Discussion

Terrorism-related CBRN events are uncommon, but it is important for first responders as well as DM specialists and Tactical Emergency Medical Support (TEMS) teams to have a sound knowledge of historical precedence, including their toxidromes and medical management. While acts of state terrorism are not included in the GTD, CTM should take into account all potential mass-casualty causing modalities such as the use of Novichok in the Salisbury (United Kingdom) attack (2018). ^{Reference Clarke and Weir9} The use of aerosolized carfentanyl during the Moscow theatre siege (Russia) by Spetsnaz agents in 2002 also provides immense educational value to CTM experts. ^{Reference Riches, Read, Black, Cooper and Timperley10}

Using TEMS teams to supplement other emergency response agencies during an incident can be advantageous in CBRN scenarios as well as in more traditional terrorist events involving explosives, firearms, or vehicle attacks. Medical providers in TEMS teams are often experienced in prehospital work and trained to provide time-sensitive care even in an unsafe environment. Their training includes an understanding of the tactical aspects of high-threat incidents and their implications on health care systems can facilitate treatment, triage, and clinical decision making. ^{11–Reference Hartle13}

There is currently no national standard curriculum for tactical medical providers in the United Stated (US). However, CBRN knowledge is part of the competencies being taught during the most prevalent tactical medicine courses, including the Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) course, and has been a part of earlier consensus work regarding TEMS training programs. ^{Reference Heiskell, Auerback, Cushing and Harris14–16} The Tactical Paramedic Certification (TP-C), which is a prerequisite for medical work in many TEMS teams in the US and abroad, also requires basic knowledge of CBRN topics. ¹⁷

The early toxidrome recognition of CBRN attacks and subsequent prehospital medical management necessitates clinicians with strong situational awareness in high-threat environments, specialized training in appropriate personal protective equipment, and clinical knowledge in the use of agent-dependent antidotes. The experience from the 1995 Sarin attacks in the Tokyo subway suggested on-the-ground clinical leadership is best provided by specialized prehospital physicians. ^{Reference Byers18} Furthermore, DM/CTM specialists have recently devised and published toxidrome recognition algorithms in chemical weapons attacks to facilitate the timely recognition and treatment in case of such events. ^{Reference Ciottone19}

There is currently no consensus globally on the best medical team composition to high-threat responses and the balance likely lies in a hybrid between traditional TEMS, tactical physicians, and DM/CTM specialists. The importance of having a senior physician available during a more conventional terrorist attack has been demonstrated in the Utöya shooting event in Norway in 2011 and the London Bridge terrorist attack in the United Kingdom in 2017. ^{Reference Lockey20,Reference Hunt21} The use of tactical physicians with CBRN knowledge has been implemented in many countries in the past decades, including the US, Finland, Denmark, and France. ^{Reference Hallikainen and Lund22–24}

Rapid medical assessment and treatment of victims in an active “hot zone” remains a challenge in time-sensitive scenarios. Solutions to this “therapeutic vacuum” have been discussed, but there has been less success solving for the added complexity of a CBRN incident. ^{Reference Park, Langlois and Smith25} The historic reliance on TEMS, specialized civilian hazardous materials (HAZMAT) teams, or the military in a terrorist CBRN incident should be reviewed, as delays in deployment into areas of threat could significantly impact the prognosis of victims and are not resources readily available in most countries. ^{Reference Miletta26} A similar approach has been adopted to the response to active shooter events, with tactics favoring a more rapid breach to provide emergency medical care. ^{Reference Martaindale and Blair27}

The United Kingdom implemented a modified response to CBRN and HAZMAT incidents that combines an initial operational response with a revision of the existing specialist operational response for ambulant casualties. ^{Reference Chilcott, Larner and Matar28} Structured multi-agency guidelines to ensure rapid and effective responses have also recently been published. ^{Reference Calamai, Derkenne and Jost29}

There are on-going discussions to integrate CRBN protocols into standardized tactical medical care within the military and within Tactical Emergency Casualty Care (TECC) working groups. These include suggestions such as expanding the well-established MARCHE mnemonic to include CBRN threats. ^{Reference DeFeo and Givens30}

Health care responses to terrorism events have historically been confined to attending to those injured, maimed, or deceased, but the emergence of CTM as a sub-specialist group aims to analyze the health care risks of terrorist activities, rethink health care vulnerabilities, and attempt to mitigate the health effects of novel attack methodologies.

Counter-Terrorism Medicine is a developing DM sub-specialty focusing on all health care aspects of the disaster cycle (prevention, preparation, mitigation, response, and recovery). The health care complexities within CTM necessitate round table discussions with DM, counter-terrorism, tactical medicine, and law enforcement specialists and emergency response services to ensure streamlined, coordinated strategies in dealing with future terrorism events. ^{Reference Kruglanski, Gunaratna, Ellenberg and Speckhard2,Reference Tin, Hart and Ciottone4,Reference Tin, Hart and Ciottone31}