Civil unrest or terrorism at mass gathering events can erupt with significant violence and multiple casualties. These are high-risk situations, not only because of physical casualties, but also because of ethical, political and psychological sequelae. Beyond specialized planning, multi-agency drills and proficient tactical medicine training, medical teams should co-create secured access and egress, alternative medical responses and rapidly-adapting coordination and secure communications with other agencies. Civil protests can escalate, especially when extremist groups infiltrate them. Multi-site violence and assaults can evolve, particularly in terroristic attacks. Key lessons include unrelenting vigilance until all participants have left the mass gathering scene in its entirety. Violence (bombs, shootings, vehicle attacks) will often erupt when mass gatherings are dispersing and considered over. Terrorists can also purposely target medical personnel or incite one event (fire, bomb, shooting) to create crushing stampedes or to herd crowds into more vulnerable areas where they can be further attacked more directly with other modern weapons. Terrorists often attack from elevated perches or generate “protracted suicide” incidents while holding hostages, including many severely-wounded. The resulting frustration, anger and guilt commonly can consume medical rescuers when beholding slaughtered innocents or simply because they were (appropriately) staged during containment of on-going violence.

Incidents of civil unrest are increasing in frequency across the United States and may involve protests or demonstrations in response to political or economic activities, responses to concerts or sporting events, or in response to controversial actions by law enforcement. During these incidents, injuries may occur either in isolation or in associated interactions with law enforcement personnel. There are specific patterns of injury that are unique to protests and encounters with law enforcement, and it is important for the urban emergency medicine practitioner to have a fundamental understanding of the management of common injuries associated with law enforcement interactions. This chapter will highlight the general principles of emergency department care during periods of civil unrest, including best practices for interacting with both public safety personnel and private citizens. Patterns of injury will be explored, including injuries occurring from kinetic impact projectiles, conducted electrical weapons, and crowd dispersal agents, in addition to other less-common injury patterns encountered during periods of civil unrest.

Chapter 7 examines the extent to which federal, state, and local governments can restrict public protest during public health and civil unrest emergencies. The chapter describes how the current system of emergency powers affects public protest rights, including through curfews, limits on movement, and bans on public gatherings. It rejects the notion that the First Amendment and other rights can be “suspended” during declared or undeclared emergencies and argues for strict judicial review of measures that ban or severely restrict public protest during emergencies. The chapter also addresses the role of the federal government, including U.S. armed forces personnel, in policing civil unrest and prosecuting protest-related offenses. It advocates a minimal federal presence and function at public protest events and urges federal cooperation with states and localities.