CS123209

	 

	 

In a Moment’s Notice:
 

Surge Capacity for Terrorist Bombings
 

Challenges and Proposed Solutions 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
 

Centers for Disease Control and Prevention
 

National	Center	for	Injury	Prevention	and	Control
 

Division	of	Injury	Response
 

Atlanta,	Georgia
 

April	2007
 
In a Moment’s Notice: Surge Capacity for Terrorist Bombings is a publication of the National 

Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 

Centers for Disease Control and Prevention 

Julie Louise Gerberding, MD, MPH
 

Director
 

Coordinating Center for Environmental Health and Injury Prevention 

Henry Falk, MD, MPH
 

Director
 

National Center for Injury Prevention and Control 

Ileana Arias, PhD
 

Director
 

Division of Injury Response 

Richard C. Hunt, MD, FACEP
 

Director
 

Authors

Scott M. Sasser, Richard C. Hunt, Bob Bailey, Jon Krohmer, Steve Cantrill, Kevin Gerold, 

Mark Johnson, Arthur Kellermann, Patricia Lenaghan, James Morris, Brent Myers, Richard 

Orr, Thomas Peters, Paul Schmidt on behalf of the Surge Capacity Expert Panel. 

Suggested Citation: National Center for Injury Prevention and Control. In a Moment’s 

Notice: Surge Capacity for Terrorist Bombings. Atlanta (GA): Centers for Disease Control 

and Prevention; 2007. 
Contents 

	 

Executive Summary	...............................................................................................................1
 

Background	............................................................................................................................3
 

Surge Capacity Challenges	....................................................................................................7
 

	 System-wide	Challenges	................................................................................................7
 

	 Discipline-specific	Challenges	.....................................................................................10
 

Surge Capacity Solutions	.................................................................................................... 19	
 

	 Addressing	System-wide	Challenges	............................................................................19
 

	 Addressing	Discipline-specific	Challenges	..................................................................21	
 

Conclusion	........................................................................................................................... 47
 

Acknowledgements	............................................................................................................ 47
 

References	........................................................................................................................... 50
 

	 

	 

	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 i 

Executive Summary 

Explosive	devices	and	high-velocity	firearms	are	the	terrorists’	weapons	of	choice.	The	 

devastation	wrought	in	two	European	capitals,	Madrid	and	London,	demonstrate	the	 

impact	that	can	be	achieved	by	detonating	explosives	among	densely	packed	civilians.	In	 

an	instant,	an	explosion	can	wreak	havoc—producing	numerous	casualties	with	complex,	 

technically	challenging	injuries	not	commonly	seen	after	natural	disasters	such	as	floods,	 

tornadoes,	or	hurricanes.	Because	many	patients	self-evacuate	after	a	terrorist	attack,	 

and	prehospital	care	may	be	difficult	to	coordinate,	hospitals	near	the	scene	can	expect	 

to	receive	a	large	influx—or	surge—of	victims	after	a	terrorist	strike.	This	rapid	surge	of	 

victims	typically	occurs	within	minutes,	exemplified	by	the	Madrid	bombings	where	the	 

closest	hospital	received	272	patients	in	2.5	hours.	Such	a	surge	differs	dramatically	from	 

the	gradual	influx	of	patients	after	an	outbreak	of	infectious	disease	or	an	environmental	 

emergency	such	as	a	heat	wave,	which	can	last	several	days	to	weeks	afterwards.	In	addition,	 

injuries	to	workers	involved	in	recovery	procedures	can	lead	to	a	secondary	wave	in	surge.	 

The	key	question	is	this:	Can	hospitals	meet	the	challenge? 

Health	care	and	public	health	specialists	anticipate	profound	problems	in	adequately	caring	 

for	the	resulting	surge	of	victims.	Our	current	health	care	system,	especially	the	emergency	 

care	system,	is	already	severely	strained	by	its	routine	volume	of	daily	care.	 

Further,	the	health	care	system,	emergency	departments,	and	intensive	care	units	(ICUs)	 

of	acute	care	hospitals	are	chronically	overcrowded	and	resource-constrained.	Without	 

immediate	federal	assistance,	many,	if	not	most,	communities	would	have	difficulty	 

caring	for	a	surge	of	victims	because	each	hospital	and	emergency	medical	service	differs	 

dramatically	in	capacity,	training,	and	level	of	coordination.	Indeed,	a	terrorist	bombing	in	 

the	United	States	would	be	a	“predictable	surprise.”	 

To	address	the	challenges	posed	by	such	an	event,	CDC’s	National	Center	for	Injury	 

Prevention	and	Control	(CDC’s	Injury	Center)	convened	an	expert	panel	in	October	 

2005	and	January	2006.	The	panel	included	experts	in	the	areas	of	emergency	medical	 

services,	emergency	medicine,	trauma	surgery,	burn	surgery,	pediatrics,	otolaryngology,	 

intensive	care	medicine,	hospital	medicine,	radiology,	pharmacology,	nursing,	hospital	 

administration,	laboratory	medicine	(blood	bank),	and	public	health.	The	panel	was	 

charged	with	identifying	creative	strategies	that	could	be	adopted	in	a	timely	manner	to	 

address	surge	issues	from	terrorism.	The	panel	focused	on	recommending	strategies	for	 

rapid	management	of	large	numbers	of	bombing	casualties.	They	examined	the	related	 

challenges	that	would	confront	not	only	the	general	emergency	medical	response	and	 

health	care	system,	but	would	also	affect	select	medical	disciplines.	Though	developed	 

in	the	context	of	a	surge	of	injuries	from	a	terrorist	bombing,	the	recommendations	in	 

this	report	may	improve	the	response	to	and	management	of	a	surge	of	patients	from	any	 

cause,	including	biological,	chemical,	or	nuclear. 

	 

This	document,	which	is	the	result	of	the	expert	panel	meetings,	reflects	the	opinions	and	 

recommendations	of	the	experts.	It	includes	a	description	of	system-wide	and	disciplineIn a Moment’s Notice: Surge Capacity for Terrorist Bombings	 1 
specific	challenges	as	well	as	recommended	solutions	to	address	these	challenges.	The	 

proposed	solutions	for	the	discipline-specific	challenges	have	been	incorporated	into	easy	 

to	use	templates	that	can	assist	various	disciplines	in	managing	surge	needs	for	injuries.	 

The	needs	and	resources	of	each	community	must	be	considered	to	effectively	plan	for	a	 

surge	of	patients	into	an	already	overburdened	health	care	system.	Admittedly,	community	 

resources	are	not	specific	to	handling	casualties	of	explosives,	but	the	likelihood	of	this	 

threat	and	the	sudden	demand	it	would	place	on	the	health	care	system	make	it	imperative	 

to	manage	deficiencies	in	surge	capacity	now—not	when	crisis	strikes—and	to	do	so	in	an	 

aggressive,	but	thoughtful	manner. 

2	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Background 

Current	patterns	in	terrorist	activity	increase	the	potential	for	civilian	casualties	from	 

explosions.	Recent	events	in	Egypt,	India,	Iraq,	Israel,	Spain,	and	the	United	Kingdom	 

clearly	indicate	that	bombings	targeting	civilian	populations	are	an	ever-present	danger	 

worldwide.	The	U.S.	Department	of	State	reported	7,000	terrorist	bombings	worldwide	 

between	1968	and	1999.1

	From	2001	through	200,	more	than	500	international	terrorist	 

bombings	caused	more	than	4,600	deaths,1-	excluding	the	attacks	of	September	11,	2001,	 

which	essentially	used	planes	as	flying	bombs.	 

The	U.S.	Federal	Bureau	of	Investigation	confirmed	24	incidents	of	terrorist	bombings	in	 

the	United	States	between	1980	and	2001.4

	More	than	21,000	bombing	incidents	(actual,	 

accidental,	attempted)	occurred	in	the	U.	S.	between	1988	and	1998.5

	 

In	2005	alone,	according	to	reports	compiled	from	the	Terrorist	Attack	Archives,	Terrorism	 

Research	Center,	758	terrorist	events	were	staged	in	45	countries,	and	more	than	half	(N	=	99)	 

were	bombings.	These	events	resulted	in	8,019	injured	persons	and	,049	deaths.6

	 

Despite	justifiable	concerns	about	the	dangers	of	chemical,	biologic,	or	nuclear	attacks,	 

bombings	with	conventional	explosives	remain	the	terrorists’	method	of	choice.	 

Explosions,	particularly	in	confined	spaces,	can	inflict	multi-system	injuries	on	numerous	 

patients	and	produce	unique	management	challenges	to	health	providers.	Unlike	the	 

gradual	influx	of	patients	after	events	such	as	infectious	diseases,	the	surge	of	patients	 

after	an	explosion	typically	occurs	within	minutes	of	the	event	and	overwhelms	nearby	 

hospital	resources.7,8	The	potential	for	large	numbers	of	casualties	and	an	immediate	surge	 

of	patients	may	stress	and	limit	the	ability	of	emergency	medical	services	(EMS)	systems,	 

hospitals,	and	other	health	care	facilities	to	care	for	the	onslaught	of	critically	injured	 

victims.9-11	 

The	ongoing	and	increasing	threat	of	terrorist	activities,	combined	with	documented	 

evidence	of	decreasing	emergency	care	capacity,	requires	preemptive	action.	Health	care	 

and	public	health	systems,	individual	hospitals	and	health	care	personnel	must	collaborate	 

to	ensure	that	strategies	are	in	place	to	effectively	receive,	evaluate,	and	treat	large	 

numbers	of	injured	patients;	to	rapidly	identify	and	stabilize	the	most	critically	injured;	to	 

evaluate	these	efforts;	and	to	strategically	plan	for	future	incidents. 

The	Role	of	the	National	Center	for	Injury	Prevention	and	Control	(CDC’s 

Injury	Center)	Centers	for	Disease	Control	and	Prevention	(CDC) 

The	mission	of	CDC’s	Injury	Center,	is	to	prevent	premature	death	and	disability	and	to	 

reduce	the	human	suffering	and	medical	cost	caused	by	injuries.	This	mission	supports	 

CDC’s	strategic	goal	to	protect	people	in	all	communities	from	terrorist	threats.	As	a	means	 

to	prevent	injuries	and	minimize	the	consequences	of	injury,	the	Injury	Center	uses	the	 

public	health	approach—a	systematic	process	to	define	the	injury	problem,	identify	risk	 

and	protective	factors,	develop	and	test	prevention	interventions	and	strategies,	and	ensure	 

widespread	adoption	of	effective	interventions	and	strategies.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings  
Many	agencies	have	addressed	issues	of	surge	capacity	for	events	such	as	biological	 

attacks—most	notably,	CDC’s	public	health	and	laboratory	surge	programs	and	the	Health	 

Resources	and	Services	Administration’s	(HRSA)	hospital	preparedness	program.	To	date,	 

little	effort	has	been	directed	toward	increasing	surge	capacity	in	response	to	terrorist	 

bombings.	After	in-depth	discussions	with	HRSA,	the	Department	of	Homeland	Security,	 

the	Federal	Emergency	Management	Agency	(FEMA),	the	National	Highway	Traffic	Safety	 

Administration	(NHTSA),	and	CDC’s	Coordinating	Office	for	Terrorism	Preparedness	and	 

Emergency	Response,	the	Injury	Center	learned	that	CDC	could	play	a	unique	role	in	 

identifying	surge	capacity	issues	related	to	terrorist	bombings	and	proposing	solutions.	 

Furthermore,	any	solutions	to	enhance	surge	capacity	in	preparation	for	terrorist	bombings	 

directly	apply	to	surge	issues	for	other	manmade	or	natural	disasters.	 

To	this	end,	CDC’s	Injury	Center	convened	an	expert	panel	in	October	2005	and	January	 

2006.	The	expert	panel	was	charged	with	identifying	creative	strategies	that	could	be	 

adopted	in	a	timely	manner	to	address	surge	issues	from	terrorism;	in	essence,	identifying	 

both	system-wide	and	discipline-specific	concerns	and	recommending	feasible	and	affordable	 

strategies	for	rapidly	managing	large	numbers	of	bombing	casualties.	This	document	is	the	 

result	of	those	meetings,	reflects	the	opinions	and	recommendations	of	this	expert	panel,	 

and	includes	its	recommendations.	These	recommendations	were	designed	for	emergency	 

medical,	health	care,	and	public	health	systems,	with	the	caveat	that	immediate	steps	be	taken	 

to	ensure	an	effective	response.	To	kick	off	the	process,	the	expert	panel	set	objectives: 

•	 Increase	collaboration	between	CDC	and	federal	agencies,	external	partners,	and	 

other	experts	on	issues	of	surge	capacity	for	injuries	from	conventional	weapons. 

•	 Identify	factors	that	limit	rapid	assessment	and	treatment	of	injured	patients	in	 

the	field	and	at	hospitals	(including	triage,	availability	of	radiology,	and	access	to	 

operating	theatres)	and	develop	mechanisms	to	address	these	factors;	and 

•	 Develop	a	strategy	and	identify	mechanisms	to	widely	disseminate	and	implement	 

findings	from	the	expert	panel	(e.g.,	Web,	print	publications,	and	training	curricula). 

The	panel	represented	a	broad	spectrum	of	medical	care	and	administrative	disciplines	 

required	to	care	for	victims	of	a	bombing.	Panel	members	included	personnel	from	emergency	 

medical	services;	physicians	specializing	in	emergency	medicine,	trauma	surgery,	burn	surgery,	 

pediatrics,	otolaryngology,	intensive	care	medicine,	hospital	medicine,	and	radiology;	experts	 

in	pharmacology,	nursing,	hospital	administration,	and	blood	banking;	and	experts	in	public	 

health.	Expert	panel	members	are	listed	in	the	acknowledgements	section	of	this	report.	 

The	Evolution	of	Terrorism 

At	the	heart	of,	and	as	an	impetus	for,	this	meeting	is	the	fact	that	terrorist	attacks	remain	 

an	ever-present	threat.	Terrorist	events	continue	to	occur	globally	and	on	an	alarming	 

scale.	Bombings—the	perpetrators’	method	of	choice—remain	a	real	and	constant	threat,	 

averaging	two	terrorist	attacks	per	day	worldwide	in	2005.6	In	the	past	thirty	years,	 

terrorism	has	evolved	from	mostly	secular,	nationalist	movements	to	diverse,	multinational,	 

global	organizations.12	These	organizations	have	different	motivations	and	tactics,	and	 

their	bombings	are	increasingly	lethal,1	as	witnessed	in	Madrid	(March	2004),	London	 

4	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
(July	2005),	and	Mumbai	(July	2006),	terrorist	efforts	reveal	an	ever-increasing	degree	of	 

sophistication,	coordination,	and	capacity	for	harm.	 

Lessons	Learned	in	Madrid 

In	an	effort	to	provide	a	framework	to	the	meetings	and	subsequent	discussions,	the	panel	 

was	presented	with	the	example	of	the	March	2004	Madrid	bombings	at	the	beginning	 

of	the	first	meeting.	The	Madrid	experience	provides	a	real-life	scenario	of	what	U.S.	 

health	care	providers	and	systems	must	be	prepared	to	confront:	a	complex,	coordinated	 

attack	with	thousands	injured	and	a	rapid	surge	of	patients	into	surrounding	hospitals.	On	 

March	11,	2004,	between	079	and	0742	hours,	ten	terrorist	bombs	detonated	on	four	 

crowded	commuter	trains,	killing	177	people	instantly	and	injuring	more	than	2,000.	Three	 

hundred	and	twelve	patients	were	evaluated	and	treated	at	Gregario	Maranon	University	 

General	Hospital	(GMUGH),	272	of	them	arriving	between	0759	and	100	hours.	The	 

Madrid	response	entailed	multiple	logistical	and	operational	challenges,	including	field	 

triage	and	transportation	of	injured	persons;	inpatient	discharge;	evacuation	of	emergency	 

departments	(EDs)	and	intensive	care	units	(ICUs),	and	multiple	surgical	procedures	and	 

tests	(hundreds	of	radiographs,	computerized	tomography	(CT)	scans,	and	ultrasounds).	By	 

2100	hours	that	same	day,	1,40	casualties	had	been	treated	at	multiple	hospitals;	of	these,	 

966	had	been	transported	to	15	public	community	hospitals.14	Panel	members	were	asked	 

to	describe	how	their	discipline	would	respond	to	the	Madrid	example. 

Terrorist	Bombings	in	the	United	States:	A	“Predictable	Surprise” 

The	reality	of	persistent,	complex,	global	terrorist	bombings,	such	as	Madrid,	make	 

terrorist	bombings	in	the	U.	S.	a	“predictable	surprise.”	The	expert	panel	reviewed	the	 

characteristics	of	“predictable	surprises”	listed	below	early	in	the	course	of	the	meeting	process,	 

to	provide	background	on	common	problems	that	could	hinder	effective	surge	response,	 

and	in	an	effort	to	identify	concerns	and	issues	that	needed	to	be	addressed	within	their	 

recommendations. 

The	following	characteristics	of	“predictable	surprises”	outlined	by	Bazerman	and	 

Watkins15	apply	to	terrorist	bombings	and	the	U.	S.:	 

1.		A	shared	trait	of	predictable	surprises	is	that	leaders	knew	a	problem	 

existed	and	that	the	problem	would	not	solve	itself.	 

Reports	of	bombings	occur	almost	daily.	When—not	if—terrorism	returns	to	the		 

U.	S.,	our	EMS	and	hospital	systems	will	be	ill-equipped	to	manage	the	
 

consequences.	
 

2.		Predictable	surprises	can	be	expected	when	organizational	members	 

recognize	that	a	problem	is	getting	worse	over	time.	 

Terrorist	events	show	no	signs	of	abating.	Between	2001	and	200,	more	than	500	 

international	terrorist	bombings	resulted	in	more	than	4,600	deaths,	as	reported	 

by	the	U.S.	Department	of	State.1-	In	2005	alone,	758	worldwide	terrorist	events	 

occurred,	of	which	99	were	bombings.	These	events	occurred	in	45	countries	and	 

resulted	in	8,019	persons	injured	and	,049	deaths.6

	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 5 
3.		Fixing	the	problem	would	incur	significant	costs	in	the	present,	while	the	 

benefits	of	action	would	be	delayed	and	ambiguous. 

A	central	issue	in	preparing	for	terrorist	bombings	in	the	U.S.	is	to	proactively	 

educate	health	care	providers	in	the	clinical	management	of	bombing	injuries.	 

Education	is	expensive.	Even	if	health	care	providers	are	initially	trained	to	care	 

for	bombing-related	injuries,	unless	these	terrorist	events	become	a	more	frequent	 

and	unfortunate	reality,	education	must	be	repeated	regularly	to	assure	currency	 

of	knowledge	and	clinical	competency.	Another	issue	concerns	the	rapid	push	of	 

clinical	information	immediately	after	an	event.	The	mechanisms	and	capability	to	 

do	this	need	to	be	developed	and	may	be	costly.	Finally,	many	EMS	systems	and	 

hospitals	do	not	have	capacity	to	care	for	patients	beyond	their	usual	volume;	and	 

some	do	not	have	capacity	to	care	for	the	volume	they	now	have,	as	evidenced	 

by	frequent	ambulance	diversions	and	lengthy	delays	for	ambulances	to	offload	patients	at	hospital	EDs.	The	cost	of	increasing	facility	capacity	in	the	EMS	 

and	hospital	systems	may	be	substantial.	Although	increasing	capacity	will	have	 

immediate	impact	on	daily	operations	in	EMS	and	hospitals,	the	benefits	of	education	 

and	better	systems	for	disseminating	information	will	not	be	fully	recognized	until	 

used	in	response	to	a	terrorist	attack	or	other	disaster.	 

4.		Decision	makers	often	fail	to	prepare	for	predictable	surprises	because	 

the	natural	human	tendency	is	to	maintain	the	status	quo.	 

Outside	the	military,	our	country’s	health	care	providers	have	little	experience	 

with	terrorist	bombings—particularly	those	capable	of	producing	many	potentially	 

survivable	injuries.	Injury	is	the	leading	cause	of	death	in	the	United	States	for	 

persons	between	the	ages	of	1	and	44;	16	thus,	many	civilian	health	care	providers,	 

especially	those	in	trauma	systems,	have	vast	experience	in	injury	care,	including	 

incidents	with	multiple	casualties.	However,	we	have	learned	from	the	experiences	 

of	our	military	and	international	colleagues	that	clinical	management	of	casualties	 

from	terrorist	bombings	differs	considerably	from	that	seen	daily	in	trauma	centers	 

(e.g.,	blunt	and	penetrating	trauma).	To	assume	we	can	provide	the	same	level	of	 

care	for	large	numbers	of	victims	from	terrorist	bombings	as	we	do	for	victims	of	a	 

bus	crash	is	self-deceiving—a	natural	reaction	is	to	maintain	the	status	quo.	Relying	 

on	traditional	disaster	management	and	trauma	life	support	training	is	far	easier	and	 

less	expensive	than	learning	and	practicing	new	skills.	 

5.		A	small	vocal	minority	benefits	from	inaction,	and	is	motivated	to	subvert	 

the	actions	of	leaders	for	their	personal	benefit. 

No	matter	what	the	motivation,	some	people	benefit	from	inaction. 

6.	Leaders	can	expect	little	credit	for	the	prevention	of	predictable	surprises.	 

Advocating	for	and	acquiring	resources	for	terrorist	bombing	preparedness	and	 

response	is	challenging—especially	when	so	many	competing	preparedness	and	 

response	needs	must	also	be	met.	With	limited	resources	and	the	need	for	near-term	 

results,	leaders	who	prepare	for	events	that	may	not	occur	can	expect	little	credit	 

for	being	proactive. 

6	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Surge Capacity Challenges 

System-wide	Challenges 

The	threat	of	terrorism	exists	at	a	time	when	our	hospitals	and	EDs	are	struggling	to	care	 

for	the	patients	who	present	during	routine	operations	each	day.	Hospitals	and	emergency	 

health	care	systems	are	stressed	and	face	enormous	challenges.	Ambulances	are	routinely	 

diverted	from	one	facility	to	another.	According	to	a	200	report	from	the	National	Center	 

for	Health	Statistics,	4%	of	U.S.	EDs	diverted	ambulances	from	primary	destinations;	 

diversions	occurred	more	frequently	in	metropolitan	areas	(50%	of	metro	hospitals).16	 

Emergency	departments	routinely	operate	above	capacity.	Sometimes,	paramedics	are	 

forced	to	wait	for	extended	periods	before	their	patients	can	be	transferred	to	hospital	 

staff.	Patients	are	evaluated	and	treated	in	ED	hallways	and	held	for	hours,	or	even	days,	 

awaiting	placement	in	an	inpatient	bed	as	hospitals	struggle	with	high	occupancy.	In	 

200,	there	were	11.9	million	visits	to	EDs	in	the	U.	S.,	representing	a	26%	increase	from	 

199’s	90.	million	visits.	During	this	same	period,	the	number	of	U.S.	EDs	decreased	 

14%.17	The	problem	became	worse	in	the	1990s	when	our	nation	lost	10,000	staffed	 

inpatient	medical	surgical	beds	and	7,800	ICU	beds.18	Reductions	in	hospitals	with	EDs,	 

regionalization	of	surgical	care,	increases	in	non-emergency	patient	visits	to	EDs,	diversion	 

of	EMS,	and	personnel	shortages	have	led	to	unprecedented	crowding	in	EDs.19-2	The	 

Institute	of	Medicine	recently	released	a	three-part	report	highlighting	the	challenges	facing	 

our	nation’s	emergency	care	system.24-26 

This	is	the	context	in	which	we	confront	the	growing	threat	of	international	terrorism.	 

Hospitals	are	wholly	unequipped	to	handle	a	sudden	surge	of	highly	complex	injuries.	 

If	a	large-scale	event	(manmade	or	natural)	occurs,	health	care	systems	and	hospitals	 

must	be	able	to	treat	an	immediate	and	potentially	large	influx	of	patients.	A	recent	 

CDC	publication	determined	that	about	three	fourths	of	hospitals	had	disaster	plans	that	 

addressed	explosives,	but	few	(one	fifth)	had	actually	conducted	a	drill	involving	imagined	 

use	of	explosives.27 

Issues	affect	the	spectrum	of	injury	care	from	prehospital	through	rehabilitation	and	also	 

affect	personnel	from	fire	chiefs,	trauma	surgeons,	and	nursing	supervisors	to	emergency	 

medical	technicians.	Many	problematic	areas	stand	between	the	current	reality	of	 

emergency	care	in	the	United	States	and	the	effective	management	of	a	Madrid-like	event: 

1.	Organization	and	Leadership	 

Effective	preparedness	and	response	demand	an	established,	functional	leadership	 

structure	with	clear	organizational	responsibilities.	In	many	instances,	particularly	 

at	a	local	operational	level,	such	preparation	has	not	occurred.	Consequently,	 

confusion	over	who	has	responsibility	for	specific	actions	will	occur,	increasing	the	 

potential	for	redundant	efforts	or	gaps	in	decision-making. 

2.		Alterations	in	Standards	of	Care 

Altering	the	standards	of	medical	care	provided	in	order	to	do	the	greatest	good	for	 

the	community	is	a	concept	and	practice	that	is	fraught	with	ethical,	societal,	and	 

legal	issues,	making	it	difficult	to	surmount.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 7 
3.		Education 

Disaster	preparedness	and	response	education	is	not	included	in	most	medical	 

or	nursing	school	curricula;	and,	with	the	exception	of	emergency	medicine,	 

preparedness	and	response	is	not	a	requirement	in	residency	training	programs.	 

Thus,	most	health	care	providers	are	not	prepared	to	handle	clinical	care	during	a	 

disaster.	As	standard	curriculum,	emergency	medical	technician	(EMT)	paramedics	 

are	required	to	complete	a	module	on	“medical	incident	command.”	Yet	EMTIntermediates	and	EMT-Basics	do	not	always	receive	this	essential	training.	A	welllinked	educational	process	for	those	involved	in	mass	casualty	disaster	preparation	 

and	response	is	not	yet	available. 

4.			Communications 

Effective	and	timely	communications	are	essential	to	functional	command	and	 

control;	admittedly,	communication	failure	(prehospital,	hospital,	and	public)	is	a	 

recurrent	theme	during	and	immediately	after	a	disaster.	 

5.			Transportation 

Coordinated	transportation	service	is	vital	and	often,	timely	and	effective	use	
 

of	mutual	aid	transport	units	to	transport	or	transfer	patients	to	tertiary	care	is	
 

challenging.	Additionally,	there	is	currently	no	comprehensive	plan	for	disaster	
 

response	which	effectively	integrates	civilian	with	military	medical	transport	
 

resources.
 

6.			Infrastructure	and	Capacity 

Communities	differ	in	their	capabilities	and	infrastructure	to	handle	disasters	in	the	 

prehospital	and	hospital	arenas.	Regardless	of	a	community’s	capabilities	and	the	level	 

of	coordination	between	resources,	those	injured	from	an	explosion	will	rapidly	seek	 

care	from	or	will	be	transported	to	the	nearest	hospital,28	and	may	not	seek	care	at	the	 

facilities	designated	by	existing	response	plans.	Thus	all	communities	need	plans	that	 

have	been	successfully	and	repeatedly	drilled.	Additionally,	facilities	vary	in	capabilities	 

and	staffing.	Any	facility,	whether	it	offers	tertiary	(i.e.,	specialty)	care	or	community,	 

rural,	or	alternate	care,	will	undoubtedly	face	problems	in	several	areas: 

•	 Personnel 

	 Shortages	of	qualified	personnel,	including	nurses	and	specialized	technicians,	 

exist	throughout	our	health	care	system.	During	a	mass	casualty	event,	these	 

shortages	could	manifest	to	catastrophic	levels.	Some	staff	may	not	respond	 

during	a	bombing	or	other	disaster	event	for	various	reasons,	including	fear	 

for	personal	safety,	family	issues,	or	injury.	Estimating	available	staff	may	be	 

difficult	because	many	work	at	multiple	facilities.	Conversely,	the	screening,	 

managing,	and	credentialing	of	well-intentioned	volunteers	during	a	disaster	 

can	be	challenging,	if	not	impossible. 

•	 Equipment and supplies 

	 Shortages	of	essential	equipment	and	supplies	often	occur	in	the	aftermath	of	 

a	large-scale	terrorist	bombing	or	natural	disaster.	Moreover,	most	facilities	in	 

a	given	region	use	the	same	suppliers	for	back-up	stock	and	equipment	(e.g.,	 

pharmaceuticals,	general	medical	supplies,	ventilators).	 

8	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
•	 Information technology (data management/data systems) 

	 Oftentimes,	software	systems	involving	EMS	services,	hospitals,	and	health	 

departments	are	incompatible.	To	maximize	patient	outcomes	and	allow	 

family	members	to	quickly	locate	loved	ones,	a	data	management	system	must	 

have	the	ability	to	track	patients	from	the	scene	to	the	hospital,	track	patients	 

throughout	the	facility,	and	track	transfers	to	other	facilities. 

•	 Cost 

	 	Preparation	and	incident	mitigation	requires	a	commitment	of	resources.	 

Training	prehospital	providers,	stockpiling	key	equipment	such	as	stretchers	 

and	reserving	capacity	in	the	blood	supply	will	be	expensive.	 

•	 Interoperability 

	 An	effective	medical	response	to	a	terrorist	bombing	demands	that	the	 

response	system	components	(personnel,	organizations,	and	command	 

structures)	are	interoperable.	Yet	services,	agencies,	and	systems	are	 

not	integrated	for	maximum	efficiency	(i.e.,	equipment;	preparation;	 

communications;	and	incident	command,	both	prehospital	and	hospital). 

	7.	Potential	Bottlenecks	 

	Despite	the	impact	of	these	events	on	multiple	areas	of	clinical	care,	there	are	some		 	 

	areas	whose	response	and	capability	may	impact	patients	across	the	spectrum	of	care:	 

•	 Radiology 

	 Given	the	nature	of	injuries	related	to	terrorist	bombings,	the	most	victims	 

will	undergo	multiple	radiology	studies.	In	Madrid,	50	radiology	studies	 

and	interventions	were	performed	the	day	of	the	bombing.14	The	numbers	 

of	patients	requiring	studies	may	lead	to	a	bottleneck,	and	hinder	the	 

institution’s	ability	to	streamline	care.	However,	to	date,	professional	 

radiology	societies	have	not	focused	on	surge	capacity	for	bombing	victims	 

and	the	potential	for	radiology	to	become	a	bottleneck.	Instead,	they	have	 

focused	exclusively	on	detection	and	treatment	of	radiation	emergencies	and	 

disasters.	 

•	 Critical Care 

	 If	a	terrorist	bombing	increases	the	demand	for	critical	care/ICU	services	 

which,	in	turn,	exceeds	reserve	ICU	capacity,	hospitals	would	have	limited	 

ability	to	divert	or	transfer	patients	to	other	hospitals	and	will	need	a	plan	in	 

place	to	provide	emergency	mass	critical	care. 

•	 Pharmacy 

	 Ensuring	an	adequate	supply	of	required	pharmaceuticals	throughout	the	 

institution,	and	community,	is	essential,	and	may	prove	challenging.	This	may	 

be	complicated	by	the	fact,	as	noted	above,	that	many	facilities	in	a	given	 

region	use	the	same	suppliers	for	back-up	stock	and	supply. 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 9 
8.		Triage 

Our	current	planning	and	preparedness	activities	assume	that	prehospital	providers	 

will	be	dispatched	in	coordinated	fashion,	will	arrive	on	the	scene	to	triage	patients,	 

and	will	transport	them	to	the	appropriate	facilities,	thereby	preventing	any	 

component	of	the	system	from	being	overwhelmed.	In	many	disasters,	however,	 

most	victims	self-transport	or	are	transported	by	other	laypersons.	Victims	do	not	 

wait	for	an	organized	field	triage	system	to	come	into	effect;	consequently,	the	 

system	or	facilities	are	overwhelmed.28 

	9.		Legal	Issues 

Multiple	legal	issues	impact	the	response	to	a	terrorist	bombing	or	other	major	 

disaster,	and	may	impact	effective,	coordinated	medical	care	that	optimally	utilizes	 

all	of	a	community’s	resources.	Examples	include	credentialing	of	providers;	altered	 

standards	of	care;	standards	for	clinical	documentation;	the	Emergency	Medical	 

Treatment	and	Active	Labor	Act	(EMTALA),	the	Health	Insurance	Portability	and	 

Accountability	Act	(HIPAA),	or	Clinical	Laboratory	Improvement	Amendments	(CLIA).	 

Discipline-specific	Challenges 

Each	of	the	aforementioned	problems	has	an	impact	on	the	spectrum	of	care;	however,	 

unique	examples	exist	for	many	disciplines.	The	expert	panel	also	identified	the	following	 

discipline-specific	challenges	and	provided	feasible	and	affordable	strategies	for	effectively	 

addressing	surge	capacity.	(The	proposed	solutions	are	provided	in	a	template	format	at	 

the	end	of	this	document.) 

1.		Emergency	Medical	Service	Response 

As	initial	responders,	EMS	providers	and	personnel	must	confront	several	issues,	 

including: 

•	 Personal protection 

	 Currently,	there	is	no	unified	approach	to	protect	rescuers	or	stage	a	 

response.	When	do	appropriate	concerns	for	scene	safety	and	the	potential	 

for	secondary	explosive	devices	hinder	the	initial	response? 

•	 Decontamination 

	 Though	treatment	will	be	delayed,	decontamination	may	be	imperative.	 

Uniform	policies	and	protocols	for	decontamination	of	personnel	and	patients	 

need	to	be	established	for	all	scenarios	(e.g.,	weather,	bombing).	 

•	 Incident command 

	 Interoperability	between	prehospital	and	hospital	command	structures	is	a	 

challenge.	This	challenge	manifests	not	only	in	the	technical	aspects	of	radio	 

interoperability,	but	also	in	the	interdisciplinary	aspects	of	communications	 

plans.	A	unified	incident	command	structure	must	be	incorporated	into	health	 

care	and	EMS	practice;	further,	EMS	must	be	designated	as	part	of	the	field	 

response	command	structure. 

10	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
•	 Field triage 

	 Although	multiple	triage	systems	are	used	across	the	country,	there	is	no	 

agreed-upon	methodology	for	field	triage	during	a	disaster. 

•	 Destination decisions 

	 	Determining	the	appropriate	destination	in	the	aftermath	of	an	event	may	be	 

difficult,	especially	if	the	initial	scene	“size-up”	has	not	been	performed.	 

•	 Hospital evacuations 

	 Whenever	EMS	transfers	patients	from	hospitals	to	free	up	acute	care	beds,	 

normal	hospital	functions	are	adversely	affected.	 

•	 Sustainability of operations 

	 Providing	personnel	with	needed	support	(e.g.,	physical,	emotional)	and	 

maintaining	facilities,	equipment	and	supplies	in	the	aftermath	of	an	event	is	 

an	ongoing	challenge. 

2.		Emergency	Department	Response 

The	emergency	department	(ED)	is	a	central	portal	to	any	hospital;	as	such,	the	 

ED	is	where	initial	information	about	a	disaster	is	communicated.	The	challenge	is	 

to	determine	the	magnitude	of	the	event	and	initiate	the	appropriate	institutional	 

response.	This	response	must	be	in	concert	with	the	assessed	magnitude,	including	 

decisions	to	declare	an	institutional	disaster,	to	declare	an	institutional	lock-down,	 

and	to	determine	if	recipient	victim	decontamination	is	needed.	To	determine	 

the	extent	of	the	response,	the	quality	and	quantity	of	information	from	the	field	 

and	between	the	regional	emergency	operations	center	and	hospital	is	critical.	 

Frequently,	information	challenges	and	communications	are	a	source	of	failure. 

In	a	large-scale	event,	each	hospital	must	have	the	capability	to	increase	staffing,	 

rapidly	assess	its	available	bed	status,	and	make	occupied	beds	available—especially	 

in	the	ED,	operating	theatres,	and	critical	care	units.	To	free	up	beds,	hospitals	 

should	cancel	elective	surgeries	and	admissions,	open	traditionally	non-patient	 

hospital	areas	for	patient	care	(e.g.,	classrooms,	offices,	etc),	and	begin	early	 

discharge	for	inpatients	as	appropriate.	 

During	a	mass	casualty	event,	transfer	of	patients	to	an	alternative	care	site	may	be	 

delayed	due	to	the	time,	personnel,	and	equipment	needed	to	set	up	that	site.	However,	 

development	of	an	alternative	site	will,	over	time,	free	up	non-critical	care	beds.	 

	Key	issues	follow: 

•	 	Ascertaining the validity and scope of the event.	Notification	is	essential	to	 

activate	and	implement	an	appropriate	response;	information/updates	must	 

be	consistent	and	frequent.	 

•	 Incident command.	A	Hospital	Incident	Command	System	(HICS)	must	be	 

implemented	within	the	ED,	hospital,	and	community.	HICS	is	a	widely	used	 

emergency	management	system	known	for	providing	a	chain	of	command	 

that	can	mobilize	at	a	moments	notice,	provide	accountability	of	position	 

functions,	allow	flexible	responses	to	emergencies,	improve	documentation	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 11 
of	facility	actions,	provide	a	common	language	to	facilitate	outside	assistance,	 

and	develop	prioritized	response	checklists	for	senior	leadership.	Each	 

hospital	should	be	part	of	a	regional	unified	command	structure. 

•	 Discharging patients from the ED.	To	free	up	resources,	patients	should	be	 

discharged,	or	transferred	to	other	areas	for	care. 

3.	Surgical	and	Intensive	Care	Unit	Response 

Multiple	factors	affect	trauma	surgery	and	its	preparedness	and	response	to	a	
 

bombing	event	or	natural	disaster.
 

•	 Changes in surgical practice 

	 The	recent	increased	interest	in	disaster	response	capabilities	is	in	contrast	to	 

the	general	surgery	community’s	decreased	interest	in	managing	emergency	 

surgery.	Thus,	the	knowledge	base	and	skill	set	to	manage	a	Madrid-type	 

scenario	is	being	concentrated	at	fewer	hospitals.	Many	hospitals	with	the	 

capacity	to	handle	surge,	as	it	relates	to	beds	and	staffing,	have	little	technical	 

capability	to	manage	a	surge	of	patients	from	a	bombing.	 

•	 Time of day 

	 As	in	the	Madrid	bombings,	the	time	of	the	event	is	critical	for	trauma	centers	 

and	community	hospitals.	However,	disaster	planning	often	does	not	consider	 

time	of	day.	At	0200	hours,	for	example,	a	community	hospital	may	not	have	 

operating	theatre	capability. 

•	 Limited ICU beds 

	 Overcrowding	may	require	decisions	to	delay	surgeries,	identify	beds	in	other	 

areas	of	the	hospital,	and/or	transfer	patients	to	another	facility. 

•	 Loss of excess capacity/Capacity on a given day 

	 The	U.S.	health	care	system	has	systematically	and	deliberately	eliminated	 

capacity	because	unused	capacity	is	an	additional	expense.	 

•	 Education 

	 More	surgeons,	especially	those	in	trauma	centers,	need	further	education	on	 

the	planning	and	response	process.	The	U.S.	military	in	Iraq	has	successfully	 

demonstrated	concepts	in	surgical	surge	capacity	management	that	should	 

be	translated	immediately	to	civilian	medicine.	Further,	Iraq’s	experience	 

with	damage-control	(emergency)	surgery	has	shown	that	more	patients’	lives	 

can	be	saved	through	temporizing	damage-control	surgery	than	if	patients	 

received	time-consuming	definitive	surgery.	 

Additionally,	after	a	terrorist	attack,	critical	care	and	ICU	services	will	be	needed	 

to	treat	the	seriously	ill	or	injured	casualties.	The	emergency	mass	critical	care	 

plan	should	address	hemodynamic	resuscitation	and	support	using	intravenous	 

fluids	and	vasopressors;	administration	of	antibiotic	and	other	disease-specific	 

countermeasures;	prophylactic	interventions	to	reduce	adverse	consequences	of	 

critical	illness;	and	basic	modes	of	mechanical	ventilation,	and	should	include: 

12	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
1.	Interventions	that	improve	survival;	without	which	death	is	likely; 

2.	Interventions	that	do	not	require	extraordinarily	expensive	equipment;	and	 

.	Interventions	that	do	not	consume	extensive	staff	or	hospital	resources. 

If	ventilators	are	unavailable	to	treat	all	patients	in	need,	minimally	skilled	individuals	 

could	use	an	endotracheal	tube	to	manually	ventilate	the	patient.	Critical	care	areas	 

should	be	equipped	to	measure,	at	a	minimum,	oxygen	saturation,	temperature,	 

blood	pressure,	and	urine	output.	When	critical	care/ICUs	are	full,	hospitals	can	 

create	additional	capacity	in	non-ICU	rooms	concentrated	on	specific	wards	or	 

floors.	Patient	care	areas	that	already	contain	equipment	similar	to	ICU’s	(endoscopy	 

and	surgical	suites)	are	good	alternatives,	but	these	ad	hoc	critical	care	areas	will	 

increase	capacity	only	slightly	and	require	cessation	of	services	normally	provided. 

When	a	hospital	cannot	meet	increased	demand	for	critical	care	services	using	 

its	existing	critical	care	practitioners,	a	two-tiered	staffing	model	comprising	 

noncritical	care	physicians	and	nurses	may	be	substituted.	Members	of	the	Working	 

Group	on	Emergency	Mass	Critical	Care	(Center	for	Bioterrorism	at	the	University	 

of	Pittsburgh)	and	the	Society	of	Critical	Care	Medicine	concluded	that	a	critical	 

care	physician	can	supervise	up	to	four	noncritical	care	physicians	who	can	each	 

manage	up	to	six	critically-ill	patients.	They	also	concluded	that	a	critical	care	nurse	 

could	supervise	up	to	three	noncritical	care	nurses	with	each	caring	for	up	to	two	 

patients.	In	this	model,	a	hospital’s	critical	care	staff	is	multiplied	to	where	one	 

critical	care	physician	could	oversee	the	care	of	up	to	24	critically-ill	patients,	and	 

one	critical	care	nurse	could	oversee	the	care	of	up	to	six	critically-ill	patients.29 

Additionally,	many	of	our	nation’s	leading	children’s	hospitals	with	large	Pediatric	 

Intensive	Care	Units	(PICUs)	operate	at	maximum	capacity.	If	a	mass	casualty	 

involving	children	and	infants	were	to	occur,	the	PICUs’	response	and	ability	to	 

provide	intensive	care	would	be	severely	constrained. 

The	emotional	issues	surrounding	the	care	for	a	dying	or	dead	child	compounds	 

this	issue	as	paramedics,	physicians,	and	others	generally	do	not	want	to	pronounce	 

children	dead	at	the	scene.	Thus,	they	will	transport	a	child	who	has	been	pulseless	 

and	apneic	for	an	hour,	and	still	hopelessly	receiving	CPR,	to	the	ED	and	ultimately	 

to	the	PICU	where	the	child	will	be	declared	deceased.	Such	considerations	affect	 

field	triage	and	care	in	a	mass	casualty	situation.	Finally,	PICUs	have	a	chronic	 

shortage	of	trained,	available,	and	experienced	staff. 

4.		Radiology	Response 

Whereas	in	many	areas	(ICU	beds,	operating	rooms,	ventilators,	etc.)	the	United	 

States	has	diminished	capacity,	it	has,	in	fact,	a	slight	surplus	of	capacity	in	 

radiology,	which	would	be	beneficial	in	managing	multiple	bombing	victims.	 

Administrators	have	learned	that	hospitals	lose	money	when	patients	wait	in	an	ED	 

or	hospital	due	to	insufficient	radiology	capacity.	For	this	reason,	hospitals	have	 

invested	in	imaging	technologies	such	as	computed	tomography	(CT),	magnetic	 

resonance	imaging	(MRI),	ultrasound,	and	digital	imaging.	Radiology	capacity	has	 

increased	and	improved	technologies	are	now	widely	used.	Still,	relatively	few	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 1 
U.S.	hospital	centers	and	health	care	systems	have	enough	capacity	and	ability	to	 

maintain	sufficient	staffing	levels	to	effectively	use	this	equipment.	Each	hospital	 

differs	in	its	capabilities,	equipment,	and	personnel	(technicians	and	radiologists).	 

Additional	problems	may	include	preserving	radiology	for	the	most	appropriate,	 

critical	patients;	ensuring	immediate	access	to	backup	components	of	critical	 

equipment;	and	interacting	with	vendor	technicians.	 

5.		Blood	Bank	Response 

In	the	last	0	years,	the	United	States	has	experienced	only	five	disasters	in	which	 

more	than	100	units	of	blood	were	used.	If	a	large-scale	terrorist	bombing	took	 

place,	large	amounts	of	blood	would	be	needed	only	if	many	victims	were	seriously	 

injured.	 

The	blood	banking	community	has	formed	an	interorganizational	task	force	to	 

address	blood	needs	in	the	event	of	a	disaster.	The	AABB	(formerly	known	as	the	 

American	Association	of	Blood	Banks)	Interorganizational	Task	Force	on	Domestic	 

Disasters	and	Acts	of	Terrorism	(AABB	Interorganizational	Task	Force)	unites	 

national	blood	organizations	representing	virtually	all	the	nation’s	blood	centers	 

(AABB,	America’s	Blood	Centers,	and	American	Red	Cross)	and	hospital	and	supplier	 

associations	with	liaisons	from	the	Department	of	Health	and	Human	Services,	Food	 

and	Drug	Administration,	CDC,	and	Armed	Services	Blood	Program	to	coordinate	 

efforts	in	preparation	for	and	response	to	disasters	affecting	the	blood	supply.	 

Potential	issues	with	our	nation’s	blood	supply	follow: 

•	 Disruption of the blood supply system 

	 Lack	of	blood	will	probably	not	be	a	problem,	but	disruption	or	interference	 

of	the	blood	supply	system	could	wreak	havoc.	During	times	of	disaster,	 

including	terrorist	attacks,	Americans	will	search	for	ways	to	help.	Potential	 

donors	will	descend	on	hospitals	and	blood	centers	and	quickly	overburden	 

the	system.	Blood	collection,	processing,	and	testing	are	highly	regulated	 

procedures	in	a	technical	system	that	requires	trained	staff.	On	September	11,	 

2001,	New	York	and	New	Jersey	used	224	units	of	blood,	while	Washington	 

and	Virginia	used	4—totaling	258	units,	all	of	which	were	on	the	shelf	before	 

the	disaster	occurred.0	Across	the	nation,	more	than	a	half	million	potential	 

donor’s	volunteered	blood.	 

	 In	the	event	of	a	disaster,	the	AABB	Interorganizational	Task	Force	will	inform	 

the	American	public	if	blood	donations	are	needed	and	tell	them	how	and	where	 

to	donate.	In	most	instances,	the	appropriate	message	is	that	additional	blood	is	 

not	needed	immediately	after	the	disaster,	but	that	individuals	should	contact	 

their	local	blood	centers	to	schedule	a	donation	in	the	upcoming	weeks. 

•	 Transportation of blood 

	 Even	when	blood	products	are	not	shelved	at	the	surge	capacity	site,	the	 

products	can	be	available	in	hours.	In	fact,	blood	can	be	transported	to	a	 

disaster	location	faster	than	donations	can	be	processed.	There	are	some	 

issues	with	transporting	blood;	for	example,	authorization	may	be	required	to	 

transport	blood	around	the	state	or	country.	In	addition,	blood	centers	may	 

14	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
have	difficulty	obtaining	diesel	and	unleaded	fuel	to	power	generators	or	to	 

operate	staff	vehicles	that	transport	blood.	Federal,	state,	and	local	emergency	 

preparedness	offices	need	to	make	blood	products	a	priority	for	obtaining	 

transportation	and	fuel. 

•	 Local organization 

	 In	a	disaster,	blood	needs	to	be	placed	exactly	where	it	is	needed—at	the	 

hospitals	serving	the	large	influx	of	patients.	Few	hospitals	regularly	collect	 

blood;	fewer	still	are	capable	of	handling	an	influx	of	donors	while	caring	 

for	disaster	patients.	In	some	metropolitan	areas,	hospitals	may	be	served	 

almost	entirely	by	one	blood	center;	in	other	areas,	hospitals	might	get	blood	 

regularly	from	several	sources.	Planned	and	coordinated	efforts	are	needed	 

during	a	disaster	to	know	which	blood	centers	will	service	the	hospitals	at	 

surge	capacity.	Within	an	hour	of	a	disaster,	the	AABB	Interorganizational	 

Task	Force	will	convene	a	conference	call	of	national	blood	organizations,	 

HHS,	and	local	affected	blood	centers	to	determine	local	needs	for	blood	and	 

actions	necessary	to	meet	those	needs.	The	Task	Force	will	meet	again	hours	 

or	days	later	to	coordinate	subsequent	blood-related	efforts.	 

•	 Staff who can administer blood 

	 Most	hospitals	aim	for	a	three-day	supply	of	blood.	If	blood	is	not	stored	at	 

the	hospital;	typically,	the	blood	can	be	readily	accessed.	For	a	hospital	to	 

consume	a	three-day	blood	supply	in	three	hours	is	highly	unlikely.	Instead,	 

the	hospital	may	have	too	few	trained	staff	to	administer	blood.	Several	 

documents	are	available	to	assist	blood	centers,	hospital	blood	banks,	and	 

transfusion	services	prepare	for	and	respond	to	disasters	and	acts	of	terrorism	 

that	could	affect	the	blood	supply.1- 

6.		Hospitalists’	Reponse 

By	the	end	of	this	decade,	there	will	be	more	hospitalists	(physicians	or	internists	 

caring	for	hospital	patients)	than	other	medical	subspecialties;	currently,	half	the	 

hospitals	with	200	or	more	beds	employ	hospitalists.	Although	they	may	not	be	 

directly	involved	in	the	care	of	casualties	from	a	terrorist	event,	hospitalists	will	be	 

vital	in	rapidly	discharging	inpatients,	accepting	transfers	from	ICUs,	and	freeing	bed	 

space	for	victims.	 

7.		Administration	Response 

When	an	institution	is	stressed	clinically,	it	will	also	be	stressed	administratively.	 

Hospitals	face	formidable	challenges	in	the	post-911	era.	Shrinking	revenue	margins	 

put	pressure	on	budgets	and	complicate	investment	decisions	to	purchase	items	for	 

contingency	operations.	Unlike	nations	with	publicly	funded	health	systems,	the	 

U.S.	health	care	industry	must	support	its	contingency	investment	needs	by	pooling	 

a	mix	of	private	funding	with	local,	state,	and	federal	resources.	As	a	result,	every	 

hospital	has	some	capability,	but	the	clinical	and	administrative	capabilities	of	each	 

vary	widely.	 

The	United	States	has	4,919	community	hospitals,	of	which	221	are	major	teaching	 

hospitals.	The	major	teaching	hospitals	are	components	of	academic	medical	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 15 
centers,	often	include	a	Level	1	trauma	center,	and	may	coordinate	local	EMS	 

transport.	These	221	hospitals	are	the	focal	points	of	graduate	medical	education,	 

technology,	and	tertiary	services.	Should	an	incident	occur,	these	hospitals	will	 

be	expected	to	serve	the	local	community,	through	either	direct	clinical	care	or	 

system	coordination.	Maintaining	these	hospitals	in	the	face	of	falling	revenue	 

margins	strains	the	ability	of	any	organization	to	support	infrastructure	for	“response	 

capability.”	 

The	rest	of	the	hospital	industry	is	similarly	stressed.	Total	staffed	beds	in	the	United	 

States	have	dropped	to	just	below	956,000.	Outsourcing	outpatient	services	and	 

procedures	to	non-hospital	settings	further	reduces	revenue.	Less	money	means	less	 

opportunity	to	invest	in	hospital	infrastructure,	which	gradually	erodes	sophisticated	 

diagnostic	services	in	hospitals	and	complicates	our	nation’s	health	care	industry	 

from	responding	in	traditional	ways,	let	alone	under	extraordinary	circumstances.	 

Within	each	community,	leadership	from	the	health	care	industry	is	a	key	element	in	 

an	effective	response.	Hospital	executives	recognize	that	major	events	will	activate	 

political	and	law	enforcement	leadership	and	that	they	must	be	proactive	and	form	 

professional	and	collegial	contacts	with	community	leaders.	Similarly,	hospitals	must	 

be	linked	to	provide	mutual	aid	and	assist	patient	transfers.	Businesses	function	on	 

increasingly	narrow	inventory	levels,	and	hospitals	in	the	same	community	usually	 

rely	on	the	same	suppliers.	In	a	crisis,	suppliers	will	resort	to	rationing	inventory.	 

Regional	and	multistate	mutual	aid	plans	should	be	developed;	but	in	catastrophic	 

events,	help	from	those	outside	the	affected	zone	may	take	days	to	arrive,	 

underscoring	the	need	to	identify	resources	to	support	three	days	of	operations	 

before	reordering	supplies.	 

Hospital	responses	to	mass	casualty	events	are	often	chaotic.	In	part,	this	is	due	 

to	lack	of	training	and	experience,	but	the	disorganized	response	is	compounded	 

by	not	having	an	appropriate	command	structure	such	as	the	HICS.	Use	of	an	 

appropriate	incident	command	system	does	not	guarantee	a	successful	response,	 

but	without	one,	failure	is	almost	certain.	Hospital	personnel	need	to	understand	 

the	concept	of	regional	unified	command	and	be	willing	to	participate	appropriately	 

during	a	disaster. 

When	a	situation	demands	swift	action,	hospital	administrators	have	to	focus	on	 

many	areas	simultaneously.	Using	a	step-by-step	approach,	administrators	can	 

bring	some	order	to	chaos	and,	in	fact,	improve	response	times	and	save	lives.	 

Administrators	should	focus	on	the	critical	areas	listed	below: 

•	 Control of the external environment 

	 The	external	environment	will	change	rapidly	during	a	large	event.	 

Maintaining	control	of	hospital	grounds	(e.g.,	facility	security	and	traffic)	is	 

essential.	Clearing	beds	to	accommodate	incoming	casualties,	redirecting	 

nonemergency	patients	to	other	resources,	and	managing	overall	comings	 

and	goings	of	staff	will	require	effective	control	of	the	external	environment,	 

including	media	control. 

16	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
•	 Implementation of Hospital Incident Command System 

	 	In	a	fast-paced	disaster	like	the	Madrid	bombings,	it	is	of	crucial	importance	to	 

have	identified	the	appropriate	decision-makers	beforehand	for	the	HICS.	In	a	 

crisis,	there	is	little	time	for	meetings	or	discussion	about	the	appropriate	use	 

of	support	functions	and	personnel. 

•	 Personnel Issues 

	 	There	should	be	a	balance	between	the	individual	needs	of	staff	and	the	 

organization	as	a	whole	to	assure	adequate	coverage	for	short-	and	long-term	 

medical	responses.	Decisions	must	be	made	early	about	when	staff	can	go	 

home	to	check	on	family	members	or	what	to	do	if	staffers	leave	in	the	middle	 

of	the	response.	A	method	to	request	additional	staff	on	short	notice	coupled	 

with	defining	an	individual	institution’s	surge	capacity	can	assist	in	finding	 

the	right	mix	of	clinical	and	nonclinical	support	to	handle	the	increased	 

workload.	 

•	 Memorandums of Understanding or Agreement 

	 	Prescripted	agreements	to	share	supplies,	personnel,	or	equipment	should	 

be	written	and	drilled	to	support	local,	regional,	and	state	partners	in	time	of	 

need. 

•	 Logistics and supplies 

	 	Coordination	with	key	suppliers	and	maintenance	of	inventories	throughout	 

the	health	system	will	make	ramping	up	the	level	of	effort	easier.	Depending	 

on	the	event,	some	areas	(i.e.,	obstetrics,	outpatient	surgery,	and	various	clinics)	 

may	not	be	directly	affected	and	could	provide	supplies.	Effective	logistics	 

management	would	also	include	patient	transportation	to	and	from	appropriate	 

care	settings.	Although	the	housing	of	evacuees	is	a	municipal	function,	 

knowing	the	locations	of	designated	Red	Cross	shelters	throughout	the	vicinity	 

and	transportation	resources	for	low-acuity	patients	and	their	family	members	 

will	hasten	discharge	planning	and	improve	patient	flow	in	the	ED.	 

•	 Alternate care sites 

	 	A	hospital	is	most	effective	when	it	can	mobilize	quickly	and	expand	care	to	 

the	city’s	walking	wounded.	Triage	systems	are	typically	used	to	prioritize	 

patients	so	that	low-priority	patients	can	be	directed	from	the	main	hospital,	 

thus	allowing	ambulances	and	hospital	staff	to	focus	on	high-priority	patients	 

(i.e.,	burns,	dehydration,	multiple	injuries).	Alternate	sites	may	allow	 

large	health	systems	to	facilitate	triage	and	direct	patients	and	families	to	 

appropriate	sources	of	care. 

•	 Credentialing 

	 	The	Joint	Commission	on	the	Accreditation	of	Healthcare	Organizations	 

(JCAHO)	emergency	credentialing	system	does	work,	but	it	must	be	tested	 

within	an	organization	before	it	is	needed.	State	Emergency	Systems	for	 

Advance	Registration	of	Volunteer	Health	Professionals	(ESAR–VHP)	reflect	 

JCAHO	requirements	and	provide	a	standardized	set	of	verified	credentials	for	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 17 
volunteers	who	may	be	called	to	assist	hospitals	during	emergency	situations.	 

Many	aspects	of	staff	credentialing	and	privileging	can	be	streamlined,	but	 

the	formal	enrollment	cannot	be	circumvented.	In	most	hospitals,	formal	 

enrollment	provides	access	to	entering	orders,	prescribing	modalities,	 

writing	prescriptions,	ordering	laboratory	tests,	and	documenting	care	using	 

automated	systems.	No	matter	whether	credentialing	is	handled	by	human	 

resources	or	a	professional	staffing	office,	the	design	of	the	system	should	 

support	the	use	of	volunteers	in	nonclinical	activities. 

•	 Patient tracking 

	 	Tracking	patient	movement	is	a	critical	function	during	any	mass	casualty	 

situation.	Successful	tracking	begins	at	the	point	a	patient	enters	the	health	 

care	system.	When	more	time	is	spent	identifying	and	tracking	patients,	the	 

prospect	of	reimbursement	for	related	costs	is	better.	The	ability	to	track	 

patients,	identify	their	supply	consumption,	and	monitor	bed	use	enables	 

senior	management	to	proactively	meet	the	needs	of	health	care	providers	on	 

the	frontline.	Many	patient	tracking	systems	exist,	and	if	at	all	possible,	the	 

system	should	allow	automated	tracking	for	exercises	and	real	disasters. 

This	list	is	not	all	encompassing	for	every	facility.	The	staff	of	any	health	care	 

organization	should	periodically	evaluate	areas	like	plant	management,	social	work	 

resources,	safety,	materials	management,	biomedical	equipment	and	repair,	service	 

procurement,	and	patient	admittance	to	help	prepare	for	the	unexpected.	Often,	 

disaster	preparedness	is	focused	solely	on	the	transfer	of	care	between	provider	and	 

patient	and	not	on	the	infrastructure	to	support	the	effort.	 

18	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Surge Capacity Solutions 

Addressing	System-wide	Challenges	 

How	do	we	address	acute	events	that	stress	our	overburdened	system?	Apparently,	we	 

must	prepare	for	the	predictable	surprise—a	bombing—which	is	the	most	common	form	 

of	terrorist	attack.	The	United	States	has	a	basic,	functional	capability	to	respond	to	the	 

surge	of	patients	following	a	terrorist	event	such	as	a	bombing;	however,	several	critical	 

areas	must	be	addressed	for	effective	surge	capacity	to	occur.	To	address	the	systemspecific	challenges	related	to	surge	capacity	that	are	highlighted	above,	the	expert	panel	 

outlined	the	following	recommendations	for	each	challenge.	 

1.		Organization	and	Leadership 

Leadership	is	important	for	successful	preparedness	and	response	at	all	levels—field,	 

hospital,	city,	state,	and	federal—and	it	is	mandatory	in	the	planning	and	response	 

phases.	 

2.		Alterations	in	Standards	of	Care 

Culturally,	the	United	States	may	need	to	revise	its	stance	on	health	care.	Instead	of	 

doing	the	greatest	good	for	the	individual,	we	may	need	to	do	the	greatest	good	 

for	the	community	(i.e.,	save	the	most	victims).	There	is,	however,	no	universally	 

accepted	methodology	of	doing	this,	and	the	process	is	fraught	with	ethical,	 

societal,	medical,	and	legal	issues.	A	protocol	is	needed	to	determine	when	and	 

how	to	deviate	from	the	norm	without	the	civilian	health	care	provider	or	facility		 

experiencing	repercussions.	An	altered	protocol	would	improve	the	civilian	sector’s	 

ability	to	manage	patient	assessment,	treatment,	flow,	and	outcomes	for	the	greatest	 

number	of	patients.	It	is	clear	that	changing	standards	of	care	will	require	efforts	to	 

preserve	quality	of	care,	a	formal	process	in	each	community	to	determine	when	 

and	how	to	transition	from	standard	operating	procedures	to	an	altered	standard	of	 

care,	and	determining	who	will	have	the	authority	to	order	the	transition.	In	August	 

2004,	the	Agency	for	Healthcare	Research	and	Quality,	U.S.	Department	of	Health	 

and	Human	Services	(HHS)	convened	a	panel	of	experts	to	examine	the	complex	 

issues	surrounding	alterations	in	clinical	care.	Their	findings	are	published	in	the	 

monograph	Altered Standards of Care in Mass Casualty Events.4 

The	rationale	for	suspending	standards	of	care	in	an	emergency	is	that	more	patients	 

will	survive	a	terrorist	attack	if	key	interventions	are	provided	to	the	greatest	 

numbers	of	casualties	likely	to	benefit	from	receiving	care.	Hospitals	and	EMS	 

systems	at	surge	capacity	will	require	autonomy	to	suspend	regular	standards	of	care	 

and	shift	to	emergency	critical	care	practices.	 

•	 	Although	care	can	be	altered	at	the	institutional	level,	if	all	hospitals	affected	 

by	a	crisis	switch	to	emergency	critical	care	practice	standards	at	the	same	 

time,	more	patients	will	receive	effective	care. 

•	 	The	ethical,	political,	legal,	regulatory,	and	logistical	implications	of	 

suspending	standards	of	care	and	triaging	patients	to	limited	resources	will	 

require	the	participation	of	state	and	federal	government.	Legislation	will	 

be	required	to	suspend	standards	of	medical	practice	during	an	emergency	 

without	practitioners	and	hospitals	incurring	legal	liability.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 19 
•	 	A	mechanism	is	needed	to	address	issues	associated	with	change	from	routine	 

to	altered	(emergency)	standards	of	care/sufficiency	of	care.	 

•	 	Community	education	before,	during,	and	after	an	event	is	necessary	for	 

acceptance	and	understanding.	 

3.		Education 

Educational	efforts	must	include	an	all-hazards	approach	that	addresses	the	most	 

likely,	predictable	terrorist	event:	a	bombing.	The	education	given	to	care	providers	 

should	reflect	the	potential	severity	of	the	event.	Training	must	be	standardized	 

across	all	levels	of	providers	so	that	there	is	consistency	among	the	disciplines.	 

Training	should	address	clinical	care	and	systems	issues. 

4.		Communications 

Communication	plans	should	include	interoperable,	redundant	regional	emergency	 

communications	systems,	ideally	with	multi-frequency	bands,	and	trunked	systems	 

with	the	capability	to	pool	user	groups	(for	example,	among	hospitals)	via	the	incident	 

command	structure.	If	a	catastrophic	incident	results	in	massive	power	failure,	 

emergency	backup	systems,	such	as	mobile	satellite	telephones,	will	be	needed	along	 

with	other	conventional	methods	of	communication.	Communication	plans	also	 

should	address	command	and	control	structures	and	disaster	crisis	counseling. 

Informatics	and	data	systems	link	information	for	real-time	impact	(i.e.,	which	 

hospitals	have	beds,	where	patients	can	be	diverted,	how	to	find	loved	ones,	and	 

how	to	access	survival	data).	Without	patient	tracking	and	informatics,	no	one	will	 

be	able	to	evaluate	what	works	and	what	does	not	work	in	a	given	situation.	 

5.		Transportation 

The	military	is	probably	the	only	group	with	the	capability	to	transport	patients	on	 

a	large	scale;	however,	not	on	short	order,	as	it	may	take	hours	to	arrange	a	single	 

transfer.	Regional,	statewide,	and	national	plans	and	agreements	should	address	 

the	roles	of	National	Guard	and	active-duty	military	personnel	for	providing	largescale	air	medical	resources	on	relatively	short	notice.	There	may	also	be	a	need	to	 

integrate	private	and	public	transportation	resources	with	military	resources. 

6.		Infrastructure	and	Capacity 

Given	the	wide	variability	that	exists	nationwide,	basic	strategies	and	solutions	must	 

be	developed	to	enable	our	hospital	and	medical	system	infrastructures	to	respond	 

more	effectively	to	mass	casualty	events.	 

Staffing	issues	must	be	addressed	in	advance.	Plans	should	address	multi-facility	 

credentialing,	interstate	licensing	agreements,	and	potential	use	of	volunteers.	The	 

Health	Resources	and	Services	Administration	(HRSA)	is	developing	guidelines	and	 

standards	to	verify	the	credentials	of	health	care	professionals.	When	completed,	 

the	Emergency	System	for	Advance	Registration	of	Volunteer	Health	Professionals	 

(ESAR-VHP)	program	will	have	established	a	network	of	state-owned	and	operated	 

systems	capable	of	registering	and	verifying	the	credentials	of	health	care	volunteers	 

before	an	emergency.	The	value	of	registries	was	demonstrated	in	the	aftermath	of	 

Hurricanes	Katrina	and	Rita	when	21	states	sent	more	than	8,00	pre-credentialed	 

(documented)	volunteer	health	professionals	to	affected	areas.	 

20	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
7.		Potential	Bottlenecks 

•	 Radiology 

	 Perhaps	a	minimalist	approach	to	using	radiology	makes	sense—identifying	 

and	standardizing	a	baseline	that	could	be	used	in	many	facilities.	By	 

identifying	and	addressing	critical	life	threats	and	major	problems	through	 

“tiered”	reports—initial	“wet”	interpretations	that	are	made	and	left	with/on	 

the	patient	and	acted	on	when	resources	become	available	and	final	reports	 

and	interpretations	are	completed–both	patient	flow	and	care	may	be	greatly	 

improved. 

•	 Critical Care 

	 Plans	must	be	in	place	to	provide	for	emergency	mass	critical	care,	including	 

basic	modes	of	mechanical	ventilation,	hemodynamic	resuscitation	and	 

support	using	intravenous	fluids	and	vasopressors,	administration	of	 

antibiotics	and	other	disease-specific	countermeasures,	and	prophylactic	 

interventions	to	reduce	adverse	consequences	of	critical	illness.	If	an	event	 

exceeds	a	locality’s	critical	care/ICU	capacity,	hospitals	must	be	able	to	 

activate	emergency	mass	critical	care	practices,	suspending	usual	standards	of	 

care	and	defining	patients	and	interventions	of	highest	priority.	 

•	 Pharmacy 

	 Pharmacies	must	be	prepared,	and	the	role	of	pharmaceutical	systems	in	the	 

overall	response	falls	into	two	areas: 

•	 Selection	of	the	proper	pharmaceuticals	for	stockpiling,	and 

•	 Proper	stockpiling	of	“CHEMPACKS.” 

8.		Triage 

Preparedness	and	response	plans	must	recognized	that	there	are	no	evidencebased	standards	for	mass	casualty	events,	including	those	that	result	from	terrorist	 

bombings,	and	that	field	triage	often	does	not	occur	for	the	majority	of	injured	 

victims.	Response	plans	must	account	for	the	self	referral	of	patients	to	nearby	 

hospitals,	and	the	impact	this	phenomena	may	have	on	the	care	of	the	critically	 

injured. 

9.		Legal	Issues 

Issues	related	to	EMTALA,	HIPAA,	and	provider	credentialing	must	be	addressed	on	 

both	a	national	and	local	level,	to	ensure	that	the	emergency	medical	system	and	 

individual	providers	can	respond	in	a	timely	and	effective	manner. 

	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 21 
	Addressing	Discipline-specific	Challenges 

Our	nation’s	health	care	system	has	a	chronic	problem	with	managing	surge	capacity.	 

Providers	and	administrators	struggle	daily	to	provide	the	full	spectrum	of	injury	care	for	 

victims	of	trauma,	placing	our	preparedness	for	terrorism	in	a	precarious	position.	 

This	section	contains	nine	templates	developed	by	the	expert	panel	to	help	various	 

disciplines	address	issues	of	surge	capacity.	Though	developed	in	the	context	of	a	surge	 

of	injuries	from	a	terrorist	bombing,	the	recommendations	in	this	section	may	improve	 

the	response	to	and	management	of	a	surge	of	patients	from	any	cause,	including	 

biological,	chemical,	or	nuclear.	Most,	but	not	all,	of	these	disciplines	(e.g.,	“Drugs	and	 

Pharmaceutical	Supplies”	and	“Nursing	Care”)	have	been	discussed	in	the	preceding	 

sections.	However	these	issues	represent	a	significant	concern	for	systems	planners	and	 

therefore,	the	expert	panel	felt	they	must	be	included	in	the	solutions	section.	Because	 

many	disciplines	will	be	affected	simultaneously,	it	is	difficult,	if	not	impossible,	to	identify	 

a	longitudinal	timeline.	For	this	reason,	the	templates	are	listed	in	a	general	order	of	flow	 

through	the	system.	 

1.	 Emergency	Medical	Service	Response 

2.	 Emergency	Department	Response
 

.	 Surgical	and	Intensive	Care	Unit	Response
 

4.	 Radiology	Response 

5.	 Blood	Bank	Response 

6.	 Hospitalists’	Response 

7.	 Administration	Response 

8.	 Drugs	and	Pharmaceutical	Supplies 

9.	 Nursing	Care 

Along	with	providing	general	information	(i.e.,	purpose,	background,	goals),	each	template	 

provides	basic,	and	in	most	cases,	low-cost	strategies	that	can	be	implemented	rapidly	to	 

avoid	problems	associated	with	managing	surge	capacity.	The	templates	emphasize	the	 

importance	of	practicing	and	evaluating	plans. 

The	templates	are	intended	as	guides	only,	as	needs,	preferences,	and	capabilities	vary	 

among	communities.	Furthermore,	templates	propose	solutions	that	assume	communities	 

are	already	actively	engaged	in	disaster	planning	and	preparedness	activities;	therefore,	it	is	 

expected	that	a	significant	portion	of	the	personnel	and	resource	costs	would	be	absorbed	 

by	these	ongoing	activities.	Exact	costs	should	be	determined	by	local	communities	and	 

institutions	therein. 

	 

22	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Managing Surge Needs for Injuries:
 

Emergency Medical Service Response
 

PURPOSE	 	 

To	provide	guidance	for	local	emergency	medical	service	(EMS)	response	and	to	 

operationalize	additional	EMS-related	resources	needed	in	a	community	within	 

four	hours	of	an	explosion.	These	resources	are	intended	to	treat	00	injured	 

patients	for	up	to	72	hours. INJURY PREVENTION 

Emergency Medical BACKGROUND 

Service Response The	Madrid	terrorist	bombings	were	used	as	a	model	to	help	develop	solutions	for	 

Emergency Department managing	rapid	surge	problems	during	a	mass	casualty	event.	 Response 

Surgical and Intensive 

Care Unit Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than 

Blood Bank Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Hospitalists’ Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Administration Response 

Drugs and Pharmaceutical 

Supplies Federal resources should not be expected to arrive sooner than 72 hours from the 

Nursing Care time of the explosion. Resources can be delayed by the time taken to deploy them 

and by responding to multiple communities. 

GOAL 

To	mobilize	the	appropriate	number	and	type	of	EMS	resources	to	adequately	 

evaluate	injuries,	initiate	triage,	begin	transporting	00	injured	patients,	and	to	 

establish	ongoing	EMS	operations	for	up	to	72	hours. 

This document is a resource guide. Local needs, preferences, and capabilities of 

affected communities may vary. 

REQUIRED	RESOURCES	 

1.	 Personnel	must	be: 

	 •	 Appropriately	equipped	and	knowledgeable	about	chemical,	biological,		 

	 radiological,	nuclear,	and	explosives	(CBRNE)	detection,	personal		 	 

	 protection,	and	decontamination. 

	 •	 Educated	in	the	care	of	blast-related	injuries	for	adult	and	pediatric	patients. 

	 •	 Prepared	to	institute	triage.	 

	 •	 Prepared	to	institute	and	participate	in	unified	incident	command.	 

2.	 A	communications	system	that	is	interoperable	with	public	safety	disciplines	 

(fire,	law	enforcement,	EMS,	and	emergency	management)	and	with	receiving	 

hospitals	and	local	public	health	officials.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 2 
.	 Rapid	access	to	sufficient	ambulance	resources	to	transport	critically	injured	patients. 

4.	 Rapid	access	to	sufficient	alternative	resources	(e.g.,	buses)	to	transport	noncritical,	 

injured	persons. 

5.	 Have	the	necessary	material	and	the	capability	to	detect	CBRNE	agents	to	assist	with	 

decontamination	plans.	 

6.	 Decontamination	equipment	for	ambulatory	and	non-ambulatory	patients;	equipment	 

should	be	rapidly	deployable	to	the	explosion	site,	a	secondary	treatment	site,	or	a	 

hospital. 

7.	 Determine/implement	secondary	triage	and	treatment	sites	within	the	community. 

ASSUMPTIONS 

1.		 EMS	systems	in	the	United	States	are	highly	variable,	with	a	wide	range	of	available	 

resources,	experience,	and	financing. 

2.		 A	functional	EMS	system	is	a	critical	component	for	planning	the	prehospital	 

management	of	injured	bombing	victims. 

ACTION	STEPS 

1.	 Education: 

•	 Train	responding	EMS	personnel	about	how	to	treat	primary,	secondary,	tertiary,	and	 

quaternary	blast-related	injuries.	For	guidance,	go	to	www.bt.cdc.gov/masstrauma/ 

explosions.asp. 

•	 Train	EMS	personnel	about	National	Incident	Management	System	(NIMS)	 

compliance;	Incident	Command	System	(ICS	Homeland	Security	Presidential	 

Directive	5);	and	the	importance	of	command,	staging,	triage,	and	treating	initial	 

casualties	(regardless	of	rank	of	the	provider)	should	be	emphasized.	 

•	 Train	EMS	personnel	about	the	use	of	personnel	protective	equipment	(PPE)	and	the	 

risks	of	transporting	potentially	contaminated	patients.	The	relative	importance	of	 

gross	vs.	technical	decontamination	should	be	reviewed. 

•	 Train	EMS	officials	in	advanced	ICS	(ICS	700	or	equivalent). 

2.	 Local	policy	and	planning:	 

	 Fire,	EMS,	law	enforcement,	emergency	management,	hospitals,	and	public	health	 

should	collaborate	to	develop	and	complete	written	plans	within	six	months,	as	listed	 

below.	Within	one	year,	other	agencies	listed	in	these	plans	(including	mutual	aid	 

agencies,	etc.)	must	be	included	in	ongoing	planning	and	evaluation. 

•	 Plan	for	mobilizing	50	ambulances	within	10	minutes	after	the	blast.		At	least	75%	of	 

these	resources	should	arrive	at	staging	areas	in	the	first	hour	with	all	arriving	in	the	 

first	90	minutes.	This	should	be	accomplished	using	9-1-1	EMS	resources,	mutual	aid	 

agreements	with	other	EMS	providers,	or	mutual	aid	agreements	with	nonemergency	 

transport	providers. 

24	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
•	 Plan	describing	each	agency’s	role	in	the	command	structure.	This	should	 

include	how	critical	functions	of	command,	staging,	triage,	and	treatment	will	be	 

accomplished	in	the	first	10	minutes	of	a	response;	how	additional	ICS	elements	 

will	be	filled	over	the	first	hour;	and	how	the	ICS	structure	will	be	formally	filled	by	 

officials	trained	in	advanced	ICS	(ICS-700	or	equivalent)	by	the	end	of	the	first	hour. 

•	 Plan	describing	how	alternative	transport	for	200	ambulatory	patients	will	be	
 

initiated	in	the	first	10	minutes	after	an	explosion.
 

•	 Plan	describing	the	details	of	interdisciplinary	communications	(primary	and	 

alternatives).	Representatives	from	fire	prevention,	EMS,	law	enforcement,	 

emergency	management,	hospitals,	and	public	health	must	be	included	in	this	plan.	 

•	 Plan	for	decontaminating	and	protecting	personnel	that	addresses	the	following: 

–	 Agency	responsible	for	scene	assessment	and	determining	what	(if	any)	 

decontamination	measures	are	required. 

–	 Realistic	assessment	of	the	time	required	to	deploy	decontamination	resources	for	 

ambulatory	and	non-ambulatory	patients. 

–	 Deployment	of	decontamination	resources	to	event	site,	secondary	triage	sites,	or	 

receiving	hospitals. 

–	 Transport	of	patients	after	gross	decontamination	(technical	decontamination	of	 

patients	before	transport;	appropriate	personal	protective	equipment,	or	PPE;	and	 

appropriately	equipped	destination	choices). 

•	 Plan	to	establish	secondary	triage	points	for	ambulatory	patients	(ideally,	within	the	 

first	hour	after	the	explosion).	This	should	address	the	following: 

–	 How	sites	can	be	activated	and	staffed	with	at	least	one	transport	ambulance,	 

sufficient	law	enforcement	personnel	for	security,	and	adequate	support	staff	to	 

record	arrivals.	 

–	 How	gross	and	technical	decontamination	could	be	accomplished	at	affected	site(s). 

–	 How	medical	care	at	secondary	triage	sites	could	be	converted	to	treatment	areas	 

(e.g.,	provision	of	medical	supplies,	additional	medical	personnel,	and	other	 

logistical	concerns). 

•	 Plan	to	establish	criteria	for	determination	of	death	at	the	scene,	particularly	in	a	 

mass	casualty	situation,	and	appropriately	manage	the	deceased.	 

EVALUATION 

1.		 Plan	and	conduct	a	community-wide	drill.	Afterwards,	evaluate	it	by	assessing	overall	 

operations	and	EMS	resources	such	as	personnel,	ambulances,	and	PPE.	Evaluate	 

compliance	with	NIMS.	 

2.		 Assess	and	refine	plan.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 25 
Managing Surge Needs for Injuries:
 

Emergency Department Response
 

PURPOSE	 	 

To	activate	additional	emergency	department	resources	needed	within	four	hours	 

of	an	explosion.	These	resources	should	treat	00	injured	patients	for	up	to	72	 

hours. 

BACKGROUND 

INJURY PREVENTION The	experiences	of	the	Madrid	terrorist	bombings	were	used	as	a	model	to	help	 

Emergency Medical develop	solutions	for	managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Service Response 

Emergency Department 

Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive 

Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than 

Radiology Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Hospitalists’ Response 

Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the 

Drugs and Pharmaceutical time of the explosion. Resources can be delayed by the time taken to deploy them 

Supplies and by responding to multiple communities. 

Nursing Care 

GOAL 

To	establish	policies,	procedures,	didactic	training,	and	drills	to	improve	 

institutional	preparedness	for	treating	00	injured	patients	for	up	to	72	hours.	 

RESOURCES	REQUIRED 

There	should	be	adequate	medical,	nursing,	and	support	staff	to	provide	initial	 

triage,	and	to	evaluate	and	stabilize	00	persons.	 

	 

This document is a resource guide. Local needs, preferences, and capabilities of 

affected communities may vary. 

ASSUMPTIONS 

1.		 Developed	packets	for	each	patient	containing	disaster	bands	(those	from	 

blood	banks	work	best),	manual	charting	forms,	and	manual	lab	and	radiology	 

order	forms.	These	packets	should	be	prepared	in	advance	and	stored	in	the	ED.	 

2.		 Established	procedures	for	obtaining	additional	personnel,	equipment,	supplies	 

and	beds;	establish	a	mechanism	for	notifying	and	activating	backup	personnel. 

.		 Established	procedures	for	triage,	patient	emergency	identification	of	patients		 

			 and	discharge,	and	quick	documentation.	 

4.		 Established	temporary	disaster	log	to	document	basic	information. 

26	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
ACTION	STEPS 

1.	 Implement	and	drill	a	hospital	emergency	incident	command	system	(such	as	Hospital	 

Incident	Command	System	or	“HICS”);	include	clinical	care	providers	in	the	training	 

and	drill. 

	 If	hospital	personnel	(e.g.,	practitioners,	administrators,	nurses)	have	not	trained	or	 

drilled	in	a	hospital	incident	command	system,	learned	about	the	National	Incident	 

Management	System	(NIMS),	or	do	not	understand	the	function	of	a	Hospital	Incident	 

Command	Center,	this	information	should	be	included	in	training	sessions. 

2.	 Instruct	clinical	staff,	especially	surgeons	and	emergency	physicians,	about	the	unique	 

aspects	of	blast-related	injuries	and	care	following	an	attack	with	a	radiation	dispersal	 

device	(RDD). 

.	 Establish	an	institutional	lockdown	process	and	drill	on	a	regular	basis;	include	 

radiation	detection	and	decontamination	of	arriving	patients. 

4.	 Update	the	institutional	call-down	list	and	perform	a	functional	call-down	exercise. 

5.	 Identify	potential	institutional	surge	staffing	from	employees	with	clinical	training,	but	 

not	currently	tasked	with	clinical	jobs. 

6.	 Identify	patient	care	supplies	for	a	surge	situation,	such	as	additional	IV	equipment,	 

bandages/dressings,	gowns,	gloves,	masks,	other	operating	room	supplies,	etc. 

7.	 Develop	a	regional	Unified	Command	Structure	that	includes	local	emergency	 

management	and	area	hospitals.	This	should	be	achieved	under	the	guidance	and	 

leadership	of	the	local	emergency	managers. 

8.	 Identify	non-patient	care	areas	in	the	institution	that	could	be	converted	to	patient	care	 

to	expand	bed	surge	capacity. 

9.	 Establish	and	drill	a	procedure	for	early	patient	discharge	to	increase	bed	capacity.	 

This	procedure	should	include	evaluation	of	ICU	patients	for	potential	movement	to	a	 

non-ICU	bed	and	evaluation	of	all	patients	for	potential	early	discharge	or	transfer	to	an	 

alternative	care	site	(internal	or	external	to	the	institution). 

EVALUATION 

When	appropriate,	evaluation	drills	have	been	incorporated	into	the	“Action	Steps”	listed	 

above.	The	institutional	disaster	preparedness	plan	should	be	updated	based	on	each	drill	 

experience.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 27 
Managing Surge Needs for Injuries:
 

Surgical and Intensive Care Unit Response
 

PURPOSE	 	 

To	mobilize	and	assign	operating	rooms	and	related	assets	for	life-	and	limb-saving	 

surgical	care	to	the	most	critically	injured	of	00	patients	from	explosions	(care	 

extends	to	patients	from	the	community	with	acute	surgical	illness	for	up	to	72	 

hours	after	a	bombing).	 

INJURY PREVENTION 

Emergency Medical BACKGROUND 

Service Response The	Madrid	terrorist	bombings	were	used	as	a	model	to	help	develop	solutions	for	 

Emergency Department managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Response 

Surgical and Intensive 

Care Unit Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than 

Blood Bank Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Hospitalists’ Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Administration Response 

Drugs and Pharmaceutical 

Supplies Federal resources should not be expected to arrive sooner than 72 hours from the 

Nursing Care time of the explosion. Resources can be delayed by the time taken to deploy them 

and by responding to multiple communities. 

GOAL 

Within	two	hours	of	a	blast	event,	establish	incident	command	for	the	operating	 

rooms	and	surgical	support	areas	for	up	to	72	hours.	 

RESOURCES	REQUIRED 

Resources	needed	for	communicating	within	the	organization	and	with	the	 

community	(e.g.,	satellite	phone,	walkie-talkie).	 

This document is a resource guide. Local needs, preferences, and capabilities of 

affected communities may vary. 

ASSUMPTIONS	 

1.		 Operating	room	(OR)	assets	are	a	critical	component	of	surge	capacity	after	an	 

explosion	and	must	be	mobilized	quickly.	 

2.		 The	OR	capacity	of	any	institution	or	community	(i.e.,	number	of	operating	 

rooms)	is	fixed	because	of	structural	requirements.	 

.		 One	or	more	surgeons,	anesthesiologists,	and	critical	care	specialists	will	be	in	 

the	hospital	or	available	immediately	after	an	event. 

28	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
4.		 Other	surgeons,	anesthesiologists,	and	critical	care	specialists	can	be	available	within	 

two	hours	of	an	event	to	provide	direct	patient	care	in	the	ORs	and	related	areas. 

5.		 The	ORs,	post-anesthesia	care	units	(PACU),	and	intensive	care	units	will	already	be	in	use. 

6.	 Casualties	of	the	blast	and	patients	already	in	the	hospital	system	or	in	other	treatment	centers	 

in	the	community	will	occupy	one	or	more	of	these	three	areas	within	the	next	72	hours.	 

7.	 If	these	areas	are	not	made	available	in	a	timely	manner,	patients	will	suffer	greater	harm.	 

8.	 Some	patients	could	be	moved	to	different	care	sites. 

9.		 Federal	resources	cannot	be	expected	to	arrive	sooner	than	72	hours	from	the	time	of	 

an	explosion. 

ACTION	STEPS 

The	near-term	(six	months)	solutions	listed	below	include	estimated	hours	for	each	task. 

1.		 Identify	medical	leadership	within	surgery	and	anesthesiology	for	disaster	planning.	 

•	 Leadership	should	collaborate	in	the	design,	implementation,	and	refinement	of	 

an	incident	command	system	for	an	operating	room.	Initially,	leadership	in	surgery	 

and	anesthesiology	should	meet	with	representatives	from	critical	care,	emergency	 

medicine,	administration,	and	others	involved	with	the	institution’s	disaster	planning.	 

These	discussions	will	be	facilitated	by	appointing	a	hospital	disaster	committee.	 

2.		 Select	individuals	for	incident	command	roles.	 

•	 Specify	the	authority,	processes,	and	responsibilities	of	the	OR	incident	command	 

and	a	call	schedule	identifying	individuals	available	to	fill	their	roles	24	hours	a	day,	 

beginning	within	two	hours	of	the	event,	and	extending	for	72	hours.	 

•	 Although	individuals	from	several	disciplines	and	departments	in	the	operating	room	 

and	related	areas	may	assist	the	incident	command,	final	decision-making	authority	 

should	rest	with	one	person—an	“Operating	Room	Czar.”	The	OR	Czar	would	have	 

authority	to	cancel	scheduled	OR	cases,	rearrange	OR	schedules,	identify	patients	 

that	could	be	transferred,	call	in	and	deploy	OR	teams,	and	prioritize	patients	for	beds	 

in	the	OR,	PACU,	and	ICUs.	The	OR	Czar	would	report	to	hospital	incident	command.	 

•	 Candidates	for	this	role	should	be	able	to	assess	the	medical	needs	of	a	variety	of	 

patients	requiring	OR	services.	They	must	be	physicians,	and	would	most	likely	be	 

surgeons.	An	individual	serving	in	this	role	should	not	have	primary	patient	care	 

responsibility	at	the	same	time	(i.e.,	be	part	of	a	surgical	team). 

•	 Communication	systems	linking	surgery,	nursing,	anesthesiology,	critical	care,	
 

emergency	department,	and	hospital	administration	should	be	specified.	
 

•	 The	OR	incident	command	system	must	account	for	personnel	availability	at	 

different	times	of	the	day	and	week	and	provide	for	transfer	of	incident	command	 

responsibility	as	the	incident	evolves	over	72	hours.	 

•	 The	circumstances	under	which	the	OR	incident	command	begins	and	ends	should	 

be	specified. 

•	 Methods	for	data	collection,	testing,	monitoring,	and	improving	the	system	should	be	 

specified. 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 29 
	.		Assure	that	individuals	who	might	assume	an	incident	command	role	are	knowledgeable	 

about	incident	command,	operations	of	other	hospital	components,	and	community	 

disaster	response.	 

	 This	step	assures	that	eligible	candidates	for	OR	incident	command	receive	appropriate	 

training.	Requirements	and	standards	for	such	training	should	be	specified.	 

4.		 Identify	lines	of	communication	and	interactions	with	other	components	of	the	 

community-wide	disaster	plan	and	regional	trauma	system.	 

EVALUATION 

1.		 Participate	in	community-wide	drills	and	evaluate	performance	of	OR	incident	 

command. 

		 Determine	when	individuals	should	be	present	onsite.	Review	triage	decisions,	quality,	 

quantity,	and	appropriateness	of	information	obtained	from	and	given	to	others,	 

including	hospital	incident	command,	emergency	medicine,	and	other	community	 

assets.	 

2.	 Refine	and	conduct	further	planning	based	on	drill	experience.	 

	 

	
 

0	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Managing Surge Needs for Injuries:
 

Radiology Response 


PURPOSE	 	 

Within	four	hours	of	an	explosion,	operationalize	radiology	support	for	the	initial	 

treatment	of	00	injured	patients	and	for	ongoing	care	up	to	72	hours. 

BACKGROUND 

INJURY PREVENTION 

The	Madrid	terrorist	bombings	were	used	as	a	model	to	help	develop	solutions	for	 

Emergency Medical managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Service Response 

Emergency Department 

Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than 

Care Unit Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Blood Bank Response 

Hospitalists’ Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response 

time of the explosion. Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical 

Supplies and by responding to multiple communities. 

Nursing Care 

GOAL 

To	establish	policies,	procedures,	and	drills	to	improve	radiological	preparedness	 

for	treating	00	patients	injured	from	an	explosion	for	up	to	72	hours.	 

RESOURCES	REQUIRED 

There	must	be	enough	radiology	personnel	(radiologists,	technicians,	and	support	 

staff),	equipment,	and	supplies	to	care	for	00	injured	patients.	 

This document is a resource guide. Local needs, preferences, and capabilities of 

affected communities may vary. 

ASSUMPTIONS 

1.	 Radiology	services	will	be	a	critical	component	of	the	hospital	response	to	a	 

bombing. 

2.	 Many	patients	over	a	relatively	short	time	period	requiring	radiology	may	lead	 

to	slow-downs	and	bottle-necks. 

ACTION	STEPS 

The	near-term	solutions	listed	below	include	estimated	number	of	hours	needed	 

to	perform	each	task.	 

1.	 Develop	a	management	plan	and	call	list	for	the	radiology	department	to	 

use	during	a	mass	casualty	event.	Drill	the	plan,	involving	radiologists	for	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 1 
immediate	(“wet”)	readings	of	plain	films	and	special	studies.	This	will	assist	in	rapid	 

evaluation	and	treatment	of	patients.	The	plan	should	also	optimize	and	streamline	 

radiology	study	protocols	for	use	during	a	mass	casualty	event. 

	 Enhanced	radiology	patient	throughput	will	be	essential	in	the	initial	evaluation	and	 

treatment	of	blast-injuries.	Each	radiology	department	must	develop	a	plan	to	ensure	 

rapid	turnaround	of	patient	studies	and	their	results. 

2.	 When	disaster	patients	arrive,	a	radiology	ultrasound	technician	should	be	available	in	 

the	emergency	department	to	support	the	performance	of	an	immediate	FAST	(Focused	 

Abdominal	Sonography	for	Trauma)	exam.	If	this	is	not	possible,	the	emergency	 

physicians	and	trauma	surgeons	should	be	trained	to	conduct	one. 

.	 Conduct	an	imaging	equipment	survey;	evaluate	the	status	of	the	equipment	for	 

multiple	traumas,	making	sure	there	are	adequate	amounts	of	portable	equipment	 

available	and	update	if	needed. 

	 Radiology	equipment	is	expensive	and	usually	requires	planning	in	advance	for	 

acquisition	and	installation.	However,	by	evaluating	how	available	equipment	could	be	 

put	to	maximum	use	during	a	mass	casualty	event	can	improve	patient	throughput. 

4.	 Establish	a	protocol	for	augmenting	patient	movement	and	monitoring	in	the	radiology	 

department.	Afterwards,	review	the	availability	of	patient	monitoring	personnel	and	 

equipment	to	enhance	departmental	throughput,	especially	for	studies	such	as	CT	 

scans. 

EVALUATION 

Where	appropriate,	evaluation	drills	have	been	incorporated	into	the	“Action	Steps”	listed	 

above.	The	institutional	disaster	preparedness	plan	should	be	updated	based	on	each	drill	 

experience. 

	 

2	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Managing Surge Needs for Injuries:
 

Blood Bank Response
 

PURPOSE	 	 

Within	four	hours	of	an	event,	provide	blood	products	for	up	to	00	injured	 

patients	and	sustain	support	for	up	to	72	hours. 

BACKGROUND 

The	Madrid	terrorist	bombings	were	used	as	a	model	to	help	develop	solutions	for	 

INJURY PREVENTION managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Emergency Medical 

Service Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response 

2,000. That day, 966 patients were taken to 15 public community hospitals. More Surgical and Intensive 

Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Radiology Response 

Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the 

Hospitalists’ Response time of the explosion. Resources can be delayed by the time taken to deploy them 

Administration Response and by responding to multiple communities. 

Drugs and Pharmaceutical 

Supplies 

Nursing Care GOAL 

During	the	first	four	hours	of	a	disaster,	ensure	that	that	appropriate	blood	 

products	can	be	located,	processed,	and	quickly	administered	to	at	least	00	 

patients	requiring	transfusions.	Identify	additional	needs	so	that	blood	products	 

can	be	collected,	processed,	and	administered	for	up	to	72	hours. 

RESOURCES	REQUIRED 

•	 AABB	documents 

•	 Disaster	response	plans	for	hospital	and	blood	collection	centers	 

•	 Laboratory	personnel	to	collect,	process,	and	distribute	products 

•	 Transportation	resources,	diesel	and	unleaded	fuel,	and	storage	equipment		 

(e.g.,	dry	ice) 

•	 Transfusion	supplies 

This document is a resource guide. Local needs, preferences, and capabilities of 

affected communities may vary. 

ASSUMPTIONS 

•	 The	most	difficult	problems	involve	disruption	or	interference	of	the	blood	 

supply	system 

–	 Historically,	blood	supply	needs	during	disaster	response	have	been	met	 

with	the	quantity	of	blood	products	available	at	that	time. 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	  
–	 Facilities	currently	maintain	about	a	three-day	supply	of	blood	products—which	may	 

need	to	be	expanded	to	a	seven-day	supply. 

–	 Typically,	fewer	casualties	require	blood	products	than	the	total	number	of	victims.	 

–	 Local	communities	have	limited	sources	of	blood	products. 

–	 If	faced	with	a	surge	in	demand,	blood	products	will	likely	be	transported	from	 

blood	centers	outside	the	local	area. 

•	 After	a	disaster,	the	public	usually	responds	by	volunteering	to	donate	larger	quantities	 

of	blood	products	than	are	needed. 

–	 An	influx	of	blood	donors	could	tax	collecting	and	processing	efforts. 

–	 When	resources	(personnel,	equipment,	and	supplies)	are	unnecessarily	applied	to	 

collecting	and	processing	unneeded	products,	these	resources	cannot	process	and	 

distribute	available	and	urgently	needed	products	to	those	in	urgent	need. 

•	 The	media	must	continuously	provide	the	community	with	reliable	information	about	 

the	need	and	supply	of	blood	products. 

•	 There	are	limited	personnel	with	the	training,	education,	and	skills	to	process	and	 

administer	blood	products	within	treating	facilities. 

–	 Additional	qualified	laboratory	personnel	may	be	needed	to	process	requests	for	 

blood	products. 

–	 Additional	nursing	personnel	may	be	needed	to	administer	blood	products. 

•	 There	may	be	limited	methods	of	transporting	or	transferring	blood	products	from	 

supplier	to	destination	during	a	disaster. 

–	 Commercial	transport	(air	and	ground)	may	be	limited. 

–	 Blood	needs	are	considered	by	federal,	state,	and	local	governments	to	be	a	critical	 

element	of	the	public	health	infrastructure	in	times	of	emergency.	 

•	 The	AABB	Interorganizational	Task	Force	on	Domestic	Disasters	and	Acts	of	Terrorism,	 

formed	in	January	2002,	has	developed	a	process	to	educate	the	community	about	 

donations	and	how	to	collect,	process,	and	move	blood	products	at	the	time	of	a	 

disaster. 

–	 This	multi-organizational	task	force	includes	federal	and	national	organizations. 

–	 Published	references	include	a	Disaster	Operations	Handbook	and	a	hospital	 

supplement	that	addresses	these	issues.	They	include	a	flow	chart	outlining	the	 

process	for	involving	the	AABB	and	appropriate	national	and	federal	organizations	 

that	provide	blood	products	during	a	disaster. 

ACTION	STEPS 

•	 Work	with	AABB	to	distribute	documents	to	hospitals	and	blood	collection	 

organizations/facilities. 

•	 Identify	resources	(personnel,	equipment,	supplies)	to	meet	local	needs	for	collection,	 

processing,	distribution,	and	transfusion	of	blood	products.	This	effort	must	include	 

local	media	to	provide	consistent	messages	to	the	community	about	blood	products,	 

supply,	and	needs.	(Note:	Individual	hospitals	and	collection	organizations	incorporate	 

the	AABB	process	into	their	local	disaster	response	plans.) 

4	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
•	 Work	with	other	organizations	and	government	agencies	(local,	regional,	state,	federal)	 

to	make	sure	blood	products	are	considered	critical	elements	of	the	public	health	 

infrastructure	in	the	event	of	a	disaster/emergency. 

EVALUATION 

•	 Ensure	that	survey	hospitals	and	collection	organizations	incorporate	AABB	processes	 

into	local	disaster	response	plans	after	4	to	6	months. 

•	 Request	that	hospitals	and	collection	organizations	participate	in	a	local	or	regional	 

exercise	requiring	administration	of	blood	products	within	four	hours	of	an	event	for	 

up	to	72	hours. 

–	 Include	activation	and	response	of	the	AABB	system,	and	local,	regional,	and	state	 

resources	in	the	exercise.		 	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 5 
Managing Surge Needs for Injuries:
 

Hospitalists’ Response
 

PURPOSE	 	 

Within	four	hours,	leverage	the	knowledge	and	skills	of	hospitalists	to	treat	00	 

patients	injured	from	explosions	and	to	sustain	care	for	72	hours. 

BACKGROUND 

INJURY PREVENTION The	Madrid	terrorist	bombings	were	used	as	a	model	to	help	develop	solutions	for	 

Emergency Medical managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Service Response 

Emergency Department 

Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than 

Care Unit Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Blood Bank Response 

Hospitalists’ Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response time of the explosion. Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical 

Supplies and by responding to multiple communities. 

Nursing Care 

GOAL 

Within	four	hours	of	an	explosion,	deploy	staff	and	functioning	beds	to	treat	at	 

least	00	injured	patients	who	require	acute	inpatient	and	intensive	care	for	72	 

hours. 

The	boldfaced	terms	have	the	following	meaning:	 

•	 deploy	–	represents	the	sum	of	the	following:	 

n	 redefine	(standards	of	care)	 

n	 reallocate	(on-site	staff) 

n	 recruit	(off-site	staff) 

•	 functioning	-	represents	the	sum	of	the	following: 

n	 supplied	(items	necessary	for	care	are	available) 

n	 serviced	(patients	with	assigned	caregivers,	available	clinical	support	 

services	such	as	laboratory,	radiology,	and	pharmacy)	 

n	 stepped-down	(patients	capable	of	being	transferred	from	ICU	but	in	need	 

of	close	monitoring) 

RESOURCES	REQUIRED 

1.	 The	general	public’s	and	health	care	communities’	education	and	acceptance	 

of	the	concept	and	need	for	altered	standards	of	care	during	a	large-scale	 

disaster	response.	 

6	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
2.	 Adequate	staffing	to	support	response	efforts	(physicians,	nurses,	technicians,	support	 

staff,	supplies,	and	equipment). 

.	 Mechanism	to	implement	an	altered	standard	of	care.	This	should	include	ways	 

to	rapidly	“step	down”	suitable	patients	(e.g.,	from	ICU	to	floor	and	from	floor	to	 

elsewhere)	 

4.		 Mechanism	within	hospitals	that	place	hospitalists	into	“real-time”	roles	that	enable	 

them	to	allocate	and	ration	resources	and	to	serve	as	advisors	to	and	outreach	arms	of	 

Incident	Command.	 

This document is a resource guide. Local needs, preferences, and capabilities of affected 

communities may vary. 

ASSUMPTIONS 

1.	 Effective	clinical	response	to	a	surge	of	patients	from	a	bombing	event	will	require	 

coordination	and	cooperation	among	multiple	medical	specialties. 

2.	 Hospitalists	will	be	an	integral	component	in	identifying	available	hospital	beds,	 

discharging	patients,	caring	for	patients,	and	providing	additional	support	during	the	 

response. 

ACTION	STEPS 

1.		 Develop	and	disseminate	an	alternate	standard-of-care	policy	for	use	during	a	disaster	 

situation.	Include	in-hospital	triage	for	alternate	levels	of	care,	early	transfer	to	lower	 

levels	of	care,	and	early	discharge.	Consider	using	the	Agency	for	Healthcare	Research	 

and	Quality	document	as	a	reference. 

2.	 Convene	ethics	panel	as	necessary.	Enlist	Society	of	Hospital	Medicine	(SHM)	Ethics	 

Committee	as	needed.	 

.		 Educate	appropriate	staff	about	the	alternate	standard	of	care	policy.	 

4.		 Ensure	that	hospitalists	are	incorporated	into	the	disaster	response	of	each	hospital	to	 

address	issues	related	to	effective	preparedness	and	response. 

EVALUATION 

1.	 Conduct	an	exercise	that	implements	the	alternate	standard	of	care	policy	and	uses	 

hospitals	as	designated	in	the	disaster	plan. 

2.	 Critique	the	exercise	against	the	response	plan;	emphasize	issues	about	alternate	 

standards	of	care	and	performance	of	hospitalists. 

.	 Revise	the	alternate	standard	of	care	policy	and	disaster	plan	based	on	the	outcome	of	 

the	exercise. 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 7 
Managing Surge Needs for Injuries:
 

Administration Response
 

PURPOSE	 	 

Within	four	hours,	operationalize	additional	administrative-related	resources	to	 

treat	00	patients	injured	from	an	explosion	and	sustain	care	for	72	hours. 

BACKGROUND 

INJURY PREVENTION The	experiences	of	the	Madrid	terrorist	bombings	were	used	as	a	model	to	help	 

Emergency Medical develop	solutions	for	managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Service Response 

Emergency Department 

Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than 

Care Unit Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Blood Bank Response 

Hospitalists’ Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response time of the explosion. Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical 

Supplies and by responding to multiple communities. 

Nursing Care 

GOAL 

To	organize	and	support	response	to	influx	of	00	patients	injured	from	an	 

explosion	for	a	72-hour	period.	 

RESOURCES	REQUIRED 

The	workload	associated	with	an	administrative	response	will	require	access	to	 

multiple	facilities	to	support	the	needs	of	patients,	staff,	and	the	general	public.	 

Administrators	will	manage	communications,	acquire	political	support,	work	 

with	and	respond	to	media,	handle	public	inquiries,	manage	internal	systems	and	 

departments. 

This document is a resource guide. Local needs, preferences, and capabilities of 

the affected communities may vary. 

ASSUMPTIONS 

•	 Health	care	systems	and	hospitals	should	function	as	an	integrated	system	for	 

the	best	use	of	resources. 

•	 A	medical	response	to	a	mass	casualty	event	must	be	comprehensive,	 

community	based,	and	coordinated. 

•	 Legal	and	regulatory	issues	need	to	be	included	in	the	hospital	emergency	 

preparedness	plan:	Emergency	Medical	Treatment	and	Active	Labor	Act	 

8	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
(EMTALA),	Health	Insurance	Portability	and	Accountability	Act	(HIPAA),	Federal	 

Volunteer	Protection	Act,	Good	Samaritan	Laws,	labor	laws,	OSHA,	and	facility	codes. 

•	 Activating	the	community	Emergency	Operations	Center	(EOC)	and	hospital’s	 

command	center	are	critical	to	success. 

•	 Communication	among	hospitals,	health	systems,	EMS,	EOC,	and	public	health	cannot	 

be	lost	or	interrupted. 

•	 Hospitals	use	the	incident	command	system	and	have	staff	who	can	implement	it. 

•	 Hospitals,	long-term	care	facilities,	offices,	and	clinics	have	Memoranda	of	 

Understanding	(MOU)	to	share	resources.	 

•	 The	EOC	includes	health	care	representatives	to	coordinate	medical	resources. 

•	 Patients	who	do	not	need	acute	care	services	should	be	treated	at	alternate	care	 

facilities. 

•	 The	institution	must: 

–	 Establish	a	response	plan	based	on	the	Incident	Management	System	(e.g.,	Hospital	 

Incident	Command	System	(HICS)	model). 

–	 Include	clinics	and	offices	with	emergency	preparedness	plans	consistent	with	the	 

hospital.	 

–	 Include	medical,	nursing,	dental,	and	pharmacy	staff;	respiratory	students;	and	house	 

staff	and	fellows,	if	available.	 

–	 Determine	the	location	of	the	command	center	(not	in	the	ED)	and	backup	sites. 

–	 Establish	written	plans	to	secure	the	perimeter	of	the	facility	and	access	points.	 

–	 Identify	a	spokesperson	for	the	hospital	(public	information	officer).	 

•	 The	preparedness	plan	should	include	mechanisms	for	modifying	admission,	discharge,	 

and	procedure	schedules.	 

–	 Defer	admissions	that	are	not	emergent	(develop	criteria	and	put	into	policy). 

–	 Notify	operating	room	manager	to	defer	or	cancel	inpatient	and	outpatient	nonemergency	surgeries.	 

•	 Incorporate	intensivist,	hospitalist,	or	Chief	of	Staff’s	designee	into	plan	for	discharging	 

patients	during	emergency	operations.	(See	template	on	Hospitalist	Response)	Set	up	 

MOUs	with	hospitals. 

Additional	staffing	issues	to	consider: 

•	 Have	available	staff	address	the	mental	health	of	victims,	families,	and	staff	(e.g.,	 

psychiatrists,	psychologists,	licensed	mental	health	practitioners,	and	volunteers). 

•	 Employ	workers	trained	by	the	American	Red	Cross,	especially	those	who	can	
 

provide	mental	health	services.
 

•	 Provide	child	care	services	so	that	staff	are	free	to	attend	to	patients.	 

•	 Compile	a	list	of	qualified	translators	for	the	disaster. 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 9 
ACTION	STEPS 

The	solutions	listed	below	include	estimated	hours	for	each	task.	 

1.	 Control of the External Environment 

	 The	external	environment	will	change	rapidly	during	a	large-scale,	mass	casualty	event.	 

The	hospital	must	be	secured	and	campus	traffic	must	be	controlled.	Such	control	of	 

the	external	environment	includes	clearing	beds	to	accommodate	incoming	casualties,	 

redirecting	non-emergency	patients	to	other	resources,	and	managing	the	comings	and	 

goings	of	staff.	Managing	media	relations	can	be	challenging	when	trying	to	provide	 

safe	and	effective	care.	The	institution’s	security	and	public	affairs	offices	must	work	 

together	and	be	in	place	before	the	media	arrives.	 

2.	 Activation of Hospital Incident Command System (HICS) 

	 HICS,	a	widely	used	emergency	management	system,	is	known	for	providing	a	chain	 

of	command	with	the	ability	to	effectively	manage	an	incident,	provide	accountability	 

of	position	functions,	allow	for	a	flexible	response	to	specific	emergencies,	improve	 

documentation	of	facility	actions,	provide	a	common	language	to	facilitate	outside	 

assistance,	and	develop	prioritized	response	checklists	for	senior	leadership.	Identifying	 

the	appropriate	people	to	make	decisions	is	pivotal	in	a	fast-paced	disaster,	such	as	 

in	the	Madrid	bombings.	There	is	little	time	for	meetings	and	discussion	about	the	 

appropriate	use	of	support	functions	and	personnel.	Staff	should	be	trained	and	drilled	 

regularly	to	ingrain	the	difference	between	incident	structure	and	normal	operations. 

3.	 Logistics and Supplies 

	 Coordinating	with	key	suppliers	and	maintaining	current	inventories	throughout	the	 

health	system	will	make	stocking	efforts	easier.	When	resources	are	limited,	providers	 

must	be	prepared	to	respond	to	care	needs	with	whatever	is	available.	 

	 Logistics	include,	but	are	not	limited	to,	patient	transportation.	For	example,	housing	 

evacuees	and	the	walking	wounded	and	their	families	is	a	function	of	the	emergency	 

management	program.	Knowing	the	locations	of	designated	shelters	throughout	the	 

vicinity	and	transportation	resources	for	low-acuity	patients	and	their	families	will	 

hasten	discharge	planning	and	patient	flow	in	acute	care	facilities.	 

4.	 Alternate Care Sites 

	 A	hospital’s	ability	to	mobilize	emergency	care	units	and	to	extend	care	to	the	city’s	 

walking	wounded	adds	to	its	effectiveness.	Triage	systems	are	used	to	prioritize	patients	 

so	that	low-priority	patients	can	be	directed	from	the	main	hospital,	allowing	ambulances	 

and	hospital	staff	to	focus	on	high-priority	trauma	patients	in	need	of	medical	assistance.	 

Alternate	sites,	like	the	ones	used	during	Hurricanes	Katrina	and	Rita,	allow	large	health	 

systems	to	facilitate	triage	and	direct	patients	to	appropriate	sources	of	care. 

5.	 Credentialing 

	 The	Joint	Commission	on	the	Accreditation	of	Healthcare	Organizations	(JCAHO)	 

emergency	credentialing	system	must	be	tested	within	an	organization	before	it	is	 

really	needed.	State	Emergency	Systems	for	Advance	Registration	of	Volunteer	Health	 

Professionals	(ESAR–VHP)	reflect	JCAHO	requirements	and	provide	a	standardized	 

set	of	verified	credentials	for	volunteers	who	may	be	called	to	assist	hospitals	during	 

emergency	situations.	 

40	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
6.	 Patient Tracking 

	 Successful	patient	tracking	begins	as	soon	as	they	enter	the	health	care	system.	When	 

more	time	is	spent	identifying	and	tracking	patients,	the	prospect	of	reimbursement	for	 

related	costs	is	better.	The	ability	to	track	patients,	identify	their	supply	consumption,	 

and	monitor	bed	use	enables	senior	management	to	proactively	meet	the	needs	of	 

health	care	providers	on	the	frontline.	Patient	tracking	systems	must	be	flexible	enough	 

to	accommodate	such	needs.	 

7. 	Identify gaps 

•	 Ensure	coordination	between	on-scene	management	and	available	community	
 

resources	so	that	specific	facilities	are	not	overloaded.	
 

•	 Communication	among	facilities	at	clinical	and	administrative	levels	is	essential. 

8. 	Identify additional sources of community support 

		 Additional	sources	of	support	can	include	local	shelters,	locally-developed	stockpiles,	 

community	pharmacies,	drug	wholesalers/warehouses,	public	health	authorities,	etc.	 

Access	to	these	resources	will	be	important	if	the	event	displaces	many	residents	due	to	 

contamination,	property	damage,	utility	failure,	etc. 

9. 	Establish communication and relationships 

•	 Develop	communications	with	local	emergency	management. 

•	 Establish	communications	with	local,	regional,	and	state	hospitals. 

10.Exercise plans 

•	 Establish	regular	schedules	to	drill	every	aspect	of	a	response	to	ensure	that	all	staff	 

understands	their	roles. 

•	 Evaluate	the	drills,	and	modify	plans	based	on	after-action	reports. 

•	 Drill	the	new	plan. 

EVALUATION 

1.		 Plan,	conduct,	and	evaluate	facility-wide	drills.	The	evaluation	should	identify	stressors	 

on	clinical	and	administrative	activities.	 

2.		 Plan,	conduct,	and	evaluate	community-wide	drills.	The	evaluation	should	identify	 

stressors	on	clinical	and	administrative	activities.	 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 41 
Managing Surge Needs for Injuries:
 

Drugs and Pharmaceutical Supplies
 

PURPOSE	 	 

Within	four	hours	of	an	explosion,	acquire	the	additional	drugs	and	 

pharmaceutical	supplies	needed	to	treat	00	injured	patients	for	up	to	72	hours. 

BACKGROUND 

INJURY PREVENTION The	Madrid	terrorist	bombings	were	used	as	a	model	to	help	develop	solutions	for	 

Emergency Medical managing	rapid	surge	problems	during	a	mass	casualty	event.	 

Service Response 

Emergency Department 

Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than 

Care Unit Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Blood Bank Response 

Hospitalists’ Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response time of the explosion. Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical 

Supplies and by responding to multiple communities. 

Nursing Care 

GOAL 

Within	four	hours	of	an	explosion,	acquire	appropriate	and	adequate	drugs	to	 

treat	00	injured	patients	for	up	to	72	hours.	 

RESOURCES	REQUIRED	 

The	list	below	includes	therapeutic	categories,	administration	route,	and	 

recommended	drug	or	pharmaceutical	supply.	For	simplicity,	purchase	and	 

stockpile	a	single	or	few	drugs	from	each	therapeutic	category.	Care	providers	 

may	have	little	or	no	prior	experience	with	a	drug.	 

This document is a resource guide. Local needs, preferences, and capabilities of 

the affected communities may vary. 

•	 Analgesics		 

p.o.,	hydrocodone/acetaminophen	(one	strength—5/500);	IV,	morphine 

•	 Anxiolytics		 

p.o.	and	IV,	lorazepam 

•	 Antipsychotics	 

p.o	and	IV,	haloperidol 

•	 Antibiotics,	broad	spectrum	with	low	allergy	risk		 

p.o.	and	IV,	ciprofloxacin 

42	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
•	 Intravenous	fluids		 

saline	and	D5W 

•	 Blood	(see	Blood	Bank	Response) 

•	 Drugs	for	intubation	 

IV	etomidate,	succinylcholine,	and	vecuronium 

•	 Topical	burn	care	agents	 

Silver	sulfadiazine	(Silvadene)	 

Bacitracin 

•	 ENT	meds	for	TM	perforation	 

Cortisporin	otic	suspension 

•	 Ocular	meds	 

Proparacaine	 

Erythromycin	ophthalmic	ointment 

•	 Tetanus	toxoid 

ASSUMPTIONS 

1.	 There	may	be	a	demand	for	certain	pharmaceuticals	following	a	bombing	event	with	 

multiple	casualties. 

ACTION	STEPS 

1.		 Identify	community	medical	leadership	and	a	committee	to	address	near-term	solutions.	 

	 Discussion	and	decision	by	EMS,	emergency	medicine,	trauma	surgery,	hospital	 

pharmacy	(PharmD),	blood	bank,	hospital	leadership,	hospital	nursing,	emergency	 

management,	public	health,	and	law	enforcement	about	transport	of	pharmaceuticals.	 

2.		 Inventory	drugs	and	quantities	available	at	points	of	care	(prehospital	and	hospital).	 

	 Assuming	4	hospitals	and	10	ambulances,	committee	should	delegate	a	point	person	to	 

contact	hospital	pharmacists	and	EMS	leadership	and	inquire	about	inventory.	 

.		 Identify	gaps	between	drugs	on	hand	and	goal.	 

4.		 Identify	potential	sources	of	drugs	in	the	community	besides	prehospital	and	hospital	 

supplies	(e.g.,	locally	developed	stockpiles,	community	pharmacies,	drug	wholesalers/ 

warehouses,	physicians’	offices	via	medical	society).	Identifying	additional	sources	 

should	include	daily,	routine	needs	of	the	community.	 

5.		 Develop	relationships	with	leadership	from	additional	sources;	ask	for	“snapshot”	 

inventory	of	drugs,	and	establish	“mutual	aid”	agreements	to	rapidly	acquire	drugs.	 

6.		 Assess	drugs	available	in	the	community	by	adding	prehospital	+	hospital	+	community	 

pharmacies	+	drug	wholesalers/warehouses	+	physicians’	offices	(through	medical	 

society).	 

7.		 If	the	drug	supply	is	low,	develop	a	plan	for	intercommunity	mutual	aid	or	rationing.		 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 4 
8.		 Develop	a	plan	to	rapidly	acquire	drugs	from	additional	sources	and	deliver	products	 

to	points	of	care.	This	plan	should	include	communications	between	point(s)	of	care	 

and	additional	sources,	mutual	aid	agreements	with	additional	community	sources,	 

transport	of	drugs,	and	reimbursement.	 

EVALUATION 

1.		 Plan,	conduct,	and	evaluate	a	community-wide	drill.	The	evaluation	should	include	 

measuring	quantity	and	names	of	drugs	and	pharmaceutical	supplies	acquired,	 

distributed	and	administered;	times	when	drill	started,	time	drugs	were	acquired	from	 

distribution	points,	duration	of	transport,	time	of	distribution	to	points	of	care,	and	 

time	of	administration	to	patients. 

2.		 Refine	plan	based	on	drill	experience.	 

	 

44	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Managing Surge Needs for Injuries:
 

Nursing Care
 

PURPOSE	 	 

To	operationalize	additional	nursing	resources	in	a	community	within	four	hours	 

of	a	terrorist	bomb	explosion	and	to	treat	00	injured	patients	for	up	to	72	hours.	 

BACKGROUND 

INJURY PREVENTION The	experiences	of	the	Madrid	terrorist	bombings	were	used	as	a	model	to	help	 

develop	solutions	for	managing	rapid	surge	problems	during	a	mass	casualty	event.	 Emergency Medical 

Service Response 

Emergency Department 

Response On March 11, 2004, 10 terrorist explosions occurred almost simultaneously on 

Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than 

Care Unit Response 2,000. That day, 966 patients were taken to 15 public community hospitals. More 

Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours. 

Blood Bank Response 

Hospitalists’ Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response time of the explosion. Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical 

Supplies and by responding to multiple communities. 

Nursing Care 

GOAL 

Within	four	hours	of	an	explosion,	mobilize	the	appropriate	number	of	facilities	and	beds,	 

nursing	staff,	and	resources	needed	to	treat	00	injured	patients	for	up	to	72	hours. 

RESOURCES	REQUIRED	 

The	workload	will	require	adequate	staffing	and	backup	personnel	for	the	 

initial	response,	and	mechanisms	for	notification	and	activation,	credentialing	 

volunteers,	and	for	ensuring	the	safety	and	welfare	of	responders.	 

This document is a resource guide. Local needs, preferences, and capabilities of 

affected communities may vary. 

ASSUMPTIONS 

1.	 Nursing	personnel	are	essential	for	an	effective	response	to	a	bombing,	 

including	patient	care,	patient	tracking	and	information	management,	and	 

logistical	support. 

ACTION	STEPS 

The	solutions	listed	below	involve	providing	clinical	nursing	for	00	patients	over	 

a	72-hour	period. 

•	 Make	all	physical	beds	available	for	care,	including	those	in	storage	and	those	 

that	can	be	rented	on	short	notice.	Place	cots	in	rooms	or	hallways. 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 45 
•	 Develop	criteria	and	policy	to	discharge	patients	who	can	go	home	or	be	quickly	 

transferred	to	long-term	care.	 

–	 Make	sure	each	department	has	a	procedure	for	mass	casualty	care.	These	 

procedures	need	to	be	reviewed	and	be	accessible	to	the	command	center. 

–	 Departments	need	to	determine	procedures	for	what	will	be	done	immediately	(0– 

120	minutes),	intermediately	(2–4	hours)	and	long	term	(4–24	hours).	 

•	 Notify	all	departments	of	incident	and	of	emergency	plan	activation. 

•	 Request	that	policies	be	approved	by	a	centralized	committee	that	oversees	the	 

emergency	operations	and	plan.	 

•	 Update	call	lists.	Every	department	should	have	a	current	list	that	identifies	staff	by	their	 

proximity	to	the	hospital.	 

•	 Make	staff	aware	of	where	to	park,	where	to	report,	how	to	respond,	etc. 

•	 Maintain	a	centralized	data	base	with	staff	competency	skills	like	ACLS	(Advanced	 

Cardiac	Life	Support®),	TNCC	(Trauma	Nurse	Core	Course),	ENPC	(Emergency	Nurse	 

Pediatric	Course),	and	PALS.	Identify	who	is	competent	to	care	for	critically	ill	patients.	 

•	 Add	on-call	staff	to	the	disaster	call	list.	 

•	 Maintain	names	of	retired	or	unemployed	staff	in	a	hospital	or	health	system	database. 

•	 Include	Medical	Reserve	Corp	information/lists	in	the	emergency	response	plan. 

•	 Prepare	badges	in	advance	for	credentialed	professional	staff.	 

•	 Credential	volunteers	in	advance.	Community	agencies	typically	manage	volunteers.	 

•	 Set	up	a	system	so	that	the	hospital	can	verify	credentials	(i.e.,	State	ESAR–VHP).	 

•	 Ensure	that	staff	is	assigned	to	tasks	with	which	they	are	most	familiar	and	perform	 

daily;	do	not	change	routine	procedures. 

EVALUATION 

Hospitals/health	systems	should	plan	and	execute	a	drill	with	EMS	at	least	once	a	year.	 

The	drill	should	include	objectives	to	accommodate	00	patients	with	beds,	staffing,	and	 

resources.	 

Critique	the	completed	drill,	write	a	report,	and	share	the	findings	with	participants.	 

Hospital	administrators	should	analyze	the	report	and	make	recommendations	to	the	 

disaster	plan.	Any	deficiencies	should	be	tested	in	the	next	drill.	 

Planning	a	drill	is	expensive.	Exercises	must	be	done	in	conjunction	with	state	or	county/ 

city	emergency	management	agency	staff	with	the	resources	to	conduct	them. 

46	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Conclusion 

Worldwide	bombings	occur	almost	daily	and	are	escalating	in	complexity	and	 

sophistication.	As	noted	throughout	this	report,	we	know	the	U.S.	health	care	system	will	 

be	overwhelmed	by	a	terrorist	bombing.	The	proposed	solutions	outlined	in	this	report,	 

provide	strategies	that	can	be	put	in	place	now—before	a	crisis	strikes—to	address	the	 

system	wide	and	discipline-specific	surge	capacity	challenges	to	providing	an	effective	 

response.	 

Acknowledgments 

CDC’s	Injury	Center	would	like	to	thank	the	many	medical	care	and	administrative	experts	 

who	contributed	to	the	conceptualization	and	content	of	this	report	by	participating	on	 

the	Surge	Capacity	Expert	Panel,	writing	sections	of	this	document,	reviewing	text	and	 

providing	valuable	comments.	 

Bob	Bailey,	MA Kevin	Gerold,	DO,	JD,	MA(Ed) 

Senior	Advisor	to	the	Director Director 

Division	of	Injury	Response Critical	Care	Medicine 

National	Center	for	Injury	Prevention	and	 Department	of	Anesthesiology 

Control Johns	Hopkins	Medicine 

Center	for	Disease	Control	and	Prevention Baltimore,	MD 

Atlanta,	GA 

Joe	Henderson,	MPA 

Palmer	Bessey,	MD,	FACS Associate	Director	 

Professor Office	of	Terrorism	Preparedness	and	 

Department	of	Surgery Emergency	Response 

Cornell	University Centers	for	Disease	Control	and	Prevention 

Associate	Director Atlanta,	GA 

William	Randolph	Hearst	Burn	Center 

New	York,	NY Richard	C.	Hunt,	MD,	FACEP 

Director 

Steve	Cantrill,	MD Division	of	Injury	Response 

Associate	Director National	Center	for	Injury	Prevention	and	 

Denver	Health	Medical	Center Control 

Denver,	CO Center	for	Disease	Control	and	Prevention 

Atlanta,	GA 

Alexander	Duncan,	MD 

Assistant	Professor Mark	Johnson,	MPA 

Emory	University	Hospital Retired	Chief,	Community	Health	and	 

Atlanta,	GA	 Emergency	Medical	Services 

Alaska	Department	of	Health	&	Social	 

Services 

Juneau,	AK 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 47 
Arthur	Kellerman,	MD,	MPH Wayne	Meredith,	MD	 

Professor	and	Chair Professor	and	Chairman,	 

Department	of	Emergency	Medicine Department	of	General	Surgeons 

Emory	University	School	of	Medicine Wake	Forest	University	 

Atlanta,	GA Winston-Salem,	NC	 

Robert	M.	Kellman,	MD Stuart	Mirvis,	MD 

Professor	and	Chair Professor 

State	University	of	New	York University	of	Maryland,	Radiology	&		 

Upstate	Medical	University 	 Shock	Treatment 

Syracuse,	NY	 Baltimore,	MD	 

Jon	Krohmer,	MD,	FACEP LCDR	J.	Morris,	MPH 

Medical	Director US	Public	Health	Service 

Kent	County	EMS National	Bioterrorism	Hospital		 

Grand	Rapids,	MI 	 Preparedness	Program 

Health	Resources	and	Services	 

David	Lehmann,	MD,	PhD Administration 

Professor	of	Medicine	and	Pharmacology Rockville,	MD	 

State	University	of	New	York,	Upstate 

	 Medical	University Brent	Myers,	MD 

Syracuse,	NY	 Wake	County	EMS	Medical	Director 

Raleigh,	NC 

Patricia	Lenaghan,	RN,	MS,	CEN,	FAAN 

Director,	Biocontainment	Unit	&	Magnet	 Robert	Novelline,	MD 

	 Program Professor	of	Radiology 

The	Nebraska	Medical	Center Harvard	Medical	School 

Nebraska	Medical	Center Boston,	MA 

Omaha,	NE	 

Richard	Orr,	MD 

LTC	John	McManus,	MD,	MCR,	FACEP Physician 

Research	Physician,	US	Army	Research Children’s	Hospital	of	Pittsburgh 

	 Program	for	Combat	Casualty	Care	 Pittsburgh,	PA 

US	Army	Institute	of	Surgical	Research	 

Transitional	Program	Director,	San	Antonio	 Thomas	A.	Peters,	MBA,	MHA 

Uniformed	Services	Health	Education Vice	President 

	 Consortium	Medical	Director	Fort	Sam University	Health	System 

	 Houston	and	Camp	Bullis	Fire	Adjunct	 San	Antonio,	TX	 

Assistant	Professor	Emergency	Medicine	 

OHSU	and	USUHS Sally	Phillips,	RN,	PhD 

Director,	Bioterrorism	Preparedness 

Norman	McSwain,	MD,	FACS 	 Research	 

Trauma	Director,	Charity	Hospital Agency	for	Healthcare	Research	and	Quality 

Tulane	University	School	of	Medicine Rockville,	MD 

New	Orleans,	LA 

48	 In a Moment’s Notice: Surge Capacity for Terrorist Bombings 
Edward	Racht,	MD,	 Richard	Serino 

Medical	Director,	Clinical	Associate	 Chief 

Professor	of	Emergency	Medicine	 Boston	Emergency	Medical	Services 

City	of	Austin/Travis	County	Emergency	 Boston,	MA 

Medical	Services	System 

University	of	Texas-Southwest		 Jason	Stein,	MD 

	 Medical	Center Director,	Quality	Improvement 

Austin,	TX Emory	Hospital	Medicine 

Emory	University	Hospital 

Scott	M.	Sasser,	MD Atlanta,	GA	 

Department	of	Emergency	Medicine 

Emory	University	School	of	Medicine Gam	Wijetunge 

Division	of	Injury	Response Highway	Safety	Specialist 

National	Center	for	Injury	Prevention		 National	Highway	Traffic	Safety 

	 and	Control 	 Administration 

Centers	for	Disease	Control	and	Prevention Washington,	DC	 

Atlanta,	GA	 

Janet	Williams,	MD,	FACEP 

Richard	Sattin,	MD Director 

Associate	Director	for	Science,	Acting	Team Center	for	Disaster	Medicine	and		 

	 Lead	(Research) 	 Emergency	Preparedness	 

Centers	for	Disease	Control	and	Prevention University	of	Rochester 

Atlanta,	GA	 Pittsford,	NY	 

Paul	Schmidt,	MD 	 

Professor 

Department	of	Pathology	and	Cell	Biology 

Tampa,	FL 

In a Moment’s Notice: Surge Capacity for Terrorist Bombings	 49 
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CS109858 

CS123209