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50 Critical Incident Team Dynamics andLogistics
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Terrorism andUrban Trauma
JoseL.Pascual, JeremyW.Cannon, andLewisJ.Kaplan
51
Introduction
The last few decades have witnessed a fundamental shift in
how the public, law enforcement, government agencies, and
the military plan to address terrorism as well as urban trauma.
Previously, terrorism and urban trauma were considered distinct entities. Terrorism in particular, was an event that primarily occurred outside of North America, most notably
affecting certain countries in the European Union, the Middle
East, and areas of South America plagued by the opium trade
and religious extremism as well. The historic events of 9/11
revamped those perceptions and painted terrorism and urban
trauma onto the same canvas. Currently, urban trauma principally—but not exclusively—occurs in large densely populated cities and in zones with depressed socioeconomics.
Nonetheless, the culture of urban intentional violent injury
has crafted its own set of norms that impact multiple forms
of media—including most notably social media (SoMe)—
and has shifted interpersonal dynamics and social behavioral
expectations [1].
Terrorism—or violent extremism—has similarly exploded
and encompasses a vast array of forms and has an expanding
set of drivers [2]. Soft targets such as schools, malls, movie
theaters, transportation hubs, and hospitals are wellpublicized sites of violent extremism [3]. Hospital assaults
are well tracked by the World Health Organization on a
yearly basis [4]. The overlap of soft target assault and urban
intentional violent injury has welded urban trauma and terrorism together in important ways [5–8]. Other forms of terrorism include cyber-terrorism, identity theft, and random
J. L. Pascual · J. W. Cannon · L. J. Kaplan (*)
Perelman School of Medicine, University of Pennsylvania,
Department of Surgery, Division of Trauma, Surgical Critical Care
and Emergency Surgery, Philadelphia, PA, USA
Corporal Michael J Crescenz VAMC, Surgical Services,
Philadelphia, PA, USA
e-mail: Jose.Pascual@pennmedicine.upenn.edu;
Jeremy.Cannon@pennmedicine.upenn.edu;
Lewis.Kaplan@pennmedicine.upenn.edu
interpersonal violence that follows a dictated form such as
“knockouts” that have occurred on public transportation and
urban sidewalks or iPhone thefts known as “apple picking”
by roving gangs on bicycles and scooters [9]. Together, terrorism, regardless of specic form, and urban trauma have
the potential to craft an interwoven culture of fear, - a goal
that underpins terrorist activities in all forms.
Forms ofTerrorism andUrban Trauma
Mass casualty scenarios often typify thinking about terrorist
events whether domestic or international. However, most
terrorist-driven mass casualty events result in large numbers
of dead individuals with far fewer individuals with serious
injury requiring inpatient hospital care. Instead, there are
large numbers who require Emergency Department care with
9/11 serving as a prime example [10]. Mass shootings, on the
other hand, like the events of 1 October in Las Vegas, Nevada,
result in large numbers of victims who require inpatient as
well as ED care. Such events lead to substantial health system stress that was in part mitigated by using existing
approaches to disaster management [11]. Natural disasters,
including typhoons and earthquakes, have a more balanced
injury prole that tends to overwhelm medical care facility
capacity and engender logistical difculties in enhancing
disaster site capabilities. Examples include those that struck
Haiti, as well as the southern USA during hurricanes Irene
and Sandy [12–14]. Individual terror attacks, including those
derived from autonomous “cells” are characterized by high
mortality at the epicenter, but decreased mortality with
increased need for care with increasing distance from the
attack’s origin. Numerous examples are found throughout
the history of Israel, and more recently in Belgium, Iraq,
Afghanistan, and Nigeria with a notable increase in female
suicide bombers [15–18].
Regardless of the precise nature of a terrorist attack, mass
panic accompanied by civil and nancial disruption are other
consequences that compound the loss of life [19]. Such
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_51
443
444
Fig. 51.1 Trauma/terror cycle
events foment a culture of fear initially characterized by
heightened awareness followed by a gradual return to normalcy—a cycle that inadvertently readies the system for the
next event (Fig.51.1) [2]. The loss of vigilance as normalcy
returns provides a weakness that may be exploited to reinitiate the cycle. Most urban trauma does not aim to create
widespread unrest but nonetheless feeds into a similar cycle.
On the other hand, the recent protest-related violence focused
on individuals who died after Police contact appeared
designed to disrupt normal activities throughout the entire
country [20]. Rioting gripped the USA throughout 2020
including marches, property destruction, looting, and rebombing including Molotov cocktail-style incendiary
devices [21]. Accordingly, both medical and law enforcement domains have evolved and adapted to respond to preserve life, limit damage, and maintain or restore peace. The
evolution of medical and law enforcement responses is
driven in part by the kinds of injuries that individuals and
groups may sustain.
Injuries andInjury Patterns
Urban trauma in population dense settings is often typied
by penetrating trauma that includes rearm and edged
weapon injuries. Nonetheless, most urban trauma centers
evaluate and care for more patients with blunt, rather than
penetrating, injury. Individuals injured in falls, motor vehicle
(including motorcycle) crashes, and vehicle-pedestrian collisions often form the majority of patients cared for at a
regional resource facility. Combined penetrating and blunt
injury in the same patient is uncommon. Scene transport
J. L. Pascual et al.
less well-resourced medical facility as part of patient care
within a tiered trauma network.
Unlike urban trauma, terrorism often leads to both penetrating and blunt injury in the same patient [22]. This circumstance derives from the increased use of devices such as
vests, backpacks, and other canisters packed with explosives
as well as metal projectiles. Explosive agents such as C4
(cyclotrimethylene trinitramine) or Semtex (RDX-research
department explosive, an explosive nitroamine, and PETNpentaerythritol tetranitrate) are more commonly used in
small devices and may be detected by technology used in
current Explosive Trace Detection systems [23, 24]. Larger
explosives including weaponized vehicles (aka suicide vehicles) may be packed with fertilizer as well as diesel fuel such
as in the 1995 Oklahoma City bombing. Vehicle bombs using
other explosives have been deployed and at multiple sites
during the Global War on Terror (GWOT), and throughout
the Mexican Cartel conicts [25, 26]. The magnitude of
vehicle bomb detonations creates shrapnel from damaged
structures as well as the vehicle in which the explosive was
delivered. Such explosives lead to penetrating injury within
the blast zone and blast effect within the blast radius; individuals may be thrown into stationary objects or mobile
objects may be explosively moved into individuals [22].
Improvised Explosive Device
Improvised Explosive Devices (IEDs) are a unique category
of explosive that became commonplace during GWOT.Often
placed in roadways, and underneath or within obstructions
that need to be cleared to permit passage, IEDs are particularly devastating to those dismounted. Early troop transport
vehicles provided little occupant protection from IEDs.
Service members often suffered both penetrating and blunt
injury from driving over an IED.The Mine-Resistant Ambush
Protected (MRAP) vehicle shields occupants and provides
substantial protection from penetrating injury related to IEDs,
rocket-propelled grenades, other explosive devices, and small
arms re [27]. Blunt injuries persist, especially the dismounted injury complex (aka. deck slap lesion) [28]. The
civilian parallel is the Lenco BearCat G3 which is an armored
vehicle suitable for use by federal and civilian law enforcement and is especially ideal for Special Weapons and Tactics
teams [29]. No vehicle provides ideal protection against blunt
forces that ow from explosive device detonation.
Blast Eect
Blast effect is a concussive injury derived from blast pressure measured in pounds per square inch (psi) during the
rapid overpressure phase of the explosion [22, 30]. For
51 Terrorism andUrban Trauma
445
example an overpressure of 1psi leads to a maximum wind
speed of 38 mph while overpressure of 10psi creates wind
up to 294 mph leading to severe damage to concrete structures and death in the majority of individuals exposed to the
overpressure wave (www.cdc.gov/niosh/docket/archive/
NIOSH- 125/125- Explosionsand refugeChambers.pdf).
While military organizations are well acquainted with such
injuries, civilian law enforcement and EMS may benet
from specic preparation including focused education,
training, and resource management (see Chap. 50 ). The
2013 Boston Marathon bombing underscored the need for
such training [31, 32].
Chemical, Biological, Radiological, Nuclear,
andExplosive (CBRN-E)
Terror-related mechanisms of injury may be housed within
a framework of Chemical, Biological, Radiological,
Nuclear, and Explosive (CBRN-E); explosives including
rearm- related penetrating injury are discussed above [33].
Of the CBRN four, the Chemical and Radiological appeared
more readily acquirable and deployable by terrorist organizations due to the seemingly more limited availability of
biologic agents such as weaponized anthrax, smallpox, or
other viruses in comparison to nerve agents or radioactive
materials [34]. The nuclear arsenal is tightly controlled and
falls under the control of nation states rather than terrorist
organizations. Nerve agents such as Sarin gas have been
previously deployed in Japan and Syria, while to date, no
radioactive “dirty bomb” has been detonated [35].
Unfortunately, CBRN-E terrorism may be initially difcult
to detect (other than a bomb or lethal gas explosion) and
result in the unprotected exposure of rst responders who
are unaware of the exposure hazard [36, 37]. Nonetheless, in
the event of a CBRN-E terrorist attack, the availability of
appropriate personal protective gear is critical to protect rst
responders who arrive to evacuate and care for the victims
of the incident.
Microbe biohazard protection is provided by the appropriate Biohazard gear (Biohazard Level I–IV suits) while
chemical and biologic protection is provided by gear including the military Mission-Oriented Protective Posture suits
(MOPP suits 0–4) [38]. The availability of higher level gear
may be limited outside of special facilities. High-level suits
are not commonly available even at major medical facilities,
including regional resource trauma centers. Accordingly, a
close working relationship with local federal and military
resources is essential in bringing suitably trained and garbed
individuals to an event site. Little, if any, nuclear radiation
protective gear is readily available outside of specialized
agencies and their designated protective details such as those
at the Lawrence Livermore National Laboratory (https://
www.llnl.gov) or investigative and decontamination crews
from the Nuclear Regulatory Commission (www.nrc.gov)
and the National Nuclear Security Administration (www.
nnsa.doe.gov). Regardless of attack type, CBRN-E events
create fear of another attack and lead to the notion that there
is no safe refuge. Indeed, a primary goal of terrorism is to
perpetuate a culture of fear [39].
Paradigm Shifts inTerrorism
The 9/11 attack on US soil launched a major change in US
policy as terror rmly landed in North America, initiating
the Global War on Terror [20]. Instead of supplanting a
country’s governmental infrastructure, or unseating its
political leadership to establish new rule, or driving out an
invading force, terrorism shifted to coordinated attacks performed by small teams of terrorists as well as independent
attacks initiated by autonomous cells [40]. While structures
were destroyed, the primary impact was on people and their
view of government. The small units termed “cells” operate
both as part of a coordinated structure and independently
[15]. Some may be in place for a short period of time prior
to their specied activity, while others may remain dormant
for long periods of time and are dubbed “sleeper cells” [15].
Thus, terrorist activities became personally focused instead
of government or country focused.
The rise of social media (SoMe) and the widespread use
of digital platforms as communication tools and enablers of
daily activity—such as the sharing of medical information
(and disinformation) during the COVID-19 pandemic in a
global fashion—has afforded multiple opportunities for
cyber-terrorism [41, 42]. Such activities span network disruption and identity theft, lead to organization member
recruitment, and have resulted in an expansive need for law
enforcement capabilities including cybersurveillance and
cyberprotection [43, 44]. Even small police departments
support electronic expertise in crime solving and therefore
complement cyber policing that is performed by federal
agencies including the National Security Agency, the
Federal Bureau of Investigation (FBI), and international
agencies that include the Central Intelligence Agency.
Education efforts to improve cybersecurity competency are
available through public (FBI)-private (citizen) partnerships
such as InfraGard that work to protect US Critical
Infrastructure [InfraGard. Partnership for Protection. https://
www.infragard.org/; accessed March 7, 2021]. Critical
Infrastructure protection is a national imperative, while episodic violent extremism is a local crisis.
Domestic terror events such as the Texas belltower shootings that occurred in 1966 spurred the formation of Special
Weapons and Tactics (SWAT) teams. Since the 1970s, the
number of SWAT teams has nearly doubled. Such teams
respond to urban and suburban terror events spanning—but
not limited to—barricaded hostage/suspect, riots, gang war-
446
J. L. Pascual et al.
fare, dignitary protection, and high-risk warrant service. US
rioting during 2020 was interwoven with the SARS-CoV-2
pandemic as well as political uncertainty in an election year;
SWAT teams prominently featured in local city responses.
Driving the development, training, and outtting of local
SWAT teams is the need to respond to the changing
demographic and advanced, high-powered equipment of perpetrators of violent crimes. Suspects and organized criminal
elements have ready access to body armor and highperformance weapons as a result of military surplus obtained
both legally and illegally. Additionally, increasing numbers of
perpetrators of violent crime may have served as members of
the armed forces, and received specic weapon and tactical
training [45]. Therefore, local police departments need to be
able to respond to a host of different events forcing a metamorphosis from community-based policing to a threat matrixbased response [46]. The transition has often been termed the
“militarization” of local police forces and is typied by the
inclusion of military-relevant rearms, body armor, communications gear, training tactics, sound and light diversionary
devices, and uparmored vehicles such as the Lenco BearCat,
or the militarily deployed MRAP as noted earlier. More relevant is the articulation of multi- jurisdictional teams whose
need is driven by the rising frequency of SWAT or Special
Response Team (SRT) activations whose intensity is unsupportable in isolation by smaller towns [47]. Shared resources,
akin to mutual aid policies, help distribute manpower
demands, resource-related nances, and oversight and afteraction evaluation responsibilities.
Similarly, instead of standard community policing where
apprehending criminals constitutes approximately 10% of
total police work, departments increasingly devote time and
resources to elements that address active shooter and mass
casualty scenarios.24 Medical threat intelligence and biohazard training—especially in the wake of COVID-19—is especially important as well [48]. Furthermore, and in a fashion
parallel to that of the military, police ofcers are increasingly
trained in self- and buddy-aid using concepts and tactics borrowed from the Tactical Combat Casualty Care (TCCC)
approach initially advocated by the Naval Special Warfare
command. Recognizing that the patrol ofcer is likely to be
the rst responder to urban trauma or terror acts, this ofcer’s capabilities need to be enhanced and reinforced to
increase the likely survival of the ofcer and those whose
lives the ofcer has sworn to protect.
Such needs have also driven increased interagency collaboration with other law enforcement agencies including
but not limited to State Police, US Marshalls, AlcoholTobacco- Firearms, Drug Enforcement Agency, FBI, US
Secret Service, and the National Guard. Local teams such as
those devoted to urban search and rescue also excel when
inter-agency collaboration works smoothly [49]. Since communication is key to such activities, the USA has developed
Fusion Centers under the aegis of the Department of
Homeland Security that are designed to funnel key and
actionable intelligence to appropriate agencies within a specied territorial domain designed to disrupt potential or validated terrorist threats [50]. Integrated domains include state,
local, tribal, and territorial as well as private sector partners
(www.dhs.gov/state- and- major- urban- area- fusion- centers).
Such communication is key in protecting and preserving
national security by establishing and improving an
information- sharing environment to help counter violent
extremism. The previously mentioned InfraGard publicprivate partnership also serves as a portal for information
channeling to relevant agencies. In turn, members serve as
subject matter experts for agencies and reect the benets of
a partnership structure.
Anti-police Violence
The last few years have been marked by mounting anti-law
enforcement sentiment within certain groups. Triggered by
the deaths of minorities during or after arrest or warrant
search, and spread across a multiplicity of digital platforms,
protests and anti-police rhetoric captured the nation’s focus.
The premeditated assassination of law enforcement ofcers
is a readily identiable sequel of such events [51–53]. More
durable impacts include enhanced scrutiny of police activity
by those outside of the law enforcement community and
swift assignation of culpability by the public when there is a
police action inquiry that is spread across SoMe. Perhaps the
most devastating effects are on law enforcement ofcer
morale, stress, and perhaps on-scene judgment. As explored
in the chapter on Critical Incident Team Dynamics, demoralization and stress exert maladaptive psychologic and physical health impacts that may degrade ofcer capability and
efciency but may also lead to suicide [54]. An overlap with
on-scene judgment may lead to hesitancy in engaging due to
fear of censure or inquiry. Critical incidents may then progress unimpeded, become intervened upon too late, or may
result in ofcer or bystander injury or death. Guilt over failing to meet performance standards may lead to depression
and suicide as well.
Collectively, it is a precarious time to serve in law enforcement, and the rich tradition of publically “serving and protecting” has been under assault. The Seattle Autonomous
Zone is a prime example of how anti-police actions have
undervalued the dedication and sacrice of those who put
their lives on the line on a daily basis [55]. Instead of having
individuals ee the scene of large gatherings such as parties
that are prohibited during the pandemic, arriving police ofcers are met with wanton property destruction and seemingly
anti-police violence [56]. National attempts, some of which
have been successful, to reduce, limit, or otherwise “defund”
51 Terrorism andUrban Trauma
447
local law enforcement budgets are anticipated to further
hamper effective policing as urban trauma and violent
extremism continue to escalate [57]. In one such city—
Portland, Oregon—law enforcement ofcers are reportedly
leaving policing in larger numbers than can be accounted for
by attrition or phase of career [58]. From a public health perspective, the intensity and longevity of anti-police actions
and public proclamations appear to condone violence toward
those sworn to uphold the law. These actions raise serious
concerns regarding the desirability of policing as a career
goal, perhaps even in families that have given rise to generations of law enforcement ofcers or military operatives. Law
enforcement is not the only sector that has undergone signicant change in structure and focus as substantial changes
have also impacted EMS.
Changes inEmergency Medical Systems
Structure
Medical care as part of an organized trauma system began in
the 1970s and continues to be rened today. In general, urban
Emergency Medical Services combine ground and rotary
wing air ambulance transport into a working network that
embraces support from both the local Fire Department and
the local Police Department. Rural trauma systems may
enfold aid from other agencies including the US National
Park Service (www.nps.gov) and in Canada, the Royal
Canadian Mounted Police (www.rcmp- grc.gc.ca). Of necessity, the EMS response to urban violence is reactive in nature
rather than preemptive. Nonetheless, despite the close working relationship with local law enforcement, only few areas
of crossover have blossomed that leverage the capabilities of
EMS in combination with those of law enforcement.
The prevalence of urban violence supports police ofcers
as medical rst responders. Indeed, during periods of lockdown and socio-political unrest, urban trauma centers noted
a substantial increase in intentional violent injury and a later
increase in motor vehicle collisions (automobile and motorcycle) [59]. As they are often rst on scene compared to
EMS workers, police ofcers are in a unique position to render aid. First Aid and STOP-The-Bleed techniques have been
advocated as key elements to teach law enforcement ofcers
since the Hartford Consensus Conference in 2013 [60].
Penetrance, and funding, however, in both large and small
cities across the USA has been more variable, especially in
comparison to military medical and special operations
domains [61]. Accordingly, rather than spending time rendering immediate healthcare, police in a few urban cities
engage in primary transport to the local trauma center with
excellent results noted for those with penetrating injury [62].
This practice stands in stark contrast to on-scene care that is
common outside of the USA, as well as EMS-based trans-
port with en route care that is more typical for US prehospital practice. While police transport appears effective for
episodic violence victim rescue when the threat has been
neutralized, a different solution is required when threat suppression or elimination has yet to be accomplished.
One approach to care is Tactical EMS, a concept spawned
in the military, and in particular, in Special Operations forces
where one individual embraces both operator and medic
roles [63]. This uniquely and dually trained operator provides immediate and skilled life-sustaining emergency care
to an injured combatant rather than needing to await evacuation to a higher echelon of care. While a superb concept,
such an individual seems more difcult to task in the civilian
domain where issues such as divided loyalty (which role at
which time) as well as skills maintenance and certication
(medic and police ofcer) are particularly problematic.
Instead, at least in US practice, the medic and police ofcer
roles are generally shouldered by separate individuals.
Previously, EMS care during a SWAT or Special Response
team activation (call-out) for a barricaded suspect/hostage
would await threat elimination and scene clearance for onscene care and extrication of a wounded individual from
within the inner perimeter or “hot” zone (Fig.51.2).
Based on the work of individuals such as Richard
Carmona, MD, a former US Army Medic and former Surgeon
General, medics embedded in US SWAT teams have ourished. Such medics train with the SWAT teams and are
viewed as integral members, but are tasked with medical
care, not room clearing or suspect apprehension. Given the
tenor and pace of active shooter scenarios starting with the
Columbine, CO, school shootings in 1999, former US
President Barack Obama provided strong support to send
medics into the warm zone to effect rapid care of injured
individuals [64]. As mass casualty events have escalated in
Fig. 51.2 Zone schematic
448
J. L. Pascual et al.
number and frequency, the role and need for embedded medics has also blossomed, as has the need for public space (soft
target) preparation for acute life-threatening injury care [65].
Indeed, the role and efcacy of tactical EMS teams were
highlighted in the aftermath of the Tree of Life Synagogue
shootings in Pittsburgh, PA [66].
Physician involvement in Tactical EMS (TEMS) is principally limited to providing medical command for the tactical
team medics, rather than direct participation. Furthermore, the
vast majority of physicians involved in TEMS in the USA are
primarily trained in Emergency Medicine; only a handful of
surgeons participate in TEMS. However, the majority of
TEMS-embedded surgeons involved do so as integrated tactical team members, deploy with the team and provide on-scene
medical care as well as medical command. Such physicians
are equipped with gear nearly identical to the SWAT operators
but generally trade rearms for medical equipment. Bearing
the added weight of body armor, communications gear, and
medical necessities can present a signicant physical challenge, leading to robust physical tness requirements for the
interested individual [67]. The ethics of placing a physician in
such a role has been extensively explored [68].
An embedded physician parallels the military structure of
some far-forward teams with on-scene physician support
such as has been utilized by the US and the Israeli militaries
[69, 70]. Moreover, once a physician integrates with a SWAT
team, the opportunities for inuencing care across the entire
Police Department abound. Importantly, such inuences
may change medical preparedness for both urban violent
injury, acts of terrorism, or routine patrol encountered medical emergencies, especially those involving hemorrhage.
Such examples may include changing the medical kits that
populate mobile police platforms to ones that include tourniquets, personal protective gear, and procoagulant dressings.
Implicit in such a change is that there is appropriate training
to enable gear deployment and use in a safe and effective
fashion. In many ways, non-law enforcement members of
the local community may have already done so in the form of
“go bags” and immediate care gear that is secured in their
personal vehicles.
Other innovations that impact the medical and law enforcement response to high-risk crises include thermal mapping
devices to detect the position and number of individuals who
are not visible behind a wall, as well as a remotely controlled
mobile explosive delivery device (i.e., drone). The latter was
deployed to great effect during the July 2016 Dallas police
ofcer shooting crisis [71]. Such devices can eliminate an
active threat while shielding ofcers from life-threatening
threats such as high-velocity projectiles or explosives. Other
mobile platforms such as those offered by Callyo or Boston
Robotics can provide video as well as audio at a remove helping keep ofcers out of the line of re while supporting communication and data acquisition [72, 73].
Improved Community Preparedness
In many ways, civilians are moving toward embracing a culture of competence. Such mobility is spurred on by terror
events such as those of the 2013 Boston Marathon bombing
where community aid was key to preserving the lives of
many of the injured. Community training and resource management enhance bystander willingness to participate in
events where they may sustain injury while offering aid.
Relatedly, lay-person transport of the injured to area facilities was a life-saving event in the Las Vegas shooting of 1
October [74]. Indeed, organizations such as the American
Red Cross and the Canadian Red Cross have a host of training courses designed to improve an individual’s ability to
provide self or buddy care. A readily downloadable app
serves as an immediate guide for most major medical emergencies if instruction or immediate aid is unavailable including step-by-step instructions as needed [75]. The US Federal
Emergency Management Agency has articulated bystander
emergency preparedness training to improve the ability of
lay responders to participate in disaster care [76]. Certainly,
wilderness exploration and the related organizations have
championed “Wilderness Medicine” courses that teach
advanced aid skills [77]. The ready availability of tactical
load-out bags, EMS bags, personal protective equipment,
and hemorrhage control aids (including tourniquets and procoagulant dressings) enables the competent civilian bystander
to be ready to render aid in an on-demand fashion be it at a
motor vehicle crash, a drive-by shooting, or a terrorist attack
[78]. In an extreme fashion, movements such as the so-called
Doomsday Preppers may have enhanced medical gear
including gas masks, providing both enhanced medical capabilities and providing increased protection from standard
SWAT techniques that utilize chemical irritant gas to deny
the suspect protected space. The widespread availability of
body armor, including shirts, backpacks, and standard vests,
has important implications for preparedness, but also for law
enforcement, EMS, and federal agency response to violent
extremism, urban trauma, and disasters.
During or in the immediate aftermath of a disaster, blood
component therapy is often in short supply. While some
trauma centers are using whole blood for acute trauma
resuscitations, the majority of transfusion occurs as individual components [79]. The military “buddy transfusion”
approach for life-threatening hemorrhage is key when separated from well-resourced blood banks and blood suppliers.
A similar approach is being explored for mass casualty
responses [80]. Unfortunately, the outpouring of blood
donors “on-demand” after an act of terrorism and poorly
coordinated acute blood drives lead to both short-term waste
and longer-term shortages. For example, after the 1 October
shootings in Las Vegas, large numbers of acute blood donations led to a 17% unnecessary excess in donated blood
51 Terrorism andUrban Trauma
449
units [81]. These authors advocated for improved oversight
of blood collection during disaster care. The 2015 Paris
attacks illustrated the life-saving role of transfusion support
in the early administration of blood products (within the
rst 6hours) for critically injured patients [82]. However,
like the Las Vegas experience, these authors did not advocate for bolstering the immediate stockpile in an acute, ondemand fashion, but rather endorsed enhanced efciency at
mobilizing existing blood supplies to the bedside. Thus,
community engagement and ongoing research to bolster
blood product inventories in an ongoing fashion—rather
than only on-demand—represents a key aspect of preparedness for violent acts of extremism.
Conclusions
Urban trauma and terrorism share a wide variety of overlapping features that impact how law enforcement and
EMS prepare for and respond to emergencies. The changing threat matrix has driven signicant changes in policing
from a community-based approach to a threat-based posture. Key events including the Global War on Terror, access
to military- grade weaponry and surplus gear, as well as
global connectivity via social media have revamped the
landscape of both urban trauma and activity designed to
thwart violent extremism. Interagency synergy hinges on
communication and the timely distribution of actionable
intelligence but at present still relegates most law enforcement and EMS activity to reacting to established events
rather than being able to preempt events. Integration of
medics and physicians into a TEMS approach may enhance
outcomes for injured individuals, as may police transport
of victims of penetrating trauma. Community preparedness and bystander involvement help to shape a culture of
competence. Both EMS and law enforcement will need to
determine how best to effectively train, utilize, and interact
with engaged bystanders during the response to urban
trauma or terrorism.
Key Points
1. Urban trauma and violent extremism share broad
areas of overlap with regard to their impact on
social structure and preparedness.
2. Terrorism paradigms have shifted to small units
that are difcult to preempt.
3. EMS and law enforcement both benet from
including medically trained personnel in rapid
response teams.
4. EMS and law enforcement will need to proactively
prepare to interact with trained bystanders.
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