion exercises include seminars, workshops, tabletop exercises, and games or simulations. Operational exercises include drills, functional exercises, and full-scale exercises. Emergency response organizations and hospitals should plan and schedule a combination of exercises over time to ensure readiness to deal with the specific aspects and requirements of explosive events and the injuries they cause. The size and frequency of exercises depend on institutional factors and available resources. The Homeland Security Exercise and Evaluation Program of the US Department of Homeland Security is an excellent source of materials and guidance for planning and conducting exercises (https://www.fema.gov/media-library/assets/ documents/32326). Although frequent exercises are important for putting a response plan into practice, responders and hospitals should incorporate processes and procedures required to deal with explosive incidents into daily routine practices so that they are familiar with them when mass casualty incidents occur. INITIAL RESPONSE Formal explosive incident scene management begins immediately after the incident has been identified and Volume 69, no. 1s : January 2017
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confirmed. As with most emergencies, notification is likely to come as a call from a layperson or witness through an emergency telephone system, such as the public-service answering point 911 system in the United States, Number 112 in Europe, or 000 in Australia. Initially, only partial information will be available: the fact that there has been an explosion, the general vicinity of the incident, and perhaps an estimate of the damage and extent of injury at the scene. This limited initial information can be disseminated through the medical priority dispatch system to responding units, ie, the police department, fire department, and EMS, with basic information to initiate the Incident Command System.1 To extract the most pertinent information from an incident notification, dispatchers should be educated and trained in concise, efficient communication skills. One recommended approach is the creation of explosionrelated scripts, similar to the organized scripts used routinely by emergency dispatchers. Proper scripting allows dispatchers to obtain crucial information and alert first responders that the event may involve special features, hazards, or the need to use specialized responses. The script should include pertinent information that responders need to know to react quickly with the appropriate equipment and supplies. Responders including fire, police, and EMS representatives should be involved in the creation of these scripts. After advising the caller to move a safe distance from the scene, dispatchers may be able to obtain important information, including magnitude of the blast; extent of affected area; potential for chemical, biological, or nuclear exposures; and number and status of victims. Some script examples include the following: What is the extent of the damage (magnitude and area)? How many victims are visible and what appears to be the extent of injury? How many buildings or vehicles appear damaged? Are there downed power lines? Is there power at the scene? Is there fire? Does it appear that gas lines or water lines have been disrupted? Is there smoke? Is there a detectable odor? Is the scene an organized venue, such as a sporting event? (If so, medical response may already be on site. However, prepositioned EMS responders may be among the injured.5,6) Alternatively, because public-service answering points (911 centers) are often overwhelmed with incoming calls during a disaster, a Reverse 911 system can be used to Annals of Emergency Medicine S11
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proactively inform the public. In their 2007 study on public notification of the San Diego wildfires, Neaves et al7 found that 42% of study respondents received their first notification through Reverse 911. Likewise, local hospitals and trauma centers should be proactively notified by 911 or dispatch centers without waiting for detailed damage reports from the scene. Depending on proximity to the event, hospitals may have anywhere from 10 minutes to an hour to implement their mass casualty protocols, including plans for surge capacity and heightened hospital security, before the system is saturated or overwhelmed. Early notification allows hospital teams and resources to be rapidly assembled to provide the best possible patient care when the surge hits. Arrival at the Scene As every out-of-hospital provider learns early in his or her training, on arriving at a scene, the first question the provider should ask is, “Is the scene safe?”8 Situational awareness is critical to the safety of everyone at the incident site. Blast incident scenes are dynamic and pose different threats according to the type and amount of explosive used and the environment or location (open versus enclosed space, underwater, etc) of the explosion.9 Responders must be situationally aware and continually perform scene assessment to ensure their own safety and to report information to the incident command. Until proven otherwise, responders should assume that all blast incidents are deliberate acts and should consider the possibility of secondary events. A secondary event may be another intentionally set device, but it may also be any additional explosions caused by the initial incident. For example, a vehicle bomb may set other nearby vehicles on fire, blow out windows, and cause structural damage, building collapse, and potential chemical or biological contamination. Secondary devices are targeted at incapacitating first responders and subsequently disrupting response efforts to maximize the damage to human life and property.10 They have been used more frequently, to deadly effect. EMS provider safety cannot be overemphasized and must be an overriding priority in scene operations. Casualty management must be understood as secondary to responder safety. EMS providers should approach incident scenes with extreme caution. They should consider waiting until evaluation of potential dangers is performed and issues are fully addressed, regardless of the condition of casualties. According to one source, rescuer fatalities make up to 70% of casualties after confined-space rescue operations. This adds to the casualty load and impairs rescue efforts.11 Although the convention of “scene safety” is widely accepted and practiced, the recent Boston Marathon bombings of April 15, 2013, at first glance seem to S12 Annals of Emergency Medicine
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challenge this concept. During the bombings, 3 spectators were killed and 264 casualties were treated in 27 local hospitals. It has been claimed that there were so few fatalities because bystanders immediately became first responders, not waiting for the area to be declared secure by law enforcement. A secondary explosive device exploded 13 seconds and 210 yards from the initial explosion but did not harm any of the responders to the first blast. Also, because of the nearby medical personnel prepositioned at the finish line, and the geographic proximity to Boston’s trauma centers, it took only 18 minutes to triage, treat, and transport most critically ill “red tag” victims and 45 minutes until the last victim of the blast was transported. No one transported to a hospital died. Although the actions of the rescuers at the 2013 Boston Marathon were indisputably heroic and Boston’s preparations were excellent, many experts observed that the outcomes could have been significantly worse. Boston may have been “fortunate,” or “lucky,” to a certain extent, in that the second device did not cause additional injury, that the incident occurred in close proximity to the finish line and prestaged first responders, and that the scene was located within a few miles of 6 major trauma centers.12,13 The Boston Marathon bystander response, with respect to scene safety, has been the topic of much discussion. Other experiences, such as the 2008 Mumbai terrorist attacks and multiple Israeli incidents, indicate that early bystander action is lifesaving in time-sensitive crises.13,14 Israeli experts, such as Drs. Avraham Rivkind and Isaac Ashkenazi, are strong proponents of the “scoop and run” approach, in which patients are not necessarily triaged on scene but are rapidly transported to a hospital by anyone (bystander, trained medical professional, etc) to ensure that the patient receives definitive care as fast as possible, minimize scene time, and decrease the risk of additional casualties by secondary devices.13,15 Although this recommendation comes from field experts, no formal data currently exist to prove that this lack of triage increases or decreases mortality. Thus, in the initial moments of any given event, the bystander or first responder will have to decide whether the benefit of reaching a victim outweighs the risk of becoming injured and increasing the overall casualty burden. At the very least, it stands to reason that public outreach programs should be included in preparedness planning to educate potential bystander-rescuers. Although the police department, fire department, and specialty teams are responsible for the overall safety at the site, everyone is responsible for maintaining situational awareness. If You See Something, Say Something16 is a public awareness campaign originally used by New York’s Metropolitan Transportation Authority and subsequently licensed to the federal Department of Homeland Security. Volume 69, no. 1s : January 2017
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All responders should be cross trained in response to blast incidents. Police should be trained to administer first aid. EMS should be trained to recognize secondary devices and to make preliminary judgments about structural damage or risk of building collapse. Every responder should be trained in security procedures needed at a blast scene. Personal protective equipment should always be used and may range from standard uniforms, gloves, and closed-toe shoes (level D) to fully encapsulated suits, such as those used with self-contained breathing apparatus gear (level A).17 OPERATIONS AND STABILIZATION Incident Command Considerations Local protocol will determine how the Incident Command System is implemented. In this respect, explosive scenario incident command is no different from a response to any other mass casualty event. Usual practice in most jurisdictions designates the initial responder on the scene as the incident commander, who then transfers command and control to a trained fire department, police department, or EMS incident commander. As noted above, 3 services are typically involved in the initial incident command: the fire service, police and other law enforcement, and EMS. This expands to involve other subject matter experts and support agencies, which may include physicians, nurses, public health, emergency management, and military (National Guard and perhaps active components, if available). Finally, community, volunteers and nongovernment organizations may be involved.6 Incident commanders need to be well trained, including having a thorough understanding of the unique aspects of blast incidents. They must have an awareness of security concerns, transportation requirements, medical supply needs, potential alterations in standards of care, and hospital locations and capabilities. Incident commanders should also have knowledge of all potential personnel who may arrive on scene and must be aware of which and when certain personnel are likely to respond. This includes additional on-duty and off-duty police, fire, and EMS responders (depending on dispatch message, local protocols, and desire to assist by volunteer or other nearby jurisdictions), state agencies, federal agencies (eg, Federal Bureau of Investigation; Bureau of Alcohol, Tobacco, Firearms, and Explosives; FEMA), the news media, and local elected officials. Safety and Security Risk Assessment Generally, police and fire departments are responsible for the organized safety and security risk assessment. As noted above, every blast incident location should be treated as an active criminal or terrorist event. This means Volume 69, no. 1s : January 2017
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that there are many related dangers that must be considered in addition to the initial explosion. EMS providers must be aware of the possibility of active shooters positioned to attack likely treatment points, ambulance staging areas or pickup points, and the incident command post. Secondary bombs may be located in buildings, vehicles, or bags near the initial blast. Particular attention must be paid to cars that appear to be out of place or unattended parcels. False ambulances are an increasingly serious threat. Police should credential all ambulances before they are permitted to enter the perimeter. Parked response vehicles should be locked to prevent bombs from being placed in them while responders are working. All casualty collection points should be routinely checked for secondary devices. Police should establish a detailed perimeter around the incident command post, casualty collection points, ambulance staging areas, and the whole area to limit access in or out by both vehicles and pedestrians. Proper identification of personnel allowed into staging areas is imperative. Casualty collection and triage points should be established a “standoff distance” from the immediate blast area and provide protection from secondary blasts or active shooters. Standoff distance, or range-to-effect distance, is defined by FEMA as the “distance, from the [asset] to [the] nearest point that an explosive device can approach from any side, assuming that all security measures are in place.”18 It is an estimate of the blast radius for a given type and location of an explosive device. Personnel and assets should be maintained at a standoff distance to avoid injury or damage in case a device is detonated. FEMA and the National Counterterrorism Center provide recommendations on standoff distances based on type of explosive.18,19 Large vehicles or other nearby structures may be used to provide physical protection from public view, line of sight from potential “shooter” locations, and secondary bombs. Implementation of these measures will be situation dependent. Cell telephones can be used by perpetrators to detonate secondary devices. Security teams may consider shutting down immediate cell service to the incident site, but only after weighing the negative effect on operations of doing so.6 Alternatively, they may consider using electronic countermeasures, such as limited-range electronic jamming, around the blast site. Teams should be on the alert for perpetrators making videos of the blast incident (or field training exercise) to measure reaction times, to improve technique, or for propaganda. Crowd Control Security teams should remove all curious bystanders from within the perimeter. Police should have a system of Annals of Emergency Medicine S13
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collecting information from potential witnesses or family members (name and contact information) for follow-up by law enforcement. All noncredentialed persons, including volunteers who want to assist, should be kept outside of the incident command location, triage locations, and ambulance staging areas. Responders will likely have to deal with the news media. The Incident Command System is capable of handling the media effectively if established early. This duty can be delegated to the information officer, who should handle all contacts with the press. This allows responders to perform their duties and limits the dissemination of partial or false information. Responders who encounter members of the news media should refer them directly to the information officer and refrain from discussing scene management details.1 Blast incidents can be emotionally catastrophic for family members and responders. EMS providers must be prepared to handle injured patients who are related (parents or children) and uninjured family members who arrive on scene to search for their loved ones. Although not discussed in detail here, experts agree that, because of the heightened emotional sensitivity at mass casualty incidents and at explosive scenes in particular, it is important for law enforcement and EMS teams to discuss and plan how to handle family interactions before an event. Specialty Teams, Decontamination, and Concealed Weapons When an explosive device is suspected, appropriate specialists, such as the bomb squad or SWAT team, should be involved. Bomb technicians should be dispatched to the scene to assist with the search for and safe disposition of secondary devices. As discussed earlier, out-of-hospital medical providers will have to weigh the risks and benefits after initial assessment of the scene to decide whether to enter the damaged area before law enforcement, fire, and structural experts have advised that the scene is secure. The incident commander on scene should coordinate whether and when EMS teams proceed. Decontamination should take place in the open in a fresh-air environment, not downwind of the explosion scene and not upwind of other victims and responders. Safety perimeters and hazard control zones should be established to control movement of individuals and decrease the possibility of further contamination of victims or responders. Hazard control perimeters are divided into hot, warm, and cold zones. Hot zones are the designated regions immediately surrounding hazardous material incidents and are created large enough to prevent any adverse consequences from contact with the hazard. Warm zones are S14 Annals of Emergency Medicine
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designated regions beyond the hot zone for close support functions, decontamination, and access control. Cold zones are designated regions beyond warm zones where incident command and other support functions are staged. Two types of decontamination are established at the blast scene: emergency decontamination for large numbers of patients, using fire department equipment or fire hydrants and hoses; and decontamination trailers or tents with water showers for less urgently needed agent dilution or removal. Special consideration should be given to decontamination for nonambulatory patients. In addition, experience with blast events demonstrates that the majority of ambulatory hazardous material mass casualty incident patients self-evacuate without decontamination in the field. Thus, nearby hospitals must be notified as soon as a concern for potential contamination is raised. Concealed weapons may be a problem. EMS providers are generally not trained to find concealed weapons and should not be responsible for searching for them. They should be aware that some victims may be armed and that some casualties may also be perpetrators, and exercise due caution. Weapons may be discovered coincidentally during the evaluation and triage process. Unless they have been previously trained, EMS providers should not attempt to handle any potential weapons. Protocols should be put in place for EMS providers to notify their law enforcement counterparts that a weapon has been identified and needs to be safely secured. Local Capabilities Incident commanders and EMS providers need to understand the capabilities of local hospitals, including, but not limited to, hospital surge capacity (bed availability in the emergency department [ED], hospital floor, critical care, operating rooms, etc) and treatment capability (trauma centers, burn centers with trauma capability, pediatric centers, etc). This information should be reviewed and frequently updated. EMS and hospital leadership should meet to discuss ways to make this information easily and automatically accessible in the event of a disaster. Equipment Supply and Rehabilitation Ambulances typically have more supplies than they normally need for the patient(s) they are actively transporting. After an explosion, during which resources will be rapidly consumed, EMS teams should consider leaving extra basic life support (BLS) supplies at the scene when they are transporting casualties to hospitals. This also requires making pre-event provisions to resupply ambulances in between transport of patients. Plans should include the staging of a medical supply truck or trailer at Volume 69, no. 1s : January 2017
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the scene. In accordance with review of past explosive incidents, additional supplies anticipated for these events include the following: Skeds and long boards to more easily move casualties from the point of the explosion to the triage area Tourniquets “Blowout” kits (specialized kits for blast events including tourniquets, combat-type hemostatic gauze, and basic airway adjuncts such as nasal airways) Additional pediatric kits Tents Generators and lights for command post and triage areas Bullhorns to communicate with bystanders or walking wounded and as a supplement to radio communications among the responders Operations should not be delayed to set up tents, generators, lights, or supplies unless it is essential to do so for protection of casualties and responders from the elements. Out-of-Hospital Primary Triage Blast injuries will yield multiple casualties who have a high likelihood of severe injury and mortality. As a result, triage must be conducted very early, well, and often. The earliest triage should occur at the place of injury on scene, where patients must be identified as alive, dead, or unlikely to survive (expectant). Patients who are alive are then moved to casualty collecting areas, the location of which should be determined according to the characteristics of the scene. Ideally, collection areas should be placed uphill and upwind from the blast zone because of the continued danger to health care providers from the initial blast and from potential secondary attacks. The minimum safe distance from the blast site will be scenario dependent. Extra care in planning and subsequent training must be taken when staging for response to a potential terrorist act is considered because using standardized locations for collection points may make these areas easy to anticipate and target by terrorists. As noted above, many terrorists have learned to exploit what is known as the “second-hit principle” or a “primary or diversion attack,” which involves attracting first responders by an initial blast and then injuring or incapacitating them with a subsequent attack.20,21 At casualty collection areas, a triage officer coordinates the assignment of triage teams, who then quickly evaluate and determine which patients will likely benefit from immediate intervention(s). Although physician triage officers have been shown to improve triage accuracy, the triage officer may come from a variety of backgrounds, including nursing or EMS.22,23 Because the triage officer cannot simultaneously serve in any other function, physicians may provide more Volume 69, no. 1s : January 2017
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benefit in their traditional direct-care provider roles during times of critically scarce resources.1 Triage Tools One of the most difficult decisions to be made in a mass casualty setting is determining which casualties should receive care and which should not. As a result, several mass casualty triage algorithms have been developed to categorize the severity of injury and optimize outcomes. Methodologies that require extensive observations and multiple points of testing simply do not work in a timeand resource-constrained setting such as a mass casualty incident. Presently, Simple Treatment and Rapid Transport (START) triage, Triage Sieve, and CareFlight Triage are the most used adult triage modalities.24 For example, Boston EMS uses the START triage method and the SMART triage tag system.* The START triage adult algorithm remains perhaps the most widely used mass triage algorithm in North America and has been used at disasters such as the 1995 Oklahoma City bombing and the 1992 and 2001 attacks on the New York City World Trade Center.24-26 The START triage algorithm assigns patient priority according to ability to walk, airway patency, respiratory rate less than or greater than 30 breaths/min, presence of radial pulse or delay in capillary refill, and ability to follow commands. Patients are next stratified into categories: minor, walking wounded (1, green); delayed, not life threatening (2, yellow); immediate, life threatening (3, red); and deceased or expectant care (4, black).27 The Triage Sieve is a widely accepted algorithm in the United Kingdom and Australia, used by EMS, hospital personnel, and the army.28 It focuses on the ability to walk, airway patency, breathing rate less than 10 or greater than 30 breaths/min, and either delay in capillary refill or pulse rate greater than 120 beats/min (depending on whether the environment is dark or cold).26,28 Although both triage modalities start the same, Triage Sieve immediately categorizes patients with a respiratory rate less than 10 breaths/min or pulse rate greater than 120 beats/min as “immediate,” whereas the START algorithm does so only if the patient also has inability to follow commands.24 The CareFlight algorithm assesses the ability to obey commands, the presence of respirations, and the palpability of the radial pulse. The respiratory rate is not assessed in the algorithm, and level of consciousness is assessed first. Because there are no numeric values associated within the *There are many commercially available triage tag systems that aid in patient triage, documentation, and tracking. The SMART Tag is one such system.
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algorithm, it may be appropriate for triaging children as well. CareFlight was used in the aftermath of the Bali nightclub bombing in 2002.24,26,29 A retrospective review found that the START and CareFlight had very similar sensitivities in predicting serious injury (85% versus 82%, respectively), whereas CareFlight triage had better specificity (96% versus 86% for START). Triage Sieve was found to be a poor predictor of identifying injury, with a sensitivity of 45%.26 Although retrospective reviews of these algorithms attempt to test for predictive validity, algorithms such as START have not been studied in real-world conditions.26 Likewise, no triage algorithm has been studied in mass casualty incident events involving biological, chemical, or radiologic agents.24 As a result, although many triage algorithms have been developed, multiple studies continue to demonstrate that the Glasgow Coma Scale motor component and the systolic blood pressure measurement remain the most specific objective values in assessing significant injury.26,30 The Sort-Assess-Lifesaving Interventions-Treatment/ Transport (SALT) triage system was designed to address evidence and efficacy issues noted in previous mass casualty triage systems. A work group was convened by the National Association of EMS Physicians in 2006 and was funded by the Centers for Disease Control and Prevention (CDC). Content experts convened to devise a triage system incorporating a review of the best literature available.31 This triage system was designed according to currently available research, best practice of existing systems, and consensus opinion from the experts involved in the work. The SALT triage system involves a few key components. Patients with obvious life-threatening injuries or apparent unconsciousness require immediate assessment. Lifesaving interventions include major hemorrhage control, opening airway maneuvers, chest decompression, or the consideration of autoinjector antidotes. After these interventions have been performed, if indicated, further assessment is conducted to determine the next level of care for the patient.31 The Model Uniform Core Criteria were created by another work group funded by the CDC to expand on the work from the group that designed the SALT triage system. It involved 4 general categories (general considerations, global sorting, lifesaving interventions, and individual assessment). The work group concluded that these are the minimum elements that all mass casualty incident triage systems must incorporate into their algorithm.32 The Federal Interagency Committee on Emergency Medical Services recommends that all states adopt triage methods that are based on the Model Uniform Core Criteria, such as the SALT triage system.32 S16 Annals of Emergency Medicine
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Under- and Overtriage Although it is important to remember that triage is a dynamic, continuous process in which patients require frequent reassessment, the accuracy of on-scene triage may affect the overall success of the medical response.33 During the initial chaos of a mass casualty event, triaging errors are prone to occur. Undertriage involves incorrectly assigning critically ill victims to delayed categories. Delaying muchneeded medical care to such individuals can lead to devastating consequences, including death.34,35 One way to reduce undertriage may be to assign clinical providers to all delayed-care areas so that they may quickly identify and upgrade deteriorating patients. Given the fact that, under normal circumstances, medical personnel often provide the greatest amount of good for the patient at hand, overuse of resources, or overtriage, becomes an issue that will quickly burden tertiary hospitals in mass casualty incidents. This involves providing immediate care to individuals who do not necessarily require it. Although overtriaging typical, small patient loads poses only economic and administrative strains on hospitals, during mass casualty incidents, it can pose a significant lifethreatening risk.13,22 A large influx of noncritical victims delays rapid identification and direct care of the critically ill. Data from mass casualty bombings, as published by Frykberg and Tepas,34 demonstrate a direct, linear relationship between overtriage rate and the mortality rate of survivors. Computer modeling further shows that quality of care provided is poorer with increasing rates of overtriage, and thus patient load.35 As a result, disaster response should aim to maximize triage accuracy while avoiding both overand undertriage. Realistically, this is difficult to do in a resource-scarce environment, and thus several elements should be implemented to help create an “error-tolerant” system with enough flexibility to account for the inevitable occurrence of some triage error.35 In the out-of-hospital setting, one way to minimize overtriage is to have multiple casualty collection areas, in which noncritical casualties are progressively filtered out and only immediate patients are transported. Continued triage on hospital arrival in the ED and hospital lockdown to prevent nonevent-related walk-ins further aims to minimize this burden. Likewise, continued reassessment of noncritical casualties both in the field and within the hospital for signs of clinical deterioration are of utmost importance in preventing devastating consequences.35 Another key component of out-of-hospital triage is to evenly distribute casualties among several hospitals through a concept known as leapfrogging.36,37 The goal in bypassing the hospital most proximal to the blast zone is to avoid overwhelming one facility, as well as to match patient Volume 69, no. 1s : January 2017
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needs with appropriate hospital-specific resources.35 The closest hospital will likely face the largest volume of selfevacuated walking wounded. Ideally, patients with severe injuries should be transported to trauma centers. Treatment In general, advanced life support (ALS) treatment should not be provided at the scene. Casualties are only to be treated on scene if there is a delay in transporting them to the hospital. While they are en route, ALS treatment may become necessary, but BLS with pain control is paramount. BLS providers should remember that pain control is not limited to medications; patient positioning, splinting, temperature control within the ambulance, blankets, etc, factor in to treating pain within the BLS scope of practice. Again, although EMS or field-trained physicians and nurses may be able to provide excellent triage, the staffing of nonscene trained medical personnel such as physicians and nurses should be avoided. EMS or field-trained physicians and nurses, on the other hand, may be able to provide better triage. Such individuals often provide too much care and prolong field time.35 Patient Tracking Scene patient tracking should be a formal, integrated system with data that include names (if possible), type and extent of injuries, times of assessment and transfer, and disposition, with the name of the receiving facility. A tracking system should also be in place for the walking and mildly wounded because they are difficult to manage and often wander around the scene. It is important to send them to a casualty collection area for further instructions and attempt to prevent them from going to the nearest hospital on their own. As discussed in the above triage section, it is easy to inundate the closest hospital, especially when ambulatory victims self-transport to the nearest facility. Blast injuries may present unique patient flow challenges, with patients often sustaining loss of sight and hearing, impeding effective communication. Instructions should be simple, and signs should be easily understandable. If available, volunteers may be a valuable resource to guide such patients to appropriate locations. Providers should gather contact information (name and contact telephone numbers) for victim tracking and potential law enforcement follow-up. All hospitals in the service area (and optimally, all hospitals in the same region) should use the same patienttracking system. Evidence Collection While providers are on scene, it is important for them to remember that every explosive event is treated by federal, Volume 69, no. 1s : January 2017
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state, and local law enforcement as a deliberate, criminal act until proven otherwise. Evidence collection, although important for law enforcement, should remain secondary to patient care and should not interfere with casualty assessment. Nonetheless, organic debris should be maintained as evidence because it may help identify the type and source of the blast explosion. Procedures should be enforced to maintain chain of custody for evidence gathered at the scene. Police should also gather the names and contact information of uninjured witnesses to the event. If possible, witnesses should be interviewed at the scene, even if briefly, with scheduled follow-up. Transportation Traffic control at the scene is essential. Ambulance and other emergency vehicle ingress and egress must be controlled very early, with staging and pickup areas clearly identified and protected. Ambulances should go to a staging area established by the incident commander until called to pick up patients. Clearing roads to casualty collecting areas and receiving hospitals is of major importance. A recommended approach is the use of contraflow. In this solution, one or more of the lanes inbound to the blast zone is reversed to become an outbound lane (in the direction of the hospital). This serves to reduce traffic and alleviate bottlenecks.38 Explosions may produce large numbers of casualties and create a need to consider nontraditional transportation. The use of buses, vans, and other nontraditional means for transporting patients classified as having minor and delayed triage should be considered. If nontraditional transport is used, medical personnel and supplies should accompany patients during transport to continually triage and reassess their status and provide immediate care if necessary. Safety or security support should also be provided during transport; for example, police escorts for nontraditional vehicles. Nonmedical drivers of nontraditional transportation, such as bus or cab drivers, may not be willing to respond to an explosive incident. In this case, out-of-hospital leadership must identify and routinely train staff members on how to operate a nontraditional vehicle and safely transport their patients with one. As always, planning, training, and exercise are required for effective response. For pediatric patients, a family member should go in the same ambulance with the child if possible. If, however, both parent and child are injured, they should be sent to a trauma center first because sending injured parents along with their children to a children’s hospital may overwhelm the staff at the children’s hospital and result in suboptimal care for the adult casualty. Annals of Emergency Medicine S17
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The organized use of private vehicles should be avoided. Although the Oklahoma City, Iraq, and Israel experiences have demonstrated that private vehicles will be used by individuals before responders arrive, this is done individually. Private vehicles are difficult to identify as authenticated victim transport vehicles and need to be screened for possible delivery of secondary devices. DEMOBILIZATION AND TERMINATION As the scene becomes more stable and casualties are transported to hospitals, the incident commander will gradually release responding units back into general service. When the incident commander is satisfied that all potential casualties have been evacuated from the scene, he or she will terminate the response and compile a final progress report, including patient totals and unit status. In the days after an explosive incident, it is likely that many providers, patients, and family members will be emotionally affected by the event. It is crucial to address the psychological health of anyone involved. Summary Explosions significantly complicate the management of a mass casualty incident scene and require that several additional issues be taken into account. The Incident Command System should be followed and basics such as situational awareness, scene safety, and rapid triage and transport are paramount. Complicating factors, such as secondary devices, concealed weapons, structural integrity, and potential criminal investigation, will affect crowd and scene control. Minimal ALS should be provided on scene. Treatment should focus on strong BLS skills, with a goal of transporting patients to definitive care as quickly and efficiently as possible. The key to optimal scene management lies in routine assessment and reassessment of all-hazards planning, with training and regular exercises that include all involved agencies. Author affiliations: The Departments of Emergency Medicine and Medicine, Rutgers, The State University of New Jersey–Robert Wood Johnson Medical School, New Brunswick, NJ (Donovan, Bryczkowski, McCoy, Tichauer, Eisenstein, Bucher, Lacy); American College of Surgeons, Chicago, IL (Chapleau); and University Center for Disaster Preparedness and Emergency Response at Robert Wood Johnson University Hospital, New Brunswick, NJ (Lacy, Eisenstein, Donovan). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and have provided the following details: funding for this project was provided by a grant to Robert Wood Johnson University Hospital from the Telemedicine and Advanced Technology Research Center (TATRC), US Army Medical
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Research and Materiel Command, under contract number W81XWH0810324. Publication of this Supplement is supported by Robert Wood Johnson University Hospital, New Brunswick, NJ. Military disclaimer: The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of Defense or the US Government.
REFERENCES 1. FEMA. Incident Command System. 2013. Available at: http://www. fema.gov/emergency/nims/IncidentCommandSystem.shtm. Accessed October 3, 2016. 2. Department of Homeland Security. National Incident Management System training program. September 2011. Available at: http://www. fema.gov/pdf/emergency/nims/nims_training_program.pdf. Accessed October 3, 2016. 3. Robert Wood Johnson Foundation. Nicole Lurie: strength needed in time of emergency. 2011. Available at: http://www.rwjf.org/en/cultureof-health/2011/04/nicole-lurie-strength-needed-in-time-ofemergency.html. Accessed October 3, 2016. 4. Department of Homeland Security. National Incident Management System Training Program. 2011. Available at: http://www.fema.gov/ pdf/emergency/nims/nims_training_program.pdf. Accessed October 3, 2016. 5. Friedman FD. Conventional explosions at a mass gathering. In: Ciottone GR, ed. Disaster Medicine. Philadelphia, PA: Elsevier/Mosby; 2006:764-766. 6. Opinion of the Best Practices for Management of Explosive Incidents—Expert Panel. Presented at: Robert Wood Johnson University Hospital; December 22, 2010; New Brunswick, NJ. 7. Neaves TT, Mann SC, Myers LB, et al. Assessing Reverse 911®: a case study of the 2007 San Diego wildfires. J Emerg Manag. 2014;12:315-325. 8. Mistovich JJ, Hafen BQ, Karren KJ, et al. Scene size up. In: Werman HA, ed. Prehospital Emergency Care, 6th ed. Upper Saddle River, NJ: Brady; 2000:128-145. 9. Leibovici D, Gofrit ON, Stein M, et al. Blast injuries: bus versus open-air bombings—a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996;41:1030-1035. 10. Dallas CE, Coule PL, James JJ, et al. Traumatic and explosive events. In: Basic Disaster Life Support Provider Manual, Version 2.6. Chicago, IL: American Medical Association; 2007:3-9:3-33. 11. Frykberg ER. Disaster management. In: Flint L, Meredith JW, Schwab CW, et al, eds. Trauma: Contemporary Principles and Therapy. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:44. 12. Biddinger P. Lessons in emergency preparedness after Boston bombings [transcript]. National Public Radio. May 2, 2013. 13. Ashkenazi I. Blast scene medical management. Keynote lecture presented at: Management of Explosive Incidents: Coordinating Health Care, Emergency Management and Law Enforcement; May 13, 2013; New Brunswick, NJ. 14. Roy N, Kapil V, Subbarao I, et al. Mass casualty response in the 2008 Mumbai terrorist attacks. Disaster Med Public Health Preparedness. 2011;5.4:273-279. 15. Rivkind A. “Scoop and Run” vs “Stay and Play”. 2008. Available at: https://www.oryarok.org.il/webfiles/.../rivkind_or_yarok_dec_2008. Accessed March 22, 2016. 16. Department of Homeland Security. If You See Something, Say Something campaign. 2013. Available at: http://www.dhs.gov/files/ reportincidents/see-something-say-something.shtm. Accessed October 3, 2016. 17. Salomone JP, Pons PT, eds. PHTLS—Pre-Hospital Trauma Life Support, 6th ed. St Louis, MO: Mosby JEMS/Elsevier; 2011.
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18. Department of Homeland Security. Buildings and infrastructure protection series: reference manual to mitigate potential terrorist attacks. 2011. Available at: http://www.dhs.gov/xlibrary/assets/st/stbips-06.pdf. Accessed October 3, 2016. 19. National Counterterrorism Center. Bomb threat stand-off distances. Available at: http://www.nctc.gov/docs/2006_calendar_bomb_stand_ chart.pdf. Accessed October 3, 2016. 20. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201-212. 21. Goh S. Bomb blast mass casualty incidents: initial triage and management of injuries. Singapore Med J. 2009;50:101-105. 22. Frykberg ER. Triage: principles and practice. Scand J Surg. 2005;94:272-278. 23. Champion HR, Sacco WJ, Gainer PS, et al. The effect of medical direction on trauma triage. J Trauma. 1988;28:235-239. 24. Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23.1:3-8. 25. Asaeda G. The day that the START triage system came to a STOP: observations from the World Trade Center disaster. Acad Emerg Med. 2002;9:255-256. 26. Garner A, Lee A, Harrison K, et al. Comparative analysis of multiplecasualty incident triage algorithms. Ann Emerg Med. 2001;38: 541-548. 27. START triage. Simple Triage and Rapid Treatment. Available at: http:// www.start-triage.com. Accessed February 14, 2012. 28. Hodgetts TJ. Triage: A Position Statement. 2001. Available at: http:// ec.europa.eu/echo/files/civil_protection/civil/prote/pdfdocs/ disaster_med_final_2002/d6.pdf. Accessed October 3, 2016.
29. Tran MD, Garner AA, Morrison I, et al. The Bali bombing: civilian aeromedical evacuation. Med J Aust. 2003;179:353-356. 30. Fries GR, McCalla G, Levitt MA, et al. A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting. Ann Emerg Med. 1994;25:885-889. 31. Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;(2 Suppl 1): S25-S34. 32. Federal Interagency Committee on Emergency Medical Services. National implementation of the model uniform core criteria for mass casualty incident triage. 2013. Available at: http://www.ems.gov/ nemsac/dec2013/FICEMS-MUCC-Implementation-Plan.pdf. Accessed October 3, 2016. 33. DePalma RG, Burris DG, Champion HR, et al. Blast injuries. N Engl J Med. 2005;352:1335-1342. 34. Frykberg ER, Tepas JJ. Terrorist bombings: lessons learned from Belfast to Beirut. Ann Surg. 1988;208:569-576. 35. Hirshberg A, Scott BG, Granchi T, et al. How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis. J Trauma. 2005;58:686-695. 36. Jacobs LM, Ramp JM, Breay JM. An emergency medical system approach to disaster planning. J Trauma. 1979;19:157-162. 37. Jacobs LM, Goody M, Sinclair A. The role of a trauma center in disaster management. J Trauma. 1983;23:697-701. 38. Urbina E, Wolshon B. National review of hurricane evacuation plans and policies: a comparison and contrast of state practices. Transportation Res. 2003;37:257-275.
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