What comes to mind when you hear the word terrorism? Bombings, mass casualties, religious or political zealotry, chemical or biological substances, mass shootings, or a particular incident such as September 11, 2001. Perhaps all of the above. Some may think first of perpetrators of terrorist acts while others may think of reasons given for such acts—and, as a healthcare worker, what comes first to your mind is quite likely all the possible results of terrorist actions.

Terrorism

The Federal Bureau of Investigation (FBI) uses a definition of terrorism that includes “the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (28 C.F.R. Section 0.85).

While the use of violence lies at the heart of most definitions of terrorism, arriving at a more nuanced definition often depends on the political, ethnic, or religious perspective of those doing the defining. In addition, terrorism is sometimes categorized as either “domestic” or “international,” referring not to where the terrorist act takes place, but to the origin of the individuals or groups responsible for it. For healthcare professionals facing the medical consequences of a terrorist act, this distinction may not seem especially pertinent.

There is much debate over the motivations for terrorism. Traditionally it has been thought to reflect religious, political, or ideological beliefs, and the targets of attacks to be symbolic in some way. Sparking fear in victims and the wider public is often a motivating element. Recent research suggests motivations may include a personal desire on the part of perpetrators to further their membership in the terrorist community and can be affected by various internal structural issues within terrorist groups (Abrahms & Potter, 2015; Abrahms, 2008).

Terrorist acts have occurred throughout history, but after the Oklahoma City bombing in 1995 and the events of September 11, 2001 in the United States, such behavior became an ongoing element of the public consciousness.

While 9/11 and other events have been planned and executed by large and well-known groups only too willing to claim responsibility, some events suggest that acts of domestic terrorism (ones fitting the FBI definition) are sometimes perpetrated by just one or a few individuals acting not as official members of a group, but claiming to be or appearing to be acting to further a known group’s goals. When those perpetrators die in the act and no charges are filed there may be no official label to be had, but they leave behind enough evidence that it doesn’t seem much of a stretch to call them terrorists.

Terrorism vs. “Mass Shootings”

The Patriot Act defines domestic terrorism as an attempt to “intimidate or coerce a civilian population; to influence the policy of a government by intimidation or coercion; or to affect the conduct of a government by mass destruction, assassination, or kidnapping” (Myre, 2017).

Increasingly, events have occurred that many think of and label as terrorism even though they fall entirely into a definitional and legal gray area. Perhaps most familiar are mass shootings, but a few have been bombings or the weaponizing of vehicles. Some of these include Sandy Hook Elementary School in Newtown, CT, the Aurora Colorado movie theater, and the Wisconsin Sikh temple in 2012; the Boston Marathon in 2013; San Bernardino, CA, and the Charleston, SC, church in 2015; the Orlando, FL, nightclub in 2016; and the Sutherland Springs, TX, church in 2017—sadly, only a small handful of the events of the last twenty years.

Wide access to the Internet means that information about these events travels more quickly, is more widely disseminated, and discussion is more animated and highly charged than ever before. Often these events have obvious things in common with events officially labeled as terrorism, but there are some important distinctions.

As Nevadans became acutely aware in October 2017, with the mass shooting outside the Mandalay Bay Resort in Las Vegas, terrifying events can be perpetrated by a single person using no weapons of mass destruction (chemical, biological, or radiological materials) and with intensely personal reasons and no apparent political motivation. Within the law the label of terrorism is impossible.

These events have sparked debate and calls for change but the issues are complex and there is often little consensus. Citizens are often surprised to find there is no domestic terrorism law that defines these terrifying events as terrorism (Axelrod, 2017; CNN, 2017; Gillin et al., 2017; Myers, 2017: Myre, 2017; Stuart, 2013). Interestingly, Nevada is one of a group of states that do have their own anti-terrorism laws (NRS: Chapter 202) but those laws are seldom invoked (Myre, 2017) and with no one to charge, it’s likely a moot point.

However, one can certainly make the argument that the way in which mass shootings (or bombings or vehicular murders) are perpetrated and the effects they have on victims and near-victims make them terrorism in everything but name. The results can be very similar—mass casualties, surge capacity issues, and widespread fear and panic must all be dealt with by healthcare professionals. Their best defense will always be good preparation.

What Is Being Done?

The U.S. government was already actively working to combat terrorist threats before September 11, 2001 and stepped up its efforts afterwards. For the public and for healthcare workers, education about the proper responses to terrorist activities, along with thorough emergency preparedness, is the best available defense.

In 2003 the Nevada legislature passed Assembly Bill 250, which mandates training for nurses and other healthcare professionals to ensure they have a basic knowledge of potential terrorist threats and how to respond to them.

As noted, the effects of terrorist acts are often not only physical; fear may loom large among citizens, not only among those at the actual site of the attack but also among others much farther away. Healthcare workers need to be prepared to address this fear, even in patients who have sustained little or no physical injury. In addition, psychological effects are recognized consequences of certain types of injuries and will be discussed in the sections that follow.

Analysis of these events and responses to them have resulted in a large body of useful information in the form of resources for individuals and organizations seeking to educate and prepare themselves. The changing nature of the Internet means that some of these resources may come and go, but websites maintained by the Department of Homeland Security (DHS), the Department of Health and Human Services (DHHS), and the CDC remain up-to-date and valuable resources for individuals and institutions.

The State of Nevada has recently restructured its health department and redesigned and updated its corresponding websites and resource links. Contact information and links to both state and federal resources appear at the end of this course.