What it takes to respond to a Brussels-type attack

Thomas Seay, Editor-in-Chief

Nearly all U.S. hospitals have made plans to respond to natural disasters, epidemics, and biological accidents. But far fewer are ready to respond to explosive attacks like last week's bombing in Brussels, according to CDC data.

That matters because bombings have different characteristics than other mass-casualty events—and they demand a different response from hospitals.

Why bombings are different

Every mass-casualty event is a crisis. But some crises erupt more rapidly than others.

An epidemic or a heat wave can unfold almost in slow motion. Even if hundreds of patients eventually reach the ED, they tend to arrive over hours or days, giving hospitals time to marshal resources and plot a response.

Bombs are different. They explode in an instant and can injure dozens or even hundreds of victims, all of whom need immediate care. After the 2004 Madrid train bombings, 272 patients arrived at Gregario Maranon University General Hospital in the two-and-a-half hour period after the first explosion.

Terror in Brussels: How Belgium's hospitals are treating hundreds after suicide bombings

And bombing victims tend to arrive in chaotic fashion: Rather than awaiting guidance from first responders, they often flee to the nearest hospital. As a result, some hospitals find themselves overwhelmed even as others nearby have excess capacity. The "walking wounded" often show up first, and their treatment may overwhelm hospital resources before the most grievously injured patients arrive. In the minutes after the 2013 Boston Marathon bombing, 280 patients sought treatment at 27 different Boston hospitals, all while the hospitals went in and out of lockdown during the citywide hunt for the bombers.

To make matters worse, most U.S. hospitals lack experience in treating explosive injuries. Bombs cause "complex, technically challenging injuries not commonly seen after natural disasters," according to a CDC report, including traumatic brain injuries, blast-wave damage to organs such as the lungs and ears, and penetrating and blunt trauma from shrapnel.

Many hospitals aren't prepared to respond to a bombing

Despite these unique demands presented by a bombing, many hospitals are underprepared to respond.

According to CDC's most recent report on hospital preparedness, published in 2011, only 80 percent of hospitals have made plans to respond to an explosive attack—compared with 98 percent that have planned for a natural disaster. Further, only 32 percent of all hospital mass-casualty drills focus on explosions.

So how can hospitals better prepare themselves?

  • Check out our sample response plans for a variety of crises, including utility failure, radiation exposure, bomb threats, and mass-casualty events.

  • Prepare for the especially severe surge of patients that follows bombings. A CDC report recommends that hospitals prepare by predicting patient inflow, declaring mass-casualty events as soon as possible, and managing potential time and workforce constraints—all practiced with regular drills. CDC also offers "Surge Action Templates" for various disciplines within a hospital, including the ED and the ICU.

  • Improve overall crisis-response practices, which can also help you better handle bombings. CDC data suggest that 31 percent of hospitals have no plans to set up alternate care areas in nonclinical space, 26 percent have no plans to establish temporary facilities when the hospital is unusable, and 14 percent have no plans to cancel elective procedures and admissions.

'Almost every hospital' has some preparation

Fortunately, even hospitals that haven't proactively prepared for bombings may be more ready than they think.

After the 2013 Boston Marathon bombing, Atul Gawande wrote that Brigham and Women's Hospital seemed almost eerily equipped to respond. "Ten years of war have brought details of attacks like these to our towns through news, images, and the soldiers who saw and encountered them," he wrote. "Almost every hospital has a surgeon or nurse or medic with battlefield experience, sometimes several …. Disaster response has become an area of wide interest and study."

Authorities warn that preparation may be tested only too soon. The FBI reported 324 terrorist bombings in the United States between 1980 and 2001. And in light of continued terrorist bombings around the world, a CDC report says "similar events in the United States could be described as a 'predictable surprise.'"

From bombings to hurricanes: How can hospitals prepare for disasters?

Hospitals must be prepared for myriad disasters that can stress health care systems to the breaking point and disrupt delivery of vital health care services.

The Advisory Board has compiled step-by-step procedures for various threats your facility may encounter—though we hope you'll never need to use them.


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