‘Terrorism is a global problem [and] it’s imperative that we learn about bomb blast injuries.’

Explosions are the most common cause of injuries associated with terrorism, according to the 2007 Institute of Medicine Report “The Future of Emergency Care in the United States Health System: Emergency Medical Services at the Crossroads.” Terrorist bombings have the potential to inflict multisystem, life-threatening injuries upon many people simultaneously, and they often present profound challenges to surge capacity at a moment’s notice.

And the scariest fact of all is that no one is immune to this ever-growing threat.

Nothing drove that point home more than the November 2008 terrorist attacks in Mumbai that killed more than 170 people. Since the 9/11 attacks utilizing aircraft in the United States, numerous high-profile attacks involving explosives have occurred in many countries worldwide.

But just how prepared are the world’s emergency physicians to treat the unique injuries often associated with blasts? The Centers for Disease Control and Prevention (CDC) approached ACEP 4 years ago with that exact question, awarding ACEP a grant to explore the issue further.

“There are some very unique injuries caused by blasts, especially those in closed spaces,” said Rick Murray, EMT-P, director of ACEP’s department of EMS and disaster preparedness. “We began these efforts with terrorist attacks in mind, but we soon realized that it didn’t matter if it was a terrorist attack, a propane explosion, or a suicide bomber on a subway—blast injuries would still result, and emergency physicians need to be prepared.”

ACEP convened experts in injury care to review the types of blast injury training that were available. “It was a huge thing for ACEP to facilitate bringing the international community from places like India and Pakistan to the United States to help us learn about bombings,” said Dr. Richard Hunt, director of the CDC’s Division of Injury Response and an ACEP member. “All of the efforts have been extremely worthwhile, and these experts have provided clinicians and public health professionals here in the United States with unique insights into the challenges of dealing with blast injuries.”

“This has very much been a two-way collaboration with our colleagues in the Indian government, because they have a great deal of experience in managing bombing and blast injury victims in circumstances that we in this country have rarely had to face,” said Vikas Kapil, D.O., M.P.H., associate director for science in the CDC’s Division of Injury Response.

Building a Curriculum

Once ACEP determined that adequate bomb injury management training material didn’t exist, it set out to develop a curriculum with emergency medicine experts, including its partner organizations in the Terrorism Injuries Information, Dissemination and Exchange project (TIIDE). The resulting curriculum, “Bombings: Injury Patterns and Care,” includes 1-hour and 3-hour didactic courses, as well as interactive training. ACEP also developed a wall poster of key points and a pocket reference guide.

“This is an open-source course for any emergency care provider—not just emergency physicians,” said Dr. Hunt. “It’s designed for trauma surgeons, EMTs, nurses, and anyone else who treats blast injury patients.”

“You don’t have to be a blast injury expert to teach this course,” said ACEP’s Mr. Murray, who is helping to disseminate the training. “Some background on the topic is necessary, but it’s designed so that any skilled instructor can present it using the provided, detailed notes and slides.”

The course, available for download on the CDC’s Web site, provides an overview of the types and severity of blast injuries and addresses other topics such as blast physics and how individual organ systems are affected by blast injuries. It also covers an area of blast injury response that’s often overlooked: the system challenges that accompany such injuries.

“The system is not just a hospital or an emergency department,” said Dr. Kapil. “There are so many system components, including prehospital care and transport, emergency department care, surgical care, anesthesia, critical care, rehabilitation after the event, communication issues, and issues related to transfers and resource sharing between facilities—all of which may have an impact on patient survival.”

Dr. Kapil cited several examples: “Patients may suffer blast-associated tympanic membrane injury; this may result in significant difficulty in communicating with a large number of victims from a blast event.” Emergency providers might also be faced with many casualties from a bombing who arrive quickly at the closest hospital by various means of transport.

In addition, a trauma center may be overwhelmed with a large volume of patients with relatively minor injuries, or patients with life-threatening injuries may present to hospitals not prepared to handle major trauma. “This is why it’s so important that the course address both the clinical care and the system challenges that are part of incidents like these,” Dr. Kapil explained.

Training Goes International

Dr. Kapil and Dr. Hunt have presented the training to an estimated 1,000 emergency physicians, nurses, and EMS personnel on at least six occasions in various areas of India, including Mumbai, New Delhi, and Ahmedabad. The training is catching on in the United States as well—even firefighters, police departments, and bomb squads have requested the training information, and a podcast held in November has already been downloaded more than 1,600 times.

“Attendees have told us that they found the training very useful, particularly because of the unique injury patterns they encounter after blast events,” said Dr. Kapil. “They also find it helpful for planning and systems issues in terms of anticipating system needs, such as managing crowds and challenges related to surge capacity.”

The CDC has received multiple requests for additional training, particularly after the recent events in Mumbai. “We’re working closely with our partners in India on how best to respond to those requests, as well as on building capacity in India to conduct this training in the future,” said Dr. Kapil. “We want to make the materials as easily accessible as possible.”

Dr. Sanjeev Bhoi knows firsthand the chaos and panic that follow a bombing or explosion. He participated in an October 2008 blast injury workshop conducted by the CDC in Pune and Vadodara, India, and has since begun conducting regular seminars on bomb blasts in his emergency department.

“Terrorism is a global problem that we must live with, and, as a result, it’s imperative that we learn about bomb blast injuries,” said Dr. Bhoi, an assistant professor and director of emergency medicine at the J.P. Narayan Apex Trauma Center of the All India Institute of Medical Sciences, a 2,300-bed premier hospital and research center in New Delhi, India.

“The training helped me to distinguish various types of injury due to primary, secondary, tertiary, and quaternary impacts,” he added. “It also provided insight on the correlation between the extent of injury; type of blast, such as low or high intensity; and closed- versus open-space events.”

“This is about preparing for what many say is a ‘predictable surprise,’ ” said Dr. Hunt, “and there is definite merit in assuring that emergency physicians have working knowledge about this.”

For more information and resources related to the treatment of blast injuries, please visit www.emergency.cdc.gov/blastinjuries or www.acep.org/blastinjury. The podcast “Blast Injuries: What Clinicians Need to Know” is available at www2a.cdc.gov/podcasts/player.asp?f=10224.