Discussion

Suicide bombings provide the perpetrators with strategic and tactical advantages. From a strategic standpoint, groups use suicide bombings as a method of coercion. They can also be used to instill fear within a populace or to gain political concession. A primary example of strategic gains occurred following the Hezbollah attacks on the US Marine and French Paratrooper barracks in Beirut in 1983, with the US and French pulling their troops from Lebanon afterwards, proving that the tactic was effective in attaining the organization’s goals. ^{Reference Markovic14}

Suicide bombing attacks are tactically harder to defend against and inflict a higher number of casualties than other forms of terrorism. For example, although suicide bombings accounted for less than one percent of all terrorist attacks perpetrated during the Al Aqsa Intifada (Second Intifada), they accounted for fifty percent of the casualties. ^{Reference Ganor15,Reference Kimhi and Even16} Suicide bombers are also considered “smart bombs.” They can move, change directions, infiltrate, or change time and location of targets in ways stationary bombs cannot. Furthermore, no exit strategies are needed from a planning perspective. Stationary bombs, if discovered, can be isolated and deactivated, whereas suicide bombers may still be able to detonate on the spot, even if the intended target is not reached, though premature detonation leads to lower victim counts. ^{Reference Almogy, Belzberg, Mintz, Pikarsky, Zamir and Rivkind17} Additionally, groups may use suicide bombings as a means of targeted assassination, which also may lead to lower victim counts.

By virtue of their ability to carry out attacks where and when they choose and migrate towards large crowds relatively undetected, SBA are more lethal, more efficient, and harder to detect. Furthermore, the unpredictability and methodology of suicide bombings can undermine public morale and inflict psychological damage to the population, far beyond the physical threat or damage it caused. ^{Reference Grimland, Apter and Kerkhof18}

The high rates of fatalities and NFI per SBA targeting transportation modalities indicate the compounding factors of targeting a closed-space (ie, bus or train) and the utilization of a “smart-bomb” that can move, change positions, and aim for an area for detonation with the greatest amount of impact. Similarly, suicide bombers can infiltrate dense crowds and areas where citizens commonly gather, like marketplaces, shops, restaurants, or internally displaced person (IDP) camps for maximum impact, as demonstrated by the high number of FI and NFI per attack on private citizens and properties.

Soft targets like civilians and systems frequently utilized in the daily life of citizens (ie, transportation, religious institutions, and businesses) are more vulnerable to SBA than traditional hard targets, such as police and the military. Higher FI and NFI counts with SBA as a methodology are likely to gain the attention of a wider audience, spread fear into the direct victims of the attack and those who may feel vicariously victimized abroad, and cause wide-spread psychological distress within the community. Furthermore, research suggests that women are potentially more effective in their attacks than men because of their ability to covertly infiltrate dense civilian areas and hit targets where groups of people generally gather, and are therefore seen as a methodology with a perceived tactical advantage by terrorist organizations. ^{Reference Davis19–Reference Pape22} The sharpest increase in female suicide bombers has been seen in the Sub-Saharan Africa region, Nigeria in particular, with some estimates placing women at over one-half the number of bombers. ^{Reference Warner and Matfess23} Given the high impact of female bombers and their ability to blend in well with soft targets, it is possible that other groups will increase the utilization of females. It would therefore be beneficial for CTM specialists and first responders to be aware of “hot spots” of female suicide bombers as part of their risk assessment strategies. ^{Reference Galehan24}

The approach to victims of SBA leans on the guidelines for trauma victims in general, though special considerations should include the large number of victims, the combined effects of penetrating trauma, blast injury, and burns, the numerous penetrating wounds sustained by each victim, and the need for mass blood transfusions and burn management. ^{Reference Almogy, Belzberg, Mintz, Pikarsky, Zamir and Rivkind17,Reference Bala, Kaufman and Keidar25}

Bombs may be composed of a variety of sources, including camping fuel, Ammonal, Semtex, petrol, jet fuel, and dynamite, and loaded with nails, nuts, bolts, glass, or other “frags,” inflicting secondary blast injuries along with any glass, concrete, or wood from surrounding structures or environments. ^{Reference Arnold, Halpern, Tsai and Smithline26,Reference Arnold, Tsai, Halpern, Smithline, Stok and Ersoy27}

Studies have suggested injuries to four or more body areas, and specific types of injuries such as facial and skull fractures and peripheral vascular injury, can herald severe trauma and the need for intensive care unit admission. ^{Reference Bala, Willner, Keidar, Rivkind, Bdolah-Abram and Almogy28} This has led to calls to incorporate these injury parameters into trauma triage protocols, given the potential bottleneck of intensive care availability.

Beyond conventional mass-casualty care, special considerations unique to suicide bombing such as the implantation of biological material from the suicide bombers themselves (also known as “human remains shrapnel”) need to be taken into account. ^{Reference Turégano-Fuentes, Caba-Doussoux and Jover-Navalón29}

Forensic documentation, preservation of evidence, suspect tissue identification and viral status, victim counselling, and post-exposure prophylaxis are also important considerations. ^{Reference Kao and McAlister30}

Blast injuries unique to terrorism that require complex and often prolonged critical care with input from various sub-specialties present a therapeutic challenge to clinicians and a resource challenge to hospitals and health care systems. ^{Reference Chim, Yew and Song31–Reference Bala, Shussman, Rivkind, Izhar and Almogy33} Terrorist attacks are also unique in their intentionality to kill or damage compared to other man-made disasters, and CTM specialists aim to better understand the health care repercussions of such events in order to streamline prioritization of immediate treatment, patient evacuation, and hospital care. ^{Reference Tin, Hart and Ciottone34,Reference Tin, Hart, Hertelendy and Ciottone35} Furthermore, health care responders and hospitals are themselves vulnerable to terrorist attacks and risk reduction strategies should be considered. ^{Reference Tin, Hart and Ciottone36}

Addressing the health care complexities within CTM requires collaboration among specialists and experts in Disaster Medicine, counter terrorism, tactical medicine, and law enforcement to ensure streamlined, coordinated strategies in dealing with future attacks. ^{Reference Tin37}