Discussion

Firearm events caused a disproportionately high death toll with the highest fatality per event ratio (Table 1), consistent with other studies reflecting the high lethality of such weapons. ^{Reference Tessler, Mooney and Witt9} Firearm-related events are of particular concern in countries such as the US, where high-grade assault weapons are readily accessible by the general population. The Orlando Pulse night club shooting in 2016 (Orlando, Florida USA) saw a single assailant, armed with an assault rifle and a handgun, kill 49 people and injure 52 more. ^{Reference Straub, Cambria and Castor10} While there is much debate around the classification of the Las Vegas (Nevada USA) shooting of 2017, it did not fulfil the Federal Bureau of Investigation’s nor the GTD’s criteria for a terrorism event. ^{Reference Gessen11}

Table 1.

Breakdown of Events by Weapon Type, Fatalities, and Non-Fatal Injuries and Relative Ratios

Abbreviation: E/B/D, explosives/bombs/dynamite.

Firearms events in the US are in stark contrast to countries such as Australia where gun access is highly regulated. Australia has seen fewer than 10 terrorism-related gun deaths in the same study period. ^{Reference Tin, Hart, Hertelendy and Ciottone12} Around the world and in the US, there has been increasing focus in training civilian Emergency Medical Services in managing firearm injuries using training courses such as Tactical Emergency Casualty Care. ^{Reference Callaway13}

Incidents related to E/B/D accounted for disproportionally high numbers of NFI. The 2013 Boston (Massachusetts USA) marathon bombing saw 264 injuries as a result of two homemade bombs detonating, accounting for 40% of all NFI sustained during the study period. Vehicle events accounted for the highest NFI per incident ratio (Table 1).

The substances involved in the four chemical attacks include acid, abrasive industrial cleaning chemicals, pepper spray, and an unknown noxious substance which caused nausea and vomiting in 11 people. ^{Reference Dalrymple14–Reference Press16} Of note, pepper spray is defined as a chemical weapon in the GTD criteria. The sole biological attack incident involved the use of HIV contaminated razor blades. ^{Reference Martinez17}

Despite accounting for over 38% of events, incendiary incidents caused no deaths and minimal injuries. Incendiary events such as arson, however, tend to cause infrastructure damage resulting in financial losses.

2018 saw the emergence of Pro-Trump extremism (as classified by the GTD) associated with a series of letter bomb threats to various critics of President Trump around the US. ^{Reference Wootson and Horton18,Reference Stanglin19} Older, historically white supremacist organizations such as the Ku Klux Klan have been in steady decline over the past decade, but newer hate groups are on the rise and have become much more visible, vocal, brazen, and connected through both online and offline communities. ^{Reference Palmer20,Reference Jones, Doxesee and Harrington21} Counter-terrorism experts anticipate a significant rise in attacks as a result of the current COVID-19 pandemic and the increase in anti-government sentiment, as people socially isolated by lockdown become increasingly susceptible to radicalization by extremist groups. ^{Reference Jones, Doxesee and Harrington21–Reference Kruglanski, Gunaratna, Ellenberg and Speckhard23}

Health care involvement in terrorist events has historically been confined to attending to casualties. The emergence of CTM as a sub-specialty aims to mitigate and prepare for the unique health care consequences of intentional mass casualties. Specialists in CTM also intend to rethink health care vulnerabilities and plan for the response to novel attack methodologies. ^{Reference Court, Edwards, Issa, Voskanyan and Ciottone5,Reference Kruglanski, Gunaratna, Ellenberg and Speckhard23–Reference Tin, Hart and Ciottone25}

While understanding past methodologies provides important educational value, policymakers need to be forward looking in anticipating the new or unexpected. The health care complexities within CTM necessitate round table discussions with disaster medicine, counter terrorism, tactical medicine, and law enforcement specialists and experts to ensure streamlined, coordinated strategies in dealing with future terrorist events. ^{Reference Tin, Hart and Ciottone24}