There are many definitions of terrorism, but the one developed by Cunningham (2003) is one of the most useful because it is not too simple, broad, or complex:

Terrorism is defined as the illegitimate use or threat of violence to further political objectives. It is illegitimate in that it targets civilians and/or non-combatants and it is perpetrated by clandestine agents of state and non-state actors in contravention of the laws of war and criminal statutes. It is symbolic and premeditated violence whose purpose is to communicate a message to a wider population than the immediate victims of violence. It is designed to affect this audience by creating psychological states of fear in order to influence decision-makers to change policies, practices or systems that are related to the perpetrators’ political objectives. These objectives can be either systemic or sub-systemic and may be motivated by complex social forces including, but not limited to, ideology, ethno-nationalism or religious extremism (p. 23).

As reflected in its definition, terrorism lacks legitimacy because the means do not justify the ends. While many terrorists think of themselves as soldiers, their tactics lack the conventions of traditional warfare in that terrorists perform criminal acts such as kidnapping and murder, including the deliberate killing of non-combatants (Moore, 2003).

As reflected in its definition, terrorism lacks legitimacy because the means do not justify the ends. Terrorism threatens the public with widespread death and disease, fear, panic, and disruption to society – both psychologically and economically (Richards, Burstein,Waeckerle, & Hutson, 1999). For instance, in the summer of 2006, intelligence information revealed the possibility of liquid explosives being detonated on an airplane. Passengers were banned from bringing their own beverages and toiletries into the cabin of aircraft (Thomas, 2006). This created fear for passengers, disrupted their flying routine, and forced them to purchase pre-approved items from airport concession stands. Because Richard Reid tried to light fuses placed in the soles of his shoes on a transatlantic flight several years ago (Thomas), now all passengers are inconvenienced by having to remove their shoes while being screened by airport security. Incidentally, Reid is the same man that Zacarias Moussaoui testified was supposed to be part of his five-man crew designated to hijack a fifth plane and fly it into the White House on September 11^th 2001 (9/11). Moussaoui’s plan was foiled by his own arrest in August 2001 (Markon & Dwyer, 2006).

Nurses...play a pivotal role in the assessment, diagnosis, and treatment of the victims of terrorism. Nurses need to comprehend their role in response to terrorist events, since they play a pivotal role in the assessment, diagnosis, and treatment of the victims of terrorism. Because of their exceptional clinical and organizational skills, nurses also play an important role in disaster planning and response, at both the individual and community level. It is imperative that nurses better prepare themselves for future acts of terrorism and be equipped to care for the victims in their respective nursing environments.

The history of these manmade disasters can teach us valuable lessons! The purpose of this article is to help readers “put it all together” by providing a brief history of terrorist events pre- and post- 2000 that have contributed to the current state of affairs, and an overview of tactics used by terrorists, such as suicide bombings and weapons of mass destruction. Suggestions are offered related to both pre- and post- disaster planning, including the status of specific nursing competencies and evidence based practices.

Brief Historical Review of Terrorism

Pre-2000 Events

Many Americans associate regional and international terrorism with the Middle East; however, tactics used by terrorists to influence policy are hundreds of years old (Friedman, 2003). In 1585, in an attempt to oust the Spaniards in Antwerp, Belgium, an Italian engineer was recruited by the Dutch to make an explosive device he labeled la macchina infernale. He packed a barrel with gunpowder, flammable materials, and bullets, and then detonated the device from a distance by pulling a shotgun trigger with a piece of string (Wikipedia, 2006b).

Readers may recall terrorist activities and associated bombings in Belfast, (Northern) Ireland and Great Britain (1969-1974); the Marine Barracks in Beirut, Lebanon (1983); the Embassies in Kenya and Tanzania (1998); the U.S.S. Cole in Aden, Yemen (2000); and the aircraft bombing over Lockerbie, Scotland (1988). However, Americans were essentially immune to domestic terrorism until the first bombing of the World Trade Center in New York City (NYC) in 1993, the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, and the attacks on 9/11 by Osama bin Laden’s Al Qaeda terrorists.

As a review, Osama bin Laden formed Al Qaeda (also spelled as “al-Qaida”) in the 1990s with the goal of reestablishing a Muslim state throughout the world by overthrowing what he viewed as corrupt regimes, as well as eliminating an American and Israeli presence in the Middle East. In 1996 and 1998, bin Laden released statements notifying Muslims that it was their duty to kill Americans, both civilian and military, as well as America’s allies, until they withdrew their support for Israel and removed troops from Islamic countries. Hence, the foundation that led to the events on 9/11 was set in place (Moore, 2001).

Post-2000 Events

What happened in the United States on 9/11 represents a form of urban terrorism, where terrorists focus on targets that represent financial, communication, and symbolic significance (Eiseman, 2001). Terrorists have two goals for an attack: to generate casualties and to produce multiple fatalities (Frykberg, 2002). A case in point for urban terrorism is the destruction of the twin towers of the World Trade Center in New York City (NYC) on 9/11. There were 2,595 deaths (Wikipedia, 2006c) and the injuries seen on this fateful day were analogous to bombings (Frykberg). The 5:1 ratio of dead to injured on 9/11 was unprecedented and is almost a reversal of the ratio expected in a classic military battle (Eiseman).

In response to the traumatic events of 9/11, the Centers for Disease and Control’s (CDC) National Center for Health Statistics generated new classifications for mortality and morbidity involving terrorism (CDC, 2002b). Additionally, the physiological consequences of 9/11 continue to this day, with particle and dust inhalation injuries being a problem for the immediate victims, residents, and medical and rescue personnel of NYC (CDC, 2002a). The events of 9/11 also had an impact on the community (e.g., post-traumatic stress disorders and/or depression) and psychological consequences were not limited to those who experienced it directly (Silver, Holman, McIntosh,Poulin, & Gil-Rivas, 2002).

Overview of Tactics Utilized by Terrorists

Bombings

Readers’ minds may be fresh with the experience of the 2004 train bombings in Madrid, Spain (Wikipedia, 2007), allegedly carried out by a Moroccan Islamic terrorist organization, and the 2005 train and bus bombings in London, England for which an Al Qaeda-like faction was allegedly responsible. Because terrorism threatens society with fear, panic, and disruption, it can be postulated that bin Laden and his Al Qaeda followers were thrilled with the 2004 election results in Spain just three days after the Madrid train bombings: Prime Minister Jose Maria Aznar’s party was defeated, and the winner of the election fulfilled a campaign promise to withdraw Spanish troops from Iraq (Wikipedia, 2007).

...suicide bombers view themselves as martyrs...Suicide bombers. Hamas, the primary anti-Israeli group in the occupied territories, views suicide terrorism as a psychological weapon effective in paralyzing its enemy. It implemented its first suicide attack in northern Israel in 1994 (Hoffman, 2006). Consequently, Israel has lots of experience with suicide bombings, which continue to this day (Atran, 2003). Hoffman also noted that suicide bombers view themselves as martyrs; thus, in their minds, they are not committing suicide or committing murder, but rather dying for their cause. They are actually content to die, because they believe that upon death, they will meet their Maker, that all of their sins will be forgiven, and that they will go on to live in paradise, where they will be able to sponsor 70 members of their family, as well as marry dark-eyed virgins. Hoffman further writes of the classic smile that many “martyrs” wear right before they blow themselves up, as exemplified when a Marine guard outside of the barracks in Beirut, Lebanon on October 23, 1983, said that the suicide driver of the truck loaded with explosives looked right at him and smiled prior to completing his mission.

Suicide bombs detonate in close proximity to victims, with two-thirds exploding in confined/closed spaces (Hiss & Kahana, 2000). To increase injuries, some bombs contain numerous metal fragments (e.g., nails), or even pellets of rodent poison, to introduce bleeding coagulopathies in injured victims (Wolf & Rivkind, 2002). A study of suicide bombings involving 892 victims in Israel from 1994 – 1997 revealed a mortality rate of 17%, with 30% of the fatalities having no obvious external cause of death (Wolf & Rivkind); this suggests that immediate death was probably related to massive pulmonary bleeding or a pulmonary embolism (Stein & Hirshberg, 1999). Another group of researchers published its experience with terrorist bombings from 1969 – 1983, with a combined sample population of 3,357 from 220 explosions, and found that there were 2,934 immediate survivors (but only 30% required hospitalization) and just 1.4% died, demonstrating that the mortality rate for blast survivors can be very miniscule (Frykberg & Tepas, 1988). Survivors of suicide bombings sustain a combination of injuries: blast injuries (including tympanic membrane perforation in 25% of cases); shrapnel injuries (20-40%); and burns (15%) (Wolf & Rivkind).

Common blast injuries. Blast injuries are a consequence of three factors that make the mechanism of injury from a bomb blast multi-factorial (Alfici, Ashkenazi, & Kessel, 2006): primary (where there is a sudden increase in air pressure); secondary (where debris is set in motion); and tertiary (where the victim’s body is displaced into other objects) (Frykberg, 2002). A typical scenario of a blast injury related to the bombing of a building would begin with direct exposure to air gas, followed by the displacement of mass movement of air; a penetrating and non-penetrating impact of blast-energized debris; burns from flash and hot gases; inhalation of noxious gases; and finally the possible collapse of the building (Cooper, Maynard, Cross, & Hill, 1983).

A pulmonary blast injury is the most common form of thoracic trauma found in immediate blast fatalities, but it is rare to find among injured survivors (Stein & Hirshberg, 1999). A study of thoracic blast injuries in rats may explain this lethality, in which a reflex of apnea, bradycardia, and hypotension occurred in the rats after the injury (which did not occur when abdominal blast injuries were tested) (Guy, Kirkman, Watkins, & Cooper, 1998). Incidentally, the presence of blood in a victim’s airway is a dependable sign that a blast lung injury has been sustained (Alfici, et al., 2006). Patients suffering from primary blast injury to the lungs are challenging to manage. Based on the Israelis’ experience, respiratory support has included volume-controlled, pressure-controlled, individual lung, or high frequency ventilation (Stein & Hirshberg). Extracorporeal membrane oxygenator was unsuccessful the only time it was used, and nitric oxide improved the respiratory status of a just few patients. Alfici et al. recommend securing the airway by means of a rapid sequence induction and intubation, followed by positive pressure ventilation (PPV); however, the authors caution that PPV may actually cause further barotrauma to the lungs, so it might not be an option for all patients.  

Head injuries are the most common contributor to both immediate and late fatality for victims of terrorist bombings, and abdominal and chest injuries contribute to late fatality in immediate survivors (Frykberg & Tepas, 1988). Patients with closed head injuries require the expertise of neurosurgery and patients with ocular injuries need to have an ophthalmologist as a part of the health care team. Abdominal trauma patients may require nasogastric tubes, intravenous fluids, and colostomies, and all patients require superb post-op care management, including antibiotics (Stein & Hirshberg, 1999).

There is an overwhelming prevalence of minor, non-life-threatening trauma. Flash burns, fractures, and eardrum injuries are seen in those closest to the bomb (Frykberg & Tepas, 1988). Eighty-four percent of all surgeries performed on survivors of bombings are to repair soft tissue and bone injuries, which do not contribute to mortality unless a traumatic amputation is involved (Frykberg & Tepas). These patients need labor-intensive wound cleansing and debridement, and may benefit from the use of vacuum-assisted closure to promote wound healing. Crush injuries can result from massive soft tissue injury in victims trapped in buildings. With a crush injury, myoglobin is released from muscle tissue, which induces rhabdomyolosis; thus, to optimize renal hemodynamics and prevent accompanying acute renal failure, survivors of crush injuries need to be aggressively hydrated and diuresed, along with alkalizing their urine (Criddle, 2003).

Factors that influence blast injury survival. There are determining factors that influence casualty survival, including the environment and its internal structure (e.g., an open air bombing has less mortality than a confined-space explosion); the position of victim (e.g., a victim within seven feet of a suicide bomber is at greater risk of death than a victim who is 30 feet away); the degree of explosive force; the time interval between injury and definitive care (e.g., based on the well known trauma principle of the Golden Hour); the anatomical site of injury (e.g., a head injury has greater mortality than a soft tissue injury); and the availability of medical resources at scene (e.g., an isolated location versus an urban area with secure definitive care facilities) (Frykberg & Tepas, 1988; Leibovici et al., 1996; Stein & Hirshberg, 1999).

Use of Weapons of Mass Destruction

Weapons of Mass Destruction (WMD) include chemical, biological, and radiological (CBR) agents (Richards et al, 1999). This section will briefly discuss each of these three agents and direct the reader to further resources available on the CDC web site.

Chemical agents. Chemical agents consist of nerve, blister, blood, choking, and incapacitating agents (Slater & Trunkey, 1997). The 1995 sarin nerve gas attack in Tokyo, Japan demonstrated the lethal consequences of an organophosphate nerve agent. This attack utilized plastic bags containing diluted sarin that were placed on subway trains, and subsequently activated when terrorists pierced them with the tips of umbrellas (Lee, 2003). Twelve passengers died as a result of this attack and thousands were injured.

Another example of the devastating effects of a chemical agent, although not used for terrorists’ means, is the events of the deadly takeover by Chechen rebels of a Moscow theater in 2002. When Russian forces stormed the theater, Russian government officials sprayed a “sleeping gas” into the building. It was later determined that the gas was fentanyl, a fast-acting opiate. The intention was to release the gas to prevent the hostage takers from triggering explosives in the theater, and the notion worked; however, the fentanyl also overwhelmed most of the captives, resulting in over 100 hostage deaths (Raddatz, 2002).

Existing antidotes for victims who have been exposed to chemical agents are too numerous to mention in this text. The most-up-to-date information for the bedside clinician can be found on the CDC (n.d.b) “Chemical Emergencies” webpage.

Biological agents. A biological agent is “any organism or toxin found in nature that can be used to incapacitate, kill, or impede an adversary” (Richards et al, 1999, p. 184). The Greeks practiced biological warfare as early as 300 BC, when they polluted wells by filling them with dead animals (Slater & Trunkey, 1997). Biological agents may be disseminated by aerosol, sprays, explosives, food, or water contamination (Richards et al).

The United States experienced the adverse effects of a biological agent in 2001, when 22 individuals contracted anthrax in the Washington, DC area, resulting in five deaths (Gerberding, Hughes, & Koplan, 2002). It is now estimated that 100 kg of anthrax released in Washington, DC could kill over one million people (Richards et al). At present, technical hurdles prohibit terrorists from mounting a large-scale bioattack (e.g., the medical community’s caution about suspicious buyers would trigger an investigation; also, most biological agents cannot be “weaponized” to produce mass casualties) (Mintz, 2004).

When a threat exists, it is normal to develop measures to counter that threat as much as possible. Active, passive, and medical defense mechanisms are examples of countermeasures that can play a crucial role when dealing with bioterrorism (as explained in Table 1). Up-to-date information and treatment recommendations for suspected bioterrorism agents can be found on the CDC’s “Bioterrorism Emergencies” web page. (CDC, n.d.a)

Table 1. Defense Measures Against Biological Warfare  (Based on the military defense model) as adapted from Richards et al. (1999) and Pavlin, Eitzen, and Caudle (1997). Note that examples noted with an asterisk (*) denote measures that may specifically involve nurses.
Measure	Examples
Active Defenses – with the exception of Good Intelligence, these measures are outside the scope of practice for most healthcare professionals	* Good Intelligence – early knowledge of specific threats allows for timely countermeasures; surveillance is the key here Rapid maneuver of forces – this measure is exercised against the enemy before it has time to become positioned or well-organized Counterattack against those with bio-weapons – entails eliminating the biological threat
Passive Defenses – these are physical countermeasures that are implemented to reduce exposure and to minimize the effects of biological agents	Environmental detection – this is the first step in identifying if an event has even occurred. Additionally, the rate of illness should be compared to previous years to determine any abnormalities. Early recognition will lead to the prompt mobilization of prophylactic antibiotics or vaccines * Individual protective gear – consists of clothing and masks that are donned for protection from chemical, biological, or radiological agents. The military version of this protective wear is known as “MOPP gear.” MOPP = Mission-Oriented Protective Posture Contamination avoidance – includes the development of multi-agent sensors to detect, identify, and warn individuals of an agent, in order to avoid exposure to the agent * Rapid decontamination – depends on the suspected agent, but in most cases is not necessary since most biological agents do not affect the skin and do not form secondary aerosols
Medical Defenses – these are the foundation of a proper response to biological agents in the civilian sector	* Laboratory diagnosis – includes obtaining specimens and institutional support for bacteriology, including a back-up plan for agents that cannot be diagnosed in a routine lab * Vaccines – includes the administration of vaccines as well as the development of new ones based on the impending threat of bioterrorism * Medications and Medical Supplies – involves administering medications and may include accessing CDC’s Strategic National Stockpile (SNS) for a catastrophic event. The SNS is a national repository for antibiotics, chemical antidotes, antitoxins, and life-saving medications as well as medical-surgical items. For more information on the SNS, explore www.bt.cdc.gov/stockpile (CDC, 2007). * Isolation or quarantine – involves enforcing infection control practices, keeping in mind that most agents are not transmitted from person to person (except for smallpox and pneumonic plague) so that nearly all patients can be managed with standard universal precautions

Radiological agents. Our knowledge of radiation exposure is based upon our experience with Hiroshima, Nagasaki, and Chernobyl. Radiation injuries can be caused by four possibilities: localized exposure, resulting in a burn; whole body exposure, resulting in acute radiation syndrome; internal contamination via inhalation, ingestion, skin, and/or wounds, resulting in radio iodine accumulation in the thyroid; and external contamination, whereby removal of the clothing alone results in 90% elimination of the contamination (Mettler &Voelz, 2002).

It is estimated that a one-megaton nuclear warhead would kill almost two million people in the Washington, DC area (Richards et al, 1999). Note that a megaton is a unit of measurement of mass used to quantify the amount of energy released with a nuclear weapon – and its destructiveness – as compared to ordinary explosives, like TNT. In other words, a one-megaton nuclear warhead will cause as much devastation as 1,000,000 metric tons of detonated TNT (Wikipedia, 2006a). In comparison, the ammonium nitrate bomb that exploded at the Murrah Federal Building in Oklahoma City in 1995 had a blast force equivalent of only two tons of TNT (Frykberg, 2002).

Again the CDC has current information for health care professionals when they suspect a radiation emergency. Information can be located on the “Radiation Emergencies” web page (CDC, n.d.c).

Pre-Disaster Planning

Surveillance

It is important to emphasize the role of both public and private surveillance in preventing terrorist attacks. It is important to emphasize the role of both public and private surveillance in preventing terrorist attacks. An example of public surveillance occurred in 2006 when British intelligence services noticed several suspected plotters searching the Internet for nonstop flights to the United States on American, Continental, and/or United Airlines. Moreover, these suspects were known to possess triacetone triperoxide (TATP), an organic peroxide that is highly explosive when detonated by a simple electrical device (e.g., a portable music player). TATP bombs can be created by mixing solvents like nail polish remover with concentrated peroxide, resulting in a concoction that looks like a sports drink when placed in a bottle. Investigators were fearful of warning airport security personnel to screen for TATP bombs, knowing that the plotters would realize that the government was on to them when they rehearsed their plan. According to Thomas (2006), it is customary for Al Qaeda to rehearse and observe targets prior to an event. Thomas further explained that authorities prefer to watch suspects until the last possible moment; however, in this case, they intercepted a martyrdom video of one of the individuals and learned that another worked in security at a London airport. Thus, arrests were quickly made prior to the occurrence of another catastrophic event and now all airline passengers are banned from bringing their own beverages and toiletries into the cabin of the aircraft, for fear of a TATP bomb.

Another illustration of public surveillance occurred in the summer of 2004 when multiple international flights were canceled. This decision was based on intelligence information that indicated terrorists might release a chemical or biological agent aboard an airliner; transport a radiological device in cargo; or attempt to assemble an improvised explosive device in the lavatory of an airplane (CNN Wolf Blitzer Reports, 2004).

Not all nurses will be first responders...but they still need to be prepared to recognize what actions would be helpful in various stages of response. Private surveillance recently prevailed when a store clerk notified authorities of a video he saw after he was asked to transfer it to a DVD. This video portrayed 10 men shooting guns at a firing range, all the while shouting for a “jihad.”  In this case, the “jihad” was a call to violence against perceived anti-Muslims, in the name of Allah. Without this tip, authorities would never have learned of the plotters’ plan to attack U.S. soldiers with automatic weapons and rocket-propelled grenades at the army base in Fort Dix, NJ (Parry, 2007).

With a biological terrorist attack, nurses have a great role in practicing surveillance by recognizing the features of possible event so that casualties are quickly identified and minimized. This would include reporting the following symptoms as noted by Richards et al. (1999, p. 187):

• A rash of multiple patients presenting with similar symptoms
• Severe illness in young, healthy persons
• The presentation of predominantly respiratory symptoms
• Unusual organisms
• Unusual antibiotic resistance patterns
• Atypical presentation of disease
• Geographic clustering
• An abundance of sick or dead animals or plants

Community Disaster Plan and Drill

Disaster plans need to be adapted to reality, and can only work if they are regularly tested via major disaster drills (Frykberg,2002). When medical personnel approach catastrophes (e.g., the aftermath of a suicide bombing), they should incorporate actions that were developed as a result of lessons learned via the Israelis (as described in Table 2). Additionally, it is helpful to be aware that chaos occurs immediately after a terrorist event. Management phases (as listed in Table 3) will eventually take over.

Table 2. Immediate Actions in a Suicide Bombing Event, Based on the Experience of the Israelis (adapted from Hiss & Kahana, 2000; Stein & Hirshberg, 1999).

Secure the scene Have a bomb squad sweep the area prior to treating the casualties (so that rescue personnel do not become victims themselves if terrorists have booby-trapped the site with more explosive devices) Prohibit responders from entering the scene if sniper fire exists Direct the wounded to pre-identified trauma centers Photograph and videotape the scene Rapidly remove victims from the scene Number the human remains sequentially and place in body bags, then transport to the medical examiner’s office Provide rapid cadaver identification, so that the victims may be identified, released to their families, and buried according to religious customs Establish a command information center, so that relatives have one source to contact, rather than calling individual hospitals in search of their loved ones

 

Table 3. Management Phases at a Disaster Scene (adapted from Stein & Hirshberg, 1999)
Chaotic Phase	Lasts approximately 15 – 20 minutes after a terrorist event
Reorganization Phase	Lasts about 60 minutes and begins once a leader is clearly identified and takes charge
Site-clearing Phase	Lasts 100 – 180 minutes and involves the evacuation of victims
Late Phase	Can persist up to 48 hours after the event and is the period utilized for evidence collection, reconstruction of the event, and clearing of all debris

Nursing Competencies for Emergency Preparedness

...nursing knowledge and competencies related to mass casualties should be defined,Nurses have been involved in disaster preparedness and response for as long as nursing has existed (Gebbie & Qureshi, 2006; Wynd 2006).  However, since 9/11, it has been acknowledged that nursing knowledge and competencies related to mass casualties should be defined, so that all can be assured that nurses know what they are doing during a catastrophic event. Not all nurses will be first responders during a disaster, but they still need to be prepared to recognize what actions would be helpful in various stages of response. The appendix in Gebbie and Qureshi’s article provides a comprehensive table of emergency preparedness competencies (e.g., core competencies, core knowledge, and professional role development) that nurses responding to a mass casualty incident should possess, based on the International Nursing Coalition for Mass Casualty Education’s (INCMCE) recommendations. Refer to Weiner (2006) for background information on INCMCE, which is now known as the Nursing Emergency Preparedness Education Coalition (NEPEC) (Romano, 2007).

Family Disaster Plan

...[nurses] need to remember they may not be immediately available to loved ones...and have a personal family plan of action in place. Nurses need to develop both a personal/family plan and a professional/employment plan in case a terrorist event occurs and they are mobilized to their respective treatment facilities to administer care to victims (Peterson, 2006). The most inclusive information for family emergency planning has been developed by the Department of Homeland Security (DHS) and can be found under the “Ready America” tab at www.ready.gov. Via this site, one can find a checklist for emergency supply kits, suggestions for developing and recording a family plan, and tips to become informed about one’s own community disaster plans and warning systems (DHS, 2007). Gebbie and Qureshi (2006) also offer information on what nurses should consider prior to being called upon to work during a disaster (e.g., who will take care of their children and/or pets and how will they get to work should a disaster affect their usual mode of transportation or route).

Post-Disaster Response

Management for Mass Casualties

Frykberg (2002) discusses several considerations for the medical management of mass casualties from terrorist bombings:

• Protection of medical assets. Medical assets (e.g., first responders, including ambulance personnel) need to be protected, based on the “second hit” principle whereby snipers may fire on first responders. This was the case in the evacuation of victims after the bombing of the Marine Barracks in Beirut, Lebanon in 1983.
• Record keeping. Record keeping has to be exceptional because it is the major means of leaving an audit trail that contributes to continuity of patient care and tracking the location of victims. Accurate records also contribute to retrospective review to explore “lessons learned.” 
• Triage. During a mass casualty incident, advanced triage systems are activated since a large number of victims will overwhelm existing resources of personnel, equipment, and supplies (refer to Table 4 for disaster management triage categories). The challenge of this form of triage is differentiate the minority of casualties who are critically injured and need immediate care from the majority of victims who do not have life-threatening injuries. Nurses may struggle morally with triaging patients to the “expectant” category as they have to shift their mindset from the normal management of day-to-day trauma (which focuses on the care of the individual) to mass casualty management (which targets care of the population). This decision-making process may result in some immediate survivors in extremis (e.g., with respiratory failure and profound shock) not being treated and then dying – an event for which many nurses find themselves unprepared.  

Table 4. Disaster Management Triage Categories (adapted from Frykberg, 2002)
Category	Color Code	Description
Immediate/Urgent	Red	Injuries that unless urgently treated will result in death (e.g., tension pneumothorax, exsanguinating hemorrhage, airway compromise)
Delayed	Yellow	Involves patients who are expected to survive, but have life-threatening wounds, but in whom delay is acceptable (e.g., open fractures, mild flash burns)
Minor, Minimal, or Ambulatory	Green	“Walking wounded” – injuries are minimal and require little or no treatment
Expectant/ Unsalvageable/Dead	Black	Injuries are so severe that they are anticipated to die, even if multiple resources are available (e.g., penetrating head wounds, large burns, cardiac arrest)

Evidenced-based Treatment Protocols

Evidenced-based treatment protocols related to mass casualty victims do not exist. Auf der Heide (2006) examined common assumptions about disasters, compared them with research findings, and concluded that there is a dearth of information regarding evidenced-based disaster planning. The author offers hypotheses for future research, but that does not help nurses at the present time. Three agencies within the National Institutes of Health (NIH, 2007), including the National Institute of Nursing Research (NINR), have funding opportunities for research involving the consequences of natural and manmade disasters, but it may be years before nurses see the fruition of this research. Please refer to Table 5 for topic areas for funding suggested by the NINR.

Table 5. National Institute of Nursing Research (NINR) Research Interests (data from NIH, 2007)

Models and interventions to improve the quality of life and function of persons affected by events such as natural disasters, environmental hazards, and other emergency situations Interventions to enhance preparedness and self-management in those with disability and chronic illness in disaster situations Interventions to assist caregivers of ill and disabled persons to prepare for and respond to disaster situations Interventions for acutely ill individuals during and after a disaster Management of symptoms in the immediate aftermath of a disaster and post disaster

Alfici’s et al. (2006) retrospective study of 467 bombing victims admitted to a level II trauma center in Israel from 1994 to 2004 offers a “lessons learned” perspective. This type of research lacks a significant level of rigor to support evidenced-based medicine. However, it would be remiss not to share the authors’ suggestions for caring for victims of mass casualties caused by terrorist bombings, since it is at least a beginning and is based on recent experience (see Table 6 for recommendations).

Table 6. Suggestions for In-hospital Care of Victims of Mass Casualties Caused by Terrorist Bombings (adapted from Alfici et al., 2006)
Stable Victims	The main concern with a large numbers of victims is that some will have a life-threatening injury that will be missed with initial triage; however, this rarely happens These patients constitute 90% of casualties, with half of them having an acute psychological reaction Primary and secondary surveys are critical in the evaluation of these patients Ancillary services (e.g., laboratory and radiology) should be utilized for unstable victims first Hemodynamically stable patients with fragment penetration from bombs should be hospitalized for observation, because it is not possible to explore all wounds at this time when assessing penetration
Unstable Victims	A patient’s respiratory rate and oxygen saturation are more reliable that a chest x-ray when evaluating lung blast injuries The presence of blood in a victim’s airway is a dependable sign that a blast lung injury has been sustained Avoid an emergency room thoracotomy in patients with a primary blast lung injury, since visualization of where to safely place the aortic clamp is hindered After stabilizing lung blast injuries, a secondary survey needs to be done to rule out other injuries Patients with head, neck, or trunk fragment penetration should have a chest X-ray and a computerized tomography (CT) scan; the CT scan is useful in identifying foreign bodies as well as sometimes projecting the tract that the foreign body has taken Those with a solitary entry wound to the neck, abdomen, or extremity should be taken immediately to the operating room to explore and control bleeding Protocol for unstable victims includes: Obtaining immediate airway control via rapid sequence induction and intubation , all the while supporting the c-spine. Using positive pressure ventilation (PPV) with intubated patients, keeping in mind that PPV may further induce barotrauma to the lungs Controlling external hemorrhages, including those on the back of the trunk; considering temporarily packing skin wounds to tamponade hemorrhages Inserting two intravenous (IV) lines and drawing baseline labs Infusing blood products and crystalloids per Advanced Trauma Life Support (ATLS) protocols Reevaluating the patient with consideration of inserting chest tubes to rule out hemothoraxes In most cases, disregarding diagnostic peritoneal lavage (DPL) and focused abdominal sonography (FAST) since these patients need to have a laparotomy to rule out significant abdominal injury
In Extremis Victims	These are not common in-hospital patients, since most die at the disaster site If these patients do make it to the hospital, the results of any immediate treatment are usually unfavorable Isolated reports of survival for in extremis patients do exist, so resuscitation may be considered if resources are available
Note: Please refer to the authors’ original article for treatment protocols related to stable, unstable, and in extremis patients.

 

Conclusion

Complacency must be replaced by careful pre-disaster preparation and competent post-disaster response.When developed, evidenced-based treatment protocols related to disaster planning, response, and management of victims will greatly assist nursing practice. Nurses need to be vigilant of possible terrorist activity and be ready to provide direct patient care to victims of terrorism, since they have an essential role in the assessment, diagnosis, and treatment of these patients. As nurses are integral to disaster management plans, they need to remember they may not be immediately available to loved ones should a terrorist event occur and have a personal family plan of action in place. Review of the history of these manmade disasters has provided valuable lessons which have forever changed our personal and professional lives. Complacency must be replaced by careful pre-disaster preparation and competent post-disaster response.

Author

Catherine Wilson Cox, RN, PhD, CCRN, CEN, CCNS
E-mail:cwc5@georgetown.edu

Catherine Wilson Cox received her BSN from Radford University in Radford, VA in 1981; MSN in Critical Care and Nursing Education from Marymount University, Arlington, VA in 1988; and her PhD in Nursing from George Mason University in Fairfax, VA in 2002. For the last five years, she has been an assistant professor of nursing at Georgetown University (GU), Washington, DC; however, she now resides in Okinawa, Japan with her active-duty, Navy spouse.  Dr. Cox is currently completing a funded research project with GU and is also a reservist in the U.S. Navy Nurse Corps, where she holds the rank of Captain. She has presented this content related to the history of terrorism and implications for preparedness at several nursing conferences, as well as to senior BSN students at GU.  She specifically developed this piece when she noticed a gap in the literature; she was unable to locate a single nursing article on terrorism that “puts it all together” for both nursing students and practicing nurses.

Markon, J., & Dwyer, T. (2006). Moussaoui says he was to fly fifth plane on 9/11. Washington Post, March 28, A1, A16.

Weiner, E. (2006). Preparing nurses internationally for emergency planning and response. OJIN: The Online Journal of Issues in Nursing, 11(3). Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume112006/Number3/PreparingNurses.aspx

Wikipedia. (2006a). Megaton. Retrieved March 30, 2006 from http://en.wikipedia.org/wiki/Megaton.

Wynd, C. (2006). A proposed model for military disaster nursing. OJIN: The Online Journal of Issues in Nursing, 11(3). Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume112006/Number3/tpc31_416085.aspx 

---

© 2008 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2008