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Medical-School Students Gain Insight Into Harsh Reality of ‘Terror Medicine’

Elective course offered at Rutgers provides overview of challenges, issues doctors might face in aftermath of mass attacks

Dr. Leonard Cole

When the Boston Marathon bombings occurred nearly a year ago, three spectators were killed nearly instantly, but none of the other 264 people with trauma injuries died.

Dr. Leonard Cole credits emergency responders and medical personnel with helping to save lives when they decided to distribute the injured among several local hospitals.

Cole is teaching a two-week elective course titled “Terror Medicine” with a goal of helping fourth-year students at Rutgers New Jersey Medical School in Newark learn how to save lives if they treat victims of acts of terror in the future.

Cole and the future doctors taking his class have been examining the common issues that medical personnel have had to deal with in responding to various types of terrorism. The final class is being held today.

“It’s one of my missions in the past year to say, ‘Can we improve our response in the United States?’ ” to terrorism, Cole said.

Cole, who has doctoral degrees in both dentistry and political science, has been studying biological warfare since the 1980s. His interest in medical issues related to terrorism grew during the “Second Intifada” of the Israeli-Palestinian conflict, which lasted from 2000 to 2005. During that period of conflict, Israeli medical personnel responded to bombings so frequently that they developed a new set of procedures that have provided much of the basis for the course in “terror medicine.”

Cole has been named the director of a program in “terror medicine and security” at the school.

He said he first addressed how to define terrorism, since no two government bodies define it the same way.

In the definition used in the class, terrorism has three common elements: the threat or use of violence; a target of noncombatants; and a motivation to influence the targeted population.

To respond to the range of threats from terrorism, which range from stabbings to the use of biological, chemical or nuclear weapons, Cole said medical doctors should focus on being prepared; knowing how to manage incidents from the initial emergency call to deciding which hospitals to send patients to; understanding common injuries, such as the multiple penetration injuries used in bombs that are packed with dozens of nails; and understanding the psychological and emotional consequences of terrorism.

“It overlaps with emergency and disaster medicine, as well as having distinguishing features,” Cole said of the course.

Cole noted in the immediate aftermath of the 1995 Oklahoma City bombings, the 2004 Madrid bombings and the 2005 London bombings, an overwhelming number of victims were sent to the nearest hospital.

“Madrid received over 300 patients in the first hours – there is no hospital in the world that could adequately absorb over 300 emergency patients, even if most of them didn’t need emergency treatment,” since each patient must be checked for internal injuries, Cole said.

That’s why the lessons applied in the Boston Marathon bombings – no hospital in the city received more than 46 patients -- are so important for states.

“You have to have plans in advance for a serious mass casualty event,” Cole said.

Cole added that one distinguishing element of responding to terrorism is the threat of a second or even a third bomb being detonated after emergency response. He noted that after the deadly first bombing in Boston, a second bomb was detonated several seconds later. If it had been placed nearer to the first bomb or detonated after responders had gathered, “there would have been far more casualties,” Cole said.

Other threats can come from ambulances that are driven by terrorists and the use of cell phones to detonate weapons, Cole said.

“That may not be uppermost in people’s minds here but it is in other countries -- and certainly Israel,” Cole said, adding that hospitals and doctors should train for such scenarios.

Cole’s work in the area began with a book he wrote in 1988, “Clouds of Secrecy,” about the US Army’s germ-warfare testing. When the threat of biological weapons arose before the 1991 Gulf War, news reporters interviewed Cole about the subject and he set out to learn more about it.

“I really became immersed in the actual variety of weapons” that could be used in biological or chemical attacks, Cole said. The idea that these weapons could be used in terrorism grew after a cult used the nerve gas sarin in a 1995 attack on the Tokyo subway. Cole began to study terrorism more closely as the term “bioterrorism” grew in use.

Cole has been teaching political science classes related to terrorism for more than a decade, but has shifted his focus to teaching doctors, drawing interest from medical school administrators.

Cole said now is the time for New Jersey doctors and hospitals to prepare for terrorism.

“I have a strong desire to see the subject raised during periods of calm between events,” Cole said, predicting that there would be a flurry of attention to the issue when the anniversary of the Boston bombings occurs on April 15. “Everyone’s keyed up, then the interest level and intensity dissipates. I think any sane person who looks around can expect more efforts and maybe successes from people who want to do us harm.”

Cole has prepared an article, set to be published in the American Journal of Disaster Medicine, that examines the capabilities of Newark area hospitals to respond to terrorism. He noted that the stretch from the Port of Elizabeth to Newark has been called “the most dangerous two miles in America” by counterterrorism officials, due to the combination of oil storage, shipping and transportation infrastructure.

Student Michael Hayoun, who starts a residency in emergency medicine in Philadelphia later this year, said he was glad the class was offered.

“As an emergency physician, I could be the person supervising at the time when an event strikes,” Hayoun said. “If you don’t have control in the beginning, then an event can spin out of control.”

Hayoun said he would like to participate in public policy planning for terrorism.

“I want to be one of the people that sits at the table and develops the plans,” and the class helped prepare for such an experience, he said. He said he hopes that the class is opened in the future to nursing and public health students.

“Dr. Cole is a world leader on this topic and we are so thankful to have him as part of our university,” said Hayoun, who grew up in Atlantic County.

Fellow student Katherine Wagner of Bloomfield plans to be a neurosurgeon, but feels what she learned in the class will be helpful even if she isn’t the first doctor to respond to an act of terrorism.

“I think it’s really important to have an idea about how my colleagues in the emergency room respond to these situations, because I’m in the next line of physicians after them,” Wagner said. She added that the guest lecturers who co-taught the class with Cole brought valuable experience, including a state official who worked on the Hurricane Sandy response. She said she also gained a better understanding of how other countries like Israel organize their hospitals to respond to terrorism.

“I never would have learned that in my regular coursework,” Wagner said.

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