The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current “Stage-and-Wait” paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account.

This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial.

The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide.

The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period.

This study emphasizes the need to rethink the current “Stage-and-Wait” paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

In the aftermath of disasters, Emergency Medical Teams (EMTs) are dispatched to help local rescue efforts. Although EMTs are recognized to be a critical component of the global health workforce, concerns have emerged over their functioning and effectiveness.1 For example, lack of cooperation and coordination between different EMTs has been a longstanding issue, resulting in fragmented disaster management.2 To enhance the provision of EMT’s field teamwork, the Training for Emergency Medical Teams and European Medical Corps (TEAMS) project was established,3 and later further updated with novel scenarios and exercises (ie, adapting EMT operations to a sudden disaster; becoming a modular team; reflecting on ethical dilemmas) in the complementary “TEAMS 3.0” project where a more comprehensive training package was developed.

The aim of this study was to assess the effectiveness and quality of the TEAMS 3.0 training package in four training programs in Portugal, Germany, Norway, and Turkey.

Participants completed a set of questionnaires designed to assess self-efficacy, teamwork, and quality of training.

The results from the Portugal and German training suggest an improvement for both teams’ self-efficacy and teamwork. The quality of training is regarded as high and deemed as an appropriate tool package for addressing the objectives of the project and the perceived needs of EMT disaster deployment.

Thus far, the TEAMS 3.0 project has demonstrated to be effective in promoting EMT teamwork capacities. The Norwegian and Turkish training results are expected to be available by the time of the WHO EMT Global Meeting 2022.

Tables and Figures (optional)

Table 1.

Comparison of Means Before and After the TEAMS 3.0 Training, per Country, for the Team Self-Efficacy Scale, Teamwork Scale, and Quality of Training Scale

Asymmetric warfare and the reaction to its threats have implications in the way far-forward medical assistance is provided in such settings. Investments in far-forward emergency resuscitation and stabilization can contribute to saving lives and increase the resilience of health systems. Thus, it is proposed to extend the use of the Haddon Matrix to determine a set of strategies to better understand and prioritize activities to prepare for and set-up frontline care in the form of Trauma Stabilization Points (TSPs).

An expert consensus methodology was used to achieve the research aim. A small subject matter experts’ group was convened to create and validate the content of the Haddon Matrix.

The result of the expert group consultations presented an overview of TSP Preparedness and Operational Readiness activities within a Haddon Matrix framework. Main strategies to be adopted within the cycle from pre- to post-event had been identified and presented considering the identified opportunities in the context of the possibility of implementation. Of particular importance was the revision of a curriculum that fits the civilian medical system and facilitates its adaptation to the context and available resources.

The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.

To compare injury patterns of different types of explosions.

A retrospective study of 4508 patients hospitalized due to explosions recorded in the Israel National Trauma Registry between January 1997 and December 2018. The events were divided into 4 groups: terror-related, war-related, civilian intentional explosions, and civilian unintentional explosions. The groups were compared in terms of injuries sustained, utilization of hospital resources, and clinical outcomes.

Civilian intentional and terror-related explosions were found to be similar in most aspects except for factors directly influencing mortality and a larger volume of severely injured body regions among terror-victims. Comparisons between other groups produced some parallels, albeit less consistent. Civilian intentional explosions and civilian unintentional explosions were different from each other in most aspects. The latter group also differed from others by its high volume of life-threatening burns and a higher proportion of children casualties.

While consistent similarities between explosion casualties exist, especially between victims of intentional civilian and terror-related explosions, the general rule is that clinical experience with a type of explosion cannot be directly transferred to other types.

Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years.

The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years.

A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study.

The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients’ sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital.

The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.