Medical Management of Disasters and Mass Casualties
From Terrorist Bombings: How Can We Cope?
Eric R. Frykberg, MD, FACS
J Trauma. 2002;53:201–212.
“. . .from a terrorist perspective, the true genius of this attack is
that the objective and means of attack were beyond the imag-
ination of those responsible for Marine security.”—Report of
the U.S. Department of Defense Commission on Beirut Airport
Terrorist Act, October 23, 1983
S
ince the terrorist suicide truck bombing of the U.S.
Marine barracks in Beirut in 1983, the “imagination” of
Americans has continued to be taxed with devastating
consistency. Explosions and bombings remain the most com-
mon deliberate cause of disasters involving large numbers of
casualties, especially as instruments of terrorism, yet we still
have not learned how to anticipate and manage the tragic
carnage they cause with any degree of effectiveness. These
attacks virtually always are directed against the untrained and
unsuspecting civilian population. Unlike the military, civil-
ians are poorly equipped or prepared to handle the severe
emotional, logistical, and medical burdens of a sudden large
casualty load, and thus are completely vulnerable to terrorist
aims.
1,2
THE CHALLENGE
The civilian medical community in the United States has
been relatively indifferent in past years to the potential threat
of deliberate terrorist attacks and mass casualties.
3
We have
been shielded from such incidents, and thus have been spared
the need to confront the unique challenges of suddenly de-
livering medical care to great numbers of injured victims. Our
naivete and inexperience in this area have been demonstrated
by the predictably confused responses to recent terrorist di-
sasters in Oklahoma City in 1995, and in New York City,
with the World Trade Center bombing in 1993 and the col-
lapse of the World Trade Center towers on September 11,
2001.
4
Trauma physicians and trauma centers are uniquely qual-
ified to play a leading role in the medical management of
disaster victims and in the overall coordination of disaster
response. They already are an integral part of the prehospital
emergency medical system and public health efforts of many
communities, and their infrastructure, training, and experi-
ence are specialized for the comprehensive evaluation and
treatment of injury.
5–7
However, the U.S. trauma community
has not at all taken the lead in the development of disaster
planning or education, which has largely defaulted to other
medical specialties and administrative and public safety or-
ganizations, and has become more of a paper drill than a
realistic guide for dealing with actual disasters.
Very few physicians have any experience with true mass
casualty events, or disasters, which by definition involve such
large numbers of victims, or such severe or unique injuries,
that local medical resources cannot fully handle them. This is
a very different situation from multiple casualty events, as we
see on a typical busy weekend night in an urban trauma
center, in which multiple patients are handled by existing
Submitted for publication March 28, 2002.
Accepted for publication March 28, 2002.
Copyright © 2002 by Lippincott Williams & Wilkins, Inc.
From the Department of Surgery, University of Florida Health Science
Center, and Division of General Surgery, Shands Jacksonville Medical Cen-
ter, Jacksonville, Florida.
Presidential address presented at the 15th Annual Meeting of the
Eastern Association for the Surgery of Trauma, January 16–19, 2002, Or-
lando, Florida.
Address for reprints: Eric Frykberg, MD, FACS, Department of Sur-
gery, University of Florida Health Science Center/Jacksonville, 653-2 West
8th Street, Jacksonville, FL 32209; email: eric.frykberg@jax.ufl.edu.
DOI: 10.1097/01.TA.0000021586.40033.BA
Eric R. Frykberg, MD, FACS
The Journal of TRAUMA
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Injury, Infection, and Critical Care
Volume 53 • Number 2 201
personnel and facilities, even if strained.
8
Predictably and
logically, medical response to terrorist disasters tends to be
most sophisticated and most effective in those countries that
most commonly are exposed to them, or among those groups
who regularly train for these contingencies, such as the mil-
itary. A large body of published data now exists from these
unusual medical experiences that can serve as a valuable
learning tool for medical communities, such as ours, in which
such experience is sparse, but in which the potential for
terrorist activity is on the rise.
2,9–12
Military medical forces are well prepared and well
trained to cope with true mass casualty events, even though
they actually deal with such events as infrequently as the
civilian sector. This training, and the systematic planning for
orderly triage, stabilization, and evacuation of casualties
through a chain of treatment stations and hospitals in times of
war (Table 1), have allowed them to cope with massive
casualty burdens that would overwhelm the ordinary civilian
community. In the Battle of the Somme in 1916, the British
military medical command was confronted with the heaviest
casualty load ever documented in war, with 123,908 wounded
managed by three armies in the month of July alone, 26,675
wounded seen in one 24-hour period, and 5,346 wounded
soldiers treated in a single day by one casualty clearing
station.
13
The fact that these victims were handled in an
orderly manner, even though severely straining the system,
demonstrates the importance of training and preparation. The
generally untrained and unprepared civilian sector must learn
from this resource and from those who have handled mass
casualties, because it is the civilian medical community that
typically is confronted by terrorist acts.
Different types of disasters, such as fires, shootings,
floods, infectious or chemical agents, radiation, or earth-
quakes, result in very different patterns of injury and medical
needs. The purpose of this review is to define those principles
that are applicable to the effective delivery of medical care
after bombings and explosions, as this is the method that most
commonly has been used by terrorists, and is most likely to
result in the largest numbers of casualties and destruction of
property.
2
It also is a scenario that requires the immediate
presence of surgeons and other specialists with an expertise in
the management of trauma. A knowledge of the patterns of
injury, and barriers to care, associated with these events, as
derived from the experience of those who have been involved
in true disasters, is essential to a proper response to current
disasters, and to provide a template for maximizing casualty
survival in the future.
LEARNING FROM THE PAST
Biology of Explosive Injury
There are three forms of bodily injury induced by explo-
sive blasts—primary, secondary, and tertiary blast injuries.
Primary blast injury is caused by the shock wave that spreads
radially outward from an explosion, at the speed of sound,
and is transmitted more rapidly and powerfully, and over a
longer distance, in water than in air. In air, this shock wave
dissipates rapidly, in relation to the cube of the distance from
the blast. The more powerful the blast, the greater the dis-
tance at which damage may occur.
2,14,15
When the shock
wave passes through the body, tissues are disrupted at air-
liquid interfaces in a process called “spalling,” and the ears
and lungs are most commonly injured. The bowels are dam-
aged only in the most powerful blasts, most typical of under-
water blasts. The degree of tissue injury is directly related to
the magnitude and the duration of the peak overpressure of
the blast shock wave. After this is a longer phase of negative
pressure, when implosion may occur, and then a major move-
ment of air known as “blast wind.”
12,16–18
Most victims of
primary blast lung injury from explosions are killed imme-
diately, as the vital organs are likely to be fatally injured in
anyone who is close enough to the blast to be hit by the shock
wave before it dissipates. Death is often caused by massive
cerebral and coronary air embolism, as well as the most
powerful forms of secondary and tertiary injuries this close in
to the explosion. Late deaths among the small number of
survivors with primary blast lung injury are caused by pro-
gressive pulmonary insufficiency, which has all the radio-
graphic and pathologic signs of parenchymal hemorrhage,
similar to blunt contusions.
19,20
Indoor detonations tend to cause more severe primary
blast injuries than open-air bombings outdoors, because the
blast wave is magnified, rather than dissipated, as it is re-
flected off walls, floors, and ceilings. Leibovici and cowork-
ers documented a 7.8% mortality among 204 casualties in-
volved in open-air bombings in Jerusalem, and a 49%
mortality among 93 victims of detonations inside buses.
12,21
Secondary blast injury is caused by debris set in motion
by the shock wave that impacts the body. Tertiary blast injury
involves the actual displacement of the victim’s body to crash
into other objects. These two forms of explosive injury cause
typical bodily trauma, and it is these injuries that predominate
among survivors of bombings.
12,22,23
Profile of Past Explosive Disasters
Two major urban explosions in the 20th century, both
accidental, serve to illustrate the enormous problems faced by
the civilian medical community in caring for mass casualties.
On December 6, 1917, a Belgian ship, the Imo, collided with
the French munitions ship Mont Blanc in Halifax harbor,
Table 1 Casualty Flow in Disasters
Rescue
2
Decontamination
2
Sorting and life support (triage)
2
Evacuation
2
Definitive care
The Journal of TRAUMA
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Injury, Infection, and Critical Care
202 August 2002
Nova Scotia, causing 35 tons of benzene to ignite on the top
deck of the latter ship in a major fire. Fifteen minutes later,
this fire ignited a cargo below decks consisting of 2,300 tons
of picric acid, 10 tons of gun cotton, 300 rounds of ammu-
nition, and 200 tons of trinitrotoluene (TNT), to cause the
largest nonnuclear man-made explosion in history. The ship
itself was blown 1 mile high, and its 2-ton anchor was found
2 miles away. Over 2.5 km
2
of the city was leveled by the
blast and subsequent 150-foot-high tidal wave, also wiping
out hundreds of firefighters and onlookers who responded to
the initial fire. The blast shattered windows 100 km away.
There were 2,000 deaths, 9,000 injured, and 20,000 left
homeless, in a city of only 50,000 population.
24
On April 16, 1947, the ship Grand Camp caught fire in
the port of Texas City, Texas. Twenty minutes later, its cargo
of ammonium nitrate fertilizer exploded, shooting a column
of smoke 2,000 feet into the air, and hurling the ship’s 1.5-ton
anchor 2 miles away. Shortly after this was another more
powerful blast, followed by a 150-foot-high tidal wave and
numerous fires throughout the area. There were 600 deaths in
a city of only 16,000 population, including, once again, the
loss of the city’s entire fire department and dozens of on-
lookers who responded to the initial fire.
25
These disasters demonstrate how a typical community’s
medical resources would be overwhelmed by such large ca-
sualty loads, especially if medical facilities also were de-
stroyed. Medical management of such great numbers must
depend on help from outside, and on the ability to evacuate
victims to other facilities and other locations for definitive
care (Table 1).
7
The panic, chaos, and emotional trauma of
such disasters can magnify the loss of life, and are best
combatted by prompt and vigorous leadership, and a preex-
isting plan for the immediate rescue, disposition, and treat-
ment of casualties.
26
Also demonstrated was the importance of protecting
medical assets by keeping them away from the explosion
scene and areas at high risk of further attack and damage. The
“second-hit” principle was well illustrated in these incidents,
involving the attraction of first responders and onlookers by
an initial fire or explosion, who then are wiped out by a
subsequent blast or other force. Terrorists have learned to
exploit this to great effect, and this has become a common
pattern in terrorist bombings to maximize injury and fear. The
fact that first responders typically include firefighters, police,
and medical personnel, who are trained to help victims, em-
phasizes the danger of this phenomenon to subsequent rescue
and care efforts, and the importance of avoiding it by restrict-
ing the initial response.
2,5
Terrorism is the unlawful exercise of random and ruth-
less violence against property or individuals, usually innocent
civilians, to intimidate governments or societies for political
or ideologic purposes.
27
The devastation caused by explo
-
sions has led to this becoming the most common deliberate
weapon of terrorism. The first recorded terrorist bombing
occurred in Antwerp, Belgium, in 1585, when 7 tons of
gunpowder were detonated to destroy a bridge on the River
Schelt, reportedly killing 1,000 soldiers, among whom
“. . .some dropped dead without any wounds, sheerly from
concussion.”
3
This is probably the first known description of
primary blast injury. The number and destructive power of
bombings reached a zenith in the 20th century. There was a
10-fold increase in terrorist bombing incidents worldwide
between 1968 and 1980, with 5,075 events documented be-
tween 1973 and 1983, causing 3,689 deaths and 7,991
injuries.
28
Even in the United States, there were 12,216 bombing
incidents just between 1980 and 1990. This trend continued
increasing during the 1990s, with 1,582 bombings causing
222 injuries and 27 deaths in the United States in 1990
alone.
3,11,29
However, Americans have continued to feel im
-
mune to any significant impact from bombings until rela-
tively recently (Table 2).
The first major loss of American lives from this form of
attack occurred with the truck-bombing of the U.S. Marine
barracks in Beirut, Lebanon, in October 1983. The detonation
of an ammonium nitrate fuel-air bomb resulted in an explo-
sive force equivalent to 6 tons of TNT, the largest nonnuclear
man-made explosion ever detonated deliberately. This caused
the complete collapse of the four-story building, with 346
casualties, including 234 (68%) immediate deaths and 112
survivors. The onshore battalion aid station was located on
the fourth floor, and its physician and several corpsmen were
killed. Initial rescue efforts were hampered by hostile sniper
fire. Sixty-five survivors were treated by an on-site U.S.
Navy surgical team aboard a ship located offshore in the first
6 hours after the incident. A total of 86 survivors were then
evacuated to Germany, Italy, and Cyprus for definitive
care.
30–32
Analysis of the patterns of injury and death from this
event demonstrates some important principles relating to di-
saster management. Most survivors had noncritical injuries.
Nineteen survivors (17%) were critically injured (Injury Se-
verity Score [ISS] ⬎ 15), among whom seven (37%) deaths
ultimately occurred days to weeks later. Six of these deaths
Table 2 Prominent Terrorist Bombings Since 1969
Event Year
Cu Chi, Vietnam 1969
IRA Bombings, U.K. 1970s
PLO in Israel 1970s
Bologna, Italy 1980
U.S. Marines, Beirut 1983
Paris bombings 1986
Lockerbie Pan Am crash 1988
World Trade Center 1993
AMIA, Buenos Aires 1994
Oklahoma City 1995
Atlanta Olympics 1996
U.S. Embassies, Africa 1998
World Trade Center collapse 2001
Disaster and Mass Casualty Management
Volume 53 • Number 2 203
(86%) were in victims who were rescued and treated more
than 6 hours after the blast (2 had severe burns), whereas only
1 occurred, from blast lung injury, among all 65 survivors
rescued early. This emphasizes the importance of a short
interval between injury and treatment, and early aggressive
resuscitation, as a prognostic factor for survival.
1,32
The high immediate death rate (68%), and the high
dead/wounded ratio of ⬎ 2:1 (which is a reversal of the
1:2–1:5 ratio typical of military combat in conventional wars)
was probably because of the extreme magnitude of the ex-
plosive force and the added impact of building collapse. Both
of these are major prognostic factors of terrorist bombings
that affect casualty outcome.
28
The high death rate among the
critically injured survivors (7 of 19 [37%]) also can be at-
tributed to these factors. This “critical mortality rate” more
accurately reflects the magnitude of the disaster and results of
medical management than the overall mortality rate of 6.3%
(7 of 112), as it measures deaths among only those truly at
risk of death. The overall mortality rate is falsely diluted by
the majority of noncritical survivors.
32,33
Most survivors of the Beirut bombing suffered soft tissue
and musculoskeletal injuries, which were relatively mild and
not life threatening. Head trauma was the most common
injury among immediate (71%) and late deaths (57%), but
only 11% (4 of 37) of those with head injuries died.
30
Chest
trauma (including blast lung) and burns occurred in only a
small number of survivors, but were major contributors to
late deaths (29% each), and had the highest specific mortal-
ities (15% and 40% mortality, respectively, among all survi-
vors with these injuries). These data indicate the importance
of anatomic site and nature of injury as a prognostic factor
among bombing victims, and may be useful in comparing
different bombing disasters with respect to medical needs and
how medical care may affect outcome. Also demonstrated in
this incident were the dangers of placing medical assets in
front-line high-risk areas, the potential for first responders to
be killed by a second-hit phenomenon (in this case, sniper
fire), and the need to triage and manage casualties at a site
distant from the disaster scene.
5
The importance of an immediate presence of surgical
capability, and an established evacuation plan, were other
lessons learned in the Beirut experience. Survivors of bomb-
ings can be expected to have a variety of injuries from
secondary and tertiary blast effects, for which surgery is
likely to be necessary in the most seriously wounded. Two
laparotomies were performed within hours of the bombing by
the on-site surgical team in Beirut, and most evacuated sur-
vivors required rapid resuscitation and surgery over the next
3 days.
32
These factors undoubtedly saved lives among the
most critically injured survivors.
Several other terrorist bombings that primarily involve
indoor detonations have been documented in the published
literature (Table 3). It is worthwhile to review the results of
these events to confirm the importance of the lessons learned
in Beirut, and delineate any other factors that may impact on
the effective delivery of medical care in these unique
circumstances.
In August 1980, the railroad terminal in Bologna, Italy,
was bombed during rush hour with an explosive device of 20
kg of TNT, causing a partial building collapse. There were
291 casualties, 73 (25%) of which were immediately killed.
Although 83% of the 218 survivors were hospitalized, only
48 (22%) were critically injured, in which group 11 deaths
occurred (6% overall mortality, 23% critical mortality rate).
23
The occurrence of building collapse, and an injury pattern of
largely noncritical soft tissue and musculoskeletal trauma,
were similar to the Beirut bombing. The percentage of criti-
cally injured survivors was also similar. The ISS distributions
of survivors from both events were remarkably similar, with
a mean ISS in both incidents of approximately 11.
32
The
lower immediate death rate, and the lower but still substantial
critical mortality rate, in the Bologna incident, were probably
because of the weaker explosive force and the building col-
lapse affecting only a portion of the casualties, with much of
the blast dissipated through the open air of the spacious
building. The large casualty load was the result of the large
number of people in the building at the time.
A series of 11 terrorist bomb explosions occurred in
Paris, France, during a 10-month period in 1986, all but one
occurring indoors. Five events produced more than 30 casu-
alties each. A total of 268 casualties occurred, with 13 im-
mediate deaths (5%) and 205 of the 255 survivors hospital-
ized. Forty survivors were critically injured (16%), among
whom seven died (17.5% critical mortality, 3% overall mor-
tality). The average ISS of all survivors was 14.8, but among
the seven late deaths it was 39.8.
28
An explosive device of 10 kg of TNT was detonated
during the noon meal in a U.S. military mess hall in Cu Chi,
Vietnam, in 1969, resulting in 46 casualties, including 12
immediate deaths (26%). Twelve of the 34 survivors were
evacuated to U.S. Army hospitals (35%), among whom 3
(25%) died.
34
In 1994, a seven-story building in Buenos Aires, Argen-
tina, which housed the Argentine Israeli Mutual Association
(AMIA), was leveled by the detonation of an ammonium
nitrate fuel-air explosive device with a blast force equivalent
Table 3 Primarily Indoor Terrorist Bombings
Event
No. of
Total
Casualties
No. of
Immediate
Deaths (%)
No. of
Critically
Injured (%)*
No. of
Survivor
Deaths (%)*
Cu Chi
34
46 12 (26) 3 (9) 3 (9)
Bologna
23
**
291 73 (25) 48 (22) 11 (6)
Beirut
32
**
346 234 (68) 19 (17) 7 (6)
Paris
28
268 13 (5) 40 (16) 7 (3)
AMIA
35
**
286 82 (29) 14 (7) 7 (3)
Oklahoma City
36
**
759 162 (21) 52 (9) 5 (0.8)
Total 1,996 576 (29) 176 (12.5) 40 (3)
* Percentage of total survivors.
** Involved major element of building collapse.
The Journal of TRAUMA
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Injury, Infection, and Critical Care
204 August 2002
to 660 lb of TNT.
35
There were approximately 286 total
casualties and 82 (29%) immediate deaths. Among the 204
survivors, 41 (20%) were hospitalized, 14 (7%) were criti-
cally injured, and 4 of these died, for an overall late mortality
of 3.4% and a critical mortality rate of 29%. The most
severely injured were those within the building at the time of
the bombing.
In 1995, an ammonium nitrate bomb designed as a fuel-
air explosive (similar to the explosions in Texas City, Beirut,
and Buenos Aires) was detonated in front of the Murrah
Federal Building in Oklahoma City, Oklahoma, with a blast
force equivalent to 2 tons of TNT.
36
This caused a partial
collapse of the building and damage to several surrounding
buildings. There were 759 total casualties, 162 (21%) imme-
diate deaths, 83 (14%) hospitalized survivors, and 52 (9%)
critically injured survivors, among whom there were 5 late
deaths (0.8% overall mortality among all 597 survivors, 9.6%
critical mortality rate). As in the AMIA bombing, the highest
mortality and most severe survivor injuries occurred in the
victims in the collapsed portion of the building (Table 4).
The collapse of the twin towers of the World Trade
Center in New York City on September 11, 2001, was dev-
astating in terms of how unexpected it was, and the realiza-
tion of how vulnerable the United States is to such attacks.
The jetliner crashes into these buildings, quite analogous to
bombings, are estimated to have imparted the equivalent of
12,500 tons of force. The subsequent building collapse is
estimated to have released the equivalent explosive force of
900 tons of TNT,
37
resulting in approximately 3,000 deaths,
and several hundred survivors with predominantly noncritical
injuries (dead/wounded ratio of 5:1). With only a few survi-
vors rescued from the collapsed buildings, the immediate
death rate among those in the buildings was over 99%.
Complete information on severity of injuries and mortality
among survivors is not yet available.
The published casualty figures and outcomes from sev-
eral bombings that were primarily outdoors
10,12,18,38–42
all
demonstrated similar patterns of predominantly noncritical
injuries, but had relatively low immediate and late
mortality.
33
Analogous results were reported after the bomb
-
ing at the 1996 Olympics in Atlanta, Georgia,
43
although the
major injuries from this incident were penetrating wounds
from strewn shrapnel, somewhat different from the blast-
related blunt trauma of most other bombings. All these events
occurred in major urban settings, with several nearby hospi-
tals and extensive medical resources available, and involved
relatively small bombs with rapid blast dissipation within a
short distance in the outdoor environment. These are proba-
bly the major factors contributing to the low critical injury
and mortality rates of these incidents.
Patterns of Injury, Severity, and Mortality
It is important to distinguish the two goals of terrorist
attacks: casualty generation, or the total number injured and
killed from the single use of a weapon; and lethality, or the
proportion of casualties killed. The magnitude of an explo-
sion, and the number of people in the vicinity, primarily
determine casualty generation, whereas indoor location and
building collapse maximize lethality.
3
Analysis of past bombing disasters reveals definite pat-
terns of injury and mortality, which provide the opportunity
to plan and prepare for future events. Immediate deaths, or
those who die before reaching medical care, appear related to
the magnitude of the explosion, the occurrence of building
collapse, and an indoor location (Table 3). A comparison of
those bombings involving a major component of building
collapse shows substantial rates of immediate deaths, and
relatively constant critical mortality rates among survivors,
with widely varying explosive forces (Table 5). Those inci-
dents involving an additional component of indoor location
were associated with the highest immediate death rates. This
suggests that building collapse is the most important deter-
minant of outcome among these variables. Indoor blasts not
only magnify the destructive power of the primary blast
shock wave but also promote complete building collapse,
which maximizes both casualty generation and lethality of a
bombing.
12,18,21,34,42
A greater magnitude of explosive force tends to maxi-
mize casualty generation, even in outdoor locations, but the
rapid dissipation of the shock in open air reduces lethality,
with a lower level of critical injuries among survivors. The
open-air bombings at Old Bailey, the Tower of London, and
Jerusalem in the 1970s, and at the 1996 Olympics, support
this observation.
11,40,41,43
This was also illustrated in the
Oklahoma City bombing in 1995, in which a very large 2-ton
TNT equivalent blast was primarily directed through the air
Table 4 Impact of Building Collapse on Outcome in
Oklahoma City Terrorist Bombing, 1995*
Casualty
Location
No. of
Casualties
No. of
Dead (%)
No. of
Survivors
No. of Survivors
Hospitalized (%)
Collapsed 175 153 (87) 22 18 (82)
Uncollapsed 186 10 (5) 176 32 (18)
Total 361 163 (45) 198 50 (25)
* Includes only 361 casualties inside the Murrah Building, strat-
ified by portion of building in which they were located. From Mallone
et al., 1996.
36
Table 5 Relation of Explosive Force and Building
Collapse to Casualty Outcome*
Event
TNT
Equivalent
(Tons)
Immediate
Deaths (%)
Critical
Survivors
(%)
Critical
Mortality
(%)
Bologna
23
0.04 25 22 23
Beirut
32
6681737
AMIA
35
0.33 94 34 29
Oklahoma City
36
2878228
WTC 9/11/01
37
900 ⬎99 ? ?
WTC, World Trade Center.
* Includes only those casualties in collapsed portion of buildings.
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