LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have increased your knowledge of the medical consequences of acts of terrorism involving the use of weapons of mass destruction and be better prepared to protect and care for yourself and your patients during emergencies relating to such an event. Specific learning objectives to address potential knowledge gaps include:

• Describe terrorism and weapons of mass destruction (WMDs).
• Identify appropriate personal protective equipment (PPE) to be used when treating patients potentially or actually exposed to biological, chemical, and nuclear agents.
• Discuss preparedness and response to biological, chemical, and nuclear agents.
• Review signs and symptoms of exposure to and emergency treatment for patients exposed to biological, chemical, and nuclear agents.
• Describe syndromic surveillance and reporting procedures.
• Explain the Health Alert Network (HAN), including its purpose and the features unique to the Nevada HAN.

OVERVIEW

Over the recent past there has been a markedly increased number of foreign and domestic terrorizing attacks such as mass shootings, bombings, biological attacks, and mass casualty incidents in the United States. Such events have led to an awareness that the U.S. population is at increasing risk for such events in the future and must be prepared to respond quickly and effectively in order to mitigate loss of life and overall impact.

Healthcare professionals in particular must be ready and able to respond to an act of terrorism. This requires education and a basic working knowledge of potential biological, chemical, and nuclear agents that may be deployed as well as the treatment options available to counteract their ill effects.

What Is Terrorism?

The U.S. Department of Defense (DOD) defines terrorism as “the unlawful use of violence or threat of violence, often motivated by religious, political, or other ideological beliefs, to instill fear and coerce individuals, governments, or societies in pursuit of terrorist goals” (DOD, 2021). Aside from the underlying motivation for a terrorist attack, the goals of the attacks themselves are to bring about:

• Mass casualties
• Loss of critical resources
• Disruption of vital services
• Disruption of the economy
  (FEMA. 2019)

Terrorist Acts As Mass Casualty Incidents

Terrorist violence may include the use of explosive, biological, chemical, or nuclear means targeted in order to result in mass or multiple casualties.

A mass casualty incident (MCI or MASCAL) is a situation that “generates more patients than available resources can manage using routine procedures” (DataTech911, 2021). The key factor is the relationship between the number of casualties generated and the capabilities and resources of the receiving facility or facilities. Examples of MCIs include:

• The 2017 shooting at the Route 91 concert in Las Vegas, which left 58 victims dead and 851 injured. It is notable that of the injured, 422 sustained gunshot wounds and the rest were injured while trying to find safety. This event is the deadliest mass shooting in the history of the United States.
• A 2017 shooting attack in a church in Sutherland Springs, Texas, that resulted in 27 people being killed, including 9 children, and 30 being injured
• A shooting at an El Paso Walmart store in 2019 that resulted in 22 dead and 23 injured
• The 2013 terrorist attack near the finish line of the Boston Marathon, in which a pair of homemade bombs were detonated in the crowd watching the race, killing 3 people and injuring more than 260 (Ray, 2022)

A second, less-frequently used term is multiple casualty incident. Although superficially similar to a mass casualty incident, this term carries a different meaning for first responders and first receivers of trauma victims. Unlike a mass casualty incident, a multiple casualty incident:

• Can be managed with heightened response by a single EMS agency or system
• Typically does not overwhelm the hospital capabilities of a jurisdiction and/or region but may exceed the capabilities of one or more hospitals within a locality
• Usually produces a short, intense peak demand for health and medical services, unlike the sustained demand typical of a mass casualty incident
  (EMS1, 2021)

Characteristics of Targets

Targets for terrorism are referred to as “hard” or “soft.” Most of the terrorism today is aimed at soft targets.

• Hard targets are crowded places with high-security measures against terrorism. Examples include:
  • Military or government facilities
  • Key industries
  • Key transportation facilities
  • Banking and finance
• Soft targets are places with high concentration of civilians without a direct association with the government and low or no security measures against terrorism. Examples include:
  • Schools
  • Theaters and cinemas
  • Civilian businesses
  • Churches
  • Hotels, bars, clubs
  • Train and bus stations
  • Shopping malls
  • Venues such as parades, athletic events, or concerts
    (Zimek, 2019)

Nature of an Attack

An act of terrorism may be either covert or overt. The timing and/or sequencing of an attack are also factors that can impact numbers and types of casualties as well as the number and mix of available first responders.

A covert attack takes its advantage from the element of surprise. A covert operation is an activity that is planned and executed to conceal the identify of or permit plausible deniability by the attacker(s). This type of attack is also called clandestine.

An overt attack is openly acknowledged by or is readily attributable to the attackers without concealment.

After an initial attack, terrorists may try to target others by using a secondary attack. Secondary devices may be found in any configuration, not limited to the primary attack method. Tactics that terrorists may use include:

• Use of a secondary device to target first responders and onlookers
• Terrorist impersonation of first responders to gain access to a secure site and create more victims
• Swatting, which refers to making a hoax 9-1-1 call to draw a response from first responders or police
• Diversion to draw first responders away from the intended primary target of attack and/or as part of a complex multipronged attack
  (JCAT, n.d.)

Weapons of Mass Destruction (WMDs)

According to the DOD (2021), WMDs are weapons capable of a high order of destruction or causing a large number of casualties, and excluding the means of transporting or propelling the weapon where such means is a separable and divisible part from the weapon. (An example of such excluded means would be an airplane used to deliver a bomb, such as occurred on 9/11.)

TYPES OF WMDS

The acronym CBRNE is a method of describing the types of weapons of mass destruction that can be used by terrorists:

• Chemical
• Biological
• Radiological
• Nuclear
• Explosives, high yield

Over the years, terrorist groups have tested new ways and means to acquire and use more dangerous weapons to maximize damage and incite terror. As advancements are made in technology and with the expanded legal and illegal commercial channels, including the dark web, some of these weapons have become increasingly accessible (UN, 2021).

This course will focus on specific implications of the triad of nuclear/radiological, biological, and chemical—or “NBC” weapons. It will not cover caring for victims of solely incendiary and/or explosive weapons. The general principles of trauma care apply to patients suffering from burn or blast injuries no matter the source.