Terrorist Motivation

Terrorists may be motivated to use hoax IEDs for a range of reasons and the academic literature in this area is limited. Lacking the resources to acquire or build real weapons, lone actors may employ easy-to-produce counterfeits as achievable alternatives to enhance the perceived lethality of their attacks and exaggerate their destructive capabilities. As such, hoax devices function as a primary intimidation tool or as a secondary force multiplier in conjunction with real, bladed weapons, intentional vehicular assaults, or firearms. Perpetrators could also view hoax IEDs as a means of delaying law enforcement intervention and causing unnecessary resource expenditure or diversion. ^{Reference Sinai9}

There were 348 hoax device incidents in the United States in 2021, with the majority being IED-type hoax devices. ¹⁰ In the United Kingdom, while one recent incident attributed to the Irish Republican Army saw the use of a hoax device, ¹¹ Islamic extremism was the reported motivation of the perpetrators in most attacks involving hoax devices and injury to victims by other means.

Islamic extremists could be drawn towards martyrdom and the notion of “fedayeen,” a term that translates as “those who sacrifice themselves” - the act of dying for a cause one believes in with a reward in the afterlife. ^{Reference Nanninga12} This concept has been exploited by extremist groups to motivate their followers to continue fighting even in the face of overwhelming odds. ^{Reference Hove and Chenzi13} As suicide is “harram” (forbidden by Islamic law), terrorists may also use fake suicide vests to induce “suicide-by-cop,” whereby a person deliberately provokes law enforcement officers into using deadly force, thus avoiding direct responsibility for their own death. Acts of terrorism involving suicide also have a wider negative psychological impact on society and higher levels of media coverage compared to non-suicide methodologies; a hoax IED permits terrorists to take advantage of this phenomenon without contravening Islamic law. ^{Reference Tin, Galehan, Markovic and Ciottone14}

Impact on Medical Care

The areas around evolving terrorist incidents have been described in terms of hot (area in which attackers are present), warm (an identified threat remains, but attackers thought to be no longer present), and cold (control measures have been implemented and safe enough for non-specialist responders to enter) zones. These designations provide a useful framework for response planning and defining the responsibilities and capabilities of emergency service personnel with tactical training and personal protective equipment, but real-world implementation can be problematic. ^{Reference Park and Grier15} The presence of a potential IED means an area is considered “hot” even after the perpetrators have been incapacitated by law enforcement until the device can be confirmed as non-functional. This focus on scene safety is vital to prevent first responders becoming victims themselves given that explosives and bombings represent the most common mode of attack deployed against emergency service personnel. ^{Reference Schmeitz, Barten and van Barneveld16}

During a marauding terrorist attack, regardless of weapon type or systems used, the time to both initial life-saving interventions and transport to definitive care increases due to the inherent difficulty of accessing casualties in the warm zone and subsequent movement from the warm to cold zones and on to definitive care. These delays lead to preventable deaths, especially in penetrating trauma where time to definitive care is the primary variable that affects survival. ^{Reference Haslam, Bouamra, Lawrence, Moran and Lockey17}

The delay in the provision of medical care to victims caused by the tactical considerations of marauding terrorist attacks has been described as a therapeutic vacuum. ^{Reference Park, Langlois and Smith18} Victims trapped in this vacuum suffer excessive hypoxic/ischemic burdens that could have been limited by simple measure such as hemorrhage control, airway maneuvers, or chest decompression and results in higher morbidity and mortality than would be predicted on the basis of injury alone. ^{Reference Young, Sena and Galante19}

While law enforcement and Emergency Medical Services are evolving systems to minimize these delays, the presence of a potential explosive device on scene will inherently complicate the extrication of patients. There is also the potential for more subtle hoax IEDs to only be discovered after neutralization of the perpetrators; prehospital trauma teams may be told to evacuate to a safer position, further delaying life-saving intervention and complicating the delivery of quality care. In jurisdictions that do not have integrated teams to provide care in the warm zone, the delay to treatment can persist even after a scene or area is declared safe enough for non-specialist responders to enter by law enforcement. ²⁰ An understanding of the variables affecting the therapeutic vacuum is paramount to victim outcomes.

Potential Solutions

Means to minimize delays to treatment caused by fake IEDs can be thought of in terms of technical, procedural, and educational solutions which parallel recent, broader advances in tactical medicine. Technical solutions fall within the law enforcement counter-terrorist and explosive ordinance disposal (EOD) remit and may include early identification of devices as non-functional (eg, permanent embedding of EOD trained staff on counter-terrorist teams) or the use of ballistic shields or armored vehicles to facilitate rapid extrication of victims to safer areas.

A shift away from the dogmatic approach to defining areas of a scene and which responders can enter when would enable teams and individuals to apply dynamic risk assessments to the specific environment they are currently facing. Adaptable teams capable of recognizing where the balance of probability lies in terms of risk could decide whether medical personnel can be brought forward, or if patients would need to be extricated to a safer area. This solution was implemented in recent United Kingdom Joint Operating Procedure guidelines.

The latter is reliant on effective joint-operability training to enable effective decision making and communication between emergency medical personnel and law enforcement officers at terrorist incidents. Enhancing the medical capabilities of tactical law enforcement officers facilitates early initial life-saving intervention, even at scenes where hazards prevent rapid entry by medical personnel. Similarly, continued public education efforts such as the “Stop the Bleed” campaign enable bystander intervention by members of the public.