A secondary device can be defined as a corresponding IED, usually placed close to a primary device, that is time-delayed to allow for crowds or emergency personnel to respond to the scene of the initial bombing. Secondary devices can be detonated by remote control, explode automatically at a given time or even be triggered by another suicide bomber. EMS providers must not think that they are immune to harm because they are there to help. Secondary devices are often aimed at killing or injuring the first wave of responders, EMS included. The demoralizing impact on the public of seeing emergency service responders made useless and helpless is often a primary goal, and not just a side benefit, to terrorists.
This practice is not unknown in the U.S. Bombings in 1997 at an abortion clinic and a nightclub in Atlanta were followed by secondary explosions; at the former location, seven more people were injured. It can’t be stressed enough that responders must be aware of their surroundings, as well as suspicious objects and individuals. The urge to rush to assist must be tempered with judicious restraint based upon the scenario. Events such as these should be cleared by public-safety agencies before EMS providers are allowed to enter. If they can’t be, then, just as in hazmat incidents, patients should be brought to an area known to be “clean.”
The ICS and Unified Command
The Incident Command System (ICS), with the concept of unified command, has become the U.S. standard for any emergency response requiring multiple disciplines to operate at the same scene. This standard must be tailored slightly, however, if it is to be used in a situation that cannot be made safe enough to allow for normal EMS operations.
Israeli EMS uses a modified ICS with a rapid triage and transport component. Patients within the immediate vicinity of an explosion are removed from the area as quickly as possible, without triage or stabilization. Basically, responders are acting as though there is a secondary device in the area until proven otherwise. Once patients and personnel are safe from danger, traditional care can be given. Using these tactics, Israeli responders have been known to clear 40 or 50 patients from the scene of a suicide bombing in 15–20 minutes without just moving the incident to the hospital. The average time from the report of an explosion to the first unit arriving on scene is 4.6 minutes. The average time until the first transport is initiated is 11.5 minutes, and, on average, the last critical patient can be transported in 30.2 minutes.1
A simple standardized triage system, such as the START (Simple Triage and Rapid Transport) system, should be used to sort and transport patients on a priority basis. This process can be taught quickly to non-medical responders at the scene, and it allows for the concentration of EMS personnel in positions that require more training. This is important because the traditional first responders—police and fire personnel—will probably not be available to assist, due to other pressing responsibilities. This may necessitate the use of bystanders for the triage function.
Remember that triage should always be conducted outside the hazard area. When necessary, patients should be evacuated to a triage point by law enforcement or tactical personnel and then managed by EMS. Only lifesaving procedures—e.g., airway management and hemorrhage control— should be performed on scene; all other supportive measures—IV establishment, splinting, etc.—can be done en route to the hospital.
To ensure a measure of success in responding to a suicide bombing, the EMS branch manager and the incident’s communications center personnel must address several critical factors. The EMS branch manager should have a field operations guide (preferably in checklist form), a well-marked identification vest, interoperable communications equipment and, possibly, a megaphone (megaphones have been shown to be effective by Israeli EMS when dealing with a concentrated incident with a multitude of patients and responders). As the event progresses, the EMS branch manager must also remember to give the communications center regular status updates.
The communications center should have its own checklist set up that includes available resources, where those resources will come from, and contact information and notification prioritization for administrators, agencies, hospitals, etc. This must all be in place prior to an incident.