In cre a sin g Te rro rist A tta cks

-A Challenge to Medical Profession

 Dr . Nidhi Sachdeva * Dr . S . K .
Naik **
 * 2nd Year P.G. student ** Assistant Professor
 Lady Hardinge Medical College & Smt .
S . K . Hospital ,
 New Delhi - 110001 , Ph - 23408158

Terrorist Attack, WTC, USA,
11th September 2001
Terrorist Attack, WTC, USA,
11th September 2001
Terrorist Attack, WTC, USA,
11th September 2001
Serial Bomb Blast, Bengaluru
25th July 2008
Serial Bomb Blast, Ahmedabad
27th July 2008
Serial Bomb Blast, Delhi
13th September 2008
Serial Bomb Blast, Guwahati
30th October 2008
Terror Attack, Mumbai,
26th November 2008
Terror Attack, Mumbai,
26th November 2008
Terror Attack, Mumbai,
26th November 2008
Terror Attack, Mumbai,
26th November 2008
Terror Attack, Mumbai,
26th November 2008
Serial Bomb Blast, Guwahati
1st January 2009
 Introduction


 9/11/2001- Terrorist attack on WTC at
USA
 Serial Blasts at Bengaluru,
Ahmedabad, Gwahati, Delhi within
last six months
 26/11/2008- Recent terrorist attack
at Mumbai
 All these lead to hundreds of deaths,
thousands of causalties, huge loss
 Introduction…


 All these incidence are increasing
day by day.


 Recent attacks also targeted

hospitals, meant for treatment of
injured victims !!
 What happens in such
incidence?
 Wounding of hundreds of people: Needing
immediate medical attention>
Overcrowding of the near by hospitals
with limited resources.

 Non availability of some life saving drugs
like Anti gas gangrene vaccine,
antibiotics, anti tetanus serum etc. in
huge quantity further aggravate the
situations.

 Deaths of large number of people: All
deaths being medico-legal, needing
postmortem examinations to fulfill
various objectives including difficult task
 What happens in such
incidence?
 Psychological trauma to the survived victims
and survivors of the victims: Needing
psychological counseling by experts over a
very longer period of time, the aspect never
practiced in India.

 Physical and mental handicapeness: Needing
rehabilitation of victims, again, very
neglected subject in India.

 Loss of parents: Needing special care of
orphans: State never take the responsibility.

 Loss of huge properties: Monetary
compensation provided by the govt. and
other agencies never satisfactory to suffered
 Medical management of such
situation

 Before the incidence:

 Preplanning and prior preparedness are
essential requisite to tackle such
incidence.
 All the live saving drugs including
antibiotics, pain killers, vaccines should
be readily available in sufficient
quantities within short notice.
 Proper training of medical and
paramedical staffs to handle such
 Medical management of such
situation

 During the incidence:

 Proper co-ordination is required among
govt. agencies, law enforcement
agencies, NGOs, electronic media and
local volunteers.
 Cordoning of the site by the police.
 Extinguishing of fire, removal of injured or
dead from the debris by fire brigades.
 Time is the key for survival of the injured
 Medical management of such
situation

 During the incidence:

 It is not possible to give emergency
treatment at the site of incidence.
 As far as possible, triage should be
started at the site of incidence. One
team of doctors should rush to the
incidence site. They should have
proper knowledge of the capacities ,
available facilities, medical manpower
of the different hospitals situated in
 Medical management of such
situation

 During the incidence:

 Depending upon the available time
periods, injured should be distributed
and prioritized then and there and
transported accordingly for proper
management.
 Large number of well equipped
ambulances with teams of doctors and
supporting staffs are required for
initiation of treatment /early
 Medical management of such
situation
 Treatment of injured:
 Saving the life of patient is most vital
 All the departments dealing with trauma
management should be available at one
place.
 Consent and other medico-legal formalities
may be ignored at that valuable time
period.
 Patient with minor injuries should be
discharged shortly after giving necessary
treatment to avoid overcrowding.
 During treatment, prevention/minimization
 Medical management of such
situation

 After the incidence (treatment):

 Physiotherapy as required.
 Rehabilitation of the survivors.
 Psychological counseling to the survivors
and survivors of the victim.

 Role of Forensic Pathologist in such
Situation
 Fixing of identity is a great challenge for
Forensic Expert, and in almost all cases
autopsy is to be performed as unknown,
unclaimed or mutilated dead bodies.
 Post mortem examination of all the
casualties is must to confirm the cause of
death.
 Fixing Identity and confirmation of event by
Preservation and collection of evidences
for Forensic Examination (DNA Evidence,
Blood Grouping etc.).
 Almost all wounded patients need Casualty
Services. Forensic experts are the best to
access internal injuries from external
examination, when time does not permit
 Role of Forensic Pathologist in such
Situation
 For Post Mortem Examination, Demarcation
of additional staff & space and rapid
disposal of cases is the need of hour in
cases of Mass Casualties.
 For creating Temporary Mortuary, use of
tents, folding tables & adequate quantity
of equipments may be needed.
 Mobile vans may be used for ‘On the Site
Post Mortem Examination’.
 Facility of ‘Cold Storage Cabinets’ or
arrangement of Ice Cubes (blocks) for
keeping the dead bodies till waiting for
relatives or final disposition of dead
 Role of Forensic Pathologist in such
Situation


 Provision for adequate water supply,
arrangement of lights must be ensured
before performing ‘On the Site Post
Mortem Examination’.
 Another important point needs emphasis
here is to ask for adequate security
arrangements to avoid ‘Secondary
Disaster’ due to Law and Order
 ….And in Future


 Till date, all these attacks were limited to
either explosion or firing.

 In the coming days, terrorist attacks using
biological weapon, chemical weapon and
nuclear weapon (“Dirty Bomb”) cannot
be denied.


 In the above scenario, are the medical

profession ready to fulfill the needs of
victims and survivors of the victims?
 In case of Bioterrorism:


 Bioterrorism is the deliberate release of
harm full pathogens into a community.
 The most likely agents to be used are
anthrax, small pox, botulism, plague,
and tularemia.
 Lassa and Ebola viruses can be additional
agents.
 Terrorist can attack at both urban and rural
localities.
 What will happen in
Bioterrorism?

 Diagnosis will be delayed for several days
because:
 No one will suspect about bioterrorism.
 Patients will come to primary doctors
instead of emergency room.
 Non specific signs and symptoms like
coughing, vomiting, fever and rashes of
the diseases will be confused with other
common disorders.
 Primary doctors will hesitate to consult an
infectious disease specialist.
 What will happen in
Bioterrorism?

 Extensive and expensive investigations
may not be advised to reduce burden on
their patient.
 Modern laboratory investigation facilities
may not be there in rural areas.
 Current system of communication among
hospitals, physician and public health
authorities is very poor. Even, doctors
have not high speed communication
systems needed to broadcast or receive
the reports.
 What will happen in
Bioterrorism?

 …..And till diagnosis is made or

bioterrorism is suspected;


 There can be huge morbidity and mortality

in the community.
 There can be spread of wave of panic in
the entire community, nation.
 Even medical and paramedical staffs will
be contaminated by the disease due to
ignorance.
 Management for
Bioterrorism


 Whenever there is doubt, doctors should
not hesitate to consult fellow colleague
and infectious disease specialist.
 Any suspicion about such diseases should
be thoroughly investigated.
 Diagnosis should be made at the earliest.
 Once, diagnosis is made, it should be
communicated to the concerned public
authority immediately.
 Management for
Bioterrorism

 Doctors, paramedical and diagnostic
laboratory staffs should take preventive
measures to avoid contamination.
 Most of these disease are treatable by
administering antibiotic or toxin
antagonist except small pox and other
viral infections where quarantine is the
key.
 Public awareness should be made through
media to calm the panic community.
 In case of Chemical
terrorism

 Several chemicals might be used in a
terrorist attack including nerve gases
(such as Sarin), cyanide, phosgene and
mustard gases.

 Unlike a bioterror attack, a chemical attack
is immediately apparent.


 Individuals present dramatic signs and

symptoms including extreme shortness
 What will happen in Chemical
Terrorism?



 Doctors and paramedical staffs will be first
to see the victims.
 Casualty will be overcrowded with the
patients.
 Reducing morbidity and mortality will
depend essentially upon rapidity of
treatment.
 As time is of essence of treating a
chemical attack, there is no time for
triage, and nearest hospital is best for
 Management for Chemical
Terrorism


 As time is most essence for treatment,
every local hospital must be prepared to
receive large number of casualties.
Practically, there will be no time to send
the victims to larger hospitals or
hospitals with experienced staffs.
 Management of a chemical attack requires
both pharmacological support and
 Management for Chemical
Terrorism


 “Dirty side” and “clean side” must be
maintained at the scene of incidence,
ambulance and hospital including
treatment apparatus. Proper planning
must be done in this regard.
 Administration of proper antidote and life
support in time.
 Doctors should use preventive measures
avoid self contamination.
 In case of Nuclear (“Dirty Bomb”)
Terrorism :


 A “dirty bomb” is a radiological weapon
consisting of a conventional explosive
packaged with radioactive material that
scatters when the bomb explodes.

 What will happen in Nuclear
Terrorism?


 The conventional explosive will cause
most of the injuries and death from a
dirty bomb

 The radiation can also cause severe illness
and death, and, in the long run, a
slightly increased cancer risk.

 Doctors of community hospital may not
bother much about the consequence of
 Management for Nuclear
Terrorism

 Proper planning is essential.
 Beside treating the injured, community
hospitals need to be well equipped and
different staffing pattern to handle
radiation bomb attack.
 All the suspected patients need
decontamination in an orderly fashion,
radiological monitoring and
decorporation ( removal of radioactive
materials that have been incorporated
into the body).
 Doctors and health professional need to
Present shortcomings to deal terrorist
attack


 Govt. gradually withdrawing from its
responsibility to provide proper health
care for all. Health budget is going less
and less.
 With increasing population, there is no
such rise in public heath facilities.
 Private hospitals never show
responsibilities towards the community.
There are several reports that dead body
was not handed over to the poor
Present shortcomings to deal terrorist
attack

 When poor people are striving to earn food
for family, never expect them to buy an
health policy by paying heptic premium.
 Most of the public health centers lack even
basic facilities including equipments and
proper staffs.
 Security arrangements at hospital
premises is very poor. When beating
duty doctors and vandalizing hospital
premises by common public are so
common occurrences, think, what
terrorist cannot do inside the hospital,
 Present shortcomings to deal terrorist
attack


 Till date, there is no proper plan to
manage such man made disasters.
 There is no synchronization among people
responsible for dealing such situations.
 Doctors and paramedical staffs are not
properly trained to deal such situations.
 There is lack of counseling centers for
victims and survivors of the victims.
 Orphans of the victims are not taken care,
even those of dead soldiers.

 Recommendations


 Govt. must take its responsibility to
provide health for all.
 More number of public health centers
should be opened to cater huge poor
Indians.
 All the public health centers should be
provided with modern facilities and
properly staffed.
 Trauma centers should be opened at every
 Recommendations


 Health professionals should be properly
trained to deal victims of terror attacks,
either by introducing it in UG curriculum
or by providing special training.
 All the public hospitals should be provided
adequate security.
 Establishment of Psychological counseling
centers.
 Establishment of more number of Finger
Print Bureau/ DNA laboratories for proper
identification of dead individuals, with
 Recommendations


 Proper rehabilitation of the terror victims.
 Proper care of orphans of the terror
victims.
 Private hospitals may be encouraged to
take social responsibilities. Whenever
possible, govt. should provide them
necessary aid.
Saluting Our Jawans, Dead and
Alive…
THANK Y
OU