“. . .from a terrorist perspective, the true genius of this attack is that the objective and means of attack were beyond the imagination of those responsible for Marine security.”—Report of the U.S. Department of Defense Commission on Beirut Airport Terrorist Act, October 23, 1983 Since 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 common 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, civilians 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 FIGUREFig. 2: Eric R. Frykberg, MD, FACSTHE 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 delivering 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 disasters in Oklahoma City in 1995, and in New York City, with the World Trade Center bombing in 1993 and the collapse of the World Trade Center towers on September 11, 2001. 4 Trauma physicians and trauma centers are uniquely qualified 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 experience 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 organizations, 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 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 military. 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.Table 1: Casualty Flow in DisastersDifferent types of disasters, such as fires, shootings, floods, infectious or chemical agents, radiation, or earthquakes, 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 and injury is by the that from an at the of and is more and and a in than in In this in to the of the from the The more the the the at which the through the are at in a and the and are most commonly The are in the most most typical of The degree of injury is to the and the of the of the this is a of and a of as victims of injury from are as the are likely to be injured in who is to the to be by the it is by massive and as well as the most forms of and this in to the among the of with injury are by which has all the and of to to cause more severe than bombings because the is than as it is and and documented a among casualties involved in bombings in and a among victims of injury is by in by the that the injury the actual of the body to other These forms of injury cause typical bodily and it is these that among of of Explosive urban in the serve to the by the civilian medical community in for mass casualties. a the with the in of to on the of the in a this a of of of of and of to cause the largest in The was and was 2 of the was by the and also of and who to the The There were and in a of population. the in the of City, of a of the and the 2 after this was more by a and the There were in a of the of the and of who to the These disasters how a typical medical resources would be by such large casualty especially if medical also were management of such great numbers must on from and on the to victims to other and other for care (Table The and trauma of such disasters can the of and are by and and a for the immediate and treatment of casualties. demonstrated was the importance of medical by them from the and at of attack and The was well in these incidents, involving the of and by an or who are by a or other have learned to this to great and this has become a common in terrorist bombings to injury and The fact that typically and medical who are trained to victims, the of this to and care and the importance of it by the response. is the of and against or to or for or The by has to this the most common deliberate of The terrorist bombing in in of were to a on the among “. . any from This is the of injury. The and of bombings a in the There was a in terrorist bombing and with events documented and 1983, and in the United were bombing and This continued the with bombings and in the United States in However, Americans have continued to to any from bombings relatively (Table 2: Terrorist Since of from this of attack with the of the U.S. Marine barracks in in October The of an in an to of the largest ever This the collapse of the with casualties, immediate and The was on the and and were efforts were by were treated by an U.S. a in the after the A of were to and for of the patterns of injury and from this demonstrates principles to disaster were injured among to of these were in victims who were and treated more than after the severe from injury, among all This the importance of a injury and and as a for The immediate and the of is a of the typical of military in was because of the of the and the of of these are of terrorist bombings that casualty The among the injured of also can be to these This more the of the disaster and of medical management than the overall of of as it among those at of The overall is by the of of the Beirut bombing and injuries, which were relatively and not trauma was the most common injury among immediate and but of of those with trauma and in a of but were to and the and among all with these These data the importance of and of injury as a among bombing victims, and be in different bombing disasters with to medical and how medical care demonstrated in this were the of medical in the potential for to be by a this and the need to and manage casualties at a from the disaster The importance of an immediate presence of and an evacuation were other learned in the Beirut of bombings can be to have a of from and for which is likely to be in the most were of the bombing by the in and most and the 3 These among the most injured other terrorist bombings that involve have been documented in the published (Table It is to review the of these events to the importance of the learned in and any other that on the effective delivery of medical care in these unique Terrorist the in was with an of of a There were casualties, of which were of the were were in which overall The of and an injury of largely and were to the Beirut The of injured was also The of from events were with a in of The immediate and the but still in the were because of the and the collapse a of the casualties, with of the through the of the The large casualty load was the result of the large of in the at the A of terrorist in a in all but one events more than casualties A of casualties with 13 immediate and of the were injured among overall The of all was but among the it was of of was the in a U.S. military in in in casualties, immediate of the were to U.S. hospitals among 3 In a in which the was by the of an with a to of There were casualties and immediate the were were and 4 of these for an overall of and a of The most severely injured were those the at the of the In 1995, an as a to the in City, and was in of the in Oklahoma City, with a to 2 of This a collapse of the and to There were casualties, immediate and injured among were overall among all in the the and most severe in the victims in the of the (Table of on in Oklahoma City Terrorist collapse of the towers of the World Trade Center in New York City on September 11, was devastating in of how it and the of how vulnerable the United States is to such The these to are to have the of of The collapse is to have the of of in and with of a few from the the immediate among those in the was on of and among is not yet The published casualty and from bombings that were all demonstrated patterns of injuries, but relatively immediate and were after the bombing at the in the from this were from different from the trauma of most other these events in urban with hospitals and medical resources and involved relatively with a in the These are the to the injury and of these of and It is to the of terrorist casualty or the injured and from the single of a and or the of casualties The of an and the of in the casualty and collapse 3 of past bombing disasters patterns of injury and which provide the to and for or those who medical care, to the of the the of and an (Table A of those bombings involving a of collapse of immediate and relatively among with forces (Table involving an of were associated with the immediate This that collapse is the most of among these not the of the but also which casualty and of a of Explosive and to Casualty of tends to casualty even in but the of the in with a of among The bombings at the of and in the and at the this This was also in the Oklahoma City bombing in 1995, in which a very large was directed through the because the was the This in casualties, but injuries, and was a However, those casualties the of the and (Table The virtually immediate of casualties the World Trade Center towers the importance of and as a The of has on than casualty it is to and than a The largest the numbers of potential casualties, the largest of to In and Oklahoma City, was on the of the collapse is also by the completely the as in and than to result in as in Oklahoma of among victims of bombings is the of medical resources at the disaster for the immediate and in Beirut was in a an prehospital system of and care, and care facilities, a for and of to British and military hospitals in and This in the bombing in In bombings in urban with and sophisticated prehospital and medical facilities, which and to care, to have body system are among those after terrorist all multiple injuries, to be most common in this as was in from from the bombings in the that was in in and other in of all immediate These are the body that most commonly cause in all other forms of trauma. and injuries, and of the and in to of but are in and virtually to of among immediate of bombings have injury, most with are as of those with The most are by the to immediate and injuries, and very infrequently among bombing for the 2 However, the few of these have a with of all injuries, of injuries, and of and to medical These be as of and need immediate care to also are relatively among of and to be with In have been more severe and a to as in of of the World Trade Center disaster on September 11, were to a with severe The of among bombing victims tends to be of to the body more than would be on the of the body area of the and exposed to the and trauma than their would This has been by with of the body exposed to of the forces of injury, such as is a common of terrorist especially among it is not as as injury, is potential for This be in the as other with to the need for planning for evaluation and of casualties. of the most injury patterns among of terrorist bombings is the of relatively that are not The of among and (Table The planning for medical management of casualties must this learned from bombing disasters, as medical resources must be of this is the importance of in of the than the overall as because of the of the by the of among (Table The be a more of the of medical care, and of the of those such as or collapse (Table It is also a to in the from different disasters. that among be as an in the of medical The and of or the of patients to injury and the need for immediate care, is to any degree in the management of trauma in the United have largely the principles of injured patients are to and resources are to injury to the to However, must great importance in mass casualty in which the large numbers of casualties overwhelm existing medical The of in this is to that of casualties who are injured and immediate care, from among the great of casualties who are not The the of casualties, the more this the more it to those immediate care, and the the of by in treatment of the most severely There are generally casualties immediate such as and but in is such as injuries, and treatment and injuries, or those that are severe and such and resources that it is not to provide care other more victims, and which not care, such as severe injury, with and and This most the in in mass casualty management from management of from the for to the for the of a must treatment of This that not be even though a that is to training in health care The as to an injury must be to the numbers and types of casualties, and the and requires planning and knowledge of mass casualty and triage, to and the most in the among bombing or the of injured casualties immediate care to a is a medical that lead to It always be by proper training of to The of virtually all published terrorist bombings this has been with of or the of to immediate care, or evacuation who are not is more an logistical, and ordinary and resources and are an of is to to and this is by trauma centers as a to to that be However, in a mass casualty it is to that be as as because of the of medical with large numbers of casualties all at which the of that with who need immediate and their A of published data from terrorist bombing incidents, or groups of in a common involving a single or medical from which and can be demonstrates that from to and from to (Table The and in these disasters that can result in the of in this These data the importance of and and as a of casualty in mass casualty disasters, and and of to in Terrorist 1: of to in terrorist bombing from to 1995, derived from data in Oklahoma of urban the of in disasters because of the immediate of medical resources to to injured victims, and is such to be associated with than In the as in Beirut and has on a because all casualties must be because of the of any to local medical in treatment of many which to the in these (Table The in published immediate injury, and the many in disasters that these and thus The of injury and patterns of past bombing disasters in the review these to be derived (Table Casualty after Terrorist THE to The learned from the past to planning and response to current and to and their experience with three disasters in a of 3 a result of the they they were to the community and disaster to more manage the and medical management of large casualty They their at a trauma to be and a typical in most disaster The they were the disaster and the and command for and medical personnel and the of medical all also typical of most disasters. was by command to administrative from medical were through by the administrative and the of to the completely by management to a of in to and patients to them by the The of physicians for care was and of care A of all involved was of the to review the which to of the to cope with and a disaster a to the of a disaster They that the of surgeons and and the of were and that the of and the of and were in their disaster after a mass casualty have this as They in by from to which that need not be by the most who be used more in They the importance of and in this which is largely even in ordinary but casualty and in disasters. 2 of is to the great of injured of terrorist who typically are the to the in large and overwhelm resources In to casualties must be of hospitals to the The of to orderly casualty and of of is in the immediate of a a of A of and the care of victims is to of in this of disaster and this is with and is any or involved in the this lead to the if is not must be in large and must be of the It is that a be to casualties to and to that those are It is also that the be from the bombing to the of a which have used commonly to and The and of of this was demonstrated in the and City explosions, as well as in the September 11, World Trade Center of and other were after to the incidents, by a or In it the of that the efforts for which a of The destruction of the medical in Beirut and also the of medical in of A a common in the current suicide bombings in the 2 This that medical as well as casualties, from the bombing they have more to than medical are trained for the of medical must be a of disaster The and casualty the importance of the The must have experience and expertise in trauma management to those immediate and to from this in the principles of and mass casualty is a essential of to medical resources most It has been that is physicians triage, and is with in this and demonstrated that and are to in and that can be The must have to treatment for casualties in the and must of victims to the medical and Casualty Flow treatment of bombing casualties at the with stabilization, of of and and of radiation, or must be and a victims the or treatment not be at this A systematic method of of casualties from the among hospitals and medical must to injury and and with the of any single from of hospitals by of casualties is the method to this in urban disasters. hospitals a of casualties treatment be for such as and injuries, as to more to victims. 2 of casualties to by be with large casualty and in The for that not be treated must be as as for those the medical to the of the the casualty and the resources patients be to be and not be and emergency be must be to and in of their resource 2 in the urban are generally resources for and this not be true in more and to immediate care must be and treated as as the of casualty 2 It is essential that casualty always and (Table or casualty and patients must be to to for casualties. those with be to the in this and must be to the principles of of and be and such as and other must be These are in disaster and severely casualty evaluation and the other has to be an effective tool for in mass casualty disasters. of must be as it is and largely in bombing disasters. can be on the of alone, such as and the casualty physicians all casualties more and treatment or evacuation of those in the and this be a of injury a in and in a of bombing It as and are to must be but be if because of the to be is or be to The of and must be and be in bombing are by and which cause a typical of with which surgeons are of these are and injuries, but to be and and and multiple are and by the of the A is to and in those with to these in of their This the importance of immediate of surgeons and personnel and to and of bombing of all and in the victims of bombing disasters is an essential part of disaster It is the means by which of care can be and and treatment can be as patients are through the of care in mass casualty These be to the to has been to against The forms that are used be to the as as to the to learn also the of casualty and that is for of the administrative and medical management of an It the and that has been to and disaster among be to the of medical care, especially among of or among injured victims. immediate care to be and the of these patients result in the as a result in of among more among be as immediate as they medical care, and not the as a of medical This can be with of other disasters to a on the of disaster management and can be used to and the to to learn from an THE The most means of for the large casualty of bombing disasters is to the patterns of and that the published experience of those who have confronted actual disasters can provide this because of the of mass casualty We must this This the of all who are involved in a disaster to and the of casualty care to the template in this these to other events, and the The of a disaster is essential for the management of mass casualties, because these are in their and In that the be and it must be on the published experience to the must be a of these effective disaster must all community and that be for the proper of mass casualties. These be regularly through and a of these lead to of the A of involved personnel is after a as to the disaster to the must be these to to the unique of but still the of the principles We must all have the “imagination” to be prepared for the most forms of attack to provide the care for the victims. for for bombing disasters is that and especially become more involved in the planning than they have been Trauma trauma and trauma are uniquely to in the and of disaster We in the for the of Trauma have the importance of this area of and have to the of surgeons and other health care in disaster management principles through Military and This a of the of that of the care and of the injured the of the