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Terrorism involves violent acts intended to intimidate or coerce a civilian population. There are various types of terrorism, including religious extremists, cyber terrorists, and single issue groups. Terrorist attacks can involve firearms or explosives. In the event of an active shooter, the protocol has changed to engage and suppress the threat. The acronym PREP is used for threat suppression, hemorrhage control, rapid extrication, and providing definitive care. Interagency training is important for effective response, and weapons of mass destruction include biologic, nuclear, incendiary, chemical, and explosive agents. We had one here locally. I was out in Boston after the Marathon bombing. It is difficult to plan for and anticipate a response to many terrorism events, but some key principles apply to every response. Things like your ICS, your NIMS, your Hazmat awareness, and scene safety. Terrorist forces have been at work since early civilization. Terrorism involves violent acts or acts dangerous to human life that violate federal or state laws and appear to be intended to intimidate or coerce a civilian population, influence policy of a government by intimidation or coercion, or affect the conduct of a government by mass destruction, assassinations, or kidnapping. International terrorism occurs primarily outside the United States, with domestic terrorism primarily occurs within the United States. Yes, we have domestic terrorism. Only a small percentage of groups actually turn to terrorism to achieve their goals. They say only about maybe 300 million people worldwide are, what you would say, radicalized enough to commit terrorist acts. Out of 7 billion people, 300 million is a very small number, right? Well, 300 million, that's the entire population of the United States. So it's still a big number. Do you think that number would increase if there was some kind of advertisement posted on social media? Are you planning on putting some up? Trying to sabotage yourself all the time. No, I'm telling you, the movies nowadays, they give ideas to people. So, what is terrorism? Terrorism, you could have religious extremists that abuse their cults. They participate in apocalyptic violence. Or extremist groups seek political, regional, economic, or social freedom. Here is a picture of the Marathon bombing. Cyber terrorists attack a population's technological infrastructure. North Korea is big on this. North Korea is one of the biggest proliferators of cyber terrorism. Single issue groups, things like anti-abortion, animal rights, anarchists, racists, eco-terrorists, you name it, there's a terrorist group for it. Low and low terrorist attack. This is the problem with terrorism today when you talk about ISIS and you talk about the Taliban. They are what we call, they do what they call cells. And you could have two or three people in a cell, or four people in a cell. They don't communicate with anybody else. They're in their own cell and they work independently. That's why you always say you cut the head off and another head will take over. That's the problem with these cells across the country. And of course you have lone wolf terrorist attacks. Frequent threat in the United States. Motives of the attacker are not always clear. Attacks may be schools, a music festival, a shopping center. That's one of the ways that you can tell if it's a terrorist act. You really want to look at the location. Where are we? Are we at an area of maximum viewers, right? You're at a music festival, a sporting event, some kind of celebration where there's a lot of people. Would there be a lot of media? Would there be a lot of attention? That's where terrorists go. There's an old saying. If a tree falls in the woods and nobody hears it, does it make a sound? Terrorists are not going to blow up the middle of Shenandoah Forest. Nobody's going to hear it. They're going to blow up something where people are going to see. They're going to make a mess. It's going to be terrible. Same with shooters. Terrorist attacks involve firearms rather than explosives like the father and son, the DC sniper. You probably don't remember that. That was maybe 15 years ago. I remember that. The DC sniper. There was a father and son. They were going around the Washington area shooting people randomly. This is promoting discussion about gun laws, mental health, and educational public and first responders on how to treat casualties. This is one of the reasons why Stop the Bleed has become such a big program. This is why we go over bleeding. We talk about stopping those tourniquets and packing wounds because this is what we deal with. Harper's Consensus recommends using the acronym PREP. Threat Suppression, Hemorrhage Control, Rapid Education, Assessments, Awareness, Guidance, and Transport. This is one of the things. Remember I told you about ALICE training? The active shooter training. If you ever get a chance, go to schools that do it and get involved in it. Be actually doing it because that's the best experience you can get. Years ago, the old police protocol for an active shooter is to stage, secure the scene, and wait for overwhelming force to enter the building. That's the way it used to be. After Columbine and the other shootings, the shooting in Connecticut, they decided they'd change that protocol now. So now local police departments, the idea is when you get on scene of an active shooter, you go in, you encounter the threat, you engage, and you fire to suppress the threat. Stop the threat, all means necessary. Because of the fact that these shooters barricade themselves in the building and they may have 200 targets that can just pick off at random. So the idea of staging outside is no longer done. And that's where you get the idea of threat suppression. Their job, not yours, their job is to suppress the threat. And you may go in with them. You may have a SWAT team or you may have a bunch of officers and you get called to the scene of a shooting and the officers say, you, come with me, follow behind me, don't get in front of me. And you'll follow them through the building as they clear the building. Then your next job is hemorrhage control. Then rapid extrication to safety, assess medical providers and provide definitive care. So what's the R and the E contained? R and the E? Oh, that's why. Okay, so I suppress the E for no reason. You'll treat him and somebody will take him out. You'll treat him and immediately when you see it, hemorrhage control. You may not carry him out, you may stop the bleeding and move on, but you're going to treat him. Oh, so you'll move on completely. You might, you might. Are the R and the E supposed to be the same because that was a threat? Say that again? Are the R and the E supposed to be the same because that was a threat? Like is rapid extrication, and then is it extrication? Oh, rapid extrication. So rapid and then extrication? Right. Okay. I think that's where they get the threat from. You're right, the threat would make sense. That's why I said threat. So in these situations, the event of a shooting or a call, it really is something that will be a safety first. And also if you're... The E, and I was like, where's the E? I thought it was like the E was spelled the wrong way. You might, right? You might. If there's nobody, if you're following the police and there's more activity up front and you come across a patient, you're not going to leave them, grab the patient and drag them out. You may just treat him there. They may call the radio and somebody may come in because they've cleared the zone. Somebody may come in and get that patient while you move on to the next one. You might do that. It depends on the scene. If the scene calls for it, you would do that. Stop the bleeding and move on. If there's one, if I can allow it, one police officer and you happen to get to the scene early, he wants you to come in with him and you go in with him? I mean, that's the caveat. You go in with him if you feel comfortable. You don't go in if you don't feel comfortable because he doesn't want a liability. If you feel comfortable, you're ready to go in with him, you go in with him. If not, say, I don't feel comfortable doing that. I don't want you going in if you can't handle it. Would you leave your partner behind or would your partner at home go in? He's behind and we'll go in with him. You'd all get killed. I think it was three years ago I did it. I actually went to an active shooter event that they held. I think it was a Westminster school. I took part of it when I was up at Pitchford State. It was actually really interesting. They do a good job. They moulage patients and they'll actually shoot off blanks so you'll hear gunfire. It's crazy. The experience was definitely worth it. For me, I had a great experience, so I would recommend anyone doing that. I highly recommend it. If you show up at scene, if you go to Heaven One Down in Rentham, and you go to Rentham and say, hey, I'm an EMT up in Levenster. Can I be involved? They'll say, sure. They might make you a patient. They might make you an EMT on scene. They might make you one of the aggressors. Who knows? The biggest thing was this. The biggest thing was this. Listen up. The biggest thing is interagency training is how the police and EMS and fire work together in order for the best outcome of the patient. Weapons of mass destruction are also called weapons of mass casualty. Any agent designed to bring out mass death, casualty, or massive property or damage to infrastructure. Be nice. Be nice and TBRNE are mnemonics for the kinds of weapons of mass destruction. I don't remember if, I think, TBRNE is the military. Be nice is civilian. So, be nice stands for biologic, nuclear, incendiary, chemical, and explosive. TBRNE means chemical, biologic, radiologic, nuclear, and explosive. Because nuclear and radiologic are different, and we'll talk about why. When I was in the military, it used to be NBC, nuclear, biological, chemical. It kind of expanded. You're not Nudge Nudge Weekly. No, I'm not Nudge Nudge Weekly. You should know them. You should know them. I haven't said anything in the book. It's right here. That one, and then there's the other one. This is TBRNE. So, explosives have been the preferred weapons of mass destruction. If you remember Oklahoma City and Timothy McVeigh, he had 500 pounds of fertilizer, ammonium nitrate, set with explosives. So, that's kind of been the preferred for many, many years. Other things would be like chemical agents. You could have vesicates, which are blister agents that cause blistering to the skin. Things like sulfur, mustard, mustard gas. Respiratory agents are choking agents. One of the first mass-produced chemicals was chlorine gas, and it was used during World War I. Nerve agents. Nerve agents would be like pesticides. Pesticides are nerve agents. Remember Fludgerman dumbbells? That's what they're talking about. And then metabolic agents, things like cyanide. Biologic agents are organisms that cause disease. The primary types are viruses, bacteria, and toxins. So, the United States, even in its early form, has a couple of records. We are the only nation that used nuclear weapons against human beings. Hiroshima and Nagasaki in World War II. We are the only known nation that used biological weapons against another people. During the French and Indian War, we gave the Indians blankets that were exposed to smallpox. Native Americans had no immunity to it. Europeans did. So, it killed many Indians, and we just moved into their territory. We're nice people, right? Nuclear and radiological terrorism, the only two publicly known incidents, Hiroshima and Nagasaki. These materials are far easier for deterrent terrorists to acquire, and require less expertise to use, and produce what we call a dirty bomb. So, you have nuclear and radiological. Yes, there is the potential to make a nuclear device in a suitcase. It's a big, heavy suitcase, but you can do it. But the expertise it would take to do that is beyond most nations. What I would worry about more is a radiological bomb, what we call a dirty bomb. I would have three pounds of plutonium and uranium wrapped around a C4 explosive. Now, when that explodes... You don't have so many pounds of uranium. Maybe two. No, just like a couple ounces. Okay, that's good. When it explodes, it sprays out, and it kills people immediately, but it irradiates that area for a thousand years. Let's take, for example, it's a sunny 75 degree day on a Saturday in the middle of summer. Daniel Hall Marketplace. What a cold day. Probably 50,000 people there at any given time. Somebody's got a backpack, puts the backpack down, walks away, boom. You'll probably kill 50 people immediately. You'll probably kill another 3,000 with cancers in the next two years, and you'll never be able to use that. You won't be able to use that area for a thousand years. That's war that I'm afraid of. Does anybody know, before the end of the Cold War, where was the highest concentration of nuclear weapons and nuclear material? Russia. Where? No, you're right. Where in Russia? The Ukraine. And after the Cold War, the Ukraine, when they fought for independence, when they sued for independence, the Russia said, okay, you want independence, you have to give up your nuclear weapons, because we don't want you to attack us with our own nuclear weapons. They would raid Russia. They took all the nuclear weapons, so Ukraine didn't have any. But at one point they did. Now, this is a little reason why dirty bombs are so dangerous, is because before the Cold War, all nuclear material was all regulated internationally. Everybody regulated, everybody knew it was all under guard. When the fall of the Soviet Union, they had 50,000% inflation, and it would cost you a million rubles to buy a loaf of bread. And so what happened was, many military officers enlisted went a year without getting paid or more. So they're like, hey, I've got to feed my family. So these people in Ukraine guarding the nuclear material, what did they do? They sold it. And so they sold it to terrorist organizations and third world nations. So at any given time, they believed there's upwards of like five tons of unknown radiologic material floating around the world. I don't know where it is. It could be in the hands of terrorists right now. Iran could have it. Who knows? You feel like the prohibition? What's that? Like the prohibition for nuclear weapons? I'm concerned. Did they what? Like the prohibition for nuclear weapons? What for? Like that's how it was? Like they like basically sold it underground? Yeah, yeah, they sold it. They sold it. Yeah, they sold it underground. So they don't have any more? No. No, no, no. There's enough. There's enough radiologic material at any given time. Ukraine has none. What nation has it? Russia? China? The United States? Australia? Pakistan? Probably North Korea. North Korea does. Iran probably does. So those nations that have it. You left out Israel. What's that? You left out Israel. Are you looking at me? Are you looking at me? I'm not holding it in my hand. And Great Britain does, obviously. And Russia and France. All of these nations have enough nuclear material. If you fired them all off, you could destroy the face of the earth 50 times over. We're dead. The United States has a lot of them. We do. It's the largest concentration. So EMS responds to terrorism. The basic foundation of patient care remains the same. Treatment can and will vary, but the foundations are the same. Always remember situational awareness. Keep your eyes on the back of your head. Pay attention to the scene. If you feel the hairs on the back of your neck standing up, and if something doesn't feel right, get out of the scene. Recognizing a terrorist event. Planning an act of terrorism is covert, but the actual act is overt. And the idea is they want to have maximum exposure. A lot of times they'll detonate explosives or do a terrorist act in an area that has not only a high population, but one that will be covered by the news. Because they want media coverage. You must know the current threat level by the Department of Homeland Security. What does it go? Blue, green, yellow, orange, and red. I think we're at orange right now, which is high. Is that threat level? And that's put out by the Department of Homeland Security. You can see it right on their website. Why are we orange? Hmm? Why are we orange right now? Why? Think about what's going on around the world. Think we're always orange, right? No, we've been down to yellow. We've never been green or blue, but we've been down to yellow. We always have our nose in everything. National terrorism advisory system. Do you guys remember a few years ago they called the Trump text? This has been around ever since cell phones first came out. For the federal government to have the ability to send out a national text to every cell phone in the country through all of the carriers. Trump was the one that actually, during his administration, he's the one that activated it and got it working. Do you remember when they had that Hawaii situation? The bomb? Yes. An imminent missile is heading to Hawaii from North Korea, a nuclear missile. So, for 30 minutes, these texts were going off and everybody thought in Hawaii that they were going to be hit by a nuclear weapon. It was a mistake. It was a test and they didn't notify us. Hilarious. So, they don't work. So, on every call you must make the following observation. The type of location. Again, the more public it is, the more it is seen, the more people that pass through it, the more likely that it's a high-profile terrorist attack. The type of a call. Explosions, shootings, mass casualties, mass casualty or mass damage. The number of patients. The more victims, the more likely it is. Victim statement. Victim statement. Yeah, I saw a guy put down a bag or there was a truck that was parked and it was there for two days. And three incident indicators like the homeland threat. I'll be honest with you. Every day, the FBI and the CIA and Department of Homeland Security has about 200 known or suspected planned terrorist events that they investigate at any given time. So, see the C-station. Stage your vehicle at safe distance. Uphill, upwind, at least 100 yards away. At least 100 yards. Wait for law enforcement personnel. Don't enter. If you have any doubt, do not enter. The best location is staging uphill, upwind. Be aware of secondary devices. Listen up. Be aware of the secondary devices. Because this doesn't happen so much in the United States, but this happens in other countries. There was a movie out many years ago with Jimmy Fox and what's his name, McGraw there? Tim McGraw. Tim McGraw. It was called The Kingdom. And it was all about the green zone in Saudi Arabia. It was a Sunday afternoon and they're all playing baseball. It's a beautiful day. You always have beautiful days in Saudi Arabia because there's no rain, but anyway. They're on a ball field playing ball and you hear this explosion go off in the parking lot. So, what does everybody do? Their military? Their first responders? What do they do? They run out to the scene. And you see this ambulance come up, goes around, pulls right up to it. Boom! A huge explosion goes off. And what does it do? It kills all the people that go in to rescue. That's not an uncommon thing. That was common in Israel. That was common during the IRA, during the Irish-English back and forth there during the 70s and 80s. Trouble, they call it. Was that a trouble? Trouble, yeah. Trouble. Where they would set off a small explosion and then set off a larger one to injure or kill first responders. Because what is more demoralizing than killing first responders? Killing police. Killing fire. Yeah. I don't know about that. I thought I saw an article in the Warren Goggins or something where they were using drones to just attack an ambulance personnel. Yeah. Yeah. Something like that. That wouldn't be an unheard of thing to happen. So now if you look at this, what seems to be wrong with this? The ambulance is way too close. Well, thank you very much. I would say they're pretty close too, wouldn't you? I don't see any placard there, but is it possible the placard came off? Is it possible that there is no placard on it? I see a little bit of fluid there. And look how close they are. No, we don't know. Maybe it's a milk truck. I don't know. I'm just saying this is a little bit close to the hangar. I've got some bystanders over here. That's not a safe thing. Responders say the best form of protection is preventing yourself from coming into contact with any agent. Contamination occurs when you have direct contact with that. Cross-contamination occurs when you contaminate somebody else or you get something from somebody else. Patients will cross-contaminate you. That's why you don't want to put them in a closed ambulance until they're decontaminated. Notify the dispatcher when you get on the radio of the nature of the event. When you get on scene, this is what you see. An explosion, a fire, a shooting, whatever. Any additional resources. Send me everybody. Estimated number of patients. A shitload. Uphill and upwind optimal route. Tell them the best way to come in. Like maybe come in through Jones Street. Don't come around by 123 Street because that is downwind and we see the smoke and the fumes going that way. You don't want the vehicles driving through that. Establish a staging area. Trained responders and PPE are the only persons equipped to handle these. So those would be like your hazmat and your responders for that. That's not you. You don't go running in. Establish command. You may need to establish command until additional personnel arrive. You and other EMTs may function as medical branch directors, triage chiefs and transport supervisors, logistical officers. Or you might be in command. You might be in command. Remember, you're always medical officer. Every scene you go on, whether you pick up hand and noodles to dialysis or you go to a four-car pileup, you are medical command. Every call you go on, you're the incident commander. One is the incident commander and one is the triage. Whether you're taking hand and noodles to dialysis or you're going to the motor vehicle crash. Think of it that way. Every scene, you're kind of running an incident commander. Reassess scene safety. Constantly assess. Have the eyes in the back of your head, that situational awareness. It's important to be aware of the scene at all times. Chemical agents or liquids or gases that can disperse to kill or injure. Persistent or non-volatile. Non-volatile means persistent, which means they don't evaporate. Most of those have oils. If you deliver a chemical in oil, it's non-volatile. It's persistent. It sticks. It sticks on doors. It sticks on leaves. It sticks on the ground. It sticks on your clothes. It sticks on you.