On March 22, 2016, Belgium was hit by a terrorist attack involving suicide bombings at the Brussels National Airport and Maalbeek metro station. At the airport, 17 people were killed and approximately 130 injured in the first bombing, while 14 died and around 210 were injured in the metro station bombing. Both the Brussels Capital and Louvain emergency medical services dispatched ambulances and mobile medical units to treat the injured according to disaster plans. Communication problems and overwhelmed networks hampered coordination between emergency responders. Identification of victims was also challenging due to language barriers and some walking wounded self-transporting to hospitals. Security issues like an abandoned third bomb further complicated the response efforts.

1. BRUSSELS BOMBINGS 22 MARCH 2016
Mortelmans LJM1; Anseeuw K1; Donahue DA2
1: Dept Emergency Medicine ZNA Camp Stuivenberg, Antwerp, Belgium
2: Healthcare Administration, The Graduate School, University of Maryland University College
FACTS:
Tuesday, 22nd of March 2016, at 07:58, Belgium was hit by a
terrorist attack. A suicide bomber blew himself up in the Brussels
National Airport terminal, shortly followed by a second one closer
to the airport exit. At 09:11, a second attack was carried out at
Maalbeek Subway station in the European quarter of Brussels. A
suicide bomber blew himself up in the middle car of a three-
carriage subway train just leaving the station.
FIGURES:
At the airport site, seventeen victims died on scene, including two
suicide bombers, and there were approximately 130 injured.
Fourteen persons (including one suicide bomber) died at the
Maalbeek site and approximately 210 were injured. Injuries
consisted mainly of burns, blast lesions, and multiple shrapnel
injuries. All casualties were transported to 50 different hospitals and
a total of 150 patients were admitted.
ACTIONS:
Both impacted EMS dispatch centers (Brussels Capital and Louvain)
activated their disaster plan, sending ambulances and mobile medical
units to both sites. Reinforcement of both ambulances and mobile
medical units was sent from adjacent provinces as had been planned
after the Paris attacks. At both sites, principles from tactical combat
casualty care (including triage and prehospital damage control
resuscitation) were applied. Several serious limb injuries were
initially stabilized with the combat application tourniquets of the
Special Forces guarding the airport. The Military Hospital Queen
Astrid, located near both sites, acted as an Advanced Medical Post.
Patients were initially stabilized and secondarily transferred to other
hospitals afterward due to the limited admission capacity of the
military hospital. Also, the Red Cross deployed its disaster response
with non-EMS ambulances, extra material, and the psychosocial
intervention team (also assisting the disaster victim identification
team of the police and seeking shelter for more than a thousand
stranded tourists).
PROBLEMS ENCOUNTERED:
The main issue, as in most incidents, was communication. Shortly
after the attacks, the mobile telephone network as well as the digital
terrestrial trunk radio network used by all emergency services were
saturated, impeding contacts on the scene, with the EMS centrals
(also saturated by numerous incoming calls), and with the hospitals.
Internet-based resources such as WhatsApp and Facetime were the
ultimate backup. Interdisciplinary staff communication and
coordination on scene was as virtually absent.
Registration and identification was another problem. Many patients
arrived in the hospital without a Medical Emergency Triage Tag
(METTAG), although this process is commonly used in national
disaster plans. Language barriers and unconscious or ventilated
patients without ID documents complicated the identification
process. Some walking wounded ended up in hospitals near their
home place, bypassing the EMS system. This is also the reason the
given numbers of injured are approximated.
Last but not least, there were security problems. A third, abandoned,
bomb was found at the airport site, impeding aid until controlled
demolition. Several fake alarms compromised local aid, even leading
to preventive evacuation of the advanced medical post.
Fig. 1: Destruction in the departure hall
Fig. 2: Second explosion site, the departure hall
Fig. 3: Exploded subway train
Fig. 4: Evacuation of passengers in tunnel
Fig. 5: Airport bombers, shortly before the attacks