Lessons learned after a bombing- the pediatric surgeon’s perspective
David Tuggle MD FAAP
Chief, Section of Pediatric Surgery
The Children’s Hospital at OU Medical Center
April 19th, 1995 9:15 am. During my second operation a nurse informed me that
a bomb had gone off downtown and did I know where I was supposed to be?
This was a typical scenario for a disaster drill at our hospital and I said yes and
finished helping the intern through the hernia. She returned about 5 minutes later
and said, “It was real”. I finished the operation, and instructed the OR to hold all
electives until further notice. I found the Chief of Pediatrics and the hospital
administrator and told them to send home all clinic patients and as many
discharges as could be safely done. This was not part of our drill procedure, and
I did not have the authority to give instructions like that, but everyone was
cooperative. My duty is the surgical triage officer in our ED, and my partners go
to the OR.
 In any mass casualty event, chaos is the rule, not the exception
 I recommend a senior surgeon be the surgical triage officer in the pediatric
ED, not a resident
 A surgeon or an ED physician must be empowered to decide what is
elective and what is emergent for surgical and non-surgical issues. There
should not be a democracy during a disaster response
In the ED, patients started arriving 30 minutes after the blast. Three of the first
five went to the operating room within 10 minutes of arrival. The injuries were an
open skull fracture with brain exposed, a femoral artery occlusion, and an open
femur fracture. We had 3 operating rooms left. At that point the adult ED was
filled and the Childrens ED began accepting less injured adult patients.
 Freestanding Children’s hospitals should be included in regional disaster
plans, especially as a surge response. Be prepared to take adult patients
 Disaster drills work
 Pediatric survivors of bombings have a variety of injuries and every
surgical specialty needs to be immediately available to help
By 90 minutes after the blast, patients had stopped coming in. However, the
countywide radio net for disaster management had intermittent reports of injured
children still at the scene and a traffic jam of ambulances. Andy Sullivan, the
Chief of Pediatric Orthopedics, and I decided to commandeer a police sergeant
and his car to go to the scene to facilitate triage. At the scene, all but 3 victims
were out, and the children we had heard about were in fact dead in the rubble
that had been a day care center. We were notified it was a crime scene, so
nothing could be moved without police approval. Volunteer rescuers were
wandering in the bombed out building trying to help. Not one had protective gear
on. Later a nurse got hit in the head from falling debris, got up and kept working
and died an hour later from an epidural hematoma.
 Some mass casualty events are crime scenes. The evidence could be
anywhere

Non-professional rescuers commonly volunteer, and do not have
protective gear or training. They should be excluded from the site, or given
proper protective gear to avoid becoming a casualty
At the scene, Dr. Sullivan and I decided I would stay on site in case emergency
surgery was needed and he would go back to the hospital to gather instruments
and medications. About 30 minutes later, the building was cleared for a
suspected second bomb, but none was found. One victim was found to have a
leg trapped under a concrete pillar that was supporting the remaining building.
Moving the pillar would bring down the rest of the building, so amputation was
the only option. Dr. Sullivan brought a complete instrument kit and anesthetic
medications from the hospital. We performed her amputation, got her out, and
traveled with her in the ambulance back to the hospital. The last patient was
extracted 11 hours after the bomb went off, and she required abdominal
exploration later that night.
 Follow on, or secondary explosions are commonly employed by terrorists,
to catch the first responders
 Most victims were out of the scene within an hour
 Late extractions of entrapped victims are always possible but do not need
the entire disaster response team
 On site surgical intervention is rarely needed, but a surgical team to
respond is a reasonable addition to any disaster plan
Pediatric providers and children’s hospitals must be ready to help respond to
mass casualty events, since events like this do not respect age or gender.
Explosions are still the most likely terrorist threat and disaster planning should be
emphasized with this fact in mind. Disaster drills work, and chaotic events should
be programmed into drills to provide realism.