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Terrorist Attacks EMS Psychological Implications and the Aftermath

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Terrorist Attacks EMS Psychological Implications and the Aftermath

Terrorist Attacks and the Aftermath

The Role of EMS - Emergency Medical Services

The New Zealand Terrorist Attack is fresh in the News

Where the Christchurch shootings happened
A gunman targeted two mosques in central Christchurch at lunchtime Friday local time. Friday is the busiest day for many mosques around the world.
The horrific attack on al Noor Mosque, including the time where shooter returns to the car to re-arm, lasts approximately six minutes.
As the shooter drove away from al Noor mosque, he opened fire on several people who were walking along the street, the video appears to show.
Social media sites such as Facebook, YouTube and Twitter struggled to halt the spread of the footage, raising new questions about the companies' ability to manage harmful content on their platforms.

What we know about the suspects
Brenton Tarrant, 28, has been charged with murder in connection to the unprecedented attack on the two mosques.
Mass shooting suspect charged with murder in New Zealand
Mass shooting suspect charged with murder in New Zealand
He appeared in Christchurch district court on Saturday. During his brief appearance, Tarrant was handcuffed and accompanied by three officers armed with tasers. He was silent during his court appearance and has been remanded in custody to reappear in court on April 5.
Just before the shootings, a link to an 87-page manifesto on Twitter and 8chan, an online messaging board that has been used by anonymous accounts to share extremist messages and cheer on mass shooters, was posted to an account in Tarrant's name.

terrorist attack and role of air ambulance medical escorts

Fifty people were killed and 50 others wounded in a terror attack on two mosques in Christchurch, New Zealand, police announced Sunday.

The unprecedented mass shootings were carefully planned, and have shocked the usually peaceful nation.

New Zealand Prime Minister Jacinda Ardern described the attack on Friday as one of her country's "darkest days." She said that the suspects held "extremist views" that have no place in New Zealand or anywhere else in the world.

On November 13, 2015, a series of coordinated attacks in Paris left 130 people dead. A week later, armed gunmen stormed a hotel in Mali, seizing hostages while also firing indiscriminately at guests, killing 27 people. And this week a mass shooting in San Bernardino, California, left 14 dead. While the motive is not known, the FBI has assigned counterterrorism agents to the case, sparking public speculation that the shooting may have been an act of terrorism.

You could spend hours every day watching, reading and listening to news related to these events. This level of exposure can significantly influence your worldviews and how you live your life.

The aftermath of events like these can make people feel more vulnerable. And as cities go on alert because of the threat of future attacks, fear can color our daily routines and world views.

With my colleague S Justin Sinclair at Harvard Medical School, I have been studying the complexity of terrorism fears, and how fear can affect and motivate people.

It is probably not a surprise that a terror attack can have a major impact on people’s mental health. But what sort of effects are common, and how long do they last?

To answer that question, we can turn to a growing body of research examining the psychological aftermath of terror attacks.

Increases In PTSD Symptoms Are Often Seen After Terror Attacks

In 1995 and 1996, France experienced a wave of bombings that killed 12 and injured more than 200. A 2004 retrospective study examined post-traumatic stress disorder rates in the victims and found that 31% experienced post-traumatic stress disorder.

Symptoms of post-traumatic stress disorder (or PTSD) can include flashbacks, nightmares, or intrusive thoughts about the event. People may also avoid situations that remind them of the trauma, or have intense feeling of anxiety they didn’t have before.

Research has also found an increase in psychiatric symptoms among people living in a city when it is attacked.

For instance, a survey of Madrid residents one to three months after the attacks on a commuter rail line in 2004 found an increase in post-traumatic stress disorder and depression.

In a 2005 study of London residents conducted a few weeks after the 7/7 attacks, 31% of respondents reported a significant elevation in stress levels and 32% reported an intention to travel less. A follow-up study conducted seven months later found that the elevated stress levels were significantly reduced. But, the study also noted that a residual level of worry remained. Many people reported relatively high levels of perceived threat to self and others, and a more negative world view.

We would expect to see an increase in psychiatric disorders among people who were directly affected, or who lived in the city at the time of the attack. But this can also happen in people who weren’t living in a city when it was attacked.

A survey conducted soon after the September 11 attacks found that 17% of the US population living outside of New York City reported symptoms related to post-traumatic stress disorder. Six months later, that dropped to 5.6%

A 2005 review of psychological research about the effect of September 11 highlighted the uptick in psychiatric symptoms and disorders immediately after the attacks and the relatively quick normalization in the following 6-12 months. However, people living closer to the area attacked, and thus more directly exposed, were more vulnerable to developing post-traumatic stress disorder, than people living further away.

Why do symptoms of post-traumatic stress disorder increase in people who weren’t directly exposed? The explanation might be the intense media coverage of terror attacks.

In the aftermath of September 11, a US study of more than 2,000 adults found that more time spent watching television coverage of the attacks was associated with elevated rates of post-traumatic stress disorder.

In essence, a media-related contagion effect is created where people live and relive the attacks when they watch or read stories about them. This overexposure may, as argued by some, produce a subjective response of fear and helplessness about the threat of future attacks in a minority of adults.

ems and medical escorts in terrorist attacks worldwide

Fear Changes Behavior, At Least For A Little While

Fear is a natural response to events like the attacks in Paris or Mali. While everyone feels and reacts to fear differently, it can push people to make different decisions about employment, whom to socialize with, using public transportation such as buses and trains, congregating in public and crowded places, and traveling on airplanes.

If you look at these changes across an entire population, you can see how fears of terrorism can have significant consequences on both the national and global economy. Tourism and shopping may be particularly vulnerable. For example, airlines suffered major economic losses after 9/11 and were forced to lay off large numbers of employees.

While stock markets in New York, Madrid and London dropped after the attacks, they rebounded relatively quickly.

Similarly, after the recent attack in Paris, there was reportedly a limited impact on the nation’s stock market.

Attacks Can Change How People Relate To Government

Terrorists use fear as a psychological weapon, and it can have serious psychological implications for individuals and whole countries.

An underlying sense of fear can linger for years after an attack. In prolonged conflicts with multiple attacks, such as the Troubles in Northern Ireland or the Israeli-Palestinian Conflict, chronic fear and anxiety have arguably resulted in a high levels of segregation and suspiciousness.

This underlying fear may also affect political engagement and trust in government policymaking.

People generally tend to place larger degrees of trust in their government’s ability to keep them safe from future violence following large-scale terrorist attacks. For example, prior to the September 11 attacks, the public’s trust in the US government was in decline, but the attacks primed people’s fears, and trust in the US government to protect and keep the public safe from future attacks rose to a level not seen in decades.

However, increased trust in the government may also come without fear. In countries where there already are high levels of trust in the government, fear has been found to play a less important role.

A study examining the association between fear and trust in Norway right before, right after, and 10 months after the 2011 terror attack found that high levels of existing trust may actually buffer against the negative effects of terrorism fears, while still creating a rallying effect around governmental policies.

The threat of terrorism does not, of course, have the same effect on everyone. Most people arguably respond to threats of future terrorism in a rational and constructive manner. For instance, very compelling research suggests that anger may actually function as a protective factor. In the context of feeling angry, people tend to have a larger sense of being in control, a preference for confrontation, and feeling optimistic; whereas with fear comes a greater sense of not feeling in control and pessimism.

The paradox of the fear that terrorism inspires, is that while it can negatively affect people and societies, it can also serve to strengthen resilience.

The effect of 9/11 on the prevalence of PTSD

Geographic proximity to the WTC crash site was significantly related to the prevalence of probable PTSD. The prevalence of probable PTSD during the second month following the terrorist attacks among persons who were in the New York City metropolitan area that day was 11.2% compared with a national prevalence estimate of 4.3%. Although the prevalence in the Washington, DC, metropolitan area (2.7%) and in other major metropolitan areas (3.6%) was slightly lower than the overall national prevalence, those differences were not statistically significant.

The prevalence of probable PTSD was also significantly associated with the number of hours of TV coverage of the attacks that participants reported watching on September 11 and in the following few days and with the number of different kinds of potentially traumatic events participants reported seeing. The prevalence among those who reported that family, friends, or coworkers were killed or injured in the attacks and among those who reported being in the military or having close family members or loved ones in the military was considerably higher than among those who did not, but neither difference was statistically significant.

Although the prevalence of probable PTSD was significantly higher in the New York City metropolitan area than in the rest of the country, some or all of the difference could be attributable to differences in the sociodemographic characteristics of the populations of those areas. When we controlled for age, sex, race/ethnicity, and education using logistic regression, however, we found that those who were in the New York City metropolitan area on September 11 were 2.9 (95% confidence interval, 1.4-5.8) times more likely to be probable cases of PTSD than those who were elsewhere that day. The model-based estimate of the difference in prevalence between the New York City metropolitan area and the rest of the United States, adjusted for sociodemographic differences in the respective populations using methods described by Korn and Graubard is 5.1 (95% confidence interval, 0.5-9.7) percentage points.

In addition, we also modeled the association of a more detailed set of exposures with the full range of PTSD symptoms, using the PTSD symptom scale score as the dependent variable. Because the most direct exposures (eg, having been in 1 of the attacked buildings the day of the attacks) occurred in adequate numbers only in the New York City metropolitan area, we conducted these analyses among the subset of N-SARS participants who were in New York City on September 11. The variables included in the model were age; sex; race/ethnicity; education; having been in the WTC or surrounding buildings at the time of the attacks; having seen the WTC in person on September 11 but after the collapse of the buildings; having been close enough to see the smoke from the WTC site on September 11; having family, friends, or coworkers injured or killed in the WTC; number of hours per day of TV coverage watched; and the TV content index (number of different kinds of graphic WTC events seen on TV). With this full set of variables controlled for, only age, sex, having been in the WTC or surrounding buildings at the time of the attacks, and a number of hours of TV coverage watched per day were significantly associated with PTSD symptoms.

ground ambulance and air ambulance

The emerging threat of complex coordinated attacks, such as those that have occurred in Mumbai, Paris and Brussels over the last 10 years, puts the safety and security of the public at risk, and will have a significant impact on EMS preparedness and response.

Mumbai, India, 2008
Beginning the night of Nov. 26, 2008, 10 men associated with the Lashkar-e-Tayyiba terrorist group conducted multiple attacks in Mumbai, India. The terrorists traveled from Pakistan to India together and then divided into four tactical units.
The first team of two terrorists initiated an attack at approximately 9:21 p.m. at the Chhatrapati Shivaji Terminus railway station. By firing into the crowds present at the station, the terrorists were able to kill 58 people over the course of 90 minutes. After exiting the station, they killed six police officers in an ambush attack. They killed ten more people before law enforcement was able to kill one of the terrorists and capture the other.
The second site attacked was Nariman House, operated by the Jewish Chabad Lubavitch movement. The attack began on November 26 at 9:30 p.m. when the gas station next to the house exploded. Two terrorists fired on the building and then entered to take hostages. It took three days and several tactical engagements to rescue the hostages and kill the terrorists.
The Leopold Café was the site of the third attack, which began on November 26 at approximately 9:30 p.m. Four of the terrorists entered the cafe and opened fire, killing ten people.
The cell then traveled to the Taj Mahal Palace and Tower Hotel to continue the attack. The siege, which killed 31 people, would continue for three days.
The fourth attack was at the Oberoi-Trident Hotel. Two of the terrorists entered the hotel restaurant on November 26 at 9:57 p.m. and opened fire on the crowd. The siege continued within the hotel until afternoon the following day. Approximately 30 people were killed.

Paris, France, 2015
The Islamic State militant group killed 130 and injured hundreds more by conducting a series of attacks around Paris within 20 minutes. The attacks began when a suicide bomber detonated explosives outside of the Stade de France during a soccer match. Two additional suicide bombers would detonate bombs outside of the stadium within the next 35 minutes.
Five minutes after the first bomb was detonated, shooters opened fire in a different area of the city at the Le Carillon bar and the Le Petit Cambodge restaurant. Approximately seven minutes later, shooters opened fire in front of a pizzeria and a cafe located several blocks away.
Five minutes later, the terrorists traveled by car to La Belle Equipe bar, where they opened fire on patrons. Within minutes, a suicide bomber detonated explosives at the restaurant, Le Comptoir Voltaire.
Simultaneous to the detonation of this suicide bomber, three men entered the Bataclan concert hall and opened gunfire on the crowd. Police engaged with one of the attackers, causing his suicide bomb to detonate. The other two terrorists in the concert hall detonated their explosives while fighting with police.

Brussels, Belgium, 2016
A coordinated attack by Islamic State-inspired terrorists took place in Brussels, Belgium, on March 22, 2016. Two suicide bombers detonated explosives within a minute of each other in the departure lounge of the Brussels Airport in Zaventem.
One hour later another suicide bomber detonated an explosive on the Brussels subway. The attacks killed 31 and injured 300.5
Preparation & Response
Response to a complex coordinated attack is challenging. Responders may not initially be aware that they are responding to a terrorist event. Also, first responders have no way of knowing if the attack is isolated or part of a larger plot—or if they are the intended target of the attacks. The uncertainty of these elements makes it difficult to assess the safety of the scene.
The Department of Homeland Security (DHS) Office of Health Affairs has provided several recommendations for improving incident response management within the First Responder Guide for Improving Survivability in Improvised Explosive Device and Active Shooter Incidents. Key recommendations include standardized use of the National Incident Management System (NIMS), active patient triaging and increased integration between EMS, the fire service and law enforcement.
The DHS Office of Health Affairs has identified additional opportunities to improve incident response management which are reliant upon a robust emergency preparedness program. Opportunities include expanding Public Safety Answering/Access Point (PSAP) intake procedures, developing interoperable communications between all first responders and receiving hospitals and a continuous training and exercise program to maintain competency for this low-frequency, high-consequence events. Training and applications should be integrated between EMS and law enforcement agencies.6
The All Hazards Disaster Response (AHDR) course provided by the National Association of EMTs also covers these essential functions for frontline EMS practitioners.
The Hartford Consensus IV: A Call for Increased National Resilience has recognized that there's a crucial response asset often present before the arrival of professional first responders: the uninjured bystanders. Bystanders have demonstrated a willingness and capacity to provide immediate lifesaving care before the arrival of the formalized EMS agency. They're a crucial component in increasing survivability and there should be further development of the capacity for the general public to provide emergency medical care.
Victims of terrorist attacks typically have trauma that's more complex than other trauma patients, and there's an increased prevalence of vascular injury. Clinical care for injured patients should be directed by evidence-based guidelines outlined within courses such as Prehospital Trauma Life Support (PHTLS) or Tactical Emergency Casualty Care (TECC).
Tourniquets are also identified as a safe and effective treatment to prevent exsanguination from a bleeding extremity injury.
A recent study found the injury patterns of civilians in mass shooting events differ from soldiers in combat operations and "a treatment strategy that goes beyond the use of tourniquets is needed to rescue the few victims with potentially survivable injuries."

Conclusion
Complex coordinated attacks present a serious threat to EMS, and a robust emergency management program is necessary to prepare practitioners for operational and clinical response to the events.
There's also an opportunity for EMS systems to support The Hartford Consensus IV by developing the capacity and resilience of immediate bystanders to provide lifesaving care during these events. Developing resilience within the general public is an invaluable capability EMS can work to cultivate.

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