1. Pre-hospital and Disaster Medicine: April-June 2004 Mass-Casualty Terrorist Bombing in Istanbul, Turkey, Nov. 2003: Report of the events and Pre-hospital Emergency Response.
Turkey with a population of 67 million, sits at the geographic, political, and cultural crossroads between Europe, Asia, and the Middle East. Turkey is a secular democracy with 99.8% muslin population. Between 1984 and 2003 there have been between 30,000-35,000 deaths related to terrorism.
A complex, retrospective, descriptive study was performed, using open source reports, interviews, hospital records, and direct measurement of distances between the bombing sites and the medical facilities.
This paper is a study of the two largest terrorist attacks in turkey’s history and the pre hospital response.
On Nov. 15, 2003 there were two truck bombings: 1. In front of Neve Shalom Synagogue, in crowed area, destroying the front of the Synagogue causing a creator 2 m deep and windows knocked out of buildings for 200m’s. 2. Within five minutes a second bomb at the Beth Israel Synagogue. Both bombs contained in trucks, an thought to be 400kg AMSO4.; killing 30 and injuring an estimated 300. Most injuries were on the street, since the worshippers inside the synagogue were protected by the front of the building.
As a result only six immediate deaths were reported in victims located within the two synagogues. Most injuries on street caused by shards of glass, masonry, and fragments of cars. At each bombing a corpse were found with wires attached, suggesting a suicide bomber. Great Eastern Raiders and Al Qaeda claimed responsibility.
Immediately post attack, bystanders performed spontaneous search and rescue at both sites. The first ambulances with EMTs arrived within 3 minutes. At 15 minutes after explosion, 26 ambulances were now at both sites and Istanbul police were beginning to establish scene security. At one hour post blast there were 50 ambulances with 170 personnel on scene.
The City’s Health Department reported that the victims were treated at 23 different hospitals. A total of 248 injuries survivors were sent to 16 medical facilities. Nine were government hospitals, six private hospitals; one is private clinic without ER. Together these 16 facilities have 4930 in- patient beds and 218 ED beds and all 16 are located within 11km of the bombing sites. Sixty nine injured survivors sought care at American Hospital (AH) 6 km away, the greatest number to any medical facilities that day; 86% with lacerations, 10% fractures, and 2% intracranial injuries and were hospitalized.
After the attack, many people tried to contact their families, rapidly overloading the communication system which subsequently failed.
On Nov. 20, 2003, a suicide bomber struck again, attacking two British facilities in Istanbul in two nearly simultaneous events. The first bombing at 1055, when a truck loaded with an estimated 700kg AMSO4 & AMN2 exploded in front of HQ of Hong Kong Shanghai Banking Corp., second largest world bank; destroying the first two floors of the building. A 3m creator was left in the street outside the bank.
At 1100, approximately 8km away, another truck with similar load, crashed through the gate of the British consulate and exploded. The consulate is only 300m from the Neve Shalom Synagogue.
Together the two bombings killed 33 persons and injured an estimated 450 others.
A famous Turkish actor, Kerem Yilmazer in his car outside the bank and the British consul general, Robert Short died in the consulate. The same group claimed responsibility for the bombing.
Immediate after the blast , bystanders began the search and rescue operation with their bare hands.
First responders responded within 3-5 minutes but did not don respiratory protection although ammonia permeated the scene as it did on the bombing of Nov. 15. TV crews were on the scene within 12 minutes and ambulances had difficulty responding due to debris on the streets. Many persons with minor injuries departed the scene and sought care at the hospitals. Bystanders help carry the bodies out to the ambulances.
Once again the police were unable to establish a secure perimeter for the first 15-20 minutes. There was little triage at either bomb site. A small clinic within 15 minutes of the blast was overrun with over 50 injuries victims, some of which, 23 severely injured victims, had to be transported to other hospitals for more detained treatment.
According to the Minister of Health the victims were treated at a minimum of 24 medical facilities. All facilities were located within 16 km of blast site.
Taksim Education and Research State Hospital the closest hospital to blast, 2km, received 184 injured survivors within one hour of blast, of which 88 (48%) were brought by ambulance. An additional 12 victims were brought by ambulance, but DOA. The remaining 96 (52%) arrived on foot.
Within five minutes of receiving notice of the blast, TERSH cleared the first three floors for the victims; 1st floor had 15 beds ED and 12 specialty beds; 2nd floor 40 bed general surgery ward; 3rd 40 beds GYN ward and the minor walk ins were treated in the parking lot.
The hospital grounds were packed with hundreds of people looking for relatives.
The AAR found important “lesions learned” as listed below.
1. Casualty mal-distribution to hospitals.
2. Not distributed to hospital according to injury but to hospitals closest to bombing.
3. Distributed to government hospitals rather to than to private or other hospitals and this was thought to be due to hospital cost of care; government care is free.
4. Little on scene command and control and not much triage at scene.
5. Istanbul sent every available ambulance to scene and many were not needed and left other areas of city uncovered for emergencies.
6. EMS unable to coordinate the distribution of casualties with hospital based on the hospital capacity to provide emergency care.
7. Istanbul police unable to rapidly control scene, resulting in bystanders and media converging on scene, getting in the way of the responders.
8. No initial scene assessment for secondary devises.
9. Government lacked official mechanism for notifying the public and keeping the public informed about the evolving situation on each date.
Conclusion:
There were two suicide truck bombings on 15 & 20 Nov. 2003; these were the two largest terrorist attacks in modern Turkish history. Collectively killing 63 persons and injuring an estimated 750 more. The majority of victims has secondary blast injuries that were relatively minor. The response was heroic, but victims were mal distributed to medical facilities. The first responders put themselves at risk to secondary devises and the public was not apprised of the evolving situation.
2. North Carolina Medical Journal, September/October 2002 Volume 63 # 5.
Mass casualty Victim “Surge” Management; Preparing for Bombings and Blast Related Injuries with Possibility of Hazardous Material Exposure. Harry W. Severance MD, FACEP.
The author stresses the fact that bombing of civilian structures, both here and abroad, is a real and ongoing threat. In the US alone between1980-1990 there were 12,216 intentional bombings. North Carolina is not immune from such events. Approximately 200 bombings were reported in state from 1996 to Sept. 1998.
Injuries can result from accidental explosions in factures or fuel depots or intentional bombing like the World Trade Center in 1993, by terrorist, that reported unsuccessfully use of cyanide gas in the bomb.
The author gives the patho-physiology of blast injuries. Injuries are classified as primary, secondary, tertiary, and quaternary. Primary injury occurs when the person is initially hit with the high pressure wave plus the heat generated by the blast. The secondary injury is caused by the debris accelerated by the pressure wave, resulting in penetrating injuries. The tertiary injury is the result of the person’s body being hurled (thrown) into another object (s) resulting in generalized body injury to include head, crushing, extremity fractures and amputations and abdominal injuries. Quaternary injuries referred to all other injuries not covered above to include organ failure and infections.
Explosives from intentional bombing and other blast are among the few instantaneous traumatic events that can produce massive numbers of casualties, of which approximately 10-15% are severe and the remainder are minimum to moderated injured and the so called “walking wounded” which can flood the hospitals and totally over run the facilities.
Even after the institution of the ICS and NIMS protocol, most hospital in this country are
“It is not likely that any North Carolina Trauma Center could maintain hazardous materials precaution while providing decontamination, primary intervention, and definitive surgical intervention services to more than 1-4 cases/hour”.
The crucial component of a local disaster or MCI planning is a unified mechanism for rapidly disposition of patients. This has to start at the scene with police perimeter control and crowd control, directing victims away from the blast site, setting up triage areas and initial treatment areas for the not so serious injuries, decontamination of victims and preventing the multitude from of patients going to hospitals.
Hospitals, urgent care clinics, and others providers should work proactively with area pre-hospital event command system to develop plans for ultimate patient disposition.
Conclusion:
Bombing and other blast related events place severe demands on pre-hospital and in-hospital systems. The resulting surge of victims can overwhelm the resources of any facilities. The challenges become even more daunting when there is possible hazard exposure.
Local communities must take the lead in developing incident command system for the initial management of the event.
Ultimately management and disposition of large number of casualties, especially if contaminated, cannot follow standard patient management protocol.
Case Study related to MCI and explosives.
Reduction in critical mortality in urban casualty incidents; analysis of triage, surge, and resource use after the London bombing on July 7, 2005
The Lancet Vol. 368 December 23/30, 2006 2219-2225
The terrorist bombing in London on July 7,2005, produced the largest mass casualty event in the UK since WW2.
The aim of the study was to analyze the pre-hospital and in hospital response to the incident and identify processes that optimized resources used and reduce critical mortality.
The study was retrospective analysis and the data for injuries, outcome, triage, patient flow, and resources used was obtained by the review of emergency services and hospital records.
There were 775 casualties, 56 deaths, 53 at the scene. 55 patients were triaged prior to dispatch and 20 victims were critically injured. The critical mortality was low at 15%. The overall triage rate was reduced where advanced pre-hospital teams did the initial triage.
The Royal London Hospital received 194 casualties, with 27 classified seriously injured. Maximum surge rate was 18 seriously injured patients/ hour and the resuscitation room capacity was reached within 15 min., 17 patients needed surgery and 264 units of blood products was used in the first 15 hours, which is close to the hospital’s routine daily blood use.
Critical mortality was reduced by rapid advanced major incident management. Hospital surge capacity can be maintained by repeated effective triage and implementing a hospital wide damage control philosophy, keeping investigations to a minimum, and transferring patients rapidly to definitive care.
The two main fundamental goals of a disaster response is rapid evacuation of all casualties from the event and reduce the mortality of critically injured patients. This is vital where there is danger of structure collapse or secondary explosions. There is a liner relationship (studied done on previous bombings) between over triage and critical mortality. This paper describes how critical mortality in mass casualty events can be reduced by efficient management of surge at every stage of a disaster response.
The overall mortality rate of mass casualty event is skewed by the large number of walking wounded, and the critical mortality rate is more indicative of effectiveness of the trauma system and disaster response.
This study feels that a more simplified triage system would enhance management at the scene. They used two classifications; seriously injured or walking wounded rather than the four tear system.
Surge, over triage, and under triage can be reduced in a stepwise fashion by systematic reassessment, reprioritization, and redirection of patients at every stage, and should happen anywhere in the system where resources are constrained. For example, London-HEMS team did few advanced on scene interventions, but instead focus on identification and extraction of the most severely injured patients.
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