Discussion

The evolution of warfare demonstrates consistency in the nature of warfare but distinct changes in its character. The advent of perpetual advances in technology and cybertechnology, the use of drones, artificial intelligence, and the internet offer additional advances that were not present in the past. However, age-old tactics of warfare such as the utilization of CBRNe weaponry maintain destructive capabilities for mass-casualty incidents and induces the highest level of fear and panic. The potential integration of CBRNe modalities with modern technology (such as the use of drones for delivery mechanisms) furthers the potential for terrorist attacks. ^{Reference Barten, Tin and De Cauwer13,Reference Tin, Kallenborn and Hart14}

Counter-measures for terrorist and CBRNe attacks are unique in that specific training is necessary to identify and respond. Medical counter-measures are critical in response to a CBRNe attack. However, identification of many CBRNe agents can be difficult and is often delayed due to their inconspicuous and inherent properties, delivery, and/or onset. This highlights the importance of medical education for counter-terrorism and CBRNe weapons and events. A baseline education is critical for all medical specialties to be able participate in a terrorist attack. This is analogous to the wide-spread teaching of Basic Life Support and cardiopulmonary resuscitation (CPR), thus offering victims a greater chance of survival based on a higher probability that someone may be able to provide some level of medical assistance. Greater attention may certainly be given to medical specialties that may deliver a higher impact on CBRNe identification and response, such as emergency medicine, critical care, and dermatology for example.

Cole emphasized the importance of at least a basic education for United States physicians on the topic of terror medicine. ^{Reference Cole6,Reference Court, Edwards and Issa7,Reference Parrillo and Christensen10,Reference Shapira, Hammond and Cole15} He examined the education and experience of physicians in countries that were embedded in CTM, such as Israel, emphasizing the importance of learning from their experiences. ^{Reference Shapira, Hammond and Cole15}

The likelihood of terrorist and CBRNe attacks remains low and thus one must justify the time and cost of CBRNe medical education. However, a basic introductory lecture (as minimum content) carries little to no cost but offers a useful framework for medical students. It also serves to stimulate interest in those who may express further interest in CTM, whether formally or informally at future points in their career. There exists a need for both CTM and CBRNe response specialists. However, there is also a benefit for community physicians to be able to recognize signs and symptoms of a CBRNe attack and be able to provide medical assistance in a terrorist attack. Certainly, this need justifies action just as in geographic locales where medical counter-terrorism measures are mandatory. However, there is no substitute for preparedness as the world saw amidst the coronavirus disease 2019 (COVID-19) pandemic.

The field of CTM continues to evolve as a subspecialty of emergency and disaster medicine. ^{Reference Tin, Cheng and Shin1,Reference Shapira, Hammond and Cole15–Reference Tin, Granholm and Hart20} Counter-terrorism medicine includes a full spectrum of medical responses, starting at the tactical level in the field, moving to immediate response and care, to the hospital, and includes a multitude of post-event components to include both acute and chronic psychological impact. Thus, there exists a wide range of medical specialties who can and should be involved in the care of those victims of terror and CBRNe events. ^{Reference Tin, Granholm and Hart20}

Counter-terrorism medicine education is primarily taught in medical residency, fellowship, and military (and law enforcement) levels. There are some medical schools that do incorporate counter-terrorism and CBRNe medical education at the undergraduate medical school level; however, the vast majority have minimal to no such curriculum in place. ^{Reference Kommor, Hodge and Ciottone21–Reference Wiesner and Kappler25} In general, the presence or absence of content offering appeared most linked to the association of faculty with high level of interest in CTM and/or CBRNe content. The Association of American Medical Colleges (AAMC; Washington, DC USA) and Liaison Committee on Medical Education (LCME; Washington, DC USA) called for the incorporation of disaster training within United States medical education following the September 11, 2001 attacks, although only a minority of schools include any form of robust disaster training. ^{Reference Jasper, Wanner and Berg23,Reference Wiesner and Kappler25} Similarly, the Centers for Medicare and Medicaid Services (CMS; Baltimore, Maryland USA) published a rule in 2016 that required all participating physicians to coordinate with local, state, and federal emergency preparedness systems. ²⁶ However, aside from hospitals and ambulatory surgery centers that are routinely inspected for such policies, this is an uncommon policy and/or prepared contingency in the vast majority of medical offices.

A multitude of studies demonstrate both the interest and proposed benefit of implementing CTM within the medical school curricula. ^{Reference Kommor, Hodge and Ciottone21–Reference Wiesner and Kappler25} There have been previous reports analyzing both United States allopathic and osteopathic medical schools. ^{Reference Court, Edwards and Issa7,Reference Parrillo and Christensen10,Reference Smith, Levy and Hsu11} Similar studies in countries other than the United States yielded similar findings. ^{Reference Robinson, Ragazzoni and Corte27–Reference Wunderlich, Ragazzoni and Ingrassia29} Cole published the success of a two-week elective course in a United States medical school. ^{Reference Cole, Natal and Fox4,Reference Cole, Wagner and Scott5} Cole also emphasized the importance of learning from countries that have greater experience with CTM, such as Israel. ^{Reference Cole, Natal and Fox4,Reference Cole, Wagner and Scott5,Reference Cole30} Specifically, Cole emphasized specific lessons that the United States can learn from Israel’s experience: crisis management, national standards, coordination, and communication. He noted differences in Israel and United States organization, in that Israeli medical responses are centered around a national disaster management system, whereas local and regional systems predominate in the United States ^{Reference Cole30} This national-based centralized system in Israel offers tiered protocols, while the more decentralized system in the United States may yield communication challenges. Additionally, the United States tends to train organizations while Israel trains individuals. ^{Reference Cole30} A clear example is the use of various code colors that often mean different circumstances in various United States hospitals.

Germany incorporated disaster medicine as part of its medical education in 2006; however, its implementation was not consistent and there is currently no standardized training. ^{Reference Wunderlich, Ragazzoni and Ingrassia29,Reference Hermann, Gerstner and Weiss31} There are elective courses available in many countries including Italy and Belgium, while the Netherlands and China had no curricula for disaster medicine in medical schools. ^{Reference Hermann, Gerstner and Weiss31}

The movement to implement CTM into medical school curriculums gained maximum momentum after the September 11, 2001 terrorist attack on the World Trade Tower (New York USA). ^{Reference Cole, Natal and Fox4–Reference Cole6,Reference Shapira, Hammond and Cole15–Reference Tin, Granholm and Hart20} Cole developed a two-week course on terror medicine for medical students, encompassing four key areas: preparedness, incident management, mechanisms of injuries, and psychological consequences. ^{Reference Cole, Natal and Fox4,Reference Cole, Wagner and Scott5} Each medical school will determine both content and time allotted for any such education. Other institutions may offer single lectures, grand round presentations, or simulations, all of which offer at least exposure of the topic to medical students. Goals in introducing CTM and CBRNe education to medical students include the following: (1) introduction to the topic, (2) familiarity with the topic, (3) association with each student’s chosen medical specialty, and (4) increased preparedness (starting with individual preparedness).

A number of studies have evaluated the need to implement counter-terrorism and disaster medicine into medical school curricula. ^{Reference Court, Edwards and Issa7,Reference Parrillo and Christensen10,Reference Smith, Levy and Hsu11} Smith examined allopathic medical schools, finding that approximately one-third included disaster medicine in the core curriculum. ^{Reference Court, Edwards and Issa7,Reference Parrillo and Christensen10,Reference Smith, Levy and Hsu11} While this is a minority, the number of United States medical schools that offer such content seems much less based on the current study. Kaiser, et al conducted a survey to United States allopathic and osteopathic medical schools and found that the majority of medical students (60%) were willing to participate in a natural disaster, a pandemic influenza response, or a radiological attack scenario. ^{Reference Kaiser, Barnett and Hsu32} However, more important than an exact statistical number is the overall trend of the need for more education on this topic.

The AAMC, the LCME, and the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) previously deemed CTM to be a necessary topic to include in medical school despite the subsequent failure of implementation. ^{Reference Jasper, Wanner and Berg23,Reference Wiesner and Kappler25} The threat of terrorism both on the domestic front and overseas continues to increase. ^{Reference Cole, Natal and Fox4} While the incidence of CBRNe attacks or the COVID-19 pandemic are infrequent, their impact is wide-reaching and substantial, thus justifying the call for increased education and preparedness. Just as civilians are trained in basic first aid, CPR, and bleeding control programs (Stop the Bleed), medical students and physicians should be proficient at higher level medical care capabilities. ³³ Additionally, there are methods to incorporate CTM and CBRNe content within medical school curricula via numerous modalities that maximize both this content and traditional content. Medical students learn standard educational content but rarely in the context of CTM. Perhaps standardization is not practical; however, there is both a need and a way for medical schools to incorporate at least an introduction to this critical topic.