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Survey of Blast Trauma
from Evolving Tactics of
TerrorismCatherine Y. Lee, MPH
Research Faculty Associate
New York Medical College
School of Public Health
October 17 2005Greater New York Hospital Association
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“Analysis of past bombing disasters reveals
definite patterns of injury and mortality,
which provide the opportunity to plan and
prepare for future events.”
Eric Frykberg, MD, FACS
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IRA: Hospital Experience, Civilian Blast Injuries
Epidemiology Started Here
1970
Israel: Mix of factors that influence pattern of trauma1990
suicidebombing
1950 Sandia, China, Sweden, Russia: Man and Blast Injury
2004 Global: Complex Tactics: different influences different
bombings – Madrid, Istanbul, London
Epidemiology ShiftEpidemiology Shift
…and non-English studies
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Small and Frequent “Traditional”: Solo
OpenOpen StructuralStructural
ConfinedConfinedSuicide Bombing
Complex Bombing…Other Considerations
Explosive Type
Quantity Delivery Method
Epicenter
People in VicinityTime of Day
Etc…
+
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I n c r e a s i n g
m o r t a l i t y
Increasing frequency
Catastrophic but rare
Complex Tactics
Traditional-Solo
Small IED, LE
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Tactic 1Tactic 1
Small Bombings, High FrequencySmall Bombings, High Frequency
Open and Confined SpacesOpen and Confined Spaces
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ProfileProfile
• Small IEDs
• HE or LE• Simple logistics, ease of coordination
• Not high profile targets, symbolic
• Open spaces
• Confined space
• 2004, 26% of combat deaths in Iraq due to thesetypes of small bombs
• Today in 2005? 70%
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OpenOpen
• Free field
• Few obstacles and hindrances
• Free movement of blast wave
• Grassy park, parking lot, market place,railroad track
• Secondary injuries most prevalent,psychological trauma/stress
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ExamplesExamples
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Horrocks, CL. Blast Injuries: Biophysics, Pathophysiology and Mnaagement
Principles.
Idealized blast overpressure waveform
Measured in atm’s, psi’s
or kPa’s
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SmallSmall IEDsIEDs, LE/HE, LE/HE
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Atlanta
70%
50%
30%
10%
0%
10%
20%
30%
40%50%
60%
70%
80%
90%100%
p u l m o n a r y
B o w e l
T y m p a n i c
O c u l a r g l o b e
C o n c u s s i o n
P e n e t r a t i n g
B r u i s e s ,
C l o s e d / O p e n
T r a u m a t i c
N e r v e
p a l s y
C r u s h
i n j u r i e s
C V D
r e l a t e d
o t h e r
Fractures from shrapnel
5: closed/open fxskull, facial skeleton
3 Strains & Sprains
1 case of HeartAttack
7 penetratingwounds
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AsaiAsai et alet al
Asai Y, Yoshida M, Jurimoto Y, Arnold JL: Case report: Penetrating cardiac injury secondary to terrorism-related, nail-bomb explosion.Prehosp Disast Med 2003;18(3):249–252.
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Victoria StationVictoria StationSimilar to Atlanta Centennial Olympic except H.ESimilar to Atlanta Centennial Olympic except H.E
• Several kilograms of Semtex in a litter bin
• 30 treated at Westminster Hospital
• Majority of injuries caused by shrapnel
Incidents of Injuries
Soft Tissue Injuries 32
Open fx 13
Neurovascular 7
Traumatic Amputation 2
Perforated Organs 4
Bone fx 5No Burns
Johnstone, DJ., Evans, SC., Field, RE., Booth, SJ.The Victoria bomb: a report from the Westminster Hospital. Injury, 1993, 24 (1): 5-9
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Secondary Blast
injury agents:
Bomb canister pieces
Glass shards
Particulate Matter
Secondary missiles
Secondary Injuries Most PrevalentSecondary Injuries Most Prevalent““Penetrating WoundsPenetrating Wounds””,, ““Open WoundsOpen Wounds”” Regardless of Bomb Type or EnvironmentRegardless of Bomb Type or Environment
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Lee, CY Development and Application of the bomb-blast Damage and Injury Scale 2003
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Low explosive
Deflagration
No overpressure
High explosive
Detonation
Overpressure
“Real life” reflectingsurfaces makecomplex blast pattern – accumulates blastpressures
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ConfinedConfined
• Small dimensional space, tight and limited
movement – Bus, Small Bar, Store, Bathroom
• Reflecting surfaces• Magnifies incident 2 – 9 times
– Primary – Energized, Secondary
• Small amount HE needed
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Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J
Trauma, 1983, 23 (11): 955-967
CooperCooper
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CooperCooper
• “Tavern in the Town”: 11 dead, 89 injured
• “Mulberry Bush”: 10 dead, 30 injured
Data from 42 total admitted from all hospitals that received:
Serious soft tissue damage 22
Burns 23
Fractures 13
Eye Damage 13
Blast Lung 3
TM Perf. 17
Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J
Trauma, 1983, 23 (11): 955-967
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Source: www.mfa.il.gov; suicide bombing May 18, 2003, Jerusalem
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ConfinedConfined
• According to Peleg, head, neck, extremities
most common injuries in confined space busexplosions
Used with permission: Kobi Peleg, Ph.D – “Epidemiology of Terror Injuries”
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Used with permission: Kobi Peleg, Ph.D – “Epidemiology of Terror Injuries”
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Confined Space, 6 kg of high explosive (not a suicide bombing)
10.3% Critical
5.2% Immediate
Katz, E., Ofek, B., Adler, J., Abramowitz, HB., Krausz, MM. Primary blast injury after a bomb explosion in a civilian bus. Ann Surg, Apr 1989, 209 (4): 484-488
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38%
24.5%
70%
14%
17.5%
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Some of the greater incidences of primary blast injury come from confined space bombingsSome of the greater incidences of primary blast injury come from confined space bombings
Lee, CY Development and Application of the bomb-blast Damage and Injury Scale 2003
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2002
Passover dinner, hotel dining room
8 – 10 kg HE TATP packed with
hundreds of small steel balls 3 – 7mm
diameter
250 people present
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33% OR, 14% 1st,2nd
burns
14% DIH first 24 hours
5 cases primary blast
50% Level II trauma
centers
75%
admitted
N=91 reflected in
graphic
N=20 (22%) DOS
44.5%PTSD
164 injured
Kluger, et al. European Journal of Emergency Medicine 12:19–23 c 2005 Lippincott Williams & Wilkins.
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KlugerKluger: Spherical Shrapnel and: Spherical Shrapnel and
BallisticsBallisticsFrom the distribution of the injured in the hall, the patterns of injuries,
and the specific organ injuries, we concluded that spherical missiles
incorporated in a bomb follow the ballistic patterns of shotgun pelletsthat are shot without choking or constriction at the barrel end. Whereas
immediate mortality resulted from injuries augmented by the addition of
steel balls, their wounding of the surviving patients followed the
classical pattern of low destructive injury.
It was consistent with Ordog’s classification of shotgun injuries:
•Type I: Long Distance (>12 m) resulting in only superficial penetration,
•Type II: close range (<12 m) resulting in penetration beyond the deep fascia,and
•Type III: point blank (<5m) resulting in devastating tissue damage and highmortality rates
Kluger, et al. European Journal of Emergency Medicine 12:19–23 c 2005 Lippincott Williams & Wilkins.
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Confined Space ComparisonConfined Space Comparison
5.3%
Peleg
8 – 16%3%14%Criticalmortality(DIH)
12.5%45%Severe
injuries %
4 – 19%29%22%Immediatemortality(DOS)
LeeFrykbergKluger
Kluger, et al. European Journal of Emergency Medicine 12:19–23 c 2005 Lippincott Williams & Wilkins.; Lee, CY Development and Application of the bomb-blast Damage and Injury Scale 2003
Requires much more investigation, several factors to consider other thanpurely the mechanical forces of the explosion & environment
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MellorMellor
Mellor, SG., Cooper, GJ. Analysis of 828 servicemen killed or injured by explosion in Northern Ireland 1970-84: the Hostile Action Casualty System. Br J Surg, Oct 1989, 76 (10): 1006-1110
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18 – 27 atm
11 – 15 atm7 – 9.5 atm
Solely theoretical, much investigation
continues
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Tactic 2Tactic 2
Larger, ConventionalLarger, ConventionalBombingsBombings
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ProfileProfile
• Single vehicle IED
• Higher degree of coordination andlogistics
• Structures and Symbolic targets• We deter with technologies and security
countermeasures
• Some cases of primary injury, STILL
secondary most common, some cases of
tertiary, quaternary - crush injuries
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VehicleVehicle IEDsIEDs
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FEMA 426- Reference Manual to Mitigate Potential Terrorist Attacks Against Buildings
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Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387
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Frykberg, ER. Medical Management of Disaster and Mass Casualties from Terrorist Bombings: How can we cope? J Trauma2002;53:201–212.
Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387
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OKC Fatal InjuriesOKC Fatal Injuries
•• 122 Multiple Trauma122 Multiple Trauma
– Multi-system, multi-dimensional injuries, constellationof 1˚, 2 ˚, 3 ˚, 4 ˚ types
– Like “Patient 4” AMIA we just saw
• 24 Head Trauma• 13 Chest Trauma
• 3 Head & Neck Trauma
• 3 Traumatic shock
• 2 Fractures cervical spine
Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387
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Weapons Systems Division, Defence Science and Technology Organisation, Edinburgh, SA.Dr Anna E Wildegger-Gaissmaier, DipIng(TU), PhD, Head Terminal Effects.Online at: http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/adfhealth_apr03/ADFHealth_4_1_03-06.html
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Source: White, Richmond
The Force behind Tertiary InjuriesThe Force behind Tertiary Injuries
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Beirut 1983Beirut 1983
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Beirut 1983Beirut 1983
• Estimated 6 Ton TNT Equivalent HE
• Complete Structural Collapse of 4 storystructure, 6am
– Medical contingent killed• 37% Critical (7/19)
• 68% Immediate• Simultaneous blast at French
paratrooopers headquarters
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AMIA
12%18%
6% 6%
18%
29%
41%
6%
29%
6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
p u l m o n a r y
b
a r o t r a u m a s ,
B o w e l
p e r f o r a t i o n
T y m p a n i c
m e
m b r a n e ( e a r
O c u l a r g l o b e
r u p t u r e
C o n c u s s i o n
P e n e t r a t i n g
b a l l i s t i c
B r u i s e s ,
c o n t u s i o n s ,
C l o s e d / O p e n
f r a c
t u r e t o s k u l l
T r a u m a t i c
a m p u t a t i o n o f
N e r v e p a l s y
C
r u s h i n j u r i e s
C V D r e l a t e d
o t h e r
Structural bombing, About 1 Ton TNT equivalence
29% Critical
29% ImmediateBiancolini, CA., Del Bosco, CG., Jorge, MA. Argentine Jewish community institution bomb explosion. J Trauma, Oct 1999, 47 (4): 728-732
Lee, CY Development and Application of the bomb-blast Damage and Injury Scale 2003
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4%O
4%C
19%S
Lee, CY. Development and Application of the Bomb-blast Damage and Injury Scale. 2003
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Tactic 4Tactic 4
Catastrophic, Rare ExplosionsCatastrophic, Rare Explosions
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Low explosive
Deflagration
No overpressure
High explosive
Detonation
Overpressure
Nuclear explosion
Fission of nuclearparticles
+ High explosivecomponent
Overpressure
“Real life” reflectingsurfaces makecomplex blast pattern
– accumulates blastpressures
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Source: de Candole, 1967
Range
yield
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Texas CityTexas City
• Within a 1,000-foot radius, all will be killed or injured.
33% DOS, 50% seriously injured, 17% less injured• Low death rate among hospitalized survivors (6.25% DIH of admitted) and
fewer serious burns that anticipated
• Thick cloud of black smoke and vapor from soot and chemicals
5,000 dead and
injured;3,500 non-fatal
injuries;
800 hospitalized(16% of total
casualties);560 killed, or
missing and
presumed Dead
Additional InformationCasualties
Primary Cause of
Damage and Injury
was the blast (blastwave, blast wind),
missiles, fire, tidal
wave (10 ft high)
1000 ft - Almost all 560
dead and 800
hospitalized; 2000ft;3000 ft damage still
seen up to 10,000 ft
(1.8 mi)
out
1.6 kt TNT-Equivalent2.3 kT AN
Key InjuriesRadius of DamageKiloton equivalentExplosives
April 17, 1947 - cargo munitions ship explodes
Blocker, V., Blocker, TG. The Texas City Disaster, a Survey of 3000 casualties 1949. American J Surgery
S i i j i
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Serious injuriesand deaths stillfound out to
1500 ft = 1/3 mi
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Tactic 3Tactic 3
Complex Bombings, Current DayComplex Bombings, Current Day
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Complex BombingComplex Bombing
1 – Combining open, confined, structural
bombings2 – “Onslaught” of several bombings using
suicide methods to one area3 – Capitalizing on crowds
Differs from a single method to a single target,
potentially increasing casualty count and
making medical response more confusing
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““250 Perish as 13 Blasts Rock India250 Perish as 13 Blasts Rock India”” – – 19931993
More than 1000 injuredMore than 1000 injured
IndiaIndia –– Pakistan ConflictPakistan Conflict
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ChechnyaChechnya –– Russia ConflictRussia Conflict
• July 2-3, 2000 - Chechen guerrillas launch 5
suicide bomb attacks on bases of Russianforces within 24 hours. In the deadliest, at least54 people are killed at a police base near
Grozny.• December 27, 2002 - Chechen suicide bombers
ram vehicles into the local government
headquarters in Grozny, bringing down the roofand floors of the four-story building. Chechenofficials say about 80 people killed.
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July 5 2003
3 SHB
20 Dead
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Bali BombingsBali Bombings
• 8/1/2000 – Car bomb, private house
– 2D, 1I• 9/13/2000
– Car bomb, Jakarta StockExchange
– 10D, 16I• 12/25/2000
– 11 churches acrossIndonesia
– 19 D, 100 I• 12/05/2002
– Bomb McDonald’s
– 3D, 11I
• 10/12/2002 – 2 bombs (1 car), Nightclubs
– 202 D• 8/5/2003
– Car bomb Marriott
– 12D, 150I
• 9/9/2004 – Suicide car bomb
Australian Embassy
– 11D, 100 I
• 10/1/2005 – 2 SHBs
– 3 restaurants
– 24D, 132I
Source: CNN, Accessed 10-3-05
AfricaAfrica –– Kenya and TanzaniaKenya and Tanzania
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AfricaAfrica Kenya and TanzaniaKenya and Tanzania
U.S EmbassiesU.S Embassies
8/7/19988/7/1998
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Riyadh May 12 2003Riyadh May 12 2003
• 4 Bombings in quicksuccession
• Combination of SHB andvehicle bombs
• 34 dead, 190 injured
• Most casualties from the AlHamra compound
• “Commando Op”
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Morocco May 16 2003Morocco May 16 2003
• 42 killed including 13 bombers, 100
injured – 24 DOS
• 100 patrons estimated in the Café elSpana at time of bombing (9 pm)
• Blast at club responsible for most
casualties
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C.Y.Lee 1 Apr 2004
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C.Y.Lee 1 Apr 2004
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Increased bomb deliveryIncreased bomb delivery
• Aug 26 2003 - 2 car blasts in Mumbai, 150wounded, 65 dead
– Minutes apart, bodies expelled 10 – 15 meters
– Train derailment blast minutes later
– Worst attack since 1993• Sept 30 2005 - Series of car bombs over 2 days
kill 200 in Iraq
– Since April 25 suicide bombers killed 1,345 people
Transportation TargetsTransportation Targets
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MOSCOW Commuter Train DEC 5 2003
745AM, Up to 41 DOS, 2 possible SHB with UXO, problems inrescue, 1st suicide train bombing (before Madrid)
Sept 2003, 6 people died, commuter train similar bombing
Transportation TargetsTransportation Targets
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Serious Train Bombings 1976 - 2005Serious Train Bombings 1976 - 2005
0
200
400
600
800
1000
1200
1400
1600
8 / 1 4 / 7 6
3 / 2 9
/ 8 2
6 / 2 6
/ 8 6
9 / 3 / 8 8
3 / 1 9 / 9 4
7 / 2 5
/ 9 5
7 / 2 5
/ 9 5
1 2 / 3 / 9 6
1 0 / 1 / 9 7
2 / 2 3
/ 9 8
2 / 2 6
/ 9 8
3 / 9 / 9 8
3 / 3 1 / 9 8
6 / 7 / 9 8
8 / 1 2 / 9 8
1 1 / 1 1 / 9 9
1 1 / 1 1 / 9 9
2 / 5 / 0 0
2 / 5 / 0 0
8 / 1 3 / 0 1
8 / 1 4 / 0 1
3 / 1 4 / 0 2
3 / 1 2 / 0 3
9 / 3 / 0 3
1 2 / 5 / 0 3
2 / 6 / 0 4
3 / 1 1 / 0 4
7 / 7 / 0 5
Dead
Injured
Dec 5 2003 Russian CommuterDec 5 2003 Russian Commuter
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Dec 5 2003 Russian CommuterDec 5 2003 Russian Commuter
TrainTrain• DOS 70% (31/44) of total fatalities
• Critical mortality 9% (13 of 148)• not unlike the 6% critical mortality reported frombombings in Israel
• occupied primarily by college students• 16 to 68 years old
• force ejected several occupants
• Up to 148 victims were admitted
• 50 were treated for minor physical injuries andreleased
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Rescue ChallengesRescue Challenges
• Friday morning rush hour
• trapped many severely injured inside• under overturned train carriage
• encumbered by a
– snarl of electrical wires – cables
– and overhead fires
“The Suicide Bombing of the Mineralnye Vody Train: A Case Study in Using Open Source Information (OSINF) for Open Source Health Intelligence (OSHINT)”. Lee, Davis, Noji
Feb 6 2004 Moscow MetroFeb 6 2004 Moscow Metro
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Feb 6 2004 Moscow MetroFeb 6 2004 Moscow Metro
8:40 AM
2 SHB’s
39 DOS
70+ injured
Smoke
No electricity
Secondary fires
Rescuers could
not open traindoors for 30minutes
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Mar 11 2004 Madrid MetroMar 11 2004 Madrid Metro
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Mar 11 2004 Madrid MetroMar 11 2004 Madrid Metro
• 10 Explosions• 15-minute Span,• Started at 7:39 AM• 28 – 33 lb high
explosive
• Backpack, 13 Bombs• 192 Dead• Approx. 1400
Wounded
Source: BBC Online
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Sequence of EventsSequence of Events7:39 a.m. – 3 backpacks loaded with explosives blow up on
a commuter train in Madrid's Atocha station.
7:39 a.m.– 4 backpack bombs explode on a commuter trainentering Atocha station.
7:42 a.m. – 1 Backpack bomb explodes as a commuter
train enters Santa Eugenia train station, nine miles fromAtocha.
7:41 a.m. – 2 bombs explode on double-deckercommuter train in El Pozo station, six miles fromAtocha.
Source: Associated Press, “Timeline for Madrid commuter train bombings”, Mar 11, 2004, San Diego-Union Tribune,signon SanDiego.com
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Most deaths
on doubledecker 70
fatalities
Source: BBC Online
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Madrid Casualty FiguresMadrid Casualty Figures
• Number of victims: 1430
• Primary care: 204 (14%)• Prehospital care: 250 (17%)
• Admitted to any Hospital: 976 (68%)• Total number of deaths: 192 (13%)
• Number DOS: 170
i S j i
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Madrid Severe InjuriesMadrid Severe Injuries
1º: Blast injuries (explosion): 56%.
2º: Penetrating injuries (shrapnel): 50%.3º: Blunt trauma (ejection): 53%.
4º: Burn injuries (flash burns): 31%
L d J l 7 2005
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London July 7 2005London July 7 2005
Four bombs:
3 on tube carriages1 on commuter bus
Deaths:
26 at Russell Square7 at Aldgate6 at Edgware Road
13 on bus at Tavistock
Place
Source: BBC Online
SS f E l i
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Seat of ExplosionsSeat of Explosions
The most deaths at Russell Square, 26 D
Aldgate, 7D, 100 injured, 10 serious
Edgware Station, 6D, 120 injured
Source: BBC Online
SR ll S I D h
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Russell Square In-DepthRussell Square In-Depth
Source: BBC Online
T i kT i t k
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TavistockTavistock
Source: BBC Online
Li lLi l
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LiverpoolLiverpool
• Sliding doors wouldn’t open
• Soot, smoke billowing up• At first panic, then collected calm
• Double-decker bus to Royal UniversityHospital
Source: BBC Online
KiKi ’’ CC
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KingKing’’s Crosss Cross
• “Intense heat of up to 60C, dust, fumes,
vermin, asbestos and initial concerns thetunnel might collapse delayed theextraction of bodies and the forensic
operation.” - BBC – 30 minutes for paramedics to arrive
– 15 minutes for survivors to get to surface – Survivor states hospital pretty well organized,
saw a lot of minor scrapes, cut legs
Source: BBC Online
T i t kT i t k S BS B
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TavistockTavistock Square, BusSquare, Bus1/81/8thth milemile
200 meters200 meters
660 feet660 feet
Source: BBC Online
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I di E l i /FiI di E l i /Fi
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Incendiary Explosions/FiresIncendiary Explosions/Fires
• Burns
• Respiratory problems to T3• Common materials in public
• Less technological skill to craft• Post-disaster, possibly more time
consuming to mortuary system• Doesn’t have to be terrorist
• Daily drills with arsons and fires
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Deagu, SOUTH KOREA Feb 18 2003
10AM, 120 DOS, incineration, major hurdles to rescue,including entrapment inside once fire started
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C lti d I j iC lti d I j i
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Casualties and InjuriesCasualties and Injuries
• 182 dead, 340 missing and presumed
dead• 2 subway trains
• Fire engulfed one 6-car train, spread tothe next train which had pulled into station
few minutes later
• Most bodies unidentifiable, charred
• Burned, trampled, suffocated to death
E C li tiE C li ti s
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Emergency ComplicationsEmergency Complications
• Fire crippled communication system
• Subway officials couldn’t warn 2nd
train• Station control center cut off electricity
• black out, no sprinkler system
• Most victims in this 2nd train
• Conductor fled without opening doors,
victims trapped• “Toxic Gas”
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Thanks for your time!Thanks for your time!
Catherine Y. Lee, MPH