Personal Protective Equipment (PPE) and Gear Considerations
Terror-related responses often present hazards that go beyond the everyday EMS call, so the right personal protective equipment (PPE) is essential. In any EMS response you’ll have your standard PPE (gloves, eye protection, etc.), but for terrorism incidents you should consider additional protective gear based on the nature of the attack.
One key consideration is the potential for ballistic or shrapnel threats. If there was gunfire, an active shooter, or explosives, there is a risk of bullets or blast fragments. Many EMS agencies now issue ballistic PPE, such as bullet-resistant vests and helmets, to their providers for use during violent incidents. In fact, national standards (like NFPA 3000) and expert consensus urge that firefighters and EMS personnel be provided with appropriate ballistic protection if they are expected to operate in areas that are not fully secured ( Source ). For example, if you’re part of a Rescue Task Force (RTF) entering a “warm zone” (an area cleared by law enforcement but not guaranteed 100% safe) to treat victims, you should be wearing body armor and helmet as a precaution. Before deploying from staging, don your ballistic vest if you have one, especially in scenarios involving an active shooter or unknown assailant – it could save your life.
If the incident involves fire or hazardous materials, adjust your PPE accordingly. In bombing scenes, there may be significant fire; consider donning fire-resistant turnout gear or at least a brush coat and gloves from your rescue truck if available, to protect against heat and sharp debris when operating near a blast site. Always wear helmets in environments with potential falling debris (after an explosion, building parts could be unstable).
For chemical, biological, radiological, or nuclear (CBRN) threats, specialized PPE is a must. While frontline EMTs and paramedics aren’t usually equipped to fully handle CBRN without support, you should recognize when it’s needed. Signs like multiple victims with similar symptoms (e.g., seizure or difficulty breathing without an obvious cause), strange odors or liquids, or a warning from dispatch (e.g., “possible chemical agent release”) should prompt extreme caution. Do not rush in without proper gear – this might mean waiting for a HazMat team or donning Level C or Level B protective suits if your service has them, along with respiratory protection (SCBA or PAPR masks). The reality is that terrorists might employ CBRN weapons, so responders must be prepared for that possibility (EMS Terrorism Response – PubMed). For example, if a white powder is suspected to be a toxin or there’s a release of gas, your standard uniform and N95 mask won’t be sufficient. In such cases, secure the area, keep yourself uphill and upwind, and request HazMat – life safety for you and the public is more important than immediate patient care in a contaminated “Hot Zone.”
Even in non-CBRN situations, respiratory protection is often overlooked. Think about the dust and smoke at a bombing or arson scene – inhaling those can be harmful. If you have an N95 or APR mask and the air is full of particulates, put it on. Eye protection is also crucial; debris or even a blast wave can cause eye injuries. Essentially, outfit yourself for the worst reasonably anticipated hazard. It’s better to be slightly over-protected than caught off guard.
Lastly, don’t forget basic EMS safety gear: high-visibility vests if you’re on a roadway (even during chaos, traffic can still be a risk), gloves when handling patients (terrorism incidents can involve traumatic injuries with lots of blood), and sturdy boots to protect your feet from debris. Check your aid bag – do you have thick gloves for handling sharp metal or glass? Do you carry a tourniquet and quick-clot bandages readily accessible on your person? In terror incidents, severe hemorrhage is common, so having those immediately on hand (even on your belt or vest) is wise.
To recap, tailor your PPE to the incident. Wear ballistic protection in the face of shooting or explosion threats ( Source ), use fire/helmet protection in blast and collapse zones, and escalate to HazMat gear if a chemical or biological agent is even suspected. Your personal safety gear is a vital part of ensuring you can do your job effectively without becoming a victim yourself.

Coordinating with Law Enforcement on Scene
In a terrorist incident, law enforcement will be a lead player, and EMS must work hand-in-hand with them for a successful outcome. These scenes are crime scenes and often active threats, so the police role is to neutralize dangers and investigate, while our role is to save lives – but neither can do their job without the other. Effective coordination starts with clear role definition and mutual trust.
Early in the incident, connect with the law enforcement incident commander or tactical team leader if possible. They will inform you which areas are “hot” (unsafe) versus “warm” or “cold” (areas that have been cleared or are out of danger). Never enter a hot zone that police have not cleared – if victims are in that area, discuss tactics like extrication by police to a safe area or forming a Rescue Task Force. The Rescue Task Force concept involves EMS and police moving together into a warm zone: police provide armed security and cover, while EMS begins triage and treatment behind that protective line (EMS Response to Active-Shooter Incidents) (EMS Response to Active-Shooter Incidents). This approach – “stop the killing, then stop the dying” – is now widely advocated as a way to save lives in active shooter and terror incidents by not waiting until everything is 100% safe ( Source ) ( Source ). However, it requires coordination: you must train for it beforehand and have the proper gear, and you must move under the direction of law enforcement. If your jurisdiction uses RTF, coordinate with the on-scene commander to deploy at the right time. If not, default to staging until an all-clear.
While operating on scene, maintain communication with officers nearby. They may have intel – for example, knowledge of a second suspect on the loose or an unexploded device in the area – which absolutely affects how you act. Conversely, you as EMS might observe something critical, such as a patient who was actually the perpetrator or suspicious wires on a patient’s clothing. Share that with law enforcement immediately. A quick word of caution: in the heat of caring for patients, do not lose track of your surroundings. It’s easy to develop tunnel vision on a critical patient, but in a terror scenario, always assign someone (even a police officer or a fellow EMT not directly treating) to serve as a lookout for scene security while you work.
Another important aspect of working with law enforcement is evidence preservation. Terrorist acts are crimes, and evidence will be vital for investigation. Obviously, life safety comes first, don’t hesitate to cut clothing or move debris off a patient when necessary, but be mindful if possible. Try to minimize disturbance of the scene beyond what’s needed for care. For instance, if you notice a suspicious backpack, don’t kick it aside; flag it for the bomb squad. If you must remove a patient’s clothing that might contain trace evidence (like explosive residue), consider handing those clothes to a police officer or placing them in a paper bag (if available) rather than tossing them on the ground. Communicate with law enforcement about deceased victims as well. In a mass casualty terrorism event, fatalities should be left in place if possible, once confirmed dead, for investigators (unless there’s a safety reason to move them). Coordinate any patient movement or ambulance ingress/egress routes with the police so you don’t inadvertently trample over a critical piece of evidence.
Scene control will largely be dictated by law enforcement, and EMS should integrate into that plan. Expect that certain areas will be cordoned off with tape; ask police where it’s best to set up your treatment area or ambulance loading zone. They might prefer it in a specific location to keep it out of line of sight or away from suspected hazards. Work with them – this improves safety for everyone. If the incident involves an explosive, the bomb squad will likely sweep the area before you’re allowed in fully – patience is key here, and coordination (they might clear one section at a time, allowing you to systematically expand your area of operations).
On the flip side, advocate for your patients’ needs to law enforcement. There may be times when police are focused on security to the point that medical access is delayed. If you know there are critical victims bleeding out, communicate that to the unified command: “We have reports of multiple critically injured in there; as soon as you can secure a corridor, we need to move in or have them brought to us.” Often, law enforcement will work to accommodate that by, for example, performing a hasty extraction of victims when feasible. Establishing a unified command as mentioned earlier really helps here, because police, fire, and EMS leaders will be side by side making decisions together rather than siloed ( Source ).
Finally, debrief and continued cooperation: after the incident, EMS might still assist law enforcement (for example, standing by during the rendering safe of a device, or providing rehab/first aid for officers exerting themselves). The partnership doesn’t end when the last patient is transported. Be prepared for post-incident investigations. You might be asked for your observations or to make a statement if you saw key details. Provide factual information to investigators as needed.
In essence, EMS and law enforcement are a team in terrorism response. By understanding each other’s priorities and constraints and communicating actively, the scene can be made safer faster, and victims can receive care sooner (Fire/EMS at Active-Shooter Incidents) (EMS Response to Active-Shooter Incidents). Mutual respect goes a long way: we rely on law enforcement to protect us from violence, and they rely on us to save lives and even their fellow officers if wounded. Coordination is the linchpin that holds that partnership together.

Operational Considerations: Triage, Treatment, and Transport
While the focus of this discussion is on safety and coordination, we can’t forget the core mission of EMS: treating and transporting the injured. Terrorist incidents often result in mass casualty incidents (MCIs), so EMS providers should be fluent in triage and disaster medicine principles. Once the scene is sufficiently secure and you’re cleared to enter the patient care area, rapid triage is usually the first step. Use your agency’s MCI triage protocol (START, SALT, etc.) to categorize patients and identify who needs immediate life-saving intervention. Triage in a terror incident can be challenging. Injuries may range from penetrating trauma and blast injuries to burns or inhalation injuries. The goal is the same: do the most good for the most people. Tag or clearly identify your Immediate (red), Delayed (yellow), Minor (green), and Expectant/deceased (black) patients.
A key point to remember is that in terrorist attacks, some injuries can be uniquely severe. Explosions, for example, cause blast injuries that include primary blast wave injuries (like lung blast injuries or eardrum ruptures) and secondary injuries from shrapnel (EMS Providers Must Prepare For Terrorist Attacks | Firehouse) (EMS Providers Must Prepare For Terrorist Attacks | Firehouse). Be prepared for victims with amputations, impaled objects, or crush injuries from structural collapse. Quick interventions for hemorrhage control are paramount. In fact, recent best practices highlight aggressive use of tourniquets and hemostatic dressings in these scenarios (Fire/EMS at Active-Shooter Incidents). If a patient has life-threatening bleeding, address that immediately (even during triage). Many lives have been saved in incidents like the Boston Marathon bombing by bystanders and EMS applying tourniquets quickly. As you triage, if someone is squirting blood, don’t walk by, stop and control bleeding, then move on if you must. This aligns with the “Stop the Bleed” campaign principles, which are highly relevant in terror incidents.
For treatment, follow trauma protocols but also be mindful of any unusual agents. If there are signs of chemical exposure (e.g., pinpoint pupils suggesting nerve agent, or respiratory distress in many patients suggesting chlorine gas), initiate decontamination and specific treatments (such as atropine/pralidoxime for nerve agents) per your training and protocols but only if you have proper PPE and it’s within your scope. Most EMS providers will focus on the basics: airway management, breathing support, bleeding control, and shock management. Remember that in MCIs, you may not have the luxury of doing extensive care on scene for each patient. The principle is “triage, treat quickly, and transport.” Set up a casualty collection point with the help of fire/police, if possible, where you can bring patients to a central area for treatment and loading, away from immediate danger.
Transport logistics can be tricky in these events. Work with incident command to establish ambulance staging and a transport officer who will communicate with area hospitals. Hospitals may need to be notified of potential terrorist involvement. They might activate their disaster plans or even their own security measures if, say, the threat could follow patients to the hospital. Distribute critical patients to different trauma centers if possible, to avoid overwhelming one ER. Also consider atypical transport methods: In a dire scenario with many critical injuries, commandeering buses or other vehicles for multiple minor-injury transports, or using police vehicles for bleeding patients when ambulances are tied up, might be on the table (these should be coordinated through command).
Throughout the treatment and transport phase, keep situational awareness. Just because you’re now focused on patient care doesn’t mean the situation can’t change. Ensure someone in your team monitors the radio and watches for any sign that conditions are deteriorating (e.g., a secondary threat or a flare-up of violence). If the incident is prolonged (like a multi-location attack or a terrorist still at large), be ready to adapt or even relocate your treatment operations on short notice.
Finally, care for the caregivers. Terror events are high-stress, emotionally charged scenes. Take brief moments, when you can, check on your partners and teammates. Encourage hydration and remind each other to take deep breaths. There is often chaos, anger, and even media presence that can add pressure. Try to stay focused on the task and tune out the noise. After the incident, an operational debrief and a critical incident stress debriefing are highly recommended. Such calls can take a psychological toll, and EMS providers should not hesitate to seek support in processing what they’ve witnessed.
Conclusion: Preparedness and Professionalism
Responding to a terrorist incident is one of the greatest challenges an EMS provider can face. It tests every aspect of our training; from medical skills and quick thinking under pressure, to our discipline in scene safety and interagency teamwork. As we’ve discussed, understanding what defines terrorism helps frame the situation: when you know an incident is likely terror-related (because it involves intentional violence with ideological aims), you can anticipate a more complex scene and a multi-agency response. Recent events like violent campus demonstrations and orchestrated arson attacks show that terrorism isn’t just the stereotypical international plot, it can erupt in any community, even under the guise of local protests or vandalism (US to probe Columbia protests for terrorism violations, official says | Reuters) ( Office of Public Affairs | Attorney General Pamela Bondi Announces Severe Charges Against Violent Tesla Arsonists | United States Department of Justice).
For EMS, the approach to these incidents builds on what we already know from handling MCIs and dangerous scenes, but with heightened awareness. Scene safety is paramount. We can’t help others if we’re injured or dead ( Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature – PMC ). That means staging at a safe distance, scanning for secondary devices ( Source ), and ensuring threats are neutralized before committing to patient care. Communication is our lifeline in coordinating such a response: using incident command structure ( Source ), staying in sync with law enforcement, and getting the right resources to the right place without delay. Having the proper PPE and using it, whether it’s a ballistic vest, helmet, or chemical suit, is an investment in our survivability, allowing us to operate in hazardous environments more safely ( Source ). And working side by side with law enforcement is not just recommended, it’s inevitable. By understanding each other’s roles and maintaining a unified command and game plan, we ensure that the scene becomes safer and that patients are reached in time.
Every EMS provider should take the time now, before such an incident happens. Train and be prepared. This includes participating in disaster drills, learning your local active shooter/terror response plans, and mentally rehearsing what you would do in a scenario like the one described. The more you prepare, the more you can fall back on practiced habits when chaos strikes. Terrorist incidents are, by their nature, meant to cause fear and confusion. Our job in EMS is to bring care, calm, and order to that chaos.
Staying professional and focused in the face of terror is challenging, but it’s what our patients and communities need from us. By adhering to safety protocols, working seamlessly with other responders, and applying our emergency medical skills under pressure, we maximize the chances of saving lives while also protecting our own. Responders on these scenes have described the surreal mix of adrenaline and discipline it requires, but also the immense reward when lives are saved in spite of an attacker’s intent to do harm.
Whether it’s a politically motivated campus bombing or a lone actor driving into a crowd, EMS must be ready. Remember the core principles: safety, communication, PPE, and coordination. Armed with knowledge and training (and guided by the official frameworks for terrorism response) we can navigate the uncertainty of these incidents. The hope is that you’ll never face a terrorism scenario in your career, but if you do, you’ll do so with your eyes open and your skills sharp, ready to fulfill the ultimate duty of EMS: To preserve life in the worst of circumstances. Stay safe, stay prepared, and stay vigilant. Godspeed!
Sources:
• Federal Bureau of Investigation – Terrorism Definitions (International vs Domestic)
• U.S. Department of Homeland Security (Homeland Security Act of 2002) – Legal Definition of Terrorism
• Reuters – DOJ Investigating Columbia University Protests for Potential Terrorism Violations (US to probe Columbia protests for terrorism violations, official says | Reuters)
• U.S. Department of Justice – Press Release: Tesla Arson Attacks as “Domestic Terrorism” ( Office of Public Affairs | Attorney General Pamela Bondi Announces Severe Charges Against Violent Tesla Arsonists | United States Department of Justice)
• Thompson et al., Prehospital and Disaster Medicine – Risks to Emergency Medical Responders at Terrorist Incidents (Scene safety hazards) ( Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature – PMC ) ( Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature – PMC )
• International Association of Fire Chiefs – Position Paper: Active Shooter and Mass Casualty Terrorist Incidents (ICS and PPE recommendations) ( Source ) ( Source ) ( Source )
• Fire Engineering – Active-Shooter Incidents (Staging and Rescue Task Force evolution) (Fire/EMS at Active-Shooter Incidents) (Fire/EMS at Active-Shooter Incidents)
• EMSWorld – Active Shooter Response (EMS-Police integrated response) (EMS Response to Active-Shooter Incidents) (EMS Response to Active-Shooter Incidents)