Major Incidents, Training

EMS Preparation and Response for Car Ramming Attacks

During the past year, ramming attacks have become somewhat of an epidemic in Israel. The country has been experiencing a variety of terror attacks, including ramming attacks, for close to 20 years. Magen David Adom, Israel’s EMS organization, has some advice for other EMS agencies to prepare for terrorist incidents.

The 2016 ramming attack that took place on July 14, Bastille Day, at the Nice boardwalk took the lives of 84 people and resulted in the injuries of some 200 people, making it the deadliest ramming attack ever to occur. When compared to other terrorist attacks that have claimed similar numbers of casualties, this one was much simpler to execute. Ramming attacks don’t require intricate planning, intelligence gathering or any logistical infrastructure. Making them that much more dangerous.

Since the First Intifada, Israel has suffered ramming attacks that have been going on to this day. Since the beginning of the recent terror wave in Israel, 31 ramming attacks took place, proving to be significantly deadlier than stabbing or shooting attacks. The latest example was on Jan. 8, 2017, when a truck driver rammed his car into a group of soldiers who were gathered in the Armon HaNatziv boardwalk in Jerusalem. Four soldiers were killed and 13 were injured, three severely.

Magen David Adom (MDA), in its 20 years of operation as Israel’s national EMS and primary response to this form of terror, has gathered protocols and ideas regarding the treatment and management of such scenes. Here are a few things EMS organizations should keep in mind about handling ramming attacks:

Be pPrepared:

  • EMS dispatchers should be trained to identify seemingly routine reports as possible ramming terror attacks. For example, receiving multiple reports of hit and run accidents in the same area at the same time, could be a sign of a deliberate attack.
  • Another way for dispatchers to detect an attack is to ask if the car stopped. In car accidents, the driver will stop immediately after realizing what happened. In a terrorist attack, this is obviously not the case. The dispatcher must figure out if the car stopped in order to be prepared for the next event.
  • If a dispatcher does identify a suspicious report (or several of them), they should dispatch extra forces so that they can look for additional scenes or injured civilians.
  • Protocols must be in place, so dispatchers know to alert security forces immediately on their suspicion and attempt to identify the type of vehicle in question to correctly assess the extent of the incident.


Scan the Scene

  • Consider the chance of an ongoing attack. We know that sometimes car ramming attackers carry a knife or a gun meant to be used when the car is disabled. We must also consider the danger of a bomb.
  • Ramming attacks can spread over a very large scene. The scene must be divided into sub-scenes and each one have an appointed a scene commander. The sub-scenes will be divided based on eyesight, meaning as far as the commander can see clearly.
  • Check under and inside the vehicle. Did the attacker kidnap the driver? Maybe he’s injured inside the car. Is there someone trapped under or inside the car?
  • Check the area for second scenes. It’s possible that the civilian caller didn’t see the attack from the beginning, missing part of the incident that was already underway.

Keep in Mind:

  • During stabbing or shooting attacks, injuries are external, penetrating wounds. In car ramming attacks, however, injuries are mostly internal wounds. When doing triage in a ramming scene, we must understand that those who are unconscious lying on the ground are probably those who have been injured most severely.
  • Because the attacker targets as many people as possible, there are civilians wounded in multiple conditions, all over the scene. In bomb attacks, the further away the wounded are from the source of the explosion, the lighter they’re likely to be wounded. In a car ramming attack, there is no way of predicting where the most severely injured are located, and are likely to be spread across the scene.
  • Understanding that almost all such attacks can seem like car accidents at the beginning. Recognizing the report for the true nature of the incident is key. Dispatchers must be highly vigilant and know when a report sounds suspicions.
  • Most ramming attackers use private civilian vehicles, however in some cases we saw use of tractors or other heavy machinery in order to increase the number of fatalities. Dispatchers must figure out which vehicle is in question in order to dispatch the correct number of teams and resources.

On Aug. 24, 2014, a tractor driver left a construction site in Jerusalem and killed a pedestrian. He then proceeded to try to knock over a bus with the shovel. The bus driver and another employee who were in the bus were both lightly injured, as well as five other civilians. All initial reports were of a tractor accident. Only after civilians notices the tractor was trying to knock over the bus did the dispatch center realize it was an attack. This is an example of how these events can evolve rapidly, and any suspicion requires the dispatchers and the teams to be highly vigilant.

These attacks are becoming an increasing phenomenon across the world, almost an epidemic, with countries including France, Germany and Israel suffering from it. These attacks are almost impossible to predict or prevent (unlike weapons, the government can’t restrict possession of vehicles), and their success is only more of an incentive for attackers to keep going. All of us as EMS providers should aspire to learn more and improve the skills we have in facing this threat.