Preparation is Key when Responding to MCIs Caused by Low-tech Terrorism

Defining the word “terrorism“ can be difficult–definitions vary between those used in state and federal laws. Most people picture foreign nationals plotting large-scale attacks that involve vehicle-borne improvised explosive devices, suicide bombers or weapons of mass destruction (WMD). Perhaps the best description, however, comes from the National Tactical Officers Association (NTOA), which defines terrorism as “any act that threatens mass casualties or widespread destruction.” 

This definition also accurately describes the relationship between terrorism and EMS. Most likely, EMS will handle casualties from low-tech terrorism instead of high-tech terrorism. Low-tech terrorism is best defined as the use of common and easily obtained knowledge and weapons in order to cause mass casualties or widespread destruction with little planning and support. 

Some examples of low-tech might include the use of a vehicle to run over victims in a crowded area, mass shootings, arson, or bombings using simple homemade explosives or incendiary devices. Anyone with Internet access can find simple instructions on the manufacture of such devices, including rudimentary timing mechanisms, and the materials are readily available at many local stores in your jurisdiction. No special training is required to kill or injure large numbers of people using such simple weapons; just look for a crowd of people, preferably in a confined area, who have little defense capability or chance of escape, and attack them. Low-tech terrorism is very effective because it creates a high level of fear but requires very little in the way of support, funding, training and planning. 

A mass casualty incident (MCI) is typically defined as an event that includes so many patients that it overwhelms local resources. Most EMS systems are trained to respond to MCIs caused by transportation accidents or natural disasters, and many prepare for MCIs caused by violence. Though MCIs are often unpredictable and may include ongoing threats to responder safety, MCIs involving violent attacks include a high likelihood of continuing violence specifically directed at responders. 

EMS responders to Columbine High School Shooting

In this image from television, a Columbine High School student is rescued by emergency personnel during the shooting spree at the school in Littleton, Colo., on April 20, 1999. EMS responders must be prepared to act outside normal protocols when responding to MCIs caused by low-tech terrorism. AP Photo/KCNC-TV Denver

Tipping the Scale

Attacks directed against buildings and public events containing numerous unarmed citizens have been a favored terrorist tactic for years. Although attackers usually operate alone or in pairs, attacks in the U.S. by larger groups have been previously planned but not carried out as successfully as in other countries. Often referred to as an “active shooter” event, these attackers are defined by the NTOA as “an armed person who has used or demonstrated the intent to use deadly physical force and continues to do so while having access to additional victims.” 

Terrorist organizations, their lone-wolf sympathizers and other attention-seeking murderers have all recognized the effectiveness and ease of low-tech, small-scale attacks when compared to 9/11-style catastrophic attacks. A recent example is the Boston Marathon bombings, in which terrorists placed backpacks filled with improvised explosive devices (IEDs) containing ball bearings and nails near the finish line of the 26-mile course. The bombs were placed on the ground where they detonated approximately 13 seconds apart. The shrapnel ripped through the crowd, killing three people and injuring more than 250 others. More than a dozen suffered amputations. 

While the death toll itself at the Boston Marathon was small compared to other low-tech attacks like the shootings at the Century Theater in Aurora, Colo. or Sandy Hook Elementary School in Newtown, Conn., the overall effect nationwide was the same in that it generated wide-spread fear in the population and made the attackers infamous. Low-tech attacks such as these will continue to happen regardless of new laws or security measures, and EMS must be prepared when they occur. 

Many EMS providers and administrators assume they will be able to follow standard protocols–staging outside the danger area–until law enforcement has made the scene safe. However, this may be easier said than done. Ambushes could be planned in potential staging areas or along ingress routes adjacent to primary targets, with secondary attacks or explosive devices aimed at first responders. There may even come a time when your crew must knowingly accompany law enforcement and fire personnel into an unsecured scene due to the overall size and scope of an incident. In Boston, EMS and fire personnel were already in the immediate area when the bombs detonated, which meant many responders were almost included in the initial casualties. 

There is no guaranteed “safe” area for EMS during a violent incident. Even if this seems scary or extraordinary, the fact remains that all public safety personnel may have to assume non-traditional roles and risks not necessarily expected before innocent victims began dying. First responders must stay alert and flexible to rapidly changing scenarios and different plans of action–a good plan enacted immediately may be better than a great plan enacted 15 minutes later if a narrow window of opportunity slips away. 

Responding to Acts of Terror 

EMS personnel in the U.S. have frequently found themselves thrust into the middle of violent incidents, including terrorist attacks. Some of these incidents targeted EMS and other first responders who were attempting to aid victims. Every terrorist act teaches vicious lessons to responders, especially those who failed to heed the lessons of the past. 

For example, on Jan. 16, 1997, an abortion clinic was bombed in Atlanta. Approximately one hour later, a secondary device detonated in the area that targeted public safety personnel responding to the first blast. Three police officers and one firefighter were injured in that secondary blast. On December, 24, 2012, a deranged, 62-year-old convicted felon killed his sister and then set fire to his house in order to ambush responding firefighters from the West Webster (N.Y.) Fire Department. He shot and killed two firefighters and wounded two other firefighters and a police officer. Seven homes burned to the ground while police attempted to locate and neutralize the attacker.

The Columbine High School massacre on April 20, 1999, in Littleton, Colo., was actually intended to be primarily a bombing instead of a mass shooting. The assailants had built nearly 100 IEDs, including two large propane-fueled bombs placed in the kitchen/cafeteria that were designed to kill hundreds of people. The assailants planned to remain outside and shoot those who attempted to flee from the explosions. They also planted IEDs in their cars, which they left in the parking lot in order to target EMS and other responders. Fortunately, neither the cafeteria bombs nor the car bombs detonated. Still, despite the attack being not nearly as successful as planned, emergency medical care didn’t reach some victims for hours due to multiple factors including the size of the school, unexploded bombs throughout the building, communication difficulties, and numerous conflicting reports regarding the number of attackers, their descriptions, their locations, and their weapons. Police officers provided suppressive fire to cover paramedics who were fired on while rescuing victims outside the school. Later, paramedics and a physician were escorted into the school to triage, treat, evacuate and pronounce patients. 

One of the many lessons learned from the Columbine massacre was the importance of tactical medical capability and the inclusion of EMS into law enforcement response to similar incidents. Tactical medical providers had been a part of a limited number of SWAT teams since the 1970s, but their value was not fully realized by many agencies until after the delayed care seen at Columbine. This provided a lifesaving change in the capabilities of EMS providers who later responded during the Virginia Tech massacre on April 16, 2007. Two student-volunteer tactical medics were attached to the Virginia Tech and Blacksburg SWAT teams. Those medics entered Norris Hall with the initial entry teams while victims were still being murdered. These two unarmed tactical medics provided immediate life-saving interventions and triage within minutes of their entry, including applying tourniquets and occlusive dressings. Additional EMS units were not permitted to enter the scene until it was declared “secure” approximately 20 minutes later. The presence and quick actions of the student tactical medics undoubtedly saved lives that day. 

EMS agencies should be prepared to discuss whether to pursue having paramedics and EMTs train to be able to enter a scene under police escort in order to establish casualty collection points (CCP) in closer proximity to the victims. A CCP may be any type of area, inside or outside, that can be reasonably secured and defended from further attack. Law enforcement officers provide security so that EMS providers can focus on triage and treatment for the patients who are brought to the CCP. If necessary in your jurisdiction, EMS agencies should help facilitate medical training of police officers who might be able to assist patients during an incident before EMS arrival. Minimum training for officers should include basic techniques in bleeding control, airway management, triage and patient movement. Higher levels of medical training for police officers have also been shown to be effective. 

For example, on Feb. 14, 2008, a gunman entered a lecture hall on the DeKalb campus of Northern Illinois University (NIU) and shot numerous people before shooting himself. The NIU police officers who responded within minutes were also certified EMTs. On finding that the gunman had committed suicide, the officers secured the scene and immediately began to triage and treat the five dead and 21 injured victims prior to the arrival of the area EMS and fire units. 

EMS responds to the Virginia Tech Massacre

Because threats can quickly re-emerge from a scene that has already been declared as safe, tactics and treatment should be limited to securing the airway, controlling bleeding, stabilizing the spine and moving the patient out of danger. Here, rescue workers wheel in stretchers after the Virginia Tech Massacre, when a gunman murdered 32 people in two attacks two hours and a half-mile apart before the university could figure out what was going on and get the warning out to students. AP Photo/Don Peterson

Preparing & Planning for Action

Attacks in the U.S. often mirror those seen in other parts of the world. In fact, many terrorism experts anticipate that low-tech terrorist attacks that are larger in scale, such as those in Beslan, Russia and Mumbai, India, will eventually be attempted within the U.S. 

The attacks in Russia and India involved multiple attackers using mostly conventional small arms and grenades that resulted in multi-day operations, hours of active combat with a determined enemy and hundreds of casualties. The Mumbai attacks were conducted by multiple pairs of gunmen who roamed the city, shooting innocent victims and placing IEDs. The use of similarly well-trained terrorist teams roaming U.S. cities conducting simultaneous attacks will greatly complicate our response and prevent the establishment of secure areas for EMS operations much like a war zone. 

How will EMS respond to such incidents, particularly when they cover a large geographic area? Staging until the “scene is safe” may not be realistic in lengthy scenarios where people are dying, law enforcement is overwhelmed and terrorists are looking to attack responders staged in one location. The U.S. has already seen small examples where roving attackers create multiple crime scenes, actively target responders and spread fear throughout an entire region. The 2002 Beltway Sniper attacks, the aftermath of the 2013 Boston Marathon bombings, and the 2013 Southern California manhunt for a former police officer turned murderer all forced emergency responders to reconsider their tactics in their daily operations.

In the Boston Marathon bombings case, the entire region was thrown into chaos as the suspected bombers murdered a police officer sitting in his patrol car, hijacked another car, robbed a convenience store and engaged in a dramatic firefight with other officers. Sixteen officers were injured but only one of the terrorists was killed. The second terrorist was finally captured after an extensive manhunt and a second firefight with officers. 

In addition, though most violent MCIs in the U.S. have typically involved firearms or homemade explosives, some have involved vehicles. In two separate incidents, both in 2006, one in San Francisco, and the other in Chapel Hill, N.C. terrorists intentionally ran people over. Combined, one person was killed and 27 were injured. 

Combat Zones

Hazardous materials response training has long separated affected areas during an incident into hot, warm and cold zones. In very basic terms, the hot zone is the contaminated area where the level of potential threat is high. The warm zone is where the potential threat level is reduced but still possible. The cold zone is the support zone where all activities can be conducted without being exposed to the threat. 

The U.S. military’s Tactical Combat Casualty Care (TCCC) separates rescue and medical care tactics in a somewhat similar manner. Terminology and tactics from both sections are useful for EMS response to low-tech terrorist attacks. 

TCCC’s Care Under Fire stage might be compared to hot zone operations where the risk is very high. To increase the odds of success, special tactics are required. Remote assessment of any potential victims should be conducted from a position of cover, using binoculars to identify viable patients who would benefit from a timely rescue. There’s no point in risking additional lives for body recovery during an ongoing hostile situation. If allowed in your service, treatment in the hot zone should only take place behind cover and be limited to immediate life-saving actions such as tourniquet application. Emergency patient moves in the hot zone may ignore C-spine precautions in favor of moving a patient from immediate danger to safety. 

The TCCC Tactical Field Care stage can be compared to warm zone operations where the threat of additional attack may be likely to occur at any moment. The area may be unsecured but have no known threat immediately apparent. The use of cover and concealment is a necessity, as is constant awareness of any potential threats. Due to the potential for threats to re-emerge, tactics and treatment should be limited to securing the airway, controlling bleeding, stabilizing the spine and moving the patient out of danger. 

Although situational awareness should always be maintained, cold zones are considered relatively safe areas where standard MCI triage, treatment and transport protocols can be followed. Cold zone operations are similar to TCCC’s Tactical Evacuation, or TACEVAC, stage.

EMS responds to shooting at Northern Illinois University

The law enforcement officers who responded to the gunman who opened fire in a Northern Illinois University lecture hall were also certified EMTs. This double certification allowed them to secure the scene immediately after finding that the gunman had committed suicide, and begin triaging and treating the 21 injured victims prior to the arrival of the area EMS and fire units. AP Photo/Charles Rex Arbogast

Using Personnel Resources

Even though EMS personnel have been taught to avoid entering an unsafe scene, they may still find themselves in the middle of a secondary attack or ambush in a supposed cold zone such as in the cases of the responders injured by the secondary explosive device at the 1997 Atlanta abortion clinic bombing or the 2012 ambush of the West Webster, N.Y. firefighters. In addition, smaller jurisdictions may have a limited number of law enforcement, fire and EMS responders available to assist with a violent MCI. The number of police officers available on scene in the first 30—60 minutes in many rural areas may be insufficient to neutralize threats, properly secure the scene, extract victims from the hot zone, and guarantee the safety of EMS and fire department units. In such a situation, it would be hard for EMS providers to stand outside in the cold zone and do nothing, knowing that victims needed medical rescue. Such notions generate much debate and should not be taken lightly. However, situations where responders are very limited may require outside-the-textbook thinking. For example, at Columbine High School, police used a fire engine and armored car to provide cover for police and EMS personnel. However, these operations require pre-planned and calculated risk if they are to be attempted. 

Planning and practicing potential response scenarios reduces future risk. It’s important to prepare for and practice response during all types of situations and with all possible types of resources, especially in rural areas where surge capacity is limited. For example, rescue teams that include tactical medics may be preferred for providing care in the hot or warm zones, but are unlikely to be available in the critical first 30—60 minutes. Patrol officers cross-trained as emergency medical responders or EMTs are more likely to be available in many areas. The best option given an overall lack of resources might be ad hoc strike teams combining non-tactical EMS personnel with covering law enforcement officers who are tasked with establishing casualty collection points within the hot zone. Non-EMS fire personnel might also supplement the strike team as litter bearers to aid in moving the victims to the cold zone. Training should include a wide variety of possible scenarios, as well as all types of resources that could be available during a violent MCI in your area. 

All EMS personnel should be well-versed in rescue team movement, cover versus concealment, incident command, remote assessment, triage and life-saving interventions. Victims may suffer from lacerations, burns, penetrating injuries or blast injuries, but interventions will likely be limited to basic bleeding control through the use of tourniquets and pressure dressings, and limited airway management. Emergency carries, drags, and the use of rescue aids, such as basket stretchers, chairs, blankets or tubular webbing, must also be practiced as much as possible. with in order to evacuate victims and minimize the exposure of EMS personnel. 


A career in EMS involves a certain amount of inherent risk. Responding to a low-tech terrorist act like a mass shooting or bombing is extremely dangerous, even if EMS units stage in a seemingly safe area. An ambush or secondary attack specifically targeting potential staging areas could quickly turn a cold zone into a hot zone. As with any high-profile event, be prepared for the possibility that you may have to assume roles and responsibilities outside your expectations. Communicate and train with other disciplines prior to a terrorist attack in order to improve your odds of success. Combined providers (medically trained police) may be desirable because they can adapt to the highest priority at the moment much in the way a military combat medic does. They can fight to neutralize the threat and/or reach, treat and defend the victims if it becomes necessary. 

Strike teams composed of police officers and EMS personnel are able to provide immediate care to victims, establish CCPs or extract victims while maintaining a security element. Such strike teams may be easier to deploy in areas where armed tactical medics are not quickly available. Similar tactics were eventually used at Columbine when paramedics were later escorted into the school and at Virginia Tech where unarmed tactical medics accompanied the SWAT teams. Entering an unsafe scene of violence, even with a law enforcement escort, violates every scene-safety rule in EMS. However, it may be necessary to save lives, particularly in rural areas where law enforcement and EMS resources are limited. Such actions, while extreme to some, may also help to minimize your time on scene and overall exposure to threats. Assume you are a target even if you think you are staging in a “safe” area or cold zone. 

You likely entered EMS, in part, because of your desire to help those in need. Despite your good intentions, there are those who will specifically target EMS personnel and other responders. Low-tech terrorist attacks may be conducted anywhere and by anyone. Will you be ready mentally and physically to respond?

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