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Correspondence: Matt Pepper, MPhil, Monash University Accident Research Centre, 4 Karloo Pde, Newport, Sydney, NSW, Australia 2106, E-mail: [email protected]
Introduction
Complex, coordinated terrorist attacks (CCTAs) present a unique challenge to prehospital medical responders. Overwhelming numbers of patients presenting almost simultaneously, multiple sites and modes of attack, varying mechanisms of injury, and secondary threats all combine to create a confusing and complex operating environment for responders.
All CCTAs are intentional, mass-violence incidents that involve coordinated tactics, various weapon types, and potentially, multiple sites of attack. Incidents such as the 2017 London Bridge/Borough Market terror attack (London, England) involved the attackers conducting a hostile vehicle attack, then dismounting to attack civilians with knives, while wearing fake suicide vests. 1 Responding to an incident such as this creates an uncertain environment with a high-index of suspicion for secondary attacks.
In the confusing and dangerous response to CCTAs, triage of victims is more difficult than in other disasters or mass-casualty incidents. This paper will compare and analyze three recent CCTAs to determine the applicability of triage systems in high-threat tactical settings and will identify successful elements that could guide development of an appropriate “tactical triage” system.
Methods
Literature identified as being descriptive of prehospital response to terrorism through a literature search was utilized to conduct a comparative analysis of the CCTAs in Norway (2011), Paris (France; 2015), and San Bernardino (California USA; 2015).
The search strategy interrogated the MEDLINE (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), MEDLINE In-process, Cochrane (The Cochrane Collaboration; Oxford, United Kingdom), EMBASE (Elsevier; Amsterdam, Netherlands), CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA), and Google Scholar (Google Inc.; Mountain View, California USA) databases for the following Medical Subject Headings (MeSH) and keywords:
(terror* OR attack OR bombing OR mass casualty incident OR explosion OR shooting OR aggressive deadly behavior OR hybrid targeted violence OR complex attack OR multi modal attack) AND (Emergency Medical Services [EMS] OR ambulance OR prehospital OR medical response OR health response).
For the three identified CCTAs, the following search string was used on the Google Scholar and Google databases:
(‘event’ and terror*) and (Emergency Medical Services or prehospital or medical or health or response).
All papers that were able to be located in full-text and...