Terrorist Activity: Are You Ready?

I was relaxing after work in my local American Legion a few weeks ago when a quiet young man entered with a backpack. He set it down to use the restroom, and when he returned a few minutes later, he picked up the backpack and walked away. After he left, a group of us discussed how lax we were about this situation. Yes, it was probably innocent—but what if it wasn’t? A sign over the bar reads, “Don’t let anyone leave a stranger.” The purpose of that sign is, of course, to make everyone feel welcome, but these days I think it also means to be aware of your surroundings. I have seen too many American flags at half-staff this year to overlook a potential tragedy.

Today, clinicians must be prepared for all possible emergencies, including terrorism. Acts of terrorism (as the word implies) are designed to instill terror and ­panic, disrupt security and communication systems, destroy property, and kill or injure innocent civilians.

Recent terrorist attacks in 2016, while shocking in their brutality, were not inconceivable—public locations where large groups gather are logical targets. Terrorists often target high-traffic areas, such as airports or shopping malls, where they can quickly disappear into a crowd if necessary (hence the concern circling the Olympic Games to be held in Brazil this month).

Attacks at restaurants, airports, and other public “hot spots” are especially frightening. With terrorist attack locations in the past year ranging from nightclubs (the Pulse Nightclub shooting in Orlando, Florida, left 49 dead) to restaurants (a bomb in Dhaka, Bangladesh, killed 20) to conference rooms (a shooting in San Bernardino, California, left 14 dead and 21 injured), it’s clear that the fundamental message terrorists want to send is: You are not safe—anywhere!

While organized events and big crowds are a bull’s-eye for terrorists, our personal surroundings have risk factors, too. Because a terrorist attack can happen anywhere at any time, you need to be prepared by knowing what to do and how to maximize your chan­ces of survival.

As this year’s attacks exemplify, we shouldn’t assume we understand the “logic” or thinking of terrorist organizations or individuals. Preparation for a terrorist attack boils down to being aware of the warning signs and being cautious and alert. Terrorists use a range of weapons and tactics, including bombs, arson, hijacking, and kidnapping (see Table).^1,2

According to Dr. Howard Mell, an EMS director in North Carolina, the overwhelming majority of gunfire in the emergency department—or anywhere—is not the result of an active shooter. Most gunfire is targeted at a specific goal (ie, escaping or avoiding capture) or person. However, should there be an active shooter, he recommends three steps to take: Run (if the path is open), hide (if your exit is blocked), or fight (if there are no other alternatives).³

Wherever you are, always have multiple potential escape routes in mind. If you run, leave all belongings behind. Help others escape if possible, and take steps to prevent others from entering once you have left the area.

If you are unable to run, decide where to hide. If possible, barricade the area; if you are in a room, turn out the lights and stay away from the door. Be silent and put your cell phone on silent. While you are hiding, prepare to fight.

Fighting is the last resort. Act aggressively and improvise weapons to use against the assailant. If you have family, friends, or colleagues with you, put them to work!

When law enforcement officers arrive, understand that their job is to go right to the source and contain the danger. Keep your hands visible at all times, with fingers spread. Do not grab them for protection, and avoid yelling or pointing. Be prepared to give the authorities any pertinent information (eg, shooter description, last known location, direction of travel, or weapons seen).

Many health care facilities and organizations have valuable disaster and terrorism training programs, which include emergency evacuation procedures. I encourage you to take advantage of them, particularly if you travel internationally.⁴

Continue for personal preparedness >>

This is about personal preparedness. While I am not promoting paranoia, I do believe the risk for terrorist activity has increased in recent years.

I therefore urge you to have a healthy suspicion when you see or hear people
• Asking unusual questions about safety procedures at work
• Engaging in behaviors that provoke suspicion
• Loitering, parking, or standing in the same area over multiple days
• Attempting to disguise themselves from visit to visit
• Obtaining unusual quantities of weapons, ammunition, or explosive precursors
• Wearing clothing not appropriate for the season
• Leaving items, including backpacks or packages, unattended
• Leaving anonymous threats via telephone or e-mail

If after conducting a risk assessment of your surroundings, you believe you could (directly or indirectly) be impacted by terrorism, you must implement evacuation plans, notification of appropriate personnel, and personal safety measures.

In the event of a terrorist incident, remain calm, follow the advice of local emergency officials, and follow radio, television, and cell phone updates for news and instructions. ⁵

If an attack occurs near you or your home, here are practical steps you can take: Check for injuries. Give first aid and get help for seriously injured people. Check for damage using a flashlight—do not light matches or candles, or use electrical switches. Check for fires, fire hazards, and other household hazards. Sniff for gas leaks, starting at the water heater. If you smell gas or suspect a leak, turn off the main gas valve, open windows, and evacuate quickly. Shut off any damaged utilities, and confine or secure your pets. Call your family contact—but do not use the telephone again unless it is a life-threatening emergency. Cell phones may or may not be working. Check on your neighbors, especially those who are elderly or disabled.

Terrorist attacks leave citizens concerned about future incidents of terrorism in the United States and their potential impact. They raise ambiguity about what might happen next and increase stress levels. You can take steps to prepare for terrorist attacks and reduce the stress you may feel, now and later, should an emergency arise. Taking preparatory action can reassure you, your family, and your children that you have a measure of control—even in the face of terrorism. If you have additional suggestions for terrorist defense preparation, you can email your ideas to PAEditor@frontlinemedcom.com.

References
1. Dworkin RW. Preparing hospitals, doctors, and nurses for a terrorist attack. Hudson Institute. www.hudson.org/content/researchattach ments/attachment/291/dworkin_white_paper.pdf. Accessed July 6, 2016.
2. Markenson F, DiMaggio C, Redlener I. Preparing health professions students for terrorism, disaster, and public health emergencies: core competencies. Acad Med. 2005;80(6):517-526.
3. Mell HK. Run, hide, fight: how to react when there’s gunfire in the emergency department. ACEP NOW. June 21, 2016. www.acepnow.com/react-theres-gunfire-emergency-department/?elq_mid=10369&elq_cid=5274988. Accessed July 6, 2016.
4. Uniformed Services University of the Health Sciences, Center for the Study of Traumatic Stress. Workplace preparedness for terrorism. www.cstsonline.org/assets/media/docu ments/CSTS_report_sloan_workplace_prepare_terrorism_preparedness.pdf. Accessed July 6, 2016.
5. American Red Cross. Terrorism Preparedness. www.redcross.org/prepare/disaster/terrorism. Accessed July 6, 2016.

I was relaxing after work in my local American Legion a few weeks ago when a quiet young man entered with a backpack. He set it down to use the restroom, and when he returned a few minutes later, he picked up the backpack and walked away. After he left, a group of us discussed how lax we were about this situation. Yes, it was probably innocent—but what if it wasn’t? A sign over the bar reads, “Don’t let anyone leave a stranger.” The purpose of that sign is, of course, to make everyone feel welcome, but these days I think it also means to be aware of your surroundings. I have seen too many American flags at half-staff this year to overlook a potential tragedy.

Today, clinicians must be prepared for all possible emergencies, including terrorism. Acts of terrorism (as the word implies) are designed to instill terror and ­panic, disrupt security and communication systems, destroy property, and kill or injure innocent civilians.

Recent terrorist attacks in 2016, while shocking in their brutality, were not inconceivable—public locations where large groups gather are logical targets. Terrorists often target high-traffic areas, such as airports or shopping malls, where they can quickly disappear into a crowd if necessary (hence the concern circling the Olympic Games to be held in Brazil this month).

Attacks at restaurants, airports, and other public “hot spots” are especially frightening. With terrorist attack locations in the past year ranging from nightclubs (the Pulse Nightclub shooting in Orlando, Florida, left 49 dead) to restaurants (a bomb in Dhaka, Bangladesh, killed 20) to conference rooms (a shooting in San Bernardino, California, left 14 dead and 21 injured), it’s clear that the fundamental message terrorists want to send is: You are not safe—anywhere!

While organized events and big crowds are a bull’s-eye for terrorists, our personal surroundings have risk factors, too. Because a terrorist attack can happen anywhere at any time, you need to be prepared by knowing what to do and how to maximize your chan­ces of survival.

As this year’s attacks exemplify, we shouldn’t assume we understand the “logic” or thinking of terrorist organizations or individuals. Preparation for a terrorist attack boils down to being aware of the warning signs and being cautious and alert. Terrorists use a range of weapons and tactics, including bombs, arson, hijacking, and kidnapping (see Table).^1,2

According to Dr. Howard Mell, an EMS director in North Carolina, the overwhelming majority of gunfire in the emergency department—or anywhere—is not the result of an active shooter. Most gunfire is targeted at a specific goal (ie, escaping or avoiding capture) or person. However, should there be an active shooter, he recommends three steps to take: Run (if the path is open), hide (if your exit is blocked), or fight (if there are no other alternatives).³

Wherever you are, always have multiple potential escape routes in mind. If you run, leave all belongings behind. Help others escape if possible, and take steps to prevent others from entering once you have left the area.

If you are unable to run, decide where to hide. If possible, barricade the area; if you are in a room, turn out the lights and stay away from the door. Be silent and put your cell phone on silent. While you are hiding, prepare to fight.

Fighting is the last resort. Act aggressively and improvise weapons to use against the assailant. If you have family, friends, or colleagues with you, put them to work!

When law enforcement officers arrive, understand that their job is to go right to the source and contain the danger. Keep your hands visible at all times, with fingers spread. Do not grab them for protection, and avoid yelling or pointing. Be prepared to give the authorities any pertinent information (eg, shooter description, last known location, direction of travel, or weapons seen).

Many health care facilities and organizations have valuable disaster and terrorism training programs, which include emergency evacuation procedures. I encourage you to take advantage of them, particularly if you travel internationally.⁴

Continue for personal preparedness >>

This is about personal preparedness. While I am not promoting paranoia, I do believe the risk for terrorist activity has increased in recent years.

I therefore urge you to have a healthy suspicion when you see or hear people
• Asking unusual questions about safety procedures at work
• Engaging in behaviors that provoke suspicion
• Loitering, parking, or standing in the same area over multiple days
• Attempting to disguise themselves from visit to visit
• Obtaining unusual quantities of weapons, ammunition, or explosive precursors
• Wearing clothing not appropriate for the season
• Leaving items, including backpacks or packages, unattended
• Leaving anonymous threats via telephone or e-mail

If after conducting a risk assessment of your surroundings, you believe you could (directly or indirectly) be impacted by terrorism, you must implement evacuation plans, notification of appropriate personnel, and personal safety measures.

In the event of a terrorist incident, remain calm, follow the advice of local emergency officials, and follow radio, television, and cell phone updates for news and instructions. ⁵

If an attack occurs near you or your home, here are practical steps you can take: Check for injuries. Give first aid and get help for seriously injured people. Check for damage using a flashlight—do not light matches or candles, or use electrical switches. Check for fires, fire hazards, and other household hazards. Sniff for gas leaks, starting at the water heater. If you smell gas or suspect a leak, turn off the main gas valve, open windows, and evacuate quickly. Shut off any damaged utilities, and confine or secure your pets. Call your family contact—but do not use the telephone again unless it is a life-threatening emergency. Cell phones may or may not be working. Check on your neighbors, especially those who are elderly or disabled.

Terrorist attacks leave citizens concerned about future incidents of terrorism in the United States and their potential impact. They raise ambiguity about what might happen next and increase stress levels. You can take steps to prepare for terrorist attacks and reduce the stress you may feel, now and later, should an emergency arise. Taking preparatory action can reassure you, your family, and your children that you have a measure of control—even in the face of terrorism. If you have additional suggestions for terrorist defense preparation, you can email your ideas to PAEditor@frontlinemedcom.com.

References
1. Dworkin RW. Preparing hospitals, doctors, and nurses for a terrorist attack. Hudson Institute. www.hudson.org/content/researchattach ments/attachment/291/dworkin_white_paper.pdf. Accessed July 6, 2016.
2. Markenson F, DiMaggio C, Redlener I. Preparing health professions students for terrorism, disaster, and public health emergencies: core competencies. Acad Med. 2005;80(6):517-526.
3. Mell HK. Run, hide, fight: how to react when there’s gunfire in the emergency department. ACEP NOW. June 21, 2016. www.acepnow.com/react-theres-gunfire-emergency-department/?elq_mid=10369&elq_cid=5274988. Accessed July 6, 2016.
4. Uniformed Services University of the Health Sciences, Center for the Study of Traumatic Stress. Workplace preparedness for terrorism. www.cstsonline.org/assets/media/docu ments/CSTS_report_sloan_workplace_prepare_terrorism_preparedness.pdf. Accessed July 6, 2016.
5. American Red Cross. Terrorism Preparedness. www.redcross.org/prepare/disaster/terrorism. Accessed July 6, 2016.

I was relaxing after work in my local American Legion a few weeks ago when a quiet young man entered with a backpack. He set it down to use the restroom, and when he returned a few minutes later, he picked up the backpack and walked away. After he left, a group of us discussed how lax we were about this situation. Yes, it was probably innocent—but what if it wasn’t? A sign over the bar reads, “Don’t let anyone leave a stranger.” The purpose of that sign is, of course, to make everyone feel welcome, but these days I think it also means to be aware of your surroundings. I have seen too many American flags at half-staff this year to overlook a potential tragedy.

Today, clinicians must be prepared for all possible emergencies, including terrorism. Acts of terrorism (as the word implies) are designed to instill terror and ­panic, disrupt security and communication systems, destroy property, and kill or injure innocent civilians.

Recent terrorist attacks in 2016, while shocking in their brutality, were not inconceivable—public locations where large groups gather are logical targets. Terrorists often target high-traffic areas, such as airports or shopping malls, where they can quickly disappear into a crowd if necessary (hence the concern circling the Olympic Games to be held in Brazil this month).

Attacks at restaurants, airports, and other public “hot spots” are especially frightening. With terrorist attack locations in the past year ranging from nightclubs (the Pulse Nightclub shooting in Orlando, Florida, left 49 dead) to restaurants (a bomb in Dhaka, Bangladesh, killed 20) to conference rooms (a shooting in San Bernardino, California, left 14 dead and 21 injured), it’s clear that the fundamental message terrorists want to send is: You are not safe—anywhere!

While organized events and big crowds are a bull’s-eye for terrorists, our personal surroundings have risk factors, too. Because a terrorist attack can happen anywhere at any time, you need to be prepared by knowing what to do and how to maximize your chan­ces of survival.

As this year’s attacks exemplify, we shouldn’t assume we understand the “logic” or thinking of terrorist organizations or individuals. Preparation for a terrorist attack boils down to being aware of the warning signs and being cautious and alert. Terrorists use a range of weapons and tactics, including bombs, arson, hijacking, and kidnapping (see Table).^1,2

According to Dr. Howard Mell, an EMS director in North Carolina, the overwhelming majority of gunfire in the emergency department—or anywhere—is not the result of an active shooter. Most gunfire is targeted at a specific goal (ie, escaping or avoiding capture) or person. However, should there be an active shooter, he recommends three steps to take: Run (if the path is open), hide (if your exit is blocked), or fight (if there are no other alternatives).³

Wherever you are, always have multiple potential escape routes in mind. If you run, leave all belongings behind. Help others escape if possible, and take steps to prevent others from entering once you have left the area.

If you are unable to run, decide where to hide. If possible, barricade the area; if you are in a room, turn out the lights and stay away from the door. Be silent and put your cell phone on silent. While you are hiding, prepare to fight.

Fighting is the last resort. Act aggressively and improvise weapons to use against the assailant. If you have family, friends, or colleagues with you, put them to work!

When law enforcement officers arrive, understand that their job is to go right to the source and contain the danger. Keep your hands visible at all times, with fingers spread. Do not grab them for protection, and avoid yelling or pointing. Be prepared to give the authorities any pertinent information (eg, shooter description, last known location, direction of travel, or weapons seen).

Many health care facilities and organizations have valuable disaster and terrorism training programs, which include emergency evacuation procedures. I encourage you to take advantage of them, particularly if you travel internationally.⁴

Continue for personal preparedness >>

This is about personal preparedness. While I am not promoting paranoia, I do believe the risk for terrorist activity has increased in recent years.

I therefore urge you to have a healthy suspicion when you see or hear people
• Asking unusual questions about safety procedures at work
• Engaging in behaviors that provoke suspicion
• Loitering, parking, or standing in the same area over multiple days
• Attempting to disguise themselves from visit to visit
• Obtaining unusual quantities of weapons, ammunition, or explosive precursors
• Wearing clothing not appropriate for the season
• Leaving items, including backpacks or packages, unattended
• Leaving anonymous threats via telephone or e-mail

If after conducting a risk assessment of your surroundings, you believe you could (directly or indirectly) be impacted by terrorism, you must implement evacuation plans, notification of appropriate personnel, and personal safety measures.

In the event of a terrorist incident, remain calm, follow the advice of local emergency officials, and follow radio, television, and cell phone updates for news and instructions. ⁵

If an attack occurs near you or your home, here are practical steps you can take: Check for injuries. Give first aid and get help for seriously injured people. Check for damage using a flashlight—do not light matches or candles, or use electrical switches. Check for fires, fire hazards, and other household hazards. Sniff for gas leaks, starting at the water heater. If you smell gas or suspect a leak, turn off the main gas valve, open windows, and evacuate quickly. Shut off any damaged utilities, and confine or secure your pets. Call your family contact—but do not use the telephone again unless it is a life-threatening emergency. Cell phones may or may not be working. Check on your neighbors, especially those who are elderly or disabled.

Terrorist attacks leave citizens concerned about future incidents of terrorism in the United States and their potential impact. They raise ambiguity about what might happen next and increase stress levels. You can take steps to prepare for terrorist attacks and reduce the stress you may feel, now and later, should an emergency arise. Taking preparatory action can reassure you, your family, and your children that you have a measure of control—even in the face of terrorism. If you have additional suggestions for terrorist defense preparation, you can email your ideas to PAEditor@frontlinemedcom.com.

References
1. Dworkin RW. Preparing hospitals, doctors, and nurses for a terrorist attack. Hudson Institute. www.hudson.org/content/researchattach ments/attachment/291/dworkin_white_paper.pdf. Accessed July 6, 2016.
2. Markenson F, DiMaggio C, Redlener I. Preparing health professions students for terrorism, disaster, and public health emergencies: core competencies. Acad Med. 2005;80(6):517-526.
3. Mell HK. Run, hide, fight: how to react when there’s gunfire in the emergency department. ACEP NOW. June 21, 2016. www.acepnow.com/react-theres-gunfire-emergency-department/?elq_mid=10369&elq_cid=5274988. Accessed July 6, 2016.
4. Uniformed Services University of the Health Sciences, Center for the Study of Traumatic Stress. Workplace preparedness for terrorism. www.cstsonline.org/assets/media/docu ments/CSTS_report_sloan_workplace_prepare_terrorism_preparedness.pdf. Accessed July 6, 2016.
5. American Red Cross. Terrorism Preparedness. www.redcross.org/prepare/disaster/terrorism. Accessed July 6, 2016.