When a vehicle becomes a weapon: intentional vehicular assaults in Israel

Factors Associated with the Number of Injured and Fatalities in Motor Vehicle Intentional Mass-Casualty Incidents: A Timely Aid for Scaling the Emergency Response

INTRODUCTION

Intentional mass-casualty incidents (IMCIs) involving motor vehicles (MVs) as weapons represent a growing trend in Western countries. This method has resulted in the highest casualty rates per incident within the field of IMCIs. Consequently, there is an urgent requirement for a timely and accurate casualty estimation in MV-induced IMCIs to scale and adjust the necessary health care resources.

STUDY OBJECTIVE

The objective of this study is to identify the factors associated with the number of casualties during the initial phase of MV-IMCIs.

METHODS

This is a retrospective, observational, analytical study on MV-IMCIs world-wide, from 2000-2021. Data were obtained from three different sources: Targeted Automobile Ramming Mass-Casualty Attacks (TARMAC) Attack Database, Global Terrorism Database (GTD), and the vehicle-ramming attack page from the Wikipedia website. Jacobs' formula was used to estimate the population density in the vehicle's route. The primary outcome variables were the total number of casualties (injured and fatalities). Associations between variables were analyzed using Spearman's correlation coefficient and simple linear regression.

RESULTS

Forty-six MV-IMCIs resulted in 1,636 casualties (1,430 injured and 206 fatalities), most of them caused by cars. The most frequent driving pattern was accelerating whilst approaching the target, with an average speed range between four to 130km/h and a distance traveled between ten to 2,260 meters. The people estimated in the MV-IMCI scenes ranged from 36-245,717. A significant positive association was found of the number affected with the estimated crowd in the scene (R2: 0.64; 95% CI, 0.61-0.67; P <.001) and the average vehicle speed (R2: 0.42; 95% CI, 0.40-0.44; P = .004).

CONCLUSION

The estimated number of people in the affected area and vehicle's average speed are the most significant variables associated with the number of casualties in MV-IMCIs, helping to enable a timely estimation of the casualties.

Democratization of terrorism: an analysis of vehicle-based terrorist events

Objectives

The COVID-19 pandemic inspired social changes that promote outdoor activities including eating at restaurants, which may linger in a world hyperfocused on disease transmission prevention, increasing the vulnerabilities to vehicle-based terrorism. Vehicle ramming attacks started to transition from a relatively rare method of attack to one of the most lethal forms of terrorism in Western countries just prior to the emergence of SARS-CoV-2. This study aims to provide a historical analysis of the terrorism-based attacks using vehicles between 1970 and 2019.

Methods

This study uses the methodology suggested by Tin et al in which the Global Terrorism Database hosted by the National Consortium for the Study of Terrorism and Responses to Terrorism was searched retrospectively for data. Data was collected from the database using the internal search function for terror events between January 1, 1970 and December 31, 2019 which used a vehicle as a means of attack.

Results

There were 257 recorded terror attacks that involved some type of vehicle between 1970 and 2019. The attacks resulted in 808 fatalities and 1715 injuries when excluding the September 11 attacks. 76 events occurred at the West Bank and Gaza Strip, 25 in the USA, 16 in Israel, and 14 in the UK. Of the 257 terror incidents, 71% (183) occurred within the last 6-year span of inquiry.

Conclusion

By 2016, vehicle attacks were the most lethal form of attack comprising just over half of all terrorism-related deaths in that year. Large gatherings such as festivals, sporting events, and now outdoor seating at restaurants, leave a number of people highly vulnerable to a vehicle ramming attacks depending on established countermeasures. The increased prevalence of outdoor activities and gatherings in a post-COVID-19 world will further expose large numbers of people to the potential vulnerabilities of vehicle-based terrorism. The scale of the casualties from a vehicle-based terror attack can overwhelm traditional resources and strain the abilities of the healthcare sector. Counterterrorism and disaster medicine specialists are crucial players in educating first responders and emergency medicine providers, allowing them to adequately prepare for an evolving threat in a world devastated by COVID-19.

Level of evidence

VI.

Injuries From Explosions: More Differences Than Similarities Between Various Types

OBJECTIVE

To compare injury patterns of different types of explosions.

METHODS

A retrospective study of 4508 patients hospitalized due to explosions recorded in the Israel National Trauma Registry between January 1997 and December 2018. The events were divided into 4 groups: terror-related, war-related, civilian intentional explosions, and civilian unintentional explosions. The groups were compared in terms of injuries sustained, utilization of hospital resources, and clinical outcomes.

RESULTS

Civilian intentional and terror-related explosions were found to be similar in most aspects except for factors directly influencing mortality and a larger volume of severely injured body regions among terror-victims. Comparisons between other groups produced some parallels, albeit less consistent. Civilian intentional explosions and civilian unintentional explosions were different from each other in most aspects. The latter group also differed from others by its high volume of life-threatening burns and a higher proportion of children casualties.

CONCLUSIONS

While consistent similarities between explosion casualties exist, especially between victims of intentional civilian and terror-related explosions, the general rule is that clinical experience with a type of explosion cannot be directly transferred to other types.

Mass casualty, intentional vehicular trauma and anaesthesia

The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.

Best Practice Injury Compensation Processes Following Intentional Vehicular Assaults and Other Large Scale Transport Incidents: A Delphi Review

OBJECTIVE

Intentional vehicular assaults on civilians have become more frequent worldwide, with some resulting in mass casualties, injuries, and traumatized witnesses. Health care costs associated with these vehicular assaults usually fall to compensation agencies. There is, however, little guidance around how compensation agencies should respond to mental and physical injury claims arising from large-scale transport incidents.

METHODS

A Delphi review methodology was used to establish expert consensus recommendations on the major components of "no fault" injury claim processes for mental and physical injury.

RESULTS

Thirty-three international experts participated in a 3-round online survey to rate their agreement on key statements generated from the literature. Consensus was achieved for 45 of 60 (75%) statements, which were synthesized into 36 recommendations falling within the domains of (1) facilitating claims, (2) eligibility rules, (3) payments and benefits for clients, (4) claims management procedures, (5) making and explaining decisions, (6) support and information resources for clients, (7) managing scheme staff and organizational response, (8) clients with special circumstances, and (9) scheme values and integrity.

CONCLUSIONS

The recommendations present an opportunity for agencies to review their existing claims management systems and procedures. They also provide the basis for the development of best practice guidelines, which may be adapted for application to compensation schemes in different contexts worldwide.

Eating for numbing: a community-based study of trauma exposure, emotion dysregulation, dissociation, body dissatisfaction and eating disorder symptoms

Objective

The current study tests the relationship between eating disorder (ED) symptoms and trauma exposure. The mechanisms via which trauma is related to ED symptoms have not been sufficiently examined. This study examines the complex role of dissociation and emotional dysregulation in the context of trauma, BMI, ED symptoms and body dissatisfaction (BD). We hypothesized that dissociation and emotional dysregulation would mediate the relationship between trauma exposure and ED symptoms/BD. We further hypothesized that BMI would play a moderating role in this association.

Method

A community sample of 229 (16.2% male) participants, with a mean age of 29.08 ± 10.68 reported online on traumatic events (Life Events Checklist), dissociation (Dissociative Experiences Scale-II), emotional dysregulation (Difficulties in Emotional Regulation Scale), ED symptoms (Eating Disorders Examination-Questionnaire) and BD (Figure Rating Scale).

Results

Participants reported experiencing a mean of 2.87 ± 2.27 traumatic events, with a relatively high percentage (~86%) reporting at least one. The most commonly reported traumatic events were transportation accidents and physical assault. Although frequency of traumatic events did not directly predict ED symptoms, BMI, dissociation, emotional dysregulation and BD did. An SEM model showed that traumatic events predicted ED symptoms indirectly through dissociation, emotional dysregulation and BMI. Dissociation and emotional dysregulation predicted ED symptoms directly. BMI also moderated the association between traumatic events and both ED symptoms and BD.

Conclusions

Therapists treating patients with high BMI or obesity should be aware of these relationships and investigate the possibility that trauma and/or PTSD may underlie the presenting disordered eating or eating disorder.

Anthropogenic Disasters

Anthropogenic disasters may be defined as any disaster caused by human action or inaction. Natural disasters occur without human interference. Injuries caused by terrorists and related criminal activities may be broadly grouped into 3 categories: blunt, blast, and penetrating trauma. Most terrorist and criminal activities that create a mass-casualty situation are performed using the weapons most readily available, such as firearms or explosives. A consistent pattern, comparing terrorism with interpersonal violence, is the greater severity of impact on the victim.

New Trends in Terrorism-Related Injury Mechanisms: Is There a Difference in Injury Severity?

STUDY OBJECTIVE

The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set.

METHODS

This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes.

RESULTS

Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks.

CONCLUSION

Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.