Suggested Citation: N a tio n a l C e n te r fo r In ju ry P re v e n tio n a n d C o n tro l. In te rim p la n n in g g u id a n c e fo r p re p a re d n e s s a n d re s p o n s e to a m ass c a s u a lty e v e n t re s u ltin g fro m te rro ris t use o f e x p lo s iv e s . A tla n ta , G A : C e n te rs fo r D is e a s e C o n tro l a n d P re v e n tio n ; 2 0 1 0 . Disclaimer T he fin d in g s a n d c o n c lu s io n s in this re p o rt a re th o se o f the a u th o rs a n d d o n o t n e c e s s a rily re p re s e n t the v ie w s o f the C e n te rs fo r D is e a s e C o n tro l a n d P re v e n tio n .#
Patient id e n tific a tio n 8
Public In fo rm a tio n 8

# Conclusion 29

# Executive Summary
Explosive devices are the most com m on weapons used by terrorists. T he damage inflicted in recent events in India, Pakistan, Spain, Israel, and the United Kingdom demonstrates the impact o f detonating explosives in densely populated civilian areas.
Explosions can produce instantaneous havoc, resulting in numerous patients with complex, technically challenging injuries not com m only seen after natural disasters. Because many patients self-evacuate after a terrorist attack, prehospital care may be difficult to coordinate and hospitals near the scene can expect to receive a large influx, or surge, o f patients after a terrorist strike.
T he threat o f terrorism exists at a time when hospitals in the United States are already struggling to care for patients who present during routine operations each day. Hospitals and emergency health care systems are stressed and face enormous challenges. W ith the occurrence o f a mass casualty event (M CE), health systems would be expected to confront these issues in organization and leadership, personnel, infrastructure and capacity, com m unication, triage and transportation, logistics, and legal and ethical challenges.
T he purpose o f this interim guidance is to provide inform ation and insight to assist public policy and health system leaders in preparing for and responding to an M C E caused by terrorist use of explosives (TUE). This docum ent provides practical inform ation to prom ote comprehensive mass casualty care in the event o f a T U E event and focuses on two areas:
1. leadership in preparing for and responding to a T U E event, and 2. effective care o f patients in the prehospital and hospital environments during a T U E event.
This guidance recognizes the critical role that strategic leadership can have on the success or failure o f preparing for and responding to a terrorist bombing. It outlines im portant leadership strategies for successfully preparing for and managing a T U E mass casualty event,
including the concept o f meta-leadership. Effective meta-leaders employ influence over authority and activate change above and beyond established lines o f their decision-making and control. T hey are driven by a purpose broader than that prescribed by their formal roles. Therefore, they are motivated and act in ways that transcend usual organizational confines, enabling them to successfully confront challenges and barriers in communication, organization and response, standards o f care, and surge capacity.
T he successful medical response to an M C E depends on effectively coordinating three critical areas o f patient care: 1) prehospital care, 2) casualty distribution, and 3) hospital care.
Critical steps must be taken throughout the response to ensure rapid and efficient patient triage, effective and appropriate distribution o f patients to available hospitals and health care facilities, and proper management o f the surge o f patients at receiving hospitals.

# Introduction Purpose
T he purpose o f this interim planning guidance is to provide valuable inform ation and insight to help public policy and health system leaders at all levels prepare for and respond to a mass casualty

# Primary Objectives
T he ultim ate aims o f this guidance docum ent are to:
1. improve decision making during T U E -M C E events, strengthen system and clinical responses, and reduce m orbidity and mortality;
2. identify leadership strategies that improve preparedness for and response to T U E -M C E events;
3. prom ote connectivity, coordination, integration, and consistency between the medical response com m unity and emergency management;
4. encourage health system resilience and maximize the ability to provide adequate medical services during an M CE;
5. enhance the quality o f existing M C E preparedness and response programs used by medical response entities; and 6. provide a resource tool that could be applied during exercises and lower intensity emergency events.

# Background and Structure
Terrorists worldwide have repeatedly shown their willingness and ability to use explosives to inflict significant death, destruction, and fear. A sudden and unpredictable bombing-related M C E requires an immediate response; disrupts com m unication systems; interrupts transportation o f casualties, medical personnel, and supplies; and may overwhelm the capacity o f responding agencies.
Even though explosives are the prim ary weapons used by terrorists, the U.S. health care system has m inimal experience in treating patients with explosion-related injuries. Detonating devices in crowded public places results in complex, technically challenging injuries not commonly seen after natural disasters. Deficiencies in response capability could result in increased m orbidity and mortality as well as stress and fear in the community.
Because o f the injuries sustained by large numbers o f people, explosions produce unique management challenges for health providers, beginning with an immediate surge o f patients into surrounding health care facilities. T he potential for large numbers of patients arriving w ithin a few hours may stress and limit the ability of emergency medical services (EMS) systems, hospitals, and other health care facilities to care for critically injured victims.4-6
T he ongoing and increasing threat o f terrorist activities, combined with docum ented evidence o f decreasing emergency care capacity within the U.S. health care system,7-14 requires proactively preparing for these situations. Health care and public health systems, individual hospitals, and health care personnel must collaborate to ensure that strategies are in place to address these key challenges:
- receive, evaluate, and treat large numbers o f injured patients,
- rapidly identify and stabilize the most critically injured,
- evaluate response efforts, and
- conduct exercises and strategic planning for future events.

# Nature of Explosions
An explosion is caused by the sudden chemical conversion o f a solid or liquid into a gas with resultant energy release. Explosive devices are categorized as either high-order explosives (HE, such as C4 and T N T ) or low-order explosives (LE, such as pipe bombs, gunpowder, and Molotov cocktails).
H E detonation involves supersonic, instantaneous transformation o f the solid or liquid into a gas occupying the same physical space under extremely high pressure. These high-pressure gases rapidly expand outward in all directions from their point o f formation as an overpressure blast wave. The extent and pattern o f injuries produced by an explosion are determined by several factors:
- am ount and com position o f the explosive material,
- delivery method,
- distance between the victim and the blast,
- setting (open vs. closed space, structural collapse, intervening barriers), and
- other accompanying environmental hazards.   D uring an M CE, health care systems will be confronted with increased demands and decreased availability o f resources. Regional health care systems best understand their own needs and resources and must, therefore, develop specific disaster medical surge capacity and capability plans.

# Nature of Injuries

# Expected Health Systems Challenges
Emergency departm ents (EDs) routinely operate above capacity, with prehospital personnel occasionally forced to wait for extended periods before transferring patient care to hospital staff.

# Leadership
Effective preparedness and response dem and an established, functional leadership structure with clear organizational responsibilities. In many instances, particularly at a local operational level, such preparation has not occurred. Confusion over roles and responsibilities may occur and increases the potential for redundant efforts or gaps in decision-making and response.

# Key Health System Challenges

# Community and media relations
Responding to terrorist bombings requires meta-leadership.
Meta-leaders are vital in preparing for and responding to bombings, and their roles extend far beyond hospitals and emergency services.
Detailed inform ation about meta-leadership and planning needs in this area is provided in C hapter 2.

# Prehospital care
Prehospital

# Hospital care
In responding to a terrorist bombing, hospitals must prepare to address large numbers o f patients in a short period o f time. Such preparedness will affect not only emergency and traum a services but also other medical, paramedical, administrative, logistical, and security functions. Decisions and policies developed in advance o f a bom bing should reflect state and local regulations and guidance.
A full exploration o f the many aspects o f hospital care relevant in a bom bing aftermath is contained in C hapter 5.

# Community an d media relations
T he com m unity targeted by a bom bing suffers the most extensive physical and psychological effects and should be part o f preparedness planning. Involving com m unity organizations, religious institutions, and local businesses in planning and response efforts can help to calm fears and prepare people should a bom bing occur. Another critical partner in this education effort is the local media.
Guidance for com m unication and inform ation sharing is included throughout this document.
potential secondary explosi and im plementing patient and distributing patients.

# CHAPTER TWO

# Principles for Health Systems' Preparedness in Emergencies
To prepare for a terrorist use o f explosives-mass casualty event (M CE), health systems leaders must focus on 12 principles.

# Provide Meta-Leadership
Managing a bom bing crisis requires more than good leadership; it requires meta-leadership. The prefix m eta has many meanings, including a more comprehensive form o f a process (e.g., meta Meta-leaders possess unique mindsets and skills, often going beyond the scope o f their experiences.
They are also able to build strong alliances with a diverse array o f leaders before an event occurs.
T he five dimensions o f a meta-leader, which m ust be used with flexibility and adaptability, are
- The Person of the Meta-Leader: Meta-leaders lead themselves and others out o f the "basement" to higher levels o f thinking and functioning.
- Situational Awareness: A problem, change, or crisis compels the meta-leader to respond.
- Leading the Silo: T he meta-leader triggers and models confidence, inspiring others to excellence.
- Leading Up: The meta-leader leads up the chain o f com m and and guides political, business, and com m unity leaders.
- Leading Cross-System Connectivity: Meta-leaders strategically and intentionally devise cross-silo linkages that leverage expertise, resources, and information.

# M e ta -leaders build and m aintain
Effective meta-leaders initiate change outside o f their previously established lines o f decision-making and control.

# relationships and establish clear
They are driven by a purpose broader than that prescribed by channels o f com m unication.

# Be Proactive and Expect the Unexpected
Preparedness must be undertaken ahead o f time. Crisis situations are bad times for planning. No m atter how carefully developed a response plan, unexpected events are likely to occur. Recognizing the likelihood o f unexpected events will allow for appropriate preparation during the response effort.
Crisis leaders should expect that planning will be imperfect and learn to expect the unexpected.

# Learn From Others

# Develop Connected Emergency Plans
Preparedness and response plans should build upon each other and be based on existing federal and state plans using standard protocols, processes, tools, and terminology. Phone numbers should be checked and updated regularly.

# Communicate During a Mass Casualty Event

# Be Prepared fo r Legal and Ethical Issues
Preparedness should include consideration o f all potential legal and ethical problems that could be related to mass casualty response. Ethical considerations should be explicit during preparedness so that critical decisions made during crises can be based on the spirit o f the ethical
The rationale for m odifying standards o f judgments that guided the p lanning p rocess.
care in an em ergency is tha t more patients w ill survive a terrorist attack.
A lte r Standards of Care
T he system should be refocused during crisis response to accomplish the greatest good for the com m unity (i.e., save the most victims). T he rationale for modifying standards o f care in an emergency is that more patients will survive a terrorist attack if key lifesaving interventions are provided to the greatest num ber o f casualties likely to benefit from care. Hospitals and emergency medical services systems above surge capacity will require autonom y to alter regular standards of care and shift to emergency critical care practices. However, no universally accepted methodology for this adjustm ent exists, and the process is associated with potential ethical, societal, medical, and legal issues.

# Maximize availability o f emergency medical services personnel and resources
- M odify and extend shifts, bring personnel from home, and recruit medical and nonmedical volunteers as appropriate.
- Prepare for excessive strain on EMS answering points and dispatch.
- Concentrate on preserving the com m unication system among EMS, other emergency responders, and hospitals and design contingencies for alternative communication.
Institute call-screening strategies to determine the level o f urgency required to address calls, including preset recommendations for various call scenarios from the anxious public, survivors, families o f missing persons, and potential volunteers.
Maximize the efficiency o f available vehicles, coordinate all ambulance services, bring ambulances to full capacity, deploy alternative vehicles, and consider air transportation for prim ary distribution (from the field to the hospital) and for secondary distribution (relocation from one hospital to another).

# Assess the situation and care required
Interim Planning G uid an ce for Preparedness a nd Response to a Mass Casualty Event Result i ng from Terro rist Use of E x p lo sive s

# Protect on-scene personnel
- Recognize that first responders may represent a num ber o f disciplines in addition to EMS, including bomb squads, firefighters, search and rescue, hazardous materials responders, media, volunteers, and law enforcement providing scene security, investigation, and traffic control.
- Before searching for casualties, receive permission from the incident com m ander to ensure that the area is safe for first responders to enter and that the threat o f secondary device detonation has been evaluated.
- Protect EMS personnel and other first responders from exposure to environmental and infectious pathogens.

# Stage and triage patients
- Remove victims from direct hazard impact areas and stage them into the EMS system for triage and distribution to definitive care.
- Establish patient holding areas to prepare for formal triage and treatm ent protocols.
Depending on the situation, patients may move through the defined holding areas or go directly into rapid triage and distribution to hospitals.
- Shift health care priorities to those critically injured patients who are most likely to survive.
- Focus treatment o f casualties in the field on basic medical care primarily directed toward stabilizing life-threatening medical conditions.

# Provide appropriate transportation and distribution o f patients
- Provide adequate transportation and be prepared to balance distribution to appropriate medical facilities.
- Do not assume that casualties will be distributed to appropriate facilities. C hapter 4 discusses factors to consider in planning for most effectively distributing casualties after a TUE.

# Manage fatalities
- Prior to a bom bing event, address such issues as cataloging o f bodies; availability o f body bags and refrigerator trucks; and return o f bodies, hum an remains, and personal belongings to authorized persons.
- Following a T U E-M C E, avoid transporting bodies and remains from the scene to hospital treatm ent areas.
- Pay attention to and be respectful o f varying religious beliefs when handling bodies and remains.
- Consider designating alternate sites outside o f hospitals for managing and storing hum an remains.
- If possible, docum ent the identity o f the dead, hum an remains, and associated personal belongings. As soon as possible after the crisis, begin to identify hum an remains using scientific means (e.g., dental records, pathology, anthropology, fingerprints, D N A samples).

# Levels of Patient Distribution
The two levels o f patient distribution are primary and secondary.
Primary distribution refers to moving patients from the scene to the hospital. T he three methods currently in use for prim ary distribution, ranked from most to least desirable, are equal numbers o f casualties to each regional hospital on a rotating basis.
- Spontaneous Primary Distribution: Although the least desirable, this distribution method is the most common. Ambulances and other vehicles transport victims to the closest hospital, with no connectivity, control, or coordination. Secondary distribution refers to moving patients from the first receiving hospital to a second medical facility to receive either a higher or more specialized level o f care or less specialized care. By practicing this secondary distribution, casualties can be redistributed from overloaded hospitals and care sites to less affected ones. All hospitals must develop formal and practical relationships with designated traum a and specialty centers to ensure that, when necessary, casualties will have access to appropriate levels o f care.

# Levels of Patient Distribution

# Effective and Controlled Distribution
Controlled distribution o f casualties during the response to a terrorist bom bing is critical for m atching needs to resources and minimizing hospital overload.
- In m atching patients to hospitals, take patient needs and hospital capabilities into account. T he vast majority of survivors o f a bom bing event will have m inor injuries and will likely be discharged after evaluation and treatm ent in an emergency department.
- Centralize coordination o f patient transport and distribution to minimize hospital overloading and maximize use o f all available medical facilities including hospitals and clinics.
A ll hospitals must develop form al and practical relationships with designated traum a and specialty centers to ensure that, when necessary, casualties w ill have access to appropriate levels o f care.

# Surge Capacities and Capabilities for Hospitals Introduction
T he major challenges that hospitals will face in a mass casualty event (MCE) include surge capacity and capability issues in emergency and traum a services, as well as medical, paramedical, administrative, logistical, and security challenges. Difficult decisions will have to be made regarding the allocation o f available resources. These decisions should reflect state and local regulations and be developed before an MCE.

# Common Challenges fo r Hospitals in Terrorist Bombing Afterm ath
Terrorist use o f explosives (TUE) often creates four distinct types o f mass events: 1) mass casualty events, 2) mass fatality events, 3) mass anxiety events, and 4) mass onlooker events (e.g., families, media, curiosity seekers, volunteers, politicians, public officials). Hospital emergency leaders should consider these events and be prepared for their simultaneous occurrence. Hospitals should formulate contingency plans to deal with the initial surge o f walking wounded patients. Less severely injured patients, including the walking wounded and worried well, often self transport from the scene to the nearest hospital immediately after the event. These patients may

# Predicting pa tien t inflow
- not have been triaged by emergency medical services (EMS),
- arrive at the hospital before the more severely injured and may continue to arrive for several hours, and
- overwhelm the receiving hospital and delay treatment o f more critically injured patients.

# Delays in declaring a mass casualty event
T he three com m on delays in declaring an M C E that may complicate hospital surge capacity are
- Late Incident Recognition: Incident recognition is the point in time at which hospital leadership becomes aware that a significant event is evolving. Limited or ineffective situational awareness is the main factor preventing adequate response.
- Delayed Notification and Activation: Delays in delivering lifesaving interventions and definitive care are caused by taking a reactive approach (partial, gradual, and linear activation of emergency systems). A proactive approach, which involves full and simultaneous activation of all emergency systems followed by gradual withdrawal based on gathered inform ation, helps avoid delay.
- Linear Mobilization of Resources: Linear transition (a form o f reactive approach) from normal operations to appropriate response level causes delays. The transition should be proactive, simultaneous, and nonlinear in scale and scope. Extensive discussion and planning support linear activation and should be reserved until after the response.

# Time constraints
T he response to a TU E -M C E requires rapid intervention and should be based primarily at the local level. Local emergency operation plans that are routinely exercised and integrated into regular operations will function effectively.

# Lim ited health care workforce
Health care workers may not report during an emergency, either because they cannot reach the facility or are concerned for their safety or that o f family members. To minimize staffing shortages, planning must include provisions for the security o f health care workers and their families. Not adequately addressing their concerns may lower the motivation for personnel to report to work.

# Poor triage
Commonly, the triage process will not function as expected because o f stress that contributes to Protocols should be simple, short, realistic, workable, and practical. They should cover interaction with other key agencies; be evaluated continuously (threats, lessons learned, experiences); enable functioning as an integrated and unified system during emergency; be easily compiled into binders, color-coded by type o f incident; be located in an easily accessible place; and be revised as soon as new inform ation compels a change in the plan and on predeterm ined revision dates.

# Surge capacity an d capability map
Hospitals should develop a planning framework (surge capacity and capability map) that presents all available and relevant internal and external resources. This framework should be transparent, updated, and shared with key disaster response participants, both during preparedness and response.

# Exercises an d drills
Prior to a TU E -M C E , m andatory regular exercises with executive officers, meta-leaders, com m unity representatives, and all relevant agencies should be conducted. These drills should include annual, unannounced limited-scale exercises and the use o f smart casualties (people posing as casualties).
Four levels o f drills are valuable:
1. focal (vertical) exercise for tasks specific to mass casualty events, 2.  T he following principles should be incorporated into protocols:

# Redundant systems
- Develop flexible triage protocols based on uniform criteria for mass casualty triage18
(see Figure 1) and strive for systems that are:
- simple, easy to remember, and amenable to quick m em ory aids;
- applicable to all ages and patient populations; and
- easily modified for changes in resource availability and patient conditions.
- Develop a color-coded patient (LSI) prioritization protocol: red (immediate), yellow (delayed), green (minimal), grey (expectant), and black (deceased).
- Consider lifesaving interventions for each patient when:
- equipm ent is readily available,
- intervention is within provider's scope o f practice,
- procedure can be quickly performed, and
- continuing post-procedure care does not require provider's presence at bedside.
- Reserve the use o f imaging and lab testing for clinical conditions based on flexible triage protocols.
- Reduce provider docum entation and other administrative responsibilities.

# Figure 1: M odel Uniform Core Criteria
Step 2 -Assess:
Ind ivid ual Assessment
Interim Planning G uid an ce for Preparedness and Response to a Mass Casualty Event Resulting from Terrorist Use of E x p lo sive s

# Hospital Incident Command System
As an incident unfolds and details begin to emerge, the hospital management team should quickly transition from reactive to proactive management. communications.
T he H IC S requires the following main components:
- Incident Commander: the individual who assumes overall authority and responsibility for the hospital preparedness and response to a mass casualty event. This individual is also responsible for activating the emergency plan.
- Command Center: the location from which the hospital's response to the emergency will be coordinated. This facility should be equipped with multiple alternative means o f internal and external com m unication, stable power source, and security.
- Operations Officer: the individual who gathers and builds an overall picture o f the event and records any actions taken by the HICS.
- Liason Officer: the individual responsible for com m unicating with external relevant agencies, including EMS, other health facilities, law enforcement, fire, search and rescue, public health, local office o f emergency preparedness, and military.
- Public Information: the organizational hub for contact with the media and coordinated com m unication between the hospital and the public. Prepared consistent messaging should be available through the HICS.

# Mass casualty event sites
Primary emergency response areas must be identified to handle the crisis. Specifically, these areas include - hospital com m and center,
- triage sites: main and alternative,
- immediate treatment,
- delayed treatment,
- m inor injuries,
- decontam ination, and
- fatality management site.
Designated areas should also be named for the worried well, media, family, and visitors. A relative center can be used as a resource for individuals searching for inform ation about their missing relatives. These centers can include water, food, mental health professionals, clergy, and simple pharmacy needs.

# Security
Hospitals should maintain control and security within their boundaries as law enforcement resources may be severely taxed. Hospitals may be targets for bom bing attacks, and security officials should m aintain increased vigilance. Strategies may include
- increasing uniform ed security presence,
- ensuring security for hospital personnel, supplies, and assets,
- enhancing m onitoring o f sensitive entry points and hospital surroundings,
- addressing crowd control and handling the influx o f individuals looking for missing relatives, and
- preventing terrorists from targeting hospital facilities.

# Recovery: Ending the emergency status
Just as preparing for rapidly transitioning from normal to emergency status is critical, preparing to quickly return to routine activities is also im portant. Debriefing o f personnel can reduce event-related mental health effects and obtain input on lessons learned for use in future crises.

# Staff capacity
The capacity to mobilize adequate numbers o f qualified personnel (particularly traum a teams) to care for victims is essential. The kinds o f expertise required include emergency medicine, traum a surgery, intensive care, hospitalists, anesthesiology, otolaryngology, mental health, pharmacy, blood bank, radiology, pediatrics, nursing, administration, and support. Consider the following issues: - compensate for extra hours and injuries,
- use licensed professionals outside their normal scopes o f practice or license geography,
- call in off-duty hospital staff and arrange transportation,
- prepare to manage health professional volunteers and other untrained individuals who appear spontaneously,
- change staff scheduling as needed, and
- make mental health professionals available for first responders and staff counseling.

# M edical supplies
To increase access to supplies, pre-arranged contracts with commercial vendors should be activated.
Pre-equipped mobile carts reserved for disaster contingencies and critical equipm ent should be transported to specific M C E sites.

# Blood bank

# Space capacity
To care for a patient surge, hospitals must augment care space dramatically. Admission capacity will be determined by the num ber o f available beds and hospital personnel. Specific considerations may include
- Facilitating Inflow: D uring an emergency event, the hospital experiences a massive inflow of - Space Availability: Hospital plans should be designed specifically to receive a massive inflow and distribute patients along predetermined routes to specified sites. Plans should consider the following areas:
- Diversion: Divert additional patients to lesscrowded facilities.
- Emergency departm ent: Discharge ED patients who can continue their care at hom e or another medical facility (reverse triage).
- Intensive care unit (ICU): Move IC U patients who can safely be managed to other care units.
- Hospital beds: Identify and discharge inpatients who may continue their care at hom e or another medical facility.
- Operating rooms (ORs): Determine availability o f ORs, cancel elective surgeries and procedures, and prepare multiple ORs for emergent procedures.
- Alternative Care Sites: Use pre-designated alternative care sites to increase space capacity, and add beds and supplementary equipment.
- Mass Mortuary Site: Establish a space to store bodies o f patients who die; this space should be in or near the hospital but away from the ED.

# Victim tracking
In an M C E, hospitals are overwhelmed with a sudden influx o f casualties and fatalities. Using a casualty tracking data system that is coordinated across all medical facilities is essential. T he system should be capable o f registering, docum enting, and tracking victims to help make families' search for missing relatives as efficient as possible.

# Hospital decompression
Large numbers o f casualties from a terrorist incident commonly self-refer or self-transport to hospitals in the immediate vicinity o f the event. Three main approaches enable hospital facilities to prevent system collapse through decompression:
1. Outside Diversion: Additional casualties and other patients should be directed to other facilities that have sufficient capacity.

# Patient identification
In an M C E, hospitals are overwhelmed with a sudden influx o f patients and fatalities. D ata systems, coordinated across all medical facilities, can help hospitals register, docum ent, and track victims.
Through this system, citizens can call any hospital throughout the region to locate family members.
T he system could include the following features:
- digital photographs o f each incoming victim with altered mental status upon arrival to the hospital;
- input o f digital pictures and any descriptions o f victims and their personal belongings into a computerized database;
- placement o f each patient's belongings in a prepared sack that accompanies the patient at all times, and
- personnel or trained volunteers to staff telephones and assist with victim identification and family liaison.

# Public Information
- Leaders have m uch influence over the expectations, understanding, and responses o f both individuals and communities to an M CE. T he management o f the acute situation sets the tone for the ways society will respond. Accurately describing ongoing efforts and successfully forecasting predictable events will enhance the credibility o f authorities and diminish negative outcomes. Informing the public in a timely m anner can decrease the flow o f worried well patients and lessen demands on the health care system. This com munications campaign should be a joint effort by EMS, hospitals, and other health care facilities.

# Conclusion
T he purpose o f this docum ent is to prepare policy planners to respond to terrorist bombings and mass casualty events. T he majority o f the inform ation focuses on first responders, hospital administrators, and hospital staff, as they are most likely to be affected.
T he docum ent discusses the concept o f meta-leadership, which draws on natural leaders who work in various settings and use their skills to help direct both their own organizations' responses and the inter-organizational responses that will be critical to a successful response. This docum ent offers these leaders interim guidance for developing plans to meet the needs o f specific facilities and locations.
Effective preparation will help maintain critical systems and can improve both the clinical and psychological outcomes o f the people affected by terrorist bombings and mass casualty events.