Discussion

Sports venues elevate athletic competition to a shared experience by a large audience and are important fixtures in many communities. They also support local economies and create jobs. Unfortunately, sports venues have also been the targets of terrorism. This study sought to analyze trends from prior attacks in the hopes of informing future emergency preparedness and medical responses.

At least 74 terrorist attacks against sports venues have been documented in the GTD. While the venues targeted represent a range of sports, soccer stadiums have been targeted most frequently, accounting for nearly 45% of all attacks. Admittedly, one-third of the attacks identified did not specify the type of sports venue targeted. However, the frequency with which soccer stadiums have been impacted likely speaks to the global popularity of soccer as well as the ability of the sport to attract large audiences. Prior to 2011, the most attacks seen in one year was four in 1987. Since 2011, each subsequent year has consistently seen over four attacks, with a peak of 11 in 2015 (Figure 2). Not surprisingly, bombings and explosions are the most frequent method of attack utilized. Given that most sports venues assemble spectators together in close proximity to one another, bombings have the potential to inflict numerous casualties rapidly. Bombs and explosives can also be portable and concealable and can be inexpensive to manufacture. ^{Reference Alpert and Grossman4}

Terrorist attacks against sports venues have the potential to strain or even overwhelm the health care system; hospitals should have a plan to manage sudden surges in patients with polytrauma. ^{Reference Khan, Sabbagh, Ranse, Molloy and Ciottone5} During the complex coordinated terrorist attacks of November 2015 in Paris, assailants detonated three explosives at the Stade de France. The first detonation occurred outside the stadium. A second detonation occurred when a suicide bomber was discovered to be wearing an explosive vest by personnel at a security checkpoint prior to entering the stadium. ^{Reference Robinson and Landauro6} The third detonation occurred outside a separate stadium entrance. In all, 53 people were injured at the Stade de France. Several additional attacks occurred elsewhere throughout Paris over the ensuing hours. Developed over 20 years ago for such an event, Paris’ emergency response plan, the “White Plan,” mobilized all 40 Paris hospitals, including “100,000 health professionals, 22,000 beds, and 200 operating rooms.” ^{Reference Carli, Telion and Baker1,Reference Hirsch, Carli and Nizard7} The “White Plan” mitigated the surge in patients and provided medical care to all those affected by the attacks. ^{Reference Carli, Telion and Baker1,Reference Philippe, Brahic, Carli, Tourtier, Riou and Vallet8} Additionally, the plan initiated a psychological support center with 35 psychiatrists along with psychologists, nurses, and volunteers to provide mental health care to patients, family members, and medical professionals participating in the response. ^{Reference Hirsch, Carli and Nizard7} All too often after an attack, the immediate focus is on the physical well-being of the victims; the negative mental health impacts of the event are frequently overlooked and can linger long after physical wounds have healed. ^{Reference Robert, Stene and Garfin9} Over the course of the Paris attacks, 124 people died, 643 were injured and received medical care, seven more died in the hospital, and over 1,500 people received mental health care. ^{Reference Philippe, Brahic, Carli, Tourtier, Riou and Vallet8} Paris’ highly-organized emergency response highlights the importance of multidisciplinary collaboration and detailed, proactive planning for mass-casualty events. ^{Reference Hirsch, Carli and Nizard7}

Medical emergency preparedness planning should start with increasing situational awareness. Health care facilities near large sports venues should incorporate event schedules into all-hazards planning for receiving mass casualties. Regular training and exercises can help familiarize emergency clinicians with hospital protocols for triage and management of the wide spectrum of injuries possible in a mass-casualty event. ^{Reference Alpert and Grossman4} Medical directors for Emergency Medical Services (EMS) and other prehospital clinicians should collaborate with sports venues in emergency planning. Formal designation of a law enforcement medical coordinator to serve as a liaison between EMS, fire/rescue, and police can enhance communication during a response, optimize use of prehospital medical assets and local hospital resources, and provide medical expertise to incident commanders in high-stress situations. ^{Reference Alpert and Grossman4}

While not specific to terrorist attacks, emergency preparedness planning should recognize and mitigate the historical risk of stampedes at sports venues. Stampedes occur when crowd surges result in trampling of individuals with subsequent crush-related injuries. In particular, stampedes can result in traumatic asphyxia and death of individuals compressed or trampled over. ^{Reference DeAngeles, Schurr, Birnbaum and Harms10} Stampedes may result from an over-excited crowd rushing the playing field to celebrate a victory or conversely seeking escape from a threat. In one such event in Johannesburg, South Africa, tear gas was deployed during a soccer match in 2001 to disperse overcrowding, but led to a stampede resulting in 43 deaths and 250 injured. ^{Reference Aljohani, Kennedy, Ciottone, Biddinger, Darling, Fares, Keim, Molloy and Suner11} More recently in October 2022, a stampede of agitated spectators dispersed with tear gas following a soccer match loss at an Indonesian stadium led to 130 deaths. ¹² The management of traumatic asphyxia relies on timely airway and respiratory support; in the event of mass casualties with this injury, first responders and emergency clinicians may be significantly engaged in individual care, including cardiopulmonary resuscitation. Crowd management plans should mitigate surges, promote safe egress of spectators, and facilitate on-site availability or rapid entry of first responders to care for the injured, all while maintaining the security of the venue. ^{Reference DeAngeles, Schurr, Birnbaum and Harms10}