DISASTER MEDICINE/ORIGINAL CONTRIBUTION
Emergency Department Impact of the
From the Section of Emergency
Medicine, Department of Surgery,*
University of Oklahoma, Oklahoma
City, OK; Department of Emergency
Medicine, Baptist Medical Center,
Menorah Medical Center, University
of Missouri–Kansas City School of
Medicine,‡ Kansas City, MO; College
of Medicine, and the National Center
for Environmental Health, Centers
for Disease Control and Prevention,§
Atlanta, GA.
Received for publication
December 17, 1998. Revision
received April 29, 1999.
Accepted for publication
May 4, 1999.
Address for reprints: David E
Hogan, DO, Disaster Emergency
Medical Services, Department of
Emergency Medicine, University of
Oklahoma Health Sciences Center,
PO Box 26307 Room EB 319,
Oklahoma City, OK 73126-0397.
Copyright © 1999 by the American
College of Emergency Physicians.
0196-0644/99/$8.00 + 0
47/1/99895
1 6 0
Oklahoma City Terrorist Bombing
David E Hogan, DO* Study objective: To collect descriptive epidemiologic injury
Joseph F Waeckerle, MD‡
data on patients who suffered acute injuries after the April 19,
Daniel J Dire, MD*
1995, Oklahoma City bombing and to describe the effect on
Scott R Lillibridge, MD§
metropolitan emergency departments.
Methods: A retrospective review of the medical records of
victims seen for injury or illness related to the bombing at 1
of the 13 study hospitals from 9:02 AM to midnight April 19,
1995. Rescue workers and nontransported fatalities were
excluded.
Results: Three hundred eighty-eight patients met inclusion cri-
teria; 72 (18.6%) were admitted, 312 (80.4%) were treated and
released, 3 (.7%) were dead on arrival, and 1 had undocu-
mented disposition. Patients requiring admission took longer to
arrive to EDs than patients treated and released (P=.0065). The
EDs geographically closest to the blast site (1.5 radial miles)
received significantly more victims than more distant EDs
(P<.0001). Among the 90 patients with documented prehospital
care, the most common interventions were spinal immobiliza-
tion (964/90, 71.1%), field dressings (40/90, 44.4%), and intra-
venous fluids (32/90, 35.5%). No patients requiring prehospital
CPR survived. Patients transported by EMS had higher admis-
sion rates than those arriving by any other mode (P<.0001). The
most common procedures performed were wound care and
intravenous infusion lines. The most common diagnoses were
lacerations/contusion, fractures, strains, head injury, abrasions,
and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and
analgesics were the most common pharmaceutical agents
used. Plain radiology, computed tomographic radiology, and the
hospital laboratory were the most significantly utilized ancillary
services.
Conclusion: EMS providers tended to transport the more
seriously injured patients, who tended to arrive in a second
wave at EDs. The closest hospitals received the greatest num-
ber of victims by all transport methods. The effects on pharma-
ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
EMERGENCY IMPACT OF THE OKLAHOMA CITY BOMBING
Hogan et al
ceutical use and ancillary service were consistent with the care
of penetrating and blunt trauma. The diagnoses in the ED sup-
port previous reports of the complex but often nonlethal nature
of bombing injuries.
[Hogan DE, Waeckerle JF, Dire DJ, Lillibridge SR: Emergency
department impact of the Oklahoma City terrorist bombing. Ann
Emerg Med August 1999;34:160-167.]
INTRODUCTION
At 9:02 AM on April 19, 1995, a bomb consisting of
more than 4,000 pounds of ammonium nitrate was
detonated in front of the Murrah Federal Building in
downtown Oklahoma City. 1 As a result of this blast,
there were 168 deaths and more than 700 known
injuries. 2 A metropolitan prehospital disaster response
and multiple hospital disaster plans were initiated. In
addition to the community response, a federal disaster
effort under the Federal Emergency Management
Agency ensued involving urban search and rescue
teams and other agencies.
Emergency health care providers are responsible for
the initial medical response to mass casualty incidents
caused by all forms of disaster, including terrorism. 3,4
The Oklahoma City bombing represents the largest ter-
rorist incident within the United States to date. The rate
of terrorist bombing incidents may be increasing with
federal, postal, and military facilities serving as com-
mon targets. 5 Although much has been published on
international terrorist bombing incidents, the United
States has been relatively free of this type of activity.
To ensure proper planning and to mitigate injury,
emergency physicians should be familiar with the med-
ical impact of such bombings. The purpose of this study
was to collect descriptive information on the acute pre-
hospital and ED medical impact from the bombing and
to compare this information with reports from similar
incidents.
M AT E R I A L S A N D M E T H O D S
Two days after the bombing, the investigators met with
all metropolitan area hospital administrators, the
Oklahoma State Health Department, the University of
Oklahoma Section of Emergency Medicine, and other
related agencies. A multidisciplinary group, the Disaster
Health Studies Group, was founded to investigate the
emergency medical management of bombing victims.6
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE
Bombing victims were defined as persons requiring
acute care services for injuries or illnesses interpreted
by treating physicians as directly related to the bomb-
ing, who were seen in 1 of the 13 metropolitan area EDs
studied between 9:02 AM and midnight, April 19, 1995
(14 hours and 58 minutes). Patients were excluded if
they were injured during rescue activities or were out-
side the time constraints of the study. In addition, 164
of 167 victims with fatal injuries were not immediately
transported from the scene, and 1 voluntary rescue
worker suffered a fatal head injury from falling debris.
These 165 fatalities are not included in the study analysis.
We developed a data collection instrument using
methods for descriptive medical record analysis from
epidemiologic studies of previous disasters.7,8 Using
this instrument, emergency physicians abstractors
sought data on the prehospital, triage, and ED phases of
the medical response to the bombing. Each abstractor
underwent 2 hours of training before data acquisition.
The State Commissioner of Health for Oklahoma
declared bombing-related injuries a reportable condi-
tion. The Office of the Governor of Oklahoma requested
that all researchers investigating the bombing coordi-
nate their efforts through the institutional review board
of the University of Oklahoma Health Sciences Center,
which approved this study.
All 13 Oklahoma City metropolitan hospitals were
requested in writing to provide medical records for
patients they identified as having been seen in their
institutions as a result of the bombing. Each institution’s
ED logs, hospital disaster victim roster, and disaster tags
(if available) were reviewed, and also checked against
lists published in the media of victims admitted to each
hospital.
Data were transcribed from the medical records to a
standardized questionnaire and entered into a custom
database using Microsoft Access (version 2.00,
Microsoft Corporation, Redmond, WA). Descriptive
analysis was performed using the statistical package in
Microsoft Excel (version 5.0c, Microsoft Corporation)
and True Epistat (version 4.01, BioMedware, Ann
Arbor, MI). Continuous data are reported as means±SD
or medians and interquartile ranges. Comparison of ED
arrival times for admitted and nonadmitted patients
were analyzed with the Mann-Whitney U test. The pro-
portion of patients treated at hospitals geographically
closer to the bombing site and various factors associated
with greater risk of admission were compared using the
χ2 test. Two-tailed P values were calculated and α was
set at .05.
1 6 1
EMERGENCY IMPACT OF THE OKLAHOMA CITY BOMBING
Hogan et al

R E S U LT S
than those not transported by EMS (58/90 [64.4%] versus
All 13 hospitals provided medical records for this study. 17/289 [5.8%]; P<.0001). Arrival modes to the hospital
There were 388 patients who met criteria for inclusion: were documented in 267 (68.8%) of the 388 patients
340 adults and 48 pediatric patients (age ≤20 years, the (Table 2).
local EMS cutoff for transport to the children’s hospital). Of the 363 patients with documented times, the first
Mean adult age was 35.8±16.3 years, median 36 years, patients arrived in EDs within 15 minutes of the bomb-
range 3 months to 85 years. There were 182 (46.9%) males, ing, with the combined peak arrival rate (220 patients per
205 (52.8%) females, and 1 (.25%) undocumented gender. hour) occurring between 60 and 90 minutes. By 3 hours
Ninety-two (23.7%) of the 388 patients were documented after the bombing, 227 (62.5%) of the 363 patients had
as having been inside the Murrah Federal Building at the been triaged at hospitals. A greater number of patients
time of injury. went to hospitals within 1.5 miles of the blast site
Seventy-two (18.6%) of the 388 patients were admitted (231/363 [63.6%] versus 132/363 [36.4%], P<.0001)
to the hospital, 312 (80.4%) were released after treatment than outside 1.5 miles.
the same day, 3 (0.7%) were dead on arrival to the ED, and Of the 265 patients triaged to EDs, 194 (73.2%) had
1 (.25%) had no information regarding disposition. documented duration of ED stay. The median duration
On arrival to the hospital, 265 (68.2%) of the 388 were was 55 minutes (mean 76±70 minutes; interquartile
triaged to the ED for treatment, 114 (29.3%) of the 388 range 35 to 85 minutes; range 2 to 563 minutes).
were triaged to minor treatment areas (MTAs) within hos- The most common procedures performed in the ED
pitals, and 9 (2.3%) of the 388 had no documentation of were wound care (laceration repair, debridement, foreign
treatment location. The only location of treatment in 7 of body removal) and intravenous lines (Table 3). The most
the 13 hospitals studied were the EDs. The admission rate common medication administered in the ED was tetanus
for patients triaged to EDs was 66 (24.9%) of 265 and to
MTAs 9 (7.9%) of 114 patients (P<.0001].
The interval times for patient travel from the blast site
to an ED were obtained in 361 (93%) of the 388 patients, Table 1.
Prehospital treatment.
and the median time from blast to ED arrival was 91 min-
utes. Patients requiring admission to the hospital took
significantly longer to arrive to EDs (P=.0065) than Treatment No. (%)
patients treated and released from the ED.
Spinal immobilization 64 (71.1)
Extrication from the bombing site (defined as patients Field dressing 40 (44.4)
being unable to remove themselves from debris or the Intravenous fluids 32 (35.5)
blast site independently) was identified in 38 (9.7%) of Endotracheal intubation 3 (3.3)
ACLS resuscitation medications 3 (3.2)
the 388 patients. The time required from blast to extrica- Tourniquet 2 (2.2)
tion was documented in 30 (78.9%) of these 38 patients; Field amputation 1 (1.1)
the median time was 20 minutes (range 5 to 800 minutes; Chest decompression 0
interquartile range, 10 to 45 minutes). Thirty (78.9%) of ACLS, Advanced Cardiac Life Support.
Documented prehospital care cases, n=90.
the 38 patients requiring extrication were transported by
EMS and 2 (5.2%) were transported by privately operated
vehicle. All 32 patients requiring extrication and triaged
to EDs for care were admitted. The remaining 6 patients Table 2.
requiring extrication were transported by privately oper- Known hospital arrival modes.
ated vehicle and triaged to an MTA for care; none were
admitted.
Transportation Mode No. (%) (n=272)
Ninety (23.1%) of the 388 cases had documentation of
prehospital EMS treatment and transport (Table 1). Fifty- Privately owned vehicle 152 (55.8)
five (64.4%) of the 90 victims with EMS treatment were EMS 90 (33.0)
admitted: 25 (27.7%) of the 90 to operating rooms, 8 Carried or walked 27 (9.9)
Other modes 3 (1.1)
(8.8%) of the 90 to ICU beds, 22 (24.4%) of the 90 to
ward beds, and 3 (3.3%) of the 90 were dead on arrival. Unknown modes=116.
Patients transported by EMS had higher admission rates

1 6 2 ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999

EMERGENCY IMPACT OF THE OKLAHOMA CITY BOMBING
Hogan et al

toxoid. No tetanus immune globulin was documented as least 1 study accounting for 30 (65.1%) of the 43 total
having been administered. studies ordered.
In the 265 patients seen in the EDs, individual orders Of the 114 patients triaged and evaluated in MTAs, 121
for a diagnostic study (plain radiology, computed tomo- separate specific diagnoses were documented with 4
graphic [CT] radiology, ultrasound, and laboratory) (3.5%) of the 114 patients having 2 or more diagnoses
occurred 294 times. Radiology was the most heavily (Table 4).
affected support service, with 120 (45%) of the patients
requiring at least 1 plain radiographic study and 19 DISCUSSION
(7.1%) requiring CT scans.
There were 545 separate diagnoses among the ED From 1984 to 1994, more than 18,000 bombings result-
patients (Table 4). Five (1.8%) of the 265 patients were ing in 256 deaths, more than 3,215 injuries, and an esti-
discharged with the single nonspecific diagnosis of mated $575 million in damages have been investigated in
“trauma.” In the remaining 260 patients, 107 (41.1%) the United States.5 The 1993 bombing at the World Trade
had 2 or more diagnoses. Center in New York City alone accounted for 6 deaths, 9
Among the 114 patients triaged to MTAs, the most serious injuries, 548 casualties, and more than 1,040 vic-
common procedures performed were also for wound care tims assisted by EMS.9 The Oklahoma City bombing had
(Table 3). Individual orders for diagnostic studies for the many more fatalities and produced more serious injuries.
114 patients triaged to MTAs were detected 43 times.
Plain radiology and CT radiology were again the most
heavily affected support services with patients needing at
Table 4.
ED and MTA discharge diagnosis frequency.
Table 3.
Procedures and treatment in EDs and MTAs.
ED Frequency MTA Frequency
Discharge Diagnosis (n=545) No. (%) (n=121) No. (%)
Procedure ED MTA
Laceration 164 (30.3) 65 (53.7)
Wound care/debridement/foreign body 184 90 Contusion 49 (9) 10 (8.2)
Tetanus immunization 66 8 Fracture (all body regions) 45 (8.3) 4 (3.3)
Intravenous line placement 64 11 Strain 34 (6.2) 8 (6.6)
Pulse oximetry 32 0 Head injury 33 (6.1) 8 (6.6)
Analgesics (intravenous, oral, intramuscular) 29 1 Abrasion 33 (6.1) 3 (2.4)
Fracture care 21 1 Foreign body 24 (4.4) 4 (3.3)
Foley catheter 21 0 Eye injury 15 (2.7) 3 (2.4)
Antibiotics (intravenous, intramuscular, oral) 17 3 Ruptured ocular globe 10 (1.8) 0
Nasogastric tube 15 0 Smoke inhalation 9 (1.6) 1 (.8)
Eye care 10 2 Pregnancy trauma evaluation 9 (1.6) 0
Central venous line 8 1 Puncture wound 8 (1.4) 2 (1.6)
Endotracheal intubation 7 0 Ruptured tympanic membrane 8 (1.4) 0
Antihypertensive 6 0 Auditory trauma 7 (1.2) 0
Tube thoracostomy 3 0 Hemorrhagic shock 7 (1.2) 1 (.8)
CPR 3 0 Tendon laceration 6 (1.1) 1 (.8)
Blood transfusion 3 0 Pulmonary contusion 6 (1.1) 1 (.8)
Antiemetic 3 0 Vascular injury 5 (.9) 3 (2.4)
Conscious sedation 2 2 Nerve laceration 4 (.7) 0
Arterial line 1 1 Penetrating neck wound 4 (.7) 0
Atropine (intravenous) 1 0 Burn 3 (.5) 1 (.8)
Epinephrine (intravenous) 1 0 Traumatic cardiac arrest 3 (.5) 0
Defibrillation 1 0 Pneumothorax 3 (.5) 0
Surgical airway 1 0 Crush injury 2 (.3) 0
Diagnostic peritoneal lavage 1 0 Renal contusion 2 (.3) 0
Needle thoracostomy 1 0 Cardiac contusion 1 (.1) 1 (.8)
Bronchoscopy 1 0 Splenic injury 1 (.1) 0
Tendon repair 0 1 Esophageal injury 1 (.1) 0
Insulin 1 0 Urethral injury 1 (.1) 0
Sedative hypnotic 1 Nontraumatic diagnosis 43 (7.9) 5 (4.1)

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EMERGENCY IMPACT OF THE OKLAHOMA CITY BOMBING
Hogan et al
The age distribution of the victims of that bombing
indicates that this site was not a true cross section of the
community population. The population characteristics of
a bombing will vary with each site, and the population of
high-risk sites such as government buildings and postal
facilities should be taken into account during community
disaster planning.
The admission rate of 18.6% seems low when com-
pared with other reports of terrorist bombings with build-
ing collapse. In a train station in Bologna, Italy, in 1980
and in the Beirut barracks in 1983, admission rates of
83.0% and 76.7%, respectively, were reported.10,11
However, the total number of patients seen in the Bologna
bombing was not clearly defined. The Beirut bombing
incident was isolated to a single structure with a confined
population. Detonation actually occurred inside on the
ground floor and not outside as in Oklahoma City,
thereby limiting the collateral damage. In fact, the injury
and mortality rates are similar for victims who were inside
the target buildings in both incidents.2,11,12 This high-
lights the importance of factors such as the nature and
location of the bomb, the structure impacted, and victim
location.
Triage is dynamic, making documentation of the triage
process and research into the nature of triage difficult.
Only the results of triage decisions may be assessed with
any reliability.13 Scene triage and retriage at the hospital
are particularly important in the proper management of
bombing victims.12-16 Unfortunately, documentation of
the process behind the triage decisions made in
Oklahoma City was practically nonexistent, similar to
other mass casualty disasters.17 Methods to improve doc-
umentation of triage should be planned by use of triage
flow sheets or checklists and implemented at both the
prehospital and ED level.
On arrival at the hospital, the majority of patients were
triaged to the ED for treatment. Seven of the 13 institu-
tions did not triage patients to any area of the hospital
other than the ED. These 7 institutions were farther from
the blast site, received patients at a slower rate, and had
fewer admissions. The admission rate for the patients
triaged to the ED was significantly higher than the rate for
patients triaged to MTAs, suggesting that the triage per-
formed generally identified the more critical patients.
As in previous disasters, extrication of trapped victims
from the site was accomplished by a combination of vic-
tims, laypersons, voluntary medical personnel, and
trained rescuers assisting victims.18 Anecdotal reports
suggest the scene was clear of the majority of trapped vic-
tims within 20 to 30 minutes.19,20 Our study found a
1 6 4
mean time of extrication of 20 minutes. On-scene EMS
providers stated that after 3 hours the rescue phase of the
disaster essentially stopped, with only 3 living victims
removed after that time.19 This is supported by our find-
ing that the majority of patients had presented to EDs
within 3 hours.
A structural collapse with trapped victims prolongs the
recovery phase of a disaster response and creates more
severely injured patients.20,21 The pancake collapse of
the Murrah Federal Building left few spaces in which vic-
tims might survive, so fewer victims were alive to be extri-
cated than in some other bombings.2 However, all
patients requiring extrication who were transported by
EMS or seen in EDs were admitted, suggesting they were
more severely injured.
Transport of victims to hospitals took precedence over
intervention at the scene. This resulted in a rapid clearing
of victims from the disaster site and less exposure of EMS
personnel to further potential terrorist action. Because 5
major hospitals were within 1.5 miles of the blast site,
only spinal immobilization, dressing application, and
some intravenous lines were performed. The 3 patients
receiving prehospital CPR did not survive, consistent
with previous reports.22,23
EMS transport was documented in 90 patients,
although unsubstantiated sources reported numbers in
the range of 100 to 250. 19,24-26 The focus of EMS during
a disaster is on patient triage, care, and transport.
Documentation typically has a lower level of priority.
However, good prehospital documentation is valuable
for clinical insight into injuries, as well as disaster
research and law enforcement investigation. The admis-
sion rates for patients transported by EMS were signifi-
cantly higher than admission rates for all other transport
modes combined. This suggests that although EMS
transported a minority of the cases, these patients
tended to be more seriously injured, further substantiat-
ing the need for careful record keeping.
In this study, more than half of the patients with
known transport mode arrived to EDs by privately
owned vehicles, including several patients in critical
condition. 27-29 This is consistent with prior reports of
terrorist bombings. 22,23,30,31 The high frequency of
non-EMS transport points out the difficulties of control-
ling patient triage and transport from the disaster site.
Another 25 to 30 patients were reported to have been
transported to local EDs by buses, 19 but we could not
confirm this. Victims not transported by EMS typically
converge on the geographically closest hospitals as the
first wave of patients. Early and efficient control of the
ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
EMERGENCY IMPACT OF THE OKLAHOMA CITY BOMBING
Hogan et al
disaster site will allow appropriate triage of more victims
and decrease the adverse impact of the first wave of walk-
ing wounded.
Similar to prior reports, victims in this study began to
arrive to EDs within 5 to 30 minutes of the bomb-
ing, 22,30-33 with patients requiring admission taking
longer to arrive than patients treated and released from
the ED. This supports previous reports that the more
seriously injured patients arrive in a “second wave.” 30
EDs should be prepared to rapidly triage and distribute
victims in the first wave while preparing for potentially
more critical patients in the second wave.
The geographically closest hospitals in Oklahoma
City received the majority of the victims, which is con-
sistent with most disasters. 13 Overloading a facility with
noncritical cases (particularly in the first wave) has been
suggested to increase the morbidity and mortality of the
critical cases at that facility. 14 Disaster planners for EMS
must take steps not to overwhelm the geographically
closest hospitals during a disaster response.
Patient contact time in the ED was approximately an
hour, which is consistent with prior reports of terrorist
bombings. 10,30-32 When the goal is rapid assessment,
stabilization, and movement of patients to definitive
care, full evaluation in the ED is less likely to be com-
pleted. Patients in prior bombing incidents have often
been found to have additional injuries after arrival in the
operating room. 16,31,32 After a bombing, EDs are com-
monly overcrowded with physicians of various special-
ties not skilled in rapid patient assessment. 31,32,34 This
also occurred in Oklahoma City. 27-29,35,36 Efficiency
and accuracy in ED processing of victims may be
enhanced by limiting access to the triage and treatment
areas to specific medical personnel. 22
The majority of victims seen in EDs had non–life-
threatening problems. This is consistent with prior
reports of the noncritical nature of most victims from
terrorist bombings. 10,14,31-33,37-41 Soft tissue injury or
lacerations were the most commonly diagnosed injury,
usually due to glass fragments. Injury control methods
such as the installation of shatter-resistant glass should
be considered for high-risk buildings. 2
Fractures accounted for the second most common
diagnosis. Head injury was the third most frequent diag-
nosis, but the diagnostic criteria used by physicians for
“head injury” were not consistent. Most patients diag-
nosed as having head injuries had minor injuries, with
only 4 requiring emergency neurosurgical intervention.
Eye injury was the fourth most common diagnosis with
10 patients having obvious or suspected globe rupture.
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE
Serious ocular injuries are commonly seen in bombing
incidents. 33,38,42,43
Auditory barotrauma was the fifth most common diag-
nosis. Auditory injury is common in bombing events,
usually consisting of tympanic membrane rupture and
conductive or mixed hearing loss.44-47 The true number
of auditory injuries was underdocumented in this study
(1.2%) due to the focus on more obvious injuries. The
true incidence of auditory injury was 35%.2
Burns were uncommon with only 4 patients admitted
with burn as the primary diagnosis. With bombs as large
as this one, a higher frequency of burns and smoke inhala-
tion may have been anticipated.30,48,49 Many of the
potential victims of burns and smoke inhalation were
instead killed in the building collapse. The blast also
occurred outside, igniting cars in a parking lot but few
buildings. In addition, the Oklahoma City Fire
Department was able to rapidly suppress the existing fires.
The types of procedures done in the ED reflect the gen-
erally nonlethal but complex nature of injuries of the blast
survivors. Wound care accounted for more than half of
the procedures. Anecdotal reports suggest that most of
these wounds were closed in the ED.50 The majority of
reports from other bombings recommend delayed pri-
mary closure for all but the most trivial soft tissue
wounds.16, 31,32,37-39,42 No follow-up studies of wound
outcome were conducted on Oklahoma City bombing
victims.
No previous reports discuss specific pharmaceutical
agents used in the medical response to a bombing. In our
study, the use of tetanus toxoid, analgesics, and antibiotics
is consistent with the treatment of complex soft tissue
wounds and other traumatic conditions.
The diagnostic and support services most heavily
affected by the bombing victims included radiology, CT
radiology, and the hospital laboratory. Other services
were more important in evaluating admitted and postop-
erative patients the following day.51,52
Use of the written medical record in assessment of the
medical impact of a disaster has known limitations.53
Despite attempts to minimize these limitations, omissions
exist in our database. All 13 institutions in our study pro-
vided all available records, but this study documented
only 92 victims seen in the ED who were in the federal
building at the time of the blast. In the physical injury study
directed by Mallonee et al,2 the location of victims in the
federal building at the time of the blast was reliably docu-
mented for 361 cases. This was achieved by using multi-
ple information sources including building occupant and
survivor surveys. The use of multiple information sources
1 6 5
EMERGENCY IMPACT OF THE OKLAHOMA CITY BOMBING
Hogan et al
increases recovery of case information in most studies
and is usually preferable to single-source studies.7
Injury severity scoring has been suggested as an impor-
tant tool in determining the appropriate triage and distri-
bution of injured patients.14 Most of the survivors’
injuries sustained from this incident were minor, and the
majority of patients were treated and released from the ED
the same day, making injury severity scoring less useful. It
was therefore decided that the disposition from the ED
was of greater value than specific trauma scoring methods
as our indicator of injury severity, particularly when plan-
ning for ED and hospital personnel needs.
In summary, the United States has little experience
with terrorist bombings. The lessons learned from bomb-
ings in foreign countries are often difficult to apply to a
domestic response because of differences in the EMS sys-
tem and medical care system. The Oklahoma City bomb-
ing presented substantial differences from the World
Trade Center event in New York City. Careful analysis of
this tragedy provides data to help those involved in crisis
management better prepare for future incidents related to
conventional bombings, as well as nuclear, biologic, and
chemical attacks on civilian populations.
The investigators would like to acknowledge the assistance of the United States
Public Health Service and the section of disaster assessment and epidemiology,
National Center for Environmental Health, Centers for Disease Control and Prevention;
Dr Kevin Yeskey from the Department of Military and Emergency Medicine at the
Uniformed Services University of the Health Sciences; Dr Richard Aghababian from
the Department of Emergency Medicine of the University of Massachusetts; Phillip
McClain from the Division of Violence Prevention, National Center for Injury Control
and Prevention, Centers for Disease Control and Prevention; Sue Mallonee from the
Section of Injury Control, Oklahoma State Health Department; Residents from the
University of Oklahoma Emergency Medicine Program, Frank Lutz, MD, Ken Turner, MD,
Taysha Howell, MD, Mark Brandenburg, MD, David Brown, MD, and Carl Spengler, DO,
for taking their personal time to serve as abstractors; Timothy Soult, DO, and Shelly
Zimmerman, DO, from the Hillcrest Osteopathic Hospital Emergency Medicine
Residency program. Finally, we would like to express appreciation to Jerry R Nida, MD,
Oklahoma Commissioner of Health, for mandating that bombing-related injuries be a
reportable condition.
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