As with any threat, recognition of the threat can inform our training and help us plan mitigation strategies. (Photo/Adam Mason)

Note from JEMS Editor Emeritus A.J. Heightman: This is a deep-thought article that is timely as we move out of the first phase of a sentinel event that most did not think could ever happen. Please read it and think about the possibilities for impact in your EMS system and how you can plan to overcome obstacles and challenges each would present.


It’s not an understatement to convey that we are living at a crossroads in time where our children’s future will look far different than ours. Envisioning future potentialities is difficult for most, the same way many of us can no longer conceptualize a hardwired phone that hung on a wall and took coins.

Transformation of the world we know, both at home and abroad, will have profound implications for prehospital medicine. And many of them will not be for the better.

Many Shades of Gray

Gray zone techniques used by revisionist powers, such as China or Russia, are shifting the world order and eroding the United States’ standing on the global stage. Gray zone techniques employ methods that fall below the threshold for traditional armed conflict; the tactics used are not peaceful (white) but fall short of open conflict (black).

Some gray zone strategies include, “disruption of order, political subversion of government or non-governmental organizations (NGOs), psychological operations, abuse of legal processes and financial corruption.”1

These are commonly also referred to hybrid threats, as they combine multiple attributes. Additional examples include manipulating social media with false news stories, cyberwarfare and associated intellectual property theft, as well as creating and militarizing disputed islands condemned by international rulings.

Internet and the Rise of Drones

Gray zone techniques are already in use here in the U.S. and across the world. Intellectual property theft by China is a Gray Zone technique that has cost United States companies between $225 billion and $600 billion, annually.2

Russia is infamous for spreading disinformation to fan the flames of political dissent abroad, including here in the U.S. Russian meddling in the 2016 presidential election in an effort to sway public opinion through the publication of fake news stories,3 exacerbate rifts and create internal dissent here in the United States.

As we focus inward, this allows Russia to continue to erode freedoms in the Ukraine and Baltics. Russia similarly exposed Germany to fake news stories in 2017,4 falsifying a story that German Soldiers on rotation to Lithuania raped a young girl.5 The promulgation of such stories is amplified by the echo chambers of the internet.

The internet has been credited with bringing proclaimed to bring people closer together, and has to an extent. Today, however, it can bring those with radical ideas half-a-world-away together and norm feelings of hate and anger. Emerging cyber technologies of nation states, as well as violent extremist organizations (VEOs), home grown or foreign, can have profound impacts on our initial assessment and scene safety, from flood zones to urban responses to the pandemic.

Model airplanes from four decades ago have been replaced by ubiquitous modern- day drones. The first modern military drone was the RQ-11 Raven, rolled out in 1999, with the U.S. executing the first-known modern-day strike in Afghanistan less than a month after 9-11.6

Over the last two decades, drones have evolved and now come in all sizes, from hand-launched to runway based. Nano drones that fit in the palm of the hand are used by deployed Soldiers for surveillance.7 But even small drones pose real threats. In August 2018, two drones were used in an attempt to assassinate the Venezuelan President.8

The Islamic State of Iraq and the Levant (ISIL) itself has utilized drones to drop hundreds of bombs.9 Here at home, the Department of Homeland Security (DHS) is so concerned about the rising threat, that they appeared before Congress to request the authorization to down drowns they deem a threat.10

A drone flown over a packed sports stadium could disperse a chemical that would quickly overwhelm any HAZMAT and EMS resources, sowing panic and potentially adding stampeded injuries to an already complex response. Likewise, a drone dropping a homemade munition on a crowded city street, while the perpetrator controls it from a tablet in a coffee shop a block away, could result in dozens of casualties. In addition, Furthermore, a second drone, targeting first responders (a new take on the secondary device in a trash can), is not a farfetched scenario.

What the Tsarnaev brothers11 did with 10 lb. pressure-cooker bombs at the Boston Marathon on April 15, 2013, can now be easily replicated by two people with two inexpensive drones that can carry a 15-20 lb. payload.

Cyber, EMPs and Future Weapons

The U.S. aging U.S. infrastructure is a prime target for cyber-attacks from nefarious state or non-state actors. Hacking a power grid during the hot summer months, while complex but not unrealistic, could prove catastrophic. Such an incident occurred in the Ukraine in 2015.12 Nursing homes would lose air conditioning. EMS would quickly be inundated by patients with heat exhaustion injuries and heat strokes.

Traffic light outages would clog intersections and transport routes for emergency response vehicles. Temperature sensitive, lifesaving medications, such as insulin, would quickly lose their efficacy, potentially leading crowds to arrive at neighborhood fire and EMS stations unannounced, seeking care.

If disenfranchised actors managed to electronically and remotely gain access to the controls of a dam, and open the flood gates, they could easily overwhelm current evacuation plans and procedures.

Cyber-attacks could also target dispatch and communication centers. Russia recently demonstrated exceptional competency in utilizing cyber techniques as a supporting effort to kinetic operations. During their physical invasion of the Ukraine, they executed a dedicated denial of service (DDOS) that prevented the use of mobile phones.13

In addition to robocalling 911, DDOS attacks can also adversely affect computer connectivity or any device connected to the internet. Such an attack that targets dispatch centers, flooding them with thousands of “flood” calls instantaneously, would result in delays in care and unnecessary deaths.

An offensive electromagnetic pulse (EMP), the secondary effect of a nuclear weapon, would permanently disable any (unshielded) electrical component within line of sight. This includes the vast majority of electrical components today; everything from car alternators and cell phones, to electricity transformers and power plants.

Most concerning would be the effect an offensive EMP would have on nuclear reactors, introducing an array of problems that are imaginable, but beyond the scope of this article (for further reading on EMP effects, including nuclear reactors, reference Electromagnetic Defense Task Force 2.0, April 2019, Air University Press). While the chances of this are remote, a solar corneal mass ejection would have a similar effect,14 though potentially less severe due to distance.

A concern more relevant than potential nuclear effects is related to new hypersonic weapons, munitions that travel at at least five times the speed of sound, covering a mile in under a second. The Army is planning to field their first hypersonic weapons in 2023.15 More narrowly on the electromagnetic spectrum than EMP, in order to defend against such future technology, concentrated microwaves are being developed that can be projected great distances.16

The premise is that the amplified, directional, microwave will fry precision targeting, guidance and explosive components on an inbound projectile a mile away. But in a case of Pandora’s Box, such a defensive weapon in the wrong hands can be turned into an offensive capability, with disastrous consequences for a modern, technology-based population.

Offensive use of a microwave weapon or EMP/solar flare could fry and disable everything from pulse oximeters to airborne MEDEVAC aircraft. Radio systems would be disabled and ambulances would be dead lined with “dead” electrical systems. Electronic suction and cardiac monitors would be little more than expensive paperweights.

EMS, fire and law enforcement would come to a grinding halt. Without public safety, the streets would be a petri dish for chaos and disorder, fueling simmering divides in this country. This is the effect entities utilizing gray zone strategies seek to create.

So concerned are forward-thinking urban emergency systems that they have purchased special EMP-shielded mobile backup base stations and antenna towers that are ready to deploy in the event that they are needed.17

While not specifically a gray zone technique or tactic, weaponizing of space has huge implications. The Outer Space Treaty of 1967 prohibited the weaponization of space with nuclear weapons or placing weapons in orbit, and since that time additional agreements have reinforced that construct. Hard lessons were learned in 2007 when China destroyed one of its own satellites in orbit, creating thousands of pieces of space debris,18 many which still threaten satellites today. What happens 1,200 miles above will directly impact the way we travel or communicate.

Today, most urban and many rural EMS services utilize some form of GPS-based tracking system to optimize dispatching the right unit, a practice that is only likely to grow. Furthermore, communication satellites often aid in facilitating information flow in remote areas or even urban areas isolated during natural disasters. Loss of either of these space-based systems would have catastrophic impacts for life here on earth and hamper emergency responses.

Mitigation Strategies

So, what can we do? Strategically, the EMS community will have minimal impact on those countries that seek to harm the U.S. We can however prepare and train for the above potentialities in order to make us a hard target. How do those scenarios inform our training guidance and local protocols?

Situational awareness and attention to detail are critical performance elements of our jobs. Whether it is noticing the subtlety narrowing pulse pressure or taking note of the sneakers a suspicious person is wearing, those minor details are responsible for keeping our patients, and us, alive.

Scene size up is critical, and unfortunately, scene safety may be contested. What was the mechanism of injury? What is out of the ordinary? Is there a strange odor or smell?

Technology is a great tool but is no substitute for knowledge. With an overabundance of information at our fingertips, from smart phones, clinical protocols to downloadable Emergency Response Guides, we’ve deferred in many instances to looking things up electronically. Could a crew locate the orange book inside the rig (likely given shift checklists) or use it if necessary (questionable)?

Could our EMS teams hand write a patient report, including the pertinent information without the prompts an electronic format provides? Would they know where to locate those “hard-copy” sheets? Similarly, the ability to utilize atlases and maps is becoming a lost art. The process should be revitalized in order to provide our teams with the ability to find that house on an obscure dead-end court when cell towers are down. This is just as relevant in the case of natural disaster response.

Finally, share best practices. “Learning by meme” and Facebook life hacks may not be the best method of acquiring knowledge in a highly technical field. There is no substitute for face-to-face dialogue at professional training events or conferences.

Listen to dissent in order to ensure you do not have blind spots. Be receptive to varying techniques, tactics and procedures. Look at online discussion boards where civil discourse can take place. All these help us evolve as individuals in a complex profession.

Conclusion

While quantum computing, cutting edge medical research, and telemedicine may make the life of the prehospital provider more dynamic and technology focused, hazards are ever looming. The rise of Skynet and artificial intelligence will not bring about human extinction in the near future but challenges and domestic vulnerabilities have the potential to detrimentally impact our profession over the next decade.

Mitigation techniques, planning, and drills will allay all but the direst of threats. However, as has always been the case since “Johnny and Roy” first burst onto the scene, the most important tool the prehospital provider remains their brain and their ability to use it to think and innovate.

Disclaimer: The views expressed are the authors alone and are not representative of the United States Army, The U.S. Army War College, or The Army Medical Department.

References

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2. Office of the United States Trade Representative [Internet]. Washington DC. Findings of the Investigation Into China’s Acts, Policies and Practices Related to Technology Transfer, Intellectual Property and Innovation Under Section 301 of the Trade Act of 1974. 2018 Mar 27. Available from https://ustr.gov/sites/default/files/Section%20301%20FINAL.PDF.

3. Jensen B, Valeriano B, Maness R. Fancy Bears and Digital Trolls: Cyber Strategy with a Russian Twist.  Journal of Strategic Studies. 2018 Jan [cited 2019 Sep 4];35(4).

4. Stelzenmuller, C. The Impact of Russian Interference on Germany’s 2017 elections (Testimony before the US Senate Select Committee on Intelligence). Brookings [Internet]. 2017 Jun 28 [cited 2019 Aug 14], Available from: https://www.brookings.edu/testimonies/the-impact-of-russian-interference-on-germanys-2017-elections/.

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13. Jensen, Valeriano and Maness.

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15. Jones-Bonbrest, N. Army awards hypersonic weapons system contract. US Army website. 2019 Aug 30 [cited 2019 Sep 11]. Available from https://www.army.mil/article/226368/.

16. Venable, H, Abercrombie, C. Muting the hype over Hypersonics: The Offence-Defense Balance in Historical Perspective. War on the Rocks [Internet]. 2019 May 28. Available from: https://warontherocks.com/2019/05/muting-the-hype-over-hypersonics-the-offense-defense-balance-in-historical-perspective/.

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