The Stage Is Set
What a great afternoon. You are at the Mall of America with your family. Your wife is shopping at Nordstrom’s; your daughter and friends are at Macy’s. You have about one hour to browse the shops of your choice while you enjoy that ice cream. You are in front of the QVC store when a horrendous blast shakes the building and knocks you thirty feet down the corridor from where you stood. You are hit with a piece of metal which strikes your arm; a tennis shoe hits your stomach. Your ears are ringing as you raise yourself to a sitting position. Surveying the situation, you see that half of the Mall’s amusement park is gone. There is an irregular hole in the roof of the building. Dust and debris are everywhere. Your damaged ears can still hear the shouts and screams. Where is your family?
In March of 2007, Dr. Greg Poland warned of this type of attack.5 His presentation showed a time line that extended only to the year 2012. He strongly implied that attacks like this are imminent and would likely happen sooner rather than much later. Articles on terrorism and terrorist bombings in law enforcement magazines began appearing.2,3 The American Medical Association National Disaster Life Support Educational Consortium meeting in the Spring of 2008 was held at the Uniformed Services University, Bethesda, Maryland. The sole continuing education topic was “Bombings: Injury Patterns and Care”.1 Sponsored by the American College of Emergency Physicians, the course focused on terrorist tactics, injuries, and medical response.
Bombing injuries are unique. The types of injuries are much different from most other traumatic injuries. They can be classified into four types.
Primary injuries are unique to high energy explosives and include head injuries, tympanic membrane injuries, abdominal injuries, and blast lung. Each of these injuries is a direct result of the impact of the blast wave and over-pressurization wave hitting body surfaces. The force of the blast decreases with the cube of the distance. For example: If a bomb squad member is next to a one-pound pipe bomb (one foot distance) in full gear, he or she will be killed. At ten feet in full gear, that same person will be knocked over, get up, and walk away.
Secondary injuries result from flying debris, and include head and neck trauma, fractures, and soft tissue injuries.
Tertiary injuries result from being thrown by the blast wind. Skull fractures and bone fractures are examples.
Quaternary injuries are all explosion-related injuries not due to the first three causes, and can include infection, radiation illness, burns, and exacerbation of pre-existing conditions.
Varying circumstances and locations will give higher or lower incidences of serious injuries. Blasts in enclosed areas, as an example, will be more serious than any out in the open. While barriers such as walls and other heavy objects can be of some protection, in the case of a large bomb close to those objects, they can become projectiles themselves.
Motive and Opportunity
The tactics of terrorists continue to evolve. Their methods and skills change with experience and technology. The “good guys” are continually trying to stay ahead of these changes. Examples of tools and technology were demonstrated at a recent visit I made to the Minneapolis Police Department Bomb Squad.4 During my time with them, I was shown the latest equipment and materials for Bomb Squad members to deal with explosive devices. Pictured is a robot that can be sent into buildings, airplanes, and open areas to investigate suspicious packages, remove them from an area, and defuse or detonate bombs. The greatest advantage is obvious: The bomb technician is safely located in a remote location, yet can work to neutralize a threat. As well, computerized radiography is used to great advantage and has nearly totally supplanted film radiography.
Medical response to a bombing scene is much different from that to any other. One of the most dangerous aspects is the possibility of a secondary explosion. A secondary device is planted near where the first responders and other medical personnel are likely to be working and is detonated when their activity is at a peak. It is a distinct possibility that there will be more casualties from the secondary blast than the first.
As a response to this situation, the International Association of Bomb Technicians and Investigators and Emergency Medical Technicians will be holding a joint, integrated training exercise, the first of its kind ever. This innovative course is designed to train first responders and medical personnel in the treatment of the unique injuries encountered, transport of victims, and on-scene protocols.
The Psychology of Terror
The psychological aspect bombings is as important, possibly even more important, than the bombing itself. The goal is to create terror. This spreads beyond people directly affected by the event, another goal of the terrorist.
The best study of this scenario has occurred in Israel. Psychologically, the Israelis are the toughest people on this planet. When bombings have occurred, reporters and camera personnel assigned to the story would rush to the scene to capture the destruction. Following this kind of reporting, the Israelis made sure the areas that were stricken would be rebuilt, in particular the structure(s) that had been bombed, and their media/public relations people would make a point of having people seen casually lounging about. This response clearly showed that their message was that while they might be bombing victims, they were not terrorized.
This resilience must be fostered in all populations targeted by terrorists. That means that we in the United States cannot succumb to fear and consequently greatly alter our daily lives because of these events. To do so would be to help accomplish the goals of the terrorists. We should, however, be vigilant as we go about our business. Examples of things to watch for would include:
1. People dressed “out of season”. Heavy sweaters and coats in warm weather could hide any number of dangerous things.
2. Unattended packages in crowded places. Again, these could be innocent or very deadly.
3. Vehicles, dumpsters, and other objects normally seen outside. Containers of size can effectively hide an enormous amount of explosives.
I believe this discussion focuses the question asked in the title of this article. The bombing incident at the Mall of America described above could just as easily happen at the Xcel Center, the I.D.S. Tower, the Jazz Festival in Duluth, at Mankato State University, Mayo Clinic, churches, schools, or in ANY busy place near any of us. n
1. “Bombings, Injury and Care”. Lecture, National Disaster Life Support Educational Consortium Conference, Earnest Sullivent MD, FACEP, Uniformed Services University, Bethesda, Maryland, April 23, 2008.
2. “Terrorism, What is it? Are we Prepared?” Maj. Richard Hughbank, Robert Hughbank. American Cop Magazine, pages 48-49, 60-64, September/ October 2007.
3. “Terrorist Attacks - Explosives”, Howard Linett, American Cop Magazine, pages 60-63, March/April, 2008.
4. Minneapolis Bomb Squad, Sgt. Wally Kruger, Minneapolis Minnesota, July 18, 2008.
5. “Suicide Bombers, The Next Step in Biowarfare”, Greg Poland MD, Southeast District/Zumbro Valley Dental Society Spring Meeting, March 9, 2007, Rochester, Minnesota.
*Dr. Nolting is the Chair of the Disaster Preparedness Subcommittee of the Minnesota Dental Association’s Environment and Safety Committee. He is a general dentist in private practice in Byron, Minnesota. E-mail is NOLTING@aol.com.