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Response to
By Dr. Hiwa omer ahmed
Assistant Professor in General
Emergency Medicine Response to

Jim Holliman, MD FACEP

Pennsylvania State University
Hershey, Pennsylvania, USA
Unfortunately, in recent years there
has been an increase in major
terrorist incidents. It is important
for all emergency health care
personnel to be familiar with
appropriate medical response to
terrorist incidents, and emergency
health care facilities should have
well-rehearsed plans in place to
deal with terrorist incidents.
U.S. Federal Bureau of
Investigation (FBI) defines the
terrorism as:
“The use of violence or the threat
of violence in furtherance of a
political or social agenda.
Terrorism represents a purposeful
attack on basically innocent or
non-involved victims”.
Types of terrorist events include the
• Use of conventional bombs or
explosives (the most common).
• Multiple gunshots or sniping.
• Hostage taking.
• Use of chemical weapons.
• Use of biological weapons.
• Use of nuclear weapons or radioactive
materials (radiologic weapons).
• “Cyber terrorism”.
The U.S. State Department has
reported that in each of the last
several years there have been
over 300 major international
terrorist incidents annually.
The risk also of use of chemical
and/or biological weapons by
terrorists has been demonstrated
recently several times.
With the collapse of the Soviet Union in the
early 1990’s and the subsequent severe
economic problems there, it has been
feared that many of the scientists and
workers involved with this extensive
bioweapons program are now employed by
terrorist organizations. For example, the
Aum Shinrikyo cult purchased the
manufacturing plans for the nerve gas
Sarin from one of the Russians previously
involved in chemical weapons
The relatively low cost of
chemical and biological
weapons with their potential to
inflict huge numbers of
casualties in unprotected
civilian populations makes
these weapons attractive to
terrorist organizations.
Another problem that has surfaced in
the last decade is the occurrence of hoax
events of biologic weapons use. In 1998
alone there were 37 such hoax events
involving the threatened release of anthrax.
Over 5000 pupil were threatened by these
events, and over 1200 ended up been
empirically treated. It has recently been
recognized that most EMS personnel and
most emergency departments are not fully
properly trained to deal with major terrorist
events involving biological or chemical
Field and scene
Two increasingly dangerous
trends in terrorist events have
emerged in the last several years.
These are the use of combined
different types of weapons and the
deliberate targeting of responding
EMS personnel.
The first responding EMS unit
should always follow the “two
in, two out” rule. The second
major principle for responding
EMS personnel to follow is
called LACES. This involves:
• Lookout.
• Awareness.
• Communications and Backup
• Escapes.
• Safety zones.
Other rules for the responding
EMS personnel to follow include
relocating at least 160 meters
away from any suspicious
appearing package and at least
300 meters away from any
suspicious vehicle.
One of the next important response
principles for EMS personnel is to
isolate the scene from further access
by the public. Control of responding
public media personnel will also be
necessary. If live filming of an event
is occurring and the terrorists are
watching the live reports, they may
obtain information enabling then to
commit further harm at the scene.
Next, if possible chemical,
radiologic, or biologic contamination
is identified on scene
decontamination of victims should
be established. Again here, an
important principle is for the EMS
and other scene personnel to
maintain proper self protection using
appropriate suits and precautions,
so that they do not also become
Health care system preparedness
for terrorist events:
There has been recent extensive
planning of the U.S. Federal government
level for improving and coordinating
response to major terrorist events i.e.:
designation of the lead agency for medical
response. One of its major responsibilities
has been to develop stockpiles of
vaccines for immunization against
biological or chemical agents.
One aspect of terrorism which
has not been discussed much in the
medical literature is cyber-terrorism. This
constitutes the use of unauthorized entrée
into computerized systems to cause
•Render useless
•Promulgate incorrect or inaccurate data
The “cyber vulnerability” of our
medical facility computer systems
to terrorism is relatively new
threat for which health care
systems should plan.
Lesson Learned from
the World Trade
Center Disaster
Lesson Learned from the World Trade
Center Disaster

Jim Holliman, MD FACEP

Pennsylvania State University
Hershey,Pennsylvania, USA
The objectives of these manuscript
are to review the EMS and
emergency medicine responses to
the September 11, 2001 World Trade
Center disaster and to identify what
went wrong and what went right with
these responses.
Some general lessons learned from this
disaster are that:
- The U.S. public is not safe from
acts by major outside terrorist
- There is broad international
sympathy and support for the victims
of this type of disaster.
- Domestic volunteer help and
cooperation can be huge in response
to this kind of an event.
The sequence of events which occur in the
WTC disaster where as follows:
08:42 AM – American Airlines Flight 11 hit the
North Tower
09:00 AM – United Airlines Flight 175 hit the
South Tower
10:05 AM – The South Tower collapsed
10:28 AM – The North Tower collapsed
17:25 PM – WTC Building (47 stories high)
23:45 PM – The last injured non-rescuer victim
of the disaster presented at nearby St.
Vincent’s Hospital
Lesson 1:
personnel are brave,
but therefore are at
risk for death or
Lesson 2:
The need for backup
and command
Lesson 3:
There is a need for
better individual
Lesson 4:
systems fail early
in a disaster.
Lesson 5:
communication may
still function despite
phone system
Lesson 6:
Better monitoring and
recording of specific
personnel responding
into a danger zone is
Lesson 7:
Special rescue
arrangements are
needed for the top
floor of very high
Lesson 8:
After a large building
collapse, most
secondary injuries
are due to dust and
Lesson 9:
Hospital E.D.
preplanning and
conducting disaster
drills pays off.
Lesson 10:
E.D. caseload from
disaster has an
initial surge, then
tapers off.
Lesson 11:
Better communication
and use of incident
command system is
needed for field
medical units.
Lesson 12:
Medical personnel
will readily volunteer
in a disaster.
Lesson 13:
Volunteers should
wait to be called in
by local authorities.
Lesson 14:
Disaster declaration
needs to account for
volunteers medical
Lesson 15:
Even well designed
modern buildings
cannot resist fire
from jet fuel-laden
large aircraft.
Lesson 16:
Post incident stress
debriefing is
• Note: These are abstracts of the lectures
reviewed by Hiwa Omer Ahmed,
Assistant Professor in general surgery.
For presentation in Sundays clinical
presentations of American-Iraqi
Association of Surgeons in Suleymani
Teaching Hospital on 24th August 2003