In 1986, I served as the hospital commander at the US Army Hospital (USAH), Berlin, West Germany. On Saturday, April 4, I retired to bed at about 11 pm. Just after midnight, I received a call from the US Military Authority Berlin. Intelligence indicated that a facility frequented by US military personnel had been targeted for a bomb attack that night. At 1:10 am, April 5, a 4- to 5-kg bomb exploded, virtually destroying the La Belle Disco, a club frequented by American soldiers.
At the time of the explosion, an estimated 300 patrons and staff were there. Of those, 261 were reported injured, including 80 US military personnel. Two individuals were killed instantly, including 1 American. Another US service member died some weeks later from recurrent sepsis and kidney failure. Two more Americans were seriously injured, including 1 whose major injury was caused by bone fragment missiles from another individual, but they went on to recover.
The injury distribution among the US casualties was what would be expected from a closed-space blast with shrapnel including burns, orthopedic injuries, lacerations, contusions, and organ injuries. Tympanic membrane perforation and contusion was the most common diagnosis, with an incidence of 42 among the 80 Americans. It was later concluded that the overall mortality was significantly limited due to the density of the patrons at the time; in essence, those closest to the blast shielded those farther away.1
Because of the advanced warning, US Army medical personnel were called in and ready to receive patients, the first of whom began to arrive approximately a half hour after the blast. The great majority of patients arrived by civilian taxi and private car, with only a limited number arriving by ambulance. Seriously injured patients were, by plan, transported to German civilian hospitals by German Red Cross ambulances and Berlin Fire Brigade vehicles. In retrospect, the evacuation of the seriously injured was expeditious and well organized. The main reason for the coordinated action was the writing and practicing of an integrated response plan between USAH Berlin and the German Red Cross.
As called for in this plan, German Red Cross personnel directed movements from the medical command center at the USAH in collaboration with hospital command personnel. There were, of course, many later reports and “lessons learned,” but first and foremost was the importance and necessity of integrated planning and planned exercise. We can never expect to fully prevent terrorist bombings, but we can reduce the attendant mortality and morbidity of their aftermath.
The importance of this strategy was again vividly demonstrated 27 years later at the Boston Marathon, when 2 terrorist bombs were detonated on April 15, just before 3 pm. The destruction and attendant coverage have been widely publicized and need not be repeated. What does need reporting is the overall response of the medical and public health systems, a description of the resultant injuries and health consequences, an analysis of these parameters, and the publication of what useful information and lessons learned have resulted from this tragedy. To provide these answers in a timely manner, this issue of the journal was purposefully delayed to allow for the preparation and submission of relevant content. We have been gratified by the rapid turnaround of these materials from the authors publishing about the bombings.
A recent article that appeared in the New Yorker online magazine on April 17 should not be overlooked.2 It was a testament to the timely, integrated response of the many medical responders who were involved from immediate onsite care through transportation and the gamut of hospital services from the emergency department through surgical intervention and intensive care units. Most importantly, the article highlighted the critical importance of planning, education and training, and drills and exercises for the multiple components of a system that must be as integrated as it was in Boston if the mortality and morbidity inflicted from terrorist bombs are to be minimized.
It was interesting that one response group that did not receive much coverage in the immediate response was that the Medical Reserve Corps (MRC) and Community Emergency Response Team (CERT) volunteers. The only documentation I could find on these volunteers was on the Homeland Preparedness Project website, which published a letter from the national MRC director following the event and an article in Boston.com.3, 4 Approximately 200 MRC volunteers provided medical and other support to the race. They were thus prepositioned and ready to provide immediate help at the bombing site. These volunteers could be easily identified, as they wore the white-and-blue striped jackets of all of the medical volunteers and the MRC baseball caps (as evident in the cover photo). The MRC volunteers went on to provide many services, including psychological support to those in need.
Given the fact that there are more than 200 000 MRC volunteers in more than 900 units nationwide, this is a prepositioned medical response asset that needs to be better used and integrated into our preparedness and response system. This goal, which will be a primary one of this journal and the Society for Disaster Medicine and Public Health, will be launched during the next several months. Together—truly together—we can create an effective disaster health system and achieve a higher level of national and global health security.