Terrorism has increasingly become an integral part of the reality in many regions of the world. In the past few decades, there has been a surge in the number and in the intensity of terrorist attacks all over the globe, and the treatment of terror-related mass casualty incidents presents a special challenge to the medical teams involved. According to the Worldwide Incidents Tracking System (WITS) of the American National Counterter-rorism Center (National Counterterrorism Center 2006), there were 3,204 terrorist incidents worldwide in the year 2004 with 6,110 fatalities and 16,257 wounded. Many of the casualties resulted from suicide bombings in Iraq, Chechnya, Uzbekistan, Israel, and Pakistan. Unfortunately, the numbers are expected to increase further and the world has realized that terrorist attacks are no longer confined to certain locations.
Consequently, management of terror-related injuries has become a global public health challenge and increased awareness of medical teams to their unique characteristics is warranted. Furthermore, the medical community should develop adequate preparedness to various nonconventional terrorist scenarios, caused by chemical, biological, and radiological weapons, in order to decrease the associated chaos and improve the probability of survival of those injured (Shemer and Shapira 2001).
The term "terrorism" itself derives from the Latin word "terrere" (to frighten), and it dates back to 1795 when it was used to describe the actions of the Jacobin Club in their rule of revolutioary France during the Reign of Terror. The modern definition of "terrorism" is emotionally and politically charged (Wikipedia 2006). However, nearly all of its definitions include certain key criteria in terms of the unlawful use of violence with political, religious or ideological motivation, while the target is civilian, and the objective is to demoralize and to provoke fear. According to a United Nations panel in 2004, acts of terrorism are "intended to cause death or serious bodily harm to civilians or non-combatants with the purpose of intimidating a population or compelling a government or an international organization to do or to abstain from doing any act" (Wikipedia 2006).
Bombs and explosions directed against innocents are the primary instrument of modern terrorist groups. These weapons are easily and inexpensively manufactured, often according to clear instructions that are freely distributed on the internet, and are usually very simple to activate either directly or remotely, automatically or manually, momentarily or at a de-ferredtime using various timers (Kluger 2003; Sutphen 2005). Terrorists use explosive devices of various levels of sophistication and power, which can be military, commercial, or homemade. The common mechanism of all explosive devices is the rapid conversion of solid or liquid material into gas with associated release of energy. The explosion substances are categorized as either high- or low-order (Sutphen 2005). High-order explosives, like TNT, Semtex, and dynamite generate heat, loud noise, and a supersonic overpressurization shock wave (blast wave) that expands outward and is followed by a returning vacuum wave. Low-order explosives, like gunpowder-based bombs and Molotov cocktails, create an explosion with a relatively slow release of destructive energy without the overpressuriza-tion wave.
Suicide bombing is currently the most effective terrorist strategy since it maximizes the effect of mass casualty incidents. Suicide bombers are difficult to identify and their entrance into crowded confined places can cause an urban disaster. They may wear either an explosive belt or vest and can also use cars or trucks heavily loaded with explosives without attracting suspicion and trigger themselves with perfectly controlled timing (Sutphen 2005). The explosive device is detonated by a simple electric charge activated either remotely or more commonly by the suicide bomber himself (Kluger 2003). Occasionally, terrorists use secondary devices to detonate at a slightly delayed time, in order to harm the emergency response personnel taking care of the victims of the first act.
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