Abstract
Introduction
Since their inception as basic medical support for the early Special Weapons and Tactics (SWAT) units in the 1980s, Tactical Emergency Medical Support (TEMS) and tactical medicine have evolved substantially. 1 Now the TEMS methodology is facing new challenges in the form of hybrid warfare.
While there is no universally accepted definition of “hybrid warfare,” it is often described as a mix of conventional warfare, irregular warfare, terrorism, and criminality, using different nonconventional modalities such as drone technology, cyberattacks, and chemical, biological, radiological, nuclear, and explosive (CBRNE) weapons in a civilian setting. 2 These concepts are not new, but the speed of their development has accelerated through technological advancements fueled by the “great power competition” in which Russia, China, and the United States compete to shape international security, trade, and geopolitics. 3
In this commentary, the authors broadly discuss the basics of hybrid warfare, how this type of conflict may affect prehospital care and TEMS in the short and long term, and how lessons learned can improve TEMS preparedness and response.
Framing the Discussion
TEMS has incorporated lessons learned from military units and civilian experiences in the past decades, which has increased the capacity of TEMS providers to respond to a wide variety of complex situations. The TEMS organization, duties, and capabilities differ depending on the country and system but usually includes preventive medicine, mission planning, emergency care, decisionmaking support to SWAT commanders, and follow-up work after missions. An important role of TEMS during an operation is to facilitate communications and interoperability between law enforcement, emergency medical services (EMS), helicopter EMS, and the emergency department.
TEMS providers must be competent in the following areas: multimodal and asymmetric terrorist attacks, hostage rescue, high-risk warrant and high-risk apprehension, providing medical care in austere conditions, urban search and rescue, CBRNE attacks, and extraction and casualty evacuation techniques. 4 In addition, today's threats have evolved and become more complex and intertwined with rapidly evolving technologies and novel methodologies that TEMS teams may not be accustomed to. Health systems have also become more reliant on technologies for planning, communication, logistics, and documentation, with many cybersecurity vulnerabilities that remain exposed.
Healthcare systems are especially vulnerable to exploitation due to the lack of experience, knowledge, and training required to respond to hybrid warfare, with its compounding, complex attacks that often use military-grade modalities, criminality, disruptive technologies, and cyberattacks. While no national standard for tactical medical provider training currently exists in the United States, there is a consensus among experts about the core areas of training and competence required. 5 It is evident from the literature on tactical medicine that the traditional focus has been on trauma and single events, whereas the threat of disruptive technologies like cyberattacks and drones has not been addressed.5-8 There is also a lack of discussion on response to attacks with multiple, simultaneous modalities and the compounding effects that contribute to scene complexity.6,7
Future conflicts will likely involve a mix of irregular and regular forces together with terrorists and criminals operating in environments with a high density of civilians. 9 This can potentially create conflict scenarios that are compounded by hybrid threats such as cyberattacks, disinformation, and disruptive technologies.10-12
By its nature, hybrid warfare creates difficulties in determining the origin or intention of a hostile action. The strategy of keeping a conflict in the blurred “gray zone” between war and peace makes it hard for traditional civilian stakeholders to respond to a hybrid attack. Mitigating such a scenario requires preplanned strategies in which TEMS works in coordination with the military, EMS, and police forces in gray-zone situations. In hybrid warfare it is likely that military-grade advanced weapons systems will be used in combination with disruptive modalities and technologies like CBRNE, drones, cyberterrorism, and disinformation warfare.
Hybrid Warfare and Similarities With Terrorism
There are several similarities between hybrid warfare and terrorism, including intentional attacks on civilians, medical responders, and healthcare facilities. The Geneva Convention, which includes the treaty regarding protection of civilians and medical personnel, does not apply to either hybrid warfare or terrorism. 13
How Hybrid Warfare Affects TEMS
The differing varieties of hybrid threat events typically have the ultimate goal of destabilizing society by disrupting core functions and key strategic sectors like healthcare, transportation, food supply, and energy. As with terrorism, attacks on these sectors using hybrid weapons, criminality, and disruptive technologies will lead to the use of SWAT teams and involve TEMS and EMS as key response components.
There is a high probability that TEMS and EMS personnel will be targets of aggression in these events because a decrease in their capacity would seriously affect a region's capability to handle complex threat scenarios. While direct threats to TEMS and EMS personnel is not new in high-risk situations such as terrorist attacks or hostage situations, what is new in many countries is the deliberate spread of disinformation through organized social media campaigns by groups of people. 14 Healthcare professionals and facilities are at risk of being primary targets through the use of any weapon systems used in hybrid warfare as possible attack modalities. 15
Cyberattacks on healthcare systems are increasing every year and represent a serious threat. 16 Healthcare organizations often use outdated information technology security systems, which makes them “soft targets” because they lack the resources to defend themselves. The use of multiple products and devices that interact with each other also increases the risk of security breaches and access to sensitive data including patient records and medical equipment technology software. 17 In TEMS and EMS daily operations there is a constant and critical dependence on digital maps and digital information for dispatch, response coordination, and communications, with high potential for cyber disruption. Cyberattacks can disable and disrupt all of these mission-critical functions as well as vital infrastructure for electricity and water. While a cyberattack may not affect the initial TEMS response related to patient stabilization and treatment, according to Tactical Combat Casualty Care 18 or Tactical Emergency Casualty Care Guidelines, 19 getting EMS or HEMS on the scene and to the correct location with the right information can be problematic and have serious implications for patient safety. Transporting a patient to a hospital and gaining access to the emergency department may also be seriously obstructed as a result of cyberattacks and other situations involving protests and criminality fueled by disinformation. Depending on the system and the country, TEMS teams may operate in a remote environment for extended periods of time with prolonged field care-like conditions. In such situations, telemedicine services have been integrated as part of tactical medicine for both military and civilian TEMS. 20 However, it is imperative to ensure that a plan is in place for situations when this capability is not available.
CBRNE incidents often necessitate a high level of complexity during the tactical prehospital response. 21 We learned from the Novichok experience in the United Kingdom that such incidents can exert an enormous strain on healthcare, police, and CBRNE experts, even with a small number of affected people.22,23
In full-scale hybrid warfare, the use of a chemical agent is likely to be combined with the use of other weapon systems, resulting in multiple victims who could be mistakenly identified as casualties of a conventional attack. 24 In hybrid warfare the use of CBRNE is a realistic threat, and familiarity with toxidromes among TEMS providers is crucial for alerting hospital clinicians to the possibility of specific classes of agents being involved in mass casualty incidents. 25
Within a society, social media misinformation and disinformation can be used to create confusion and instability. 26 Disinformation often spreads rapidly in social media and can potentially lead to large masses of people quickly assembling for various reasons such as riots, looting, or attacks on police and EMS. The problem of misinformation and disinformation on social media has been amplified by the COVID-19 crisis and has created new opportunities for violent state and nonstate actors, with terrorist organizations encouraging it as a legitimate tactic of war. 27
Civilian and military drone technology poses a substantial threat to healthcare systems as well as police and military forces. 28 In hybrid warfare, the main target could be casualty evacuation operations and helicopter EMS, since it is relatively simple for a drone to disrupt safe takeoff and landing. It is therefore important to take this threat into consideration when planning for emergency patient evacuation in a tactical situation. The use of drones to carry CBRNE agents has also been proposed.
Criminality can also be an easy way for an adversary to attack society below the threshold of open warfare, although the level of violence and conflict may be very high, as gangs have increasingly used military weapons and explosives over the past decade. Disruptive criminal behavior could be perpetrated through attacks on police officers, ambulance crews, fire and rescue services, and through rioting and looting, all of which can impede access to victims and hospitals. 29
Terrorism is a complex part of the hybrid warfare paradigm, particularly when it is asymmetric in power, strategy, or tactics, and with compounding threats and attacks. The trauma experienced after a terrorist attack is relatively well described in the literature and a growing number of studies are reporting on aspects of tactical emergency medicine during response phases.30-32 Counterterrorism operations are a core competency for TEMS providers; however, multimodal attacks require investment in planning and multiagency training to achieve successful outcomes. 33
Hybrid Warfare and Counterterrorism Medicine
The increasing complexity, frequency, and multimodal nature of terrorism has led to the emergence of counterterrorism medicine, a subspecialty of disaster medicine focusing on the healthcare aspects of terrorist attacks. 34 The counterterrorism medicine framework can be used to analyze both hybrid warfare and terrorist events and can be used by tactical physicians and TEMS managers as a tool to mitigate, prepare, respond, and recover in hybrid situations.
Conclusion
Hybrid warfare is a growing multimodal threat against all parts of society and TEMS will likely be a strategic component of mitigating its effects. The responsibility of responding to hybrid threats should therefore be incorporated into the primary roles and duties of TEMS providers. Current guidelines should be modified and adapted to address hybrid threats, with an understanding that future attack modalities may be unanticipated and will require flexibility for novel situations. Vulnerabilities related to a cyberattack in particular must be addressed within the TEMS scope of practice and in cooperation with partner organizations including law enforcement, rescue services, and hospitals.
Our recommendation is not for TEMS to create new solutions but to use an “all-hazards” approach 35 integrated with medical guidelines. However, it should be acknowledged that quickly pivoting from an all-hazards approach to an unconventional hazards approach may be necessary. An all-hazards approach cannot be used for novel attack methodologies that require a unique treatment pathway. For example, automated drones can be programmed to attack vehicles that have lights and sirens on, thus rendering the usual transport algorithm next to useless. It is therefore imperative that response and preparedness efforts address how threats can play out and how they can be combined in synergistic ways, including the potential for compounding effects. TEMS providers, tactical physicians, and SWAT personnel at all levels should be knowledgeable about the different components of hybrid warfare to mitigate the confusion that arises from an attack and in the gray zone situations between war and peace.