According to a Belgian defense official with knowledge of the response to the terrorist attacks at Brussels Airport in Zaventem, Belgium, on March 22, 2016, quick emergency medical action on the part of Belgian military personnel on duty at the Brussels Airport may have saved a number of lives following the attacks. Unconfirmed preliminary findings of the medical response to the attacks show that combat application tourniquets (CATs) placed on victims at the scene may have helped to save the lives of those suffering from uncontrolled bleeding as a result of the two blasts at the airport.

According to the Belgian defense source, the Belgian army unit happened to be present at the airport on the day of the bombings, essentially performing guard duty at the airport as part of a program to reinforce the local police. The military presence at key locations throughout the country had been in place for more than a year at the time of the attack, likely as a precaution to prevent or deter just such an event.

Reportedly, only minutes before the attack, the military personnel had moved through the area where the bombs detonated, thus barely avoiding becoming casualties themselves. This close proximity to the site allowed the unit to respond immediately and to begin treating victims within seconds of the blasts. While they did not deter the attacks, sadly, the military unit did quickly respond to them, and saved lives.

The military personnel carried individual first aid kits (IFAKs), which were equipped with the tourniquets. The military members placed the tourniquets on the wounded civilians before emergency medical services (EMS) units arrived. Some early press reports claimed that as many as 10 lives were saved in the process, though that number is not yet confirmed.

Of note, the majority of Belgian police reportedly do not carry IFAKs, though some select police units do. Police-issued IFAKs are commonly seen in many parts of the United States, allowing first-arriving police units to perform immediate emergency care, such as the placement of tourniquets and/or cardio pulmonary resuscitation (CPR) efforts, until EMS units arrive.

The Belgian conventional military forces’ IFAKs contain two CATs each, following the example set by Belgian special operations forces (SOF), which have carried IFAKs for at least the last 13 years. American military medical personnel have worked with Belgian defense officials to put just such a program in place.

Additionally, according to the same Belgian defense official, the first medical professionals to arrive on scene after the attacks were emergency medicine physicians and EMTs from the country’s only military medical facility, Queen Astrid Military Hospital. One emergency physician, who was first at the scene of the airport attack and took command of the triage efforts, was part of an ambulance team dispatched from Queen Astrid. The doctor was, in fact, part of a standing contingency plan in place for just such a mass casualty event at the Brussels Airport.

No additional tourniquets were applied over those initially placed by the military unit on duty at the airport. This would seem to indicate that the initial tourniquets placed were effective at stopping the bleeding, though that fact has yet to be confirmed. It is not uncommon for tourniquets to be improperly placed on a victim—especially if they are improvised from belts, clothing, or other items—and for victims to continue to hemorrhage even after the placement of an ineffective tourniquet.

Moreover, a nurse involved in the Belgian SOF surgical support program, who assisted in the operating room at Queen Astrid Military Hospital following the attacks, reportedly drew on his experience working a rotation in the trauma facility at the U.S. hospital in Kandahar, Afghanistan, to treat victims. The nurse’s war zone experience in an American combat medical facility allowed him to effectively deal with combat trauma in the heart of Brussels. This is a sad reality of modern life, though an effective use of the lessons learned in military combat trauma in the civilian setting.

Dozens of casualties from the attacks remain hospitalized in civilian hospitals in Belgium, as well as at Queen Astrid. Internal debriefs have also been conducted with healthcare professionals involved in the events, but no information or conclusions have yet been made public. Such after-action reports are integral to formulating responses to future attacks, and to efforts to refine standard operating procedures for such events.

With regard to tourniquet use in the civilian EMS system in Belgium, it is not abnormal for civilian ambulances to carry only a single tourniquet onboard. This would bely the obvious necessity in mass casualty events of quickly treating multiple casualties for extremity hemorrhage. Those with knowledge of tactical combat casualty care (TCCC), while viewing this as a good starting point, nevertheless point out the need to equip ambulances with up to a dozen tourniquets each for similar casualty events.

Another frustration expressed by some involved in the medical response in Belgium was that no collective medical supplies, or cached medical kits, were available for deployment. Following decades of budget cuts in the Belgian military, such kits are reportedly in short supply, and issued only to military units for deployments abroad. Only Belgian SOF units are issued the more substantive medical kits on a permanent basis.

The above case study underscores the necessity of properly training and equipping civilian emergency medical response units in Western countries, and beyond, for mass casualty events. Whether active-shooter scenarios with multiple casualties, or terrorist attacks that injure scores of civilians, these types of events are all too frequent in many parts of the world, and necessitate the proper training and equipping of all of those units that might respond.

Lives literally depend on it.

Image courtesy of EPA