Tips to Prepare for Terrorist and Other Large Scale Attacks

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By A.J. Heightman, MPA, EMT-P, Editor-in-Chief, JEMS
As the threat of attacks and use of automatic weapon assaults and use of explosive devices by terrorists continue to accelerate, with the United States now labeled a prime target and objective, emergency response agencies need to educate and re-educate their personnel to be ready.
We must be ready not just for the predicted assaults in the USA, but for the aftereffects. EMS response agencies need to have their command, treatment and transportation plans in place and be prepared for an overwhelming number of patients that need to be managed in a short time period.
The Centers for Disease Control has multiple documents that are available to help prepare your agency and personnel for Terrorist or Other Large Scale Attacks

Bombings: Injury Patterns and Care

Bombings: Injury Patterns and Care curriculum was developed through the Linkages of Acute  Care and EMS to State and Local Injury Prevention Programs project that was funded by the Centers for Disease Control and Prevention (CDC). The American College of Emergency Physicians (ACEP) served as the lead grantee for this project.
The curriculum was developed with the assistance of a task force that included representative experts from emergency medicine including physicians, surgeons, nursing, and EMS. Bombings: Injury Patterns and Care curriculum is designed to be the minimum content that should be included in any all-hazards disaster response training program.
This content is designed to update personnel with the latest clinical information regarding blast related injuries from terrorism. CDC Releases Blast Injury Mobile Application The Centers for Disease Control and Prevention (CDC) recently announced the release of a new Blast Injury mobile application to assist in the response and clinical management of injuries resulting from terrorist bombings and other mass casualty explosive events.
The application provides clear, concise, up-to-date medical and healthcare systems information to assist healthcare providers and public health professionals in the preparation, response, and management of injuries resulting from terrorist bombing events. Download the mobile application for free for your smart phone by searching for ‘CDC Blast Injury.’
Medical Record Abstraction Form for Domestic Bombing Events Data capture regarding the diagnosis and treatment of injuries is important to quantify the true impact of a disaster. This one-page form allows public health personnel, at the city, county, state, or federal level, to quickly extract basic medical information from hospital and emergency medical services’ records in order to advise officials as to the immediate impact of the event and the potential need for special resources (e.g., blood products, types of medical personnel, etc.).
Download the Medical Record Abstraction Form.
Blast Injuries: Fact Sheets for Professionals – Centers for Disease Control & Prevention (CDC) These fact sheets address background, clinical presentation, diagnostic evaluation, management and disposition of blast injury topics. The fact sheets may be viewed and downloaded for use in the treatment of blast injury patients, in the training of clinical staff or to disseminate to others. Topics include: Blast Injuries: Essential Facts; Injury Care: Prehospital; Lung Injury: Prehospital Care; Lung Injury; Radiological Diagnosis; Crush Injury and Crush Syndrome; Post Exposure Prophylaxis for Bloodborne Pathogens; Abdominal Injuries; Extremity Injuries; Ear Injuries; Eye Injuries; Thermal Injuries; Pediatrics; Older Adults; and Bombings and Mental Health.


 Abdominal Blast Injuries   Prehospital Care   Crush Injury and Crush Syndrome   Ear Blast Injuries   Essential Facts   Blast Extremity Injuries   Eye Blast Injuries   Blast Lung Injury   Blast Lung Injury: An Overview for Prehospital Care Providers   Bombings and Mental Health   Treatment of Older Adults   Pediatrics   Post Exposure Prophylaxis for Bloodborne Pathogens    Radiological Dispersal Devices and Radiation Injury   Radiological Diagnosis   Thermal Injuries   Traumatic Brain Injuries   Field Triage Decision Scheme (PDF)
 Blast Injuries Audio Podcast Now Available on the CDC’s Website

 Bombings: Injury Patterns and Care Class Material

Download the one-hour interactive course The full Flash course (Flash player required) can be downloaded and run of your computer. Instructions: Download compressed file to your computer.  Extract the files to a folder on your computer.  Then open the folder and click the file named Start to begin the application.
Bombings: Injury Patterns and Care Pocket Guide – free pocket guide available for download. This guide can be printed on 8 1/2″ x 14″ paper.
In A Moment’s Notice: Surge Capacity for Terrorist Bombings  (UPDATED VERSION)


I also want to share a few high priority areas your service should address and equipment you should carry, to manage the large number of patient presented by terrorist attacks or other large scale incidents.
  1. RESOURCES-RESOURCE-RESOURCES!  You should have an automatic EMS response and Escalation plans developed and in place to insure you can get 12, 24, 36 or more ambulances automatically send to the scene of a major incident in your service areas. Some areas call these EMS Task Forces, EMS 1-2-3 Box Alarms, MCI Response Level 1, 2, 3. Regardless of what you call them, you goal should be to have in to predetermined and easily dispatched “waves” of ambulances, engines, ALS providers and MCI supplies in place so you can have 12-24-36 ambulances and support vehicles sent to you when you need them.
  2. ESCALATION PLAN: Escalation Plans are nothing more complex than taking (subtracting) the Level 1 resources (For up to 10 patients = 12 ambulances) away from the Level 2 plan (10-25 patients involved = 24 ambulance) or Level 1 from Level 3 plans – and sending those predetermined resources/ambulances to the scene on an “Escalation form Level 1 to Level 2 MCI. You will then get the 12 additional ambulance sent to you without confusion by your dispatch center; your dispatcher will have a Level 1, 2 & 3 plan as well as an escalation plan to go from Level 1 to Level 2, and Level 1 to Level 3 subtracting what resources would be sent on a second alarm MCI or MCI Level 2 response plan. Any questions; email and I’ll assist you in developing them.
  3. SURGE CAPACITY: Your hospitals should have Surge Capacity plans in place to take care of a large onslaught of victims. These plans include early discharging or transfer of patients; converting hospital areas into additional ICUs; covering cafeterias into receiving and treatment areas, etc.  Read the updated CDC Guide: “In A Moment’s Notice: Surge Capacity for Terrorist Bombings” and consult with your hospitals to learn fit into their surge plans.
  4. SCOUT OUT and ARRANGE FOR MASS CARE AREAS: If you are hit with 150 patients, do you have areas you can use to treat patients in a MASH-type environment (out of the weather) for a mass of patients until hospital can catch up and receive the. School cafeterias, Church Social Halls, farmersequipment storage barns, warehouses with loading docks and other easily accessible structures that can be opened up at 3 AM, lighted and heated should be on your list of resources, along with 24/7 contact names/numbers to get them open in less than 30 minutes.
  5. MCI SUPPLIES: Don’t wait until after an incident to be prepared. Get these supplies ordered ASAP so that you are ready, not just for a terrorist attack but also a school bus accident, school shooting or plane crash. This is my TOP 10 list:
At a minimum
Other vests can be (for the folks manning RED-YELLOW-GREEN TARPS)
TRIAGE TAGS: 100 per vehicle – Minimum (4 EMTs or Medics can each be handed 25 tags and triage and tag and are in less than 5 minutes. (Make sure your tags have a TRANSPORT STUB to ensure you can log and track where you send all patients. And use a pre-prepared TRANSPORTATION LOG SHEET (Samples attached).
RED – YELLOW – GREEN – BLACK (Min. 20’x20’) TARPS to bring triaged patients to (and where you perform secondary/re0check Triage and distribute patients from. Best investment you can make.
RECOMMENDED: 1 set per ambulance, 2 sets per supervisor and MCI vehicles; I set per FD engine and ladder company (NOTE: They can also be used by FD as salvage covers at fire scenes when not needed as patient collection point identifiers/treatment areas.)
  • Assign one to each provider to carry (and maybe use on themselves)
  • FOUR (4) per unit (minimum) – Patients can lose all of their extremities in 1 second
  • (RECOMMENDED: Multiple in a designated MCI KITs assigned to each unit, supervisor vehicles and MCI vehicles)
Note: Many agencies are buying IFAK (Individual First Aid Kits) to their staff (equipped with tourniquets, would clot dressings, chest seals, pressure wrap bandages, Chest decompression needles, Triage Tags, tape and scissors.
  • Five (5) per trauma kit and five in an ambulance cabinet;
  • (RECOMMENDED: Multiple in a designated MCI KITs assigned to each unit, supervisor vehicles and MCI vehicles)
  • Five (5) per trauma kit and five in an ambulance cabinet;
  • (RECOMMENDED: Multiple in a designated MCI KITs assigned to each unit, supervisor vehicles and MCI vehicles)
CHEST SEAL NOTE #1:  One shotgun blast or one Improvised Explosive Device (IED) can send cause multiple projectiles to instantly penetrate a single patient in multiple areas of their chest and abdomen, causing sucking chest wounds and hemorrhage sites in more than one area, necessitating the need for more than one chest seal.
CHEST SEAL NOTE #2:  Chest seals today offer adhesives that (after a quick wipe-away of blood and sweat) adhere well to a patient, making them not only good for closure of sucking chest wounds but also to hold compresses and wound clot dressings in place – inside a packed wound. (The “Hartford Conesus” documents and TECC (Tactical Emergency Casualty Care) recommends that emergency personnel be taught to “pack” wounds – something not stressed or allowed in many states before. It can be lifesaving.)
All vehicles should have large, easy-to-see VEHICLE ID NUMBERS on all four sides, on the roof and on each microphone. This aids command officers (particularly Staging and Transportation officials) in seeing, identifying and directing units (directly or by radio) at a busy, chaotic scene.
Teach your personnel to pick and use helicopter landing zones not directly at large scale, congested, hazardous or dangerous scene, particularly where terrorist snipers can easily access, shot at or  down them.
It is often beneficial and high effective to assign one or two crews to do nothing but move assigned helicopter patients from the Transportation/Patient Disbursement area – to helicopter Landing Zones.
By specifically assigning one or two crews to this task:
#1) You will ensure effective use on helicopters because the assigned crews will continually ask for patients that need to be flown – and Transport will not “forget” that helicopters are on scene or at a remote landing zone.
#2) The assigned crews will be more efficient because they will know where the LZ(s) are and not need directions (or often, an ambulance) to get the patients to the LZs.
One canister-style Chem-BIO respirator should be assigned to each responding crew position or member (if fit testing required), and carried close to the responding crew members so they can be rapidly donned in the event that arrive at a Chem-BIO scene or caught in a Chem-BIO incident or attack.

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