The recent wave of terrorist attacks against Israelis during the last 6 months has been characterized mainly by stabbings and shootings events usually carried out by individuals. Thus, the perpetrators are being nicknamed “lone wolves”.
This paper deals with the medical perspectives of the current wave of terrorism with recommendations for action in order to strengthen Israeli public resilience.
As a result of an ongoing wave of terrorist attacks against Israelis since September 13, 2015, 30 people have been killed and approximately 350 people have been injured. According to official reports, the attacks have included 170 stabbings and attempted stabbings, 70 shootings, and 38 vehicular (ramming) attacks . In contrast to previous periods of Palestinian uprising, this current wave of terrorist attacks is characterized by seemingly unguided, non-organized popular acts that are being carried out by young, lone terrorists (some as young as 13-15), most of them from east Jerusalem and some from other parts of Judea and Samaria. Such incidents, which have earned the nickname "lone wolf" attacks, have become a popular means of terrorist activity. These “lone wolves” are not directed by any organization, but rather are inspired by intensive incitement that is easily accessible to them in the local media and via social networks. As these attacks were designed to be an expression of "popular resistance", the assailants use cold weapons such as knives, scissors and screwdrivers in most of the incidents. In the majority of these incidents, the attacker was killed at the scene by a soldier, law enforcement personnel, or even by a civilian bystander.
These “lone wolf” attacks require a change of approach in several aspects of counter-terrorism. One of the most problematic issues is the lack of intelligence needed in order to prevent such attacks. It can be a matter of only a few hours, or even an impulse decision, for an individual to grab a knife and to choose a suitable victim in proximity to his or her place of living. Preemptive action in such circumstances is practically impossible. Instead, such attacks can be reduced or prevented through education, influence via social networks, and the identification of potential attackers who reveal their intentions on Internet sites. Since it is so difficult to anticipate who the next attacker will be, or where and when such an attack is about to take place, the major counter-terrorism actions involve increasing security personnel (police, border police and military) at major junctions, crowded places, near Jewish communities in Judea and Samaria and so on. In addition, civilians have been encouraged to learn simple ways to counteract an assault and those with a license have been encouraged to carry their weapons.
The medical aspects of the “lone wolf” terrorist attacks also differ from the suicide bombings of the past. This type of attack requires proper adjustments from medical care providers, as well as domestic preparedness to enable better medical response to the injuries inflicted in these attacks. The suicide bombings that we experienced two decades ago were characterized by multiple casualties scattered over a large scale scene. The circles surrounding the core of a terrorist attack are divided into a hot zone, a warm zone, and a cold zone. The hot and warm zones are potentially hazardous for caregivers due to continuous risk. In suicide bombings, the hot and warm circles are large as there is the risk of another bomb detonating in the same area, as well as debris, unstable wreckage, toxic fumes, etc. In the recent stabbing and shooting attacks, the hot circle shrinks very rapidly following the neutralization of the attacker, making it possible for caregivers to reach the victim almost immediately and to start treating his injuries. The main type of injury in this wave of terrorism is penetrating trauma, which differs from the multi-dimensional nature of explosions, which cause blast injuries, penetrating wounds, blunt force trauma, burns, and smoke or chemical gas inhalation. The injuries also differ from the blunt force trauma injuries that most trauma surgeons in Israel encounter in over 80% of cases during routine times, making it essential for both first responders and hospital medical personnel to refresh their knowledge and skills in order to provide the best level of care for these patients.
The main cause of death in penetrating trauma is hemorrhage. The experience and lessons learned by the American army from the thousands of combat casualties it has suffered over the last 15 years in the conflicts in Iraq and Afghanistan should be applied in the civilian sector . For internal hemorrhage injuries, the emphasis should be on rapid transfer of the wounded to the nearest suitable trauma center, and on limited fluid infusion ("permissive hypotension") until the victim reaches the trauma center where the bleeding can be controlled surgically. External hemorrhage control is essential within minutes from injury in order to save the patient’s life. As mentioned above, the nature of “lone wolf” attacks allows caregivers to approach the victim early. Recent events have shown that, in many instances, the immediate responders were laymen bystanders. For this reason, it is recommended that both the general public as well as professional first responders, such as medics, paramedics, policemen and firefighters, learn and master a few simple steps and techniques that can be implemented at the scene of the attack. The increased threat of intentional mass-casualty events in the United States led to the creation of the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events. The Hartford Consensus is the product of the work of this committee , and depicts the guidelines for an integrated response system that includes the public, law enforcement, emergency medical systems, and definitive care systems (trauma centers) to work together to provide the best response to such events. The Hartford Consensus coined the acronym THREAT to summarize the necessary response in these events: Threat suppression; Hemorrhage control; Rapid extrication to safety; Assessment by medical providers; Transport to definitive care.
It is important to re-emphasize the role of first responders in these attacks. The Hartford Consensus correctly calls for empowering the public to provide immediate necessary life-saving emergency measures. Primarily, first responders contribute to the critical step of controlling external hemorrhage, thereby reducing the chances of the victim dying before he can reach the hospital for further treatment. In the same manner that policy makers called for creating laws to enable more civilians to carry weapons and to permit them to be used in terrorist incidents, steps should also be taken to improve the ability of civilians to react during traumatic events and not just serve as passive bystanders until professional health providers reach the scene. Educational programs should be established and the public should be encouraged to engage in training activities to learn hemorrhage control. Awareness of these programs should be spread through by announcements and advertising by various media outlets. Individual First Aid Kits (IFAK) that contain hemostatic bandages and tourniquets should be supplied to all citizens. Professional responders should also undergo thorough refreshment courses and be provided with the more advanced means for hemorrhage control. Furthermore, this is the time to invest in more research and development of hemostatic agents and products that have the potential to cease bleeding efficiently, both in the pre-hospital and in-hospital environments.
In conclusion, while terrorism may change its form from time to time, it unfortunately seems that the phenomenon will last for many years to come. Part of society’s ability to cope with the consequences of terrorism and to improve our resilience is an improved medical response and the elimination of unnecessary preventable deaths.
 Israel Ministry of Foreign Affairs. Wave of terror 2015/16. http://mfa.gov.il/MFA/ForeignPolicy/Terrorism/Palestinian/Pages/Wave-of-terror-October-2015.aspx
 Holcomb JB, Hoyt DB. Comprehensive injury research. JAMA 2015, 313(14):1463-1464.
 The Hartford Consensus III: Implementation of Bleeding Control. Lenworth MJ, and Joint Committee to Create a National Policy to Enhance Survivability From Mass-Casualty Shooting Events. July 1, 2015. http://bulletin.facs.org/2015/07/the-hartford-consensus-iii-implementation-of-bleeding-control/