Medical personnel work outside the medical tent in the aftermath of two blasts which exploded near the finish line of the Boston Marathon on April 15.
The bombs went off, one after the other. There was the potential more would explode, or some other threat would come to pass. The EMS providers were prepared for athletes, and an occasional bystander injury. But special events with big crowds mean rescuers must be prepared for any type of emergency.
In Boston on April 15, the scene evolved within seconds from marathon medicine to bomb and blast injuries, and EMS responders performed in the midst of hundreds of cameras. They did so with the highest level of professionalism.
Big Events, Bigger Risks
All-hazards preparedness begins with assessment of the community and preparation of emergency response personnel. It means EMS organizations and their individual EMTs must be prepared for responding to mass-casualty events of any cause, and have triage, treatment and transportation plans in place for all contingencies. An all-hazards plan means everyone understands the basic steps of scene safety, triage, primary interventions and transportation.
Start with identification of high-risk major events and likely scenarios. As in Boston, many communities have large events for which EMS providers must be accountable. Common ones are fairs, festivals, and athletic, faith-based and entertainment events. Each of these events requires a large-event plan. Contained within that must be contingencies for weather, acts of violence and unplanned structural problems (e.g., bleacher collapse at an athletic event, accidental carbon monoxide release). All event plans should address an element of unknown risks, and specify how further levels of resources can be tapped. EMS providers are typically assigned duties for planned medical events. Those personnel must serve as the center point of an MCI response should the unexpected occur.
Preparation of Personnel
Emergency providers must have three elements of preparedness firmly in place.
- Caregivers must be a flexible resource. With all-hazards training, EMTs and others can be used to provide care for a wide variety of medical problems, even those that change quickly. Day-to-day management of emergency medical problems provides the basis for this flexibility.
- Emergency providers must be provided with appropriate personal protective equipment and trained in its use. The elements of PPE (masks, gloves, gowns, eye protection) may change over time and even during an incident, but all personnel must have those measures of protection available. In Boston, providers were equipped primarily to manage running injuries, heat illnesses and metabolic stress. But the boxes of gloves and sports dressings were quickly adaptable for the treatment of bomb and blast injuries.
- All providers must be trained in recognizing unsafe incident scenes as part of their general preparedness for work in the field. They must know when to back away if a scene is not safe, and be capable of working within the National Response Framework and an incident management system. Day-to-day use of Incident Command principles provides the basis of this skill. At the Boston Marathon finish line, a variety of medical providers already had vests in place that identified their places in the incident and medical management systems. The responsible individuals could quickly adapt the management structure to the bombing incident.
Provision of initial emergency care for multiple victims requires providers to recognize the event that’s occurred, and for someone to declare that operations have switched from routine to extranormal. This is easier to do when a bomb has detonated or thunderstorm winds have just collapsed a tent onto a big crowd.
Care must begin with the basic elements of triage. Rapid evaluation and a few primary interventions will minimize the loss of life among those closest to the event. EMS providers must be prepared to do this evaluation with no medical equipment; most medical triage systems (START, SALT and others) allow for that to occur with just a pair of gloves.
To protect personnel while accomplishing triage, EMS leaders should consider that large-event supply packs include a box of extra gloves, goggles, gowns and masks, and a box that includes triage cards, MCI vests and signage, and a set of MCI management worksheets.
Responders must be prepared for an event that represents an ongoing threat to them or the public. The recognition of continuing risk is now obvious in events involving explosives. There can be secondary explosive devices. Law enforcement and fire personnel will have to be responsible for identifying areas where those devices may be located, and areas that, at least for a short time, can be used for triage and treatment. EMS personnel may be asked to move patients out of high-risk areas, maybe even using sheets or tarps.
Equally important is identifying risks from ongoing structural instability and moving rescuers and victims away from them. If building parts are still coming down, high winds are still blowing or exhaust is still coming from a defective furnace, the risks are escalating, and the victims and rescuers must be moved. If an event is a result of chemical, biological or radiologic hazards, it will also be necessary to evacuate outside any hot zone.
Proper use of PPE is integral to approaching unsafe scenes. Regardless of the risks, EMS workers should be confident that their lives and the well-being of their families will be protected. That must begin with a day-to-day use of proper turnout gear, personal protective equipment, education, and all tools to mitigate risks for EMS workers.
The most difficult issue in coordinating a major incident response, especially a terrorism incident, is how to establish and maintain effective communications. The first priority is to minimize damage at the original scene, perform a safe operation, involve law enforcement and activate the next level of providers needed.
Communication systems must be established quickly. The first priority is establishment of Incident Command and communication systems that link public-safety providers and the dispatch/9-1-1 center. Some communication will occur face-to-face at the scene. This was facilitated in Boston by the presence of all the providers, in identifying vests, at the scene in a pre-established structure. Those providers changed their roles to respond to the bomb incident, and added the next layers of fire, medical and transportation resources. Hospitals were notified so they could deal with the first-arriving victims, who always arrive by foot or car ahead of the first ambulances.
One important note on communication systems that comes from recent bomb incidents: The EMS plan cannot rely on cellular phones for critical communications. Law enforcement may decide at a bombing incident to shut down the cellular phone network in the immediate area to mitigate the risk of secondary devices activated by cell phones. EMS providers, unless their phones are specifically equipped, will not be able to use their phones in the area.
Quickly following a terrorist incident, prehospital and hospital-based emergency providers must agree on medical management strategies for victims. If it is determined that safe care can be delivered away from the hospital, field treatment without transportation may be instituted. Supplies needed for field care may be delivered to areas near the incident scene or to community collection points where victims are directed to seek care. Transportation to hospitals may be reserved for only those meeting certain triage criteria. Planning activity by hospitals will need to cover the potential to “lock down” and secure a hospital in the event it could become a target, either intentionally or unintentionally. Hospitals need plans to secure themselves with minimal law enforcement assistance, as the community’s initial complement of law enforcement may be committed to scene activity.
Blast and burn injuries require special consideration. The event may be categorized as one involving high-order explosives (HE) or low-order explosives (LE), which produce different patterns of injury. Examples of HE include TNT, C4, Semtex, nitroglycerin, dynamite and ammonium nitrate fuel oil (ANFO). High-order explosive incidents result in large numbers of casualties and major structural damage. Examples of LE include pipe bombs, gunpowder and most pure petroleum-based bombs such as Molotov cocktails and aircraft improvised as guided missiles. Lower-order incidents can result in high numbers of casualties, as on 9/11/01, but more typical events will produce a smaller number of victims, some with survivable wounds. There will be some with burn injuries requiring expedient burn care.
Blast injuries are categorized into four types.
- Primary blast injuries are caused by the atmospheric pressure of the blast wave. Organs most affected are gas-filled structures such as the lungs, GI tract and middle ear. Other injuries may include the central nervous and cardiovascular systems.
- Secondary blast injuries result in penetrating trauma from flying debris and bomb fragments. Devices may incorporate additional projectiles to increase secondary injuries. Improvised devices may include nails, ball bearings, nuts and bolts and/or metal debris. In the Middle East, larger devices have been improvised that also distribute chemical hazards including cyanide and tanks of chlorine gas. Any system of the body may be affected by secondary injury.
- Tertiary blast injuries occur when the patient’s body is propelled by the blast wave into walls or scene debris. This results in additional blunt or penetrating trauma, fractures, amputations and brain injuries.
- Quaternary injuries include the inhalation of dust, smoke, carbon monoxide and other chemicals, exacerbation of pre-existing medical conditions, thermal burns from gases or secondary fires, and crush injuries resulting from entrapment under collapsed structures.
Burn injuries are particularly devastating in the patient who has also been exposed to a blast, so burn patients must be covered, warmed, cleaned of any gross debris and transported to a prepared hospital.
The best EMS major incident response program comes from excellent day-to-day delivery of care, combined with commonsense preparedness and an excellent relationship with hospitals, law enforcement and regional public health officials. Expansion of a few physical assets, understanding of the regional resources that can be utilized for major incidents, and routine use of an incident management system will lay the necessary groundwork for a major terrorist incident response. System leaders must consider the adaptation of triage efforts and response, with security and responder safety issues becoming an immediate consideration.
This article is courtesy of Cygnus Business Media sister publication EMS World. Visit them at http://www.emsworld.com.
James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. He was assistant fire chief and medical director for District of Columbia Fire and EMS. Jim also served as chair of ASTM Task Group E54.02.01, which develops standards for hospital preparedness under Committee E54 on Homeland Security Applications. He spent 32 years as a firefighter and EMT.