Discussion

The September 11, 2001 attacks by Al Qaeda remains the deadliest terrorist attack in recent history, with nearly 3,000 FI and over 25,000 NFI. This event marked the beginning of the “War on Terror,” an on-going US-led international military campaign against extremist terrorist groups.

The rise of the Islamic State of Iraq and the Levant (ISIL) was tied to the large spike in terrorist events in the Middle East and North Africa region. Notable ISIL attacks include the Sinjar massacre on August 3, 2014 (953 FI), which marked the beginning of the United Nations recognized genocide of the Yazidis; and the Badush Prison Massacre during which 670 Shia prisoners were executed on June 10, 2014.^{10,Reference Labott and Kopan11} The October 10, 2017 truck bombing in Mogadishu by the terrorist group Al-Shabaab caused 588 FI and remains the deadliest bombing event in Africa.¹²

The interdependencies amongst terrorist organizations are complex, but the regional presence of well-recognized and established terrorist organizations (such as those mentioned above) and their affiliations should alert organizations of the increased risks of potential mass-fatality events, especially in areas with high civilian populations and other soft targets.¹³

Disasters are often described as low-frequency, high-acuity events and are rarely defined by a specific casualty toll. Rather, they are defined as events that overwhelm locally available resources, leading to changes in care provision or the requirement of outside resources. It is worth noting that historically, 91% of terrorism-related events caused ten or fewer FI (86% resulted in ten or fewer NFI), and 3.78% of events caused between 11-100+ FI (5.67% resulted in 11-100+ NFI). Though FI and NFI are not mutually exclusive, these numbers should give health care providers a risk estimate of the potential casualty numbers during terrorist events.

Bombings/explosions contributed to 30.87% of the attack modalities, and the mean and range of FI and NFI per incident and injury prediction varies widely depending on bomb type, method of detonation, and the environment in which it occurs. Classification of such attacks remains complex, with variables such as suicide versus non-suicide bombing, open versus semi-confined or confined spaces, and the presence or absence of building collapses to be taken into account.^{Reference Rozenfeld and Peleg14} Previous studies showed suicide bombings resulted in greater FI and NFI than non-suicide bombings, incidents involving building collapse resulted in higher FI, and closed space attacks (such as train compartments) were more likely to inflict primary blast injuries, whereas open space attacks resulted in greater tertiary blast injuries, particularly amputations.^{Reference Edwards, McMenemy, Stapley, Patel and Clasper15} These findings have implications in blast mitigation strategies such as retro fitting cladding layers and choice of materials to use as structural components of buildings and transport systems.^{Reference Magnus, Khan and Proud16} Further studies reveal the predominant post-explosion injuries amongst survivors involve standard penetrating and blunt trauma, with “blast lung” being the most common FI amongst initial survivors. Importantly, one-half of all initial casualties will seek medical care over a one-hour period, with the most severely injured arriving after the less injured, a potential useful predictor for response resource needs and allocation.^{Reference Sorbie17}

Armed assaults and the use of conventional firearms such as during the 2008 Mumbai attacks, 2011 Norway attacks, and 2016 Orlando nightclub shootings, remain a prominent terrorist attack methodology. Previous research has shown firearm-related injuries have a disproportionally high fatality rate.^{Reference Tessler, Mooney and Witt18} Health care professionals should be up to date with wound ballistics treatment literature and address common misconceptions about the physical effects of penetrating projectiles in tissue, as these may adversely affect the proper management of gunshot injuries. Understanding the difference in ballistic dynamics of high velocity assault rifles versus small arms, the fragmentation patterns of bullets, and the energy transfer characteristics affecting the temporary cavitation and size of permanent wound channels can all enhance clinical and surgical care.^{Reference Stefanopoulos, Mikros, Pinialidis, Oikonomakis, Tsiatis and Janzon19}

While these are well-recognized attack modalities extensively described in medical literature and generally well-understood by emergency personnel, Disaster Medicine specialists have identified educational and capability gaps in the health care sector when dealing with terrorist and mass-casualty events and recognized the need for further research and discussion into novel, non-traditional attack methodologies.^{Reference Tin, Hertelendy, Issa and Ciottone20–Reference Gabbe, Veitch and Curtis22} The emergence of CTM as a Disaster Medicine sub-specialty addresses these unique terrorism-related issues relating to mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks.^{Reference Court, Edwards, Issa, Voskanyan and Ciottone7} Furthermore, health care facilities and medical responders are at risk of being primarily or secondarily targeted, and risk mitigation strategies need to be reviewed and vulnerabilities addressed.^{Reference De Cauwer, Somville, Sabbe and Mortelmans23–Reference Tin, Hart and Ciottone26}

The COVID-19 response highlighted flaws in the traditional All-Hazards Approach framework in disaster risk planning and reduction, and is a major wakeup call in the approach to mass casualties and disasters.^{Reference Peleg, Bodas, Hertelendy and Kirsch27} Terrorism events are unique in their intentionality to kill and cause havoc and are inherently different than natural or other man-made disasters, and as such, require different mitigation and planning tactics. Funding for CTM activities should be considered a priority, as the potential for mass-casualty terrorist events remains a significant threat globally.