Terrorism Training for First Responders: Diminishing “Responder Fatigue”

by Steven Hare

It has been more than seven years since the events of 9/11. There are indications that “responder fatigue” is setting in, given that much emphasis has been placed on training, but no significant events have occurred. This article reviews the strategies an emergency manager can use in a local jurisdiction to address responder fatigue.


The threat of foreign terrorism on American soil became a reality on February 26, 1993, with the first attack on the World Trade Towers, an attack carried out by Muslim radicals using an improvised high-explosive device, killing six and injuring thousands.1 Since that date, radical elements around the world attacked American citizens and interests, including in the following incidents:

  • November 13, 1995. A truck bomb attacked a military base in Riyadh, Saudi Arabia, killing five Americans.
  • June 25, 1996. The Khobar Towers in Saudi Arabia were bombed. Nineteen Americans were killed and hundreds were injured.
  • August 7, 1998. The U.S. embassies in Kenya and Tanzania were attacked with truck bombs. More than 250 people were killed.
  • October 12, 2000. The U.S.S. Cole was attacked by suicide bombers off the coast of Yemen, killing 17 U.S. sailors.
  • The U.S. Intelligence Services learned about and prevented several other attack plans.2

These attacks culminated on September 11, 2001, in the attack on the World Trade Center towers when well-organized hijackers commandeered four domestic passenger aircraft to launch nearly simultaneous attacks on the towers, The Pentagon, and another unknown target in Washington, D.C.3,4 The hijackers’ plan to crash the final plane into the unknown target in D.C. was foiled when the passengers revolted and the plane crashed into a field in rural Pennsylvania. More than 2,900 people died in the combined incidents, the largest one-day loss of lives on American soil since the surprise Japanese attack on Pearl Harbor on December 7, 1941.5,6


In response to these attacks and the continued threat of terrorist attacks, including attacks using weapons of mass destruction (WMD), the President and Congress, through the Homeland Security Act of 2002, established the Department of Homeland Security (DHS). The mission of the DHS is “to prevent terrorist attacks within the United States; reduce the vulnerability of the United States to terrorism; and minimize the damage, and assist in the recovery, from terrorist attacks that do occur within the United States.”7 The creation of the DHS consolidated 22 agencies and 180,000 employees, unifying once-fragmented federal functions in a single agency dedicated to protecting America from terrorism.8

With the creation of the DHS came new opportunities for funding for states and local municipalities, with more than $27 billion dollars awarded since 2002.9 Individual emergency service organizations have benefited through grant programs administered through the Department of Justice (DOJ), Federal Emergency Management Agency (FEMA), and the Department of Education to improve response capabilities to terrorist incidents in their own communities.10 In FY 2004 alone, the DHS trained more than 205,000 first responders.11

The Fiscal Year (FY) 2009 budget request for homeland security is $50.5 billion, an increase of 7 percent ($ 3.6 billion) over the FY 2008 funding level.12 Since its inception, Homeland Security funds have been used to improve interoperability among various federal, state, and local responders; to develop new technologies to detect nuclear, radiological, biological and chemical compounds; to improve port and border security; and to foster improved communications among all the organizations involved with antiterrorism activities.13

The collective consciousness of emergency service organizations regarding the potential for terrorist attacks was raised on September 11, 2001, and has remained at a high level for many agencies, particularly in large, urban areas. The new threat of terrorist attacks and the potential for the use of WMD have created a climate in which emergency service providers must constantly train on new tools, techniques, and strategies for handling incidents terrorists may initiate. Many organizations, and the providers who work for them, have spent countless hours learning how to respond to incidents that may involve a biological agent, a chemical agent, a radiological agent, or a high explosive. They have learned to identify a potentially dangerous scene as they approach, to be wary of secondary devices as they arrive on the scene, to don level B personal protective suits and self-contained breathing apparatus (SCBA), to perform mass decontamination, START triage, administer 2-Pam chloride and cyanide exposure kits, and to work within the National Incident Management System (NIMS).14

But what has happened since September 11, 2001? Nothing. Not one terrorist incident on American soil. Our emergency responders have been given extensive training and may be starting to show fatigue from the amount and pace of the training they have had to endure. It may be time to look at how to refocus our providers so that they do not become burned out from excessive and redundant training primarily focused on the response to terrorism-generated incidents.


If responders are growing fatigued by the constant training for a terrorist incident that never seems to happen, the continuing threat against the United States and its citizens needs to be reinforced for the responders. Osama Bin Laden first declared “war” against U.S. military personnel on the Arabian Peninsula in August 1996. In February 1998, Bin Laden upped the ante when he called on Muslims to kill Americans worldwide.15

Despite the lack of an attack in this country, the threat of terrorism remains high, and first responders must remain vigilant of their responsibilities to prepare for another attack. In early August 2004, the country’s threat level was elevated to orange, as reports circulated of an al Queda plan to attack financial centers in New York City; Washington, D.C.; and Newark, New Jersey.16 On October 29, 2004, a videotape showing Osama Bin Laden was distributed through Arabic news agencies. President George W. Bush, in a statement to the press, reminded the American people that “we’re at war with these terrorists, and I am confident that we will prevail.”17

Al Queda cells have staged attacks in other countries since September 11, 2001, with deadly results. In October 2002, an Al Queda-linked terrorist group launched an attack on nightclub patrons in the island nation of Bali, killing more than 200 people.18 An attack on three separate train stations in Madrid, Spain on March 11, 2004 killed at least 190 people and wounded more than 1,240.19

America’s first responders must be cognizant of the fact that it is not a matter of if the United States will be attacked by terrorists again, but when. In fact, since 9/11, U.S. counterterrorism organizations, in cooperation with foreign governments, have prevented 19 known terrorist conspiracies aimed at U.S. citizens and/or infrastructure.20 The preparation and training of our first responders will help them to be better prepared for the next attack.


Another step an emergency services manager can take is to refocus first responders’ training requirements to reevaluate the level of threat to their community, not only from terrorist attacks but also from other threats

Terrorist attacks are usually classified as “low probability – high consequence” events, meaning that it is unlikely that they will occur, but they can have significant impact if an attack were to happen.21 A threat and vulnerability assessment should be performed to identify the level of significant risks in the community and areas of vulnerability that have not been addressed. Although a terrorist attack must be considered a possibility in every community, it is less likely to occur in some communities than in others. For example, a small farming town in rural Nebraska probably has a much lower probability of sustaining a terrorist attack than a major metropolitan area, such as New York; Washington, D.C.; or Los Angeles, California. The population of the farming community may be too small and too widely scattered to have the kind of impact a terrorist would hope for.

However, the farming community must look at the hazards that exist in its community and plan to mitigate these hazards or to respond to them if an incident occurs. Railroad lines may run through the town. What types of materials are commonly carried in the freight and tanker cars? Even though a terrorist may have no interest in the community, a rail car carrying hazardous materials or high explosives involved in an accident or fire could have a devastating effect on the community. If passenger trains travel over the rail lines, there is the potential for a mass casualty incident in the event of a derailment. These risks should be addressed in the community’s Emergency Operations Plan.


Much first responder training for terrorist attacks can be applied to their roles in nonterrorist events. By capitalizing on crossover knowledge, responders can train for events they are likely to encounter in their daily duties and also for responses to terrorist events.

Natural disasters and manmade “accidents” occur much more frequently than terrorist incidents, but they may produce similar numbers of casualties and injury patterns. In respect to the ability to cause sudden death and injury to innocent civilians, “Mother Nature proves to be the worst of all terrorists.”22 Hurricanes, tornados, floods, earthquakes, volcanic eruptions, and tsunami waves are all examples of natural disasters that can strike with little or no warning and that are capable of producing mass casualties and extensive property destruction. Mass transportation crashes, structural collapses, and chemical releases are examples of manmade events that may also generate large numbers of casualties.

The types of services first responders will need to provide at the outset of a natural or manmade disaster may be very similar to those needed in a terrorist incident. Victims trapped under debris or collapsed structures will benefit from having highlytrained, multidisciplinary urban search and rescue (USAR) teams at their disposal.23 Victims trapped by structural collapse after an earthquake often die slowly of crush injury.24 The availability of an USAR team may help to prevent some of these deaths.25 Training in how to manage crush injury will prepare responders to function appropriately when treating patients in natural and manmade disasters as well as in terrorist incidents.

Mass-casualty response is another area of crossover from daily practice to terrorism response. Familiarization with the principles of S.T.A.R.T. triage, patient tagging, casualty collection, and victim transportation are needed in natural and manmade disasters as well as in terrorism response. If responders train to become proficient in mass-casualty response, it will benefit their patients, regardless of what type of incident generated the casualties. Proper triage and timely transport from the incident scene have been proven to definitively reduce morbidity and mortality in trauma patients.26

Emergency responders have been made aware of the threats presented by biological agents, which have long been considered as a possible weapon of choice by terrorists becaue these agents can sicken large numbers of persons with a small amount of material. Anthrax was used as a weapon in the United States in 2001, when 22 people were infected by anthrax spores sent through the mail.27 The training received emergency responders received to deal with biological agents can also help them in dealing with the consequences of a pandemic disease outbreak.

Many scientists believe that the world is overdue for an influenza pandemic. If an influenza pandemic were to occur, computer models suggest that between 89,000 and 207,000 victims could die; 314,000 to 734,000 people would require hospitalization; and 18 million to 42 million people would seek outpatient treatment in the United States alone.28 Severe Acute Respiratory Syndrome (SARS) is another global threat. It first appeared in China in 2002 before spreading to more than two dozen countries on five continents.29

The actions necessary to respond to the outbreak of an infectious disease caused by the suspected release of a biological agent are very similar to the actions responders would take in the event of a pandemic–the use of appropriate personal protective equipment, including particulate filter masks or respirators; decontamination procedures; patient triage and transport to an appropriate treatment facility. Training in infectious diseases and personal protection practices is beneficial for responders who may have to respond to either type of incident.

Steven Hare, M.S., FF/NREMT-P has been involved in emergency services for 25 years as a firefighter and paramedic. He worked for more than12 years with the Philadelphia (PA) Fire Department, rising to the rank of EMS captain. He has also worked as the executive director of a fire/ EMS organization in the suburban Philadelphia area. For the past 11 years, he has worked as a flight paramedic for PennSTAR Flight at the University of Pennsylvania Health System. He has a master’s degree in emergency health services from the University of Maryland, Baltimore County.


1. http://www.adl.org/learn/jttf/wtcb_jttf.asp “The World Trade Center Bombing”. Accessed April 2, 2009.
2, http://belfercenter.ksg.harvard.edu/publication/18249/preventing_terrorist_attacks.html. Accessed April 2, 2009.

3. Cook L. “The world trade center attack. The paramedic response: an insider’s view,” Crit Care. 2001; Dec.5(6), 301-3.

4. Jordan MH, KA Hollowed, DG Turner, et al.,”The pentagon attack of September 11, 2001: A burn center’s experience,” J Burn Care Rehabil.; 2005; Mar-Apr;26(2):109-16..

5. McCool G, “World Trade Center fatalities drop by 40,” The Courier-Mail. Oct. 31, 2003..

6. Fulton RD, “Surviving Emmittsburg resident remembers attack on pearl harbor.,” The Emmittsburg Dispatch. 2004; III (18). Dec.1.

7. Department of Homeland Security -Title I, Sec. 101. Executive Department; Mission. The Homeland Security Act of 2002. From H.R. 5005-8, the Homeland Security Act of 2002.

8. http://www.infoplease.com/ce6/history/A0909720.html Accessed March 22, 2009.

9. DHS Announces Fiscal Year 2009 Grant Guidance for over $3 Billion in Preparedness Grant Programs, Nov. 5, 2008. Accessed at http://www.dhs.gov/xnews/releases/pr_1225900531284.shtm on April 1, 2009.

10. Department of Homeland Security. Fact Sheet: An overview of America’s security since 9/11. Sep. 7, 2004.

11. Ibid.

12. http://www.dhs.gov/xlibrary/assets/budget_bib-fy2009.pdf “Homeland Security Budget-in-Brief, FY 2009.” Accessed March 31, 2009.

13. Department of Homeland Security. Fact Sheet: An overview of America’s security since 9/11. Sep. 7, 2004.

14. “Domestic preparedness. Defense against weapons of mass destruction,” Technician-EMS course handbook, 1998.

15. Bin-Ladin M. “Jihad against Jews and crusaders,” World Islamic Front Statement. Feb 23, 1998. Accessed at http://www.fas.org/irp/world/para/docs/980223-fatwa.htm on March 25, 2009.

16. http://www.USNews.com Decoding the threat. U.S. News and World Report. Aug 16, 2004. Accessed March 23, 2009.

17. http://www.msnbc.msn.com/ID/6363306/ Oct. 30, 2004. Accessed March 23, 2009.

18. Kennedy PJ, PA Haertsch, PK Maitz. “The bali burn disaster: implications and lessons learned.” J Burn Care Rehabil; 2005; Mar-Apr;26(2):125-31.

19. http://www.foxnews.com/printer_friendly_ story/0,3566,113887,00.html Fox news. “Madrid
station blasts kill 190″. Mar 11, 2004. Accessed April 1, 2009.

20. Carafano, JJ. “U.S. thwarts 19 terrorist attacks against America since 9/11”. Backgrounder. 2007 Nov; No. 2085.

21. Federal Transit Sdministration. “Connecting communities – Emergency preparedness and security forums,”. Chapter 7: Threat and vulnerability assessment and resolution. June 2002.

22. Healy, B. “Mother nature, terrorist,”. U.S. News and World Report. Jan. 10, 2005.

23. Barbera JA, A Macintyre, “Urban search and rescue,” Emerg Med Clin North Am. 1996; May;14(2):399-412.

24. Pretto, EA, DC Angus, JL Abrams, et al. “An analysis of prehospital mortality in an earthquake. Disaster,” Reanimatology Study Group. Prehospital Disaster Med. 1994; Apr-Jun;9(2):107-17.

25. Angus DC, EA Pretto, JL Abrams, et al. “Epidemiologic assessment of mortality, building collapse pattern, and medical response after the 1992 earthquake in Turkey,”. Disaster Reanimatology Study Group (DSRG). Prehospital Disaster Med. 1997; Jul-Sep;12(3):222-31.

26. Malik ZU, M Pervez, A. Safdar, et al. “Triage and management of mass casualties in a train accident,” J Coll Physicians Surg Pak. 2004; Aug;14(8):513-4.

27. Centers for Disease Control, Fact Sheet. “Anthrax: What you need to know,” Jul. 31, 2003.

28. Centers for Disease Control, Fact Sheet, “Information about influenza pandemics,” Mar. 5, 2005.

29. Centers for Disease Control, Fact, “Sheet for SARS patients and their close contacts,’ Feb. 6, 2004.

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