Intended for healthcare professionals

Feature Essay

How to stop the dying, as well as the killing, in a terrorist attack

BMJ 2020; 368 doi: (Published 30 January 2020) Cite this as: BMJ 2020;368:m298
  1. Claire L Park, medical adviser1 2 3,
  2. Matthieu Langlois, medical director4,
  3. E Reed Smith, operational medical director5 6,
  4. Matt Pepper, president7,
  5. Michael D Christian, research lead1 2,
  6. Gareth E Davies, innovation lead1 2 3,
  7. Gareth R Grier, director, Institute of Pre-Hospital Care1 2
  1. 1Bart’s Health NHS Trust, London, UK
  2. 2Institute of Pre-Hospital Care at London’s Air Ambulance, London, UK
  3. 3Metropolitan Police Service Specialist Firearms Command, London, UK
  4. 4Service Medical du RAID (Recherche, Assistance, Intervention, Dissuasion), Paris, France
  5. 5Arlington County Fire and Police Departments, Arlington, VA, USA
  6. 6George Washington University Medical Centre, Washington DC, USA
  7. 7Australian Tactical Medical Association, Sydney, Australia
  1. Correspondence to: C Park clairepark1{at}

There’s a therapeutic vacuum in the “hot zone” of a terror attack. Claire Park and colleagues describe efforts in the UK and beyond to deliver expert medical care to casualties trapped at the centre of an attack

Mobile attackers with bladed weapons, firearms, or explosive devices are currently a significant global threat to the public and emergency responders. The risk of chemicals, vehicles, and fire used as weapons adds further complexity to such attacks.

Recent attacks have killed many innocent people: more than 9800 terror attacks occurred worldwide in 2018, resulting in 22 980 deaths.1 Some of these people might have survived had the medical response gained to access to them earlier. Emergency services face the problem of how to provide medical care to casualties in an area deemed under direct threat, known as the “hot zone.” Although many of the armed police responding in the hot zone are also trained to provide some lifesaving medical care, they are the same armed officers who are trained to first locate and stop the attackers—delaying their focus on medical interventions until the threat is controlled. The resulting therapeutic vacuum of medical intervention can last for minutes to hours after people are injured.

We believe that the UK should adopt standard military practice in these attacks and enable armed police to give “care under fire,” alongside management of the immediate threat. Appropriately trained medical officers should also be integrated with the police in the hot zone: this happens in France, as seen in the Paris terror attacks in 2015. These steps would tackle many of the areas that currently encourage this potentially lethal therapeutic vacuum in the UK.

The story so far

The “hot zone” in a terror attack is one that poses a credible and continuing threat to life, including attackers with weapons. The “warm” zone …

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