Theme 1: Experience with Terrorism-Related Incidents and Response Protocols.

This theme explores pharmacists’ experiences with terrorism-related disasters and their corresponding responses. All pharmacists revealed that they have experienced, responded to, and managed different types of TRDs at TC. Among those, improvised explosive devices and suicidal attacks were repeatedly mentioned by most of the pharmacists. The suicide incidents of August 2016 and November 2024 were specifically mentioned as having collectively resulted in >100 deaths and countless injuries. In addition to the damaged infrastructure, the fear and panic in the city were sickening and unimaginable.

“The 2024 event is something I can never forget. It was terrifying and horrifying for all of us at the TC. I was very close to the bomb blast, just a short distance away in a crowded part of the city. The sound was so overwhelming that it felt as if the explosion had happened right at the TC. Many lives were lost that day.” (Pharmacist 2, Male)

Another pharmacist (male) shared his experience that he was at the TC when the Bethel Memorial Methodist Church was attacked. “The blast, and then the mass shooting, created such a horrible and overwhelming atmosphere - not just for the victims but for all of us at the TC. It was truly an awful and disturbing experience for the whole city (Pharmacist 9, Male).”

It is crucial that, when a terrorism-related disaster occurs, the healthcare team is informed immediately and without delay. Timely communication ensures a quick, efficient, and effective response to the event. To achieve this, healthcare centres, allied institutions, and related organizations must adopt advanced technological information systems. In parallel, local governments should take proactive measures to strengthen information sharing during such calamities. The pharmacists were asked about the source of information and the call-up mechanism in their institute during TRDs.

“For situations like this, we rely on a dedicated WhatsApp group. As soon as a disaster happens, the Department of Health posts an alert there, with the directions we need to take immediate action.” (Pharmacist 4, Male)

During the interviews, we asked the respondents about the call-up mechanism contingent upon terrorism-related disaster emergencies. Pharmacists of the current study were satisfied with the response mechanism in contacting the healthcare professionals during an emergent condition.

“At the TC, we work around the clock on rotation. Whoever is on duty responds right away when a disaster happens. As part of our job, we report to the TC as soon as we get the information, and the duty pharmacist also calls the rest of us to make sure we’re on our way. Usually, all of us manage to reach the TC within minutes.” (Pharmacist 8, Male)

Theme 2: Pharmacists’ Responses to Terrorism-Related Disasters.

While dealing with TRDs, an efficient and resourceful response of the healthcare system saves lives and curtails health risks. A rapid response results in timely care of the critically affected individuals, prevents debilities, and limits psychological traumas. In short, a well-coordinated response helps in utilizing scarce resources, supports calming the distressing environment, and builds societal confidence [36]. In the case of TRDs, a quick and effective response ensures that victims receive necessary care and have equitable access to services, minimizing further harm and promoting recovery [37]. Subsequently, this theme examines pharmacists’ responses to TRDs while delivering services at the Trauma Centre.

Pharmacists of the current study reported feeling prepared while responding to TRDs both professionally and psychologically. However, certain deficiencies and reservations were also observed during the interviews. The responses are discussed as subthemes accordingly.

Subtheme 2(a): Professional response

Respondents of our study agreed on the importance of a professional response in disaster management. They believed a professional response is critical for ensuring that victims receive the appropriate care in a timely and efficient manner, which can significantly reduce both immediate and long-term harm. Accordingly, a pharmacist responded that “the moment we receive an emergency alert, medicine trolleys filled with essential medicines, surgical items, and disposables are placed at the ER, OTs, and wards. The chief pharmacist supervises this process to ensure everything is ready before patients come in. We remain on guard until the situation stabilizes, and all victims are taken care of (Pharmacist 6, Male).”

Subtheme 2(a): Personal response

Personal responses in managing TRDs are indispensable to the overall success of disaster management. Effective and coordinated actions taken by pharmacists save lives, reduce harm, and strengthen resilience in the face of adversity. However, pharmacists also face security risks and are susceptible to developing post-traumatic anxiety, stress, and depression. These psychological impacts can adversely affect their physical, mental, and emotional well-being, ultimately reducing their efficiency in disaster response. Therefore, it is equally important to consider the psychological condition of pharmacists in such situations to ensure their well-being and maintain the effectiveness of their contributions.

“The moment victims arrive at the TC, crowds of attendees pour in and overwhelm the place, making everything more chaotic. The atmosphere feels unsafe, beyond words. I try hard to keep myself steady, but those moments are deeply scarring. For several days afterward, I couldn’t eat properly, and I struggled with constant sleep problem.” (Pharmacist 3, Male)

Theme 3: Preparing for terrorism-related disaster events.

Ideally, healthcare systems must be equipped to handle any type of emergency, including TRDs. In such scenarios, preparedness becomes crucial for minimizing loss of life, reducing psychological trauma, improving coordination, and supporting long-term recovery. Moreover, effective preparation allows for a swift and organized response, limits the social and economic fallout, and strengthens community resilience. By being proactive, healthcare providers and systems can ensure they are ready to protect public safety and contribute meaningfully to community healing and recovery in the aftermath of a terrorist event.

In this study, we focused on the preparedness of pharmacists and their familiarity with terrorism-related disaster management. The pharmacists participating in the study expressed significant concerns about their knowledge and familiarity with managing TRDs. Moreover, all respondents acknowledged the lack of training, seminars, or workshops on the subject, and they did not foresee any such initiatives soon. Additionally, the pharmacists in the study indicated that their role in terrorism-related preparedness is limited. Inline, Theme 3 and its subthemes discuss pharmacists’ preparedness for TRDs.

Subtheme 3(a): Knowledge and understanding of terrorism-related disaster management protocol and policies

Effective disaster management requires a thorough understanding of management protocols and policies to mitigate the risks associated with such events. The pharmacists involved in the research expressed significant uncertainty regarding their knowledge and awareness of TRDM.

“I’ve been working at the TC for almost five years, but I haven’t received any formal training in disaster management. There have been no training modules, resources, or written guidelines provided by the administration. So, most of what I know comes from my own experience in handling terrorism-related emergencies.” (Pharmacist 6, Male)

Subtheme 3(b): The gaps in managing terrorism-related disasters

In the event of a terrorism-related event, the primary responsibility of a pharmacist is to ensure the availability and continuous delivery of pharmaceutical supplies. While the American Society of Health-System Pharmacists recommends pharmacists be actively involved in selecting appropriate medications and managing their supply [38,39], this involvement was not observed among the respondents in the current study. Although the pharmacists acknowledged the critical importance of ensuring the availability and timely provision of medicines and relevant supplies to save lives, they also expressed significant reservations that hinder their preparedness when responding to TRDs.

“At the TC, we don’t have enough staff to cope with the sheer number of emergencies, and the space is already too limited. When there’s a large-scale terrorism incident, we have no choice but to use other areas of the hospital, and sometimes we even refer patients elsewhere. But no matter how tough it gets, we make every effort to handle the overload because in the end, it’s about saving lives.” (Pharmacist 9, Male)

Theme 3(c): Triage, assessment and coordination

Triage and coordination aid in prioritizing resources. These are of high importance in resource-deprived settings that help in saving lives by guaranteeing an effective response. Triage categorizes patients based on their injuries and classifies victims needing immediate, intermediate, or minimal care. Consequently, well-organized triage systems are imperative for enhancing disaster preparedness and resilience, including TRDs [40].

The study respondents demonstrated a lack of awareness of the term ‘triage’ and insufficient knowledge of treatment prioritization, which they attributed to limited training in disaster management. Pharmacists identified challenges in coordination and communication. They acknowledged that coordination and communication within the TC functioned satisfactorily but expressed concerns regarding interactions with other hospital departments. They explained that receiving simultaneous instructions from both the TC administration and the hospital administration often generated confusion and communication conflicts.

“Triage? (nodding). When victims come in, we examine them right away and begin with basic life support, ACLS, or CPR as needed. But there are no standard treatment protocols we follow. To be honest, I don’t even know what triage is; I’ve never come across the term before.” (Pharmacist 1, Male)

The clarification makes it apparent that both individuals and the institution are missing critical disaster training and standardized triage procedures. Pharmacists’ reliance on ad hoc clinical judgment reflects the lack of structured preparedness mechanisms and clear role integration within multidisciplinary emergency response systems.

Theme 4: Barriers towards terrorism-related disaster management.

Subtheme 4(a): Security issues (internal and external)

The barriers to effective TRDs management are provided by theme 4 and the related themes. All pharmacists uniformly reported that victims’ attendants display threatening and aggressive behaviour, which places the safety of healthcare professionals at high risk in the TC during a terrorist attack. A pharmacist quoted that “such an aggravated crowd destroys institutional assets and even physically tortures healthcare professionals (Pharmacist 8, Male).” Therefore, the institutional administration and health authorities must ensure the safety of the institute and the healthcare workers as a priority so they can work efficiently without fear.

Secondly, following a terrorism-related event, particularly a suicide attack, volunteers and victims’ relatives often rush to the hospital, creating overcrowded conditions. Such congestion can make the hospital an easy target for a secondary attack. Therefore, controlling the influx of people into the hospital is crucial to prevent further incidents.

“I’ll never forget the attack on the principal of the local law college. When his body was brought here and the lawyers gathered, it turned into a massive assault that killed many people. In moments like that, I find it so hard to focus on my work. There’s always the fear of another suicide attack breaking out in the crowd. That fear weighs heavily on us and makes it harder to provide emergency care.” (Pharmacist 8, Male)

Subtheme 4(b): Curriculum deficiencies

The pharmacist at the TC explained that the pharmacy curriculum in Pakistan does not include disaster management, particularly terrorism-related disaster management, which creates another barrier. Even after the degree is awarded, there is no residency program offered to the pharmacists. Although the TC on its own offers an internship program to pharmacists, this initiative is not enough. Notably, pharmacists have no idea of disaster management when they start pharmacy practice at a healthcare institute.

“In pharmacy school, we never learned about disaster management, and even in our hospital internships, the topic was never brought up. But given what we face today, it’s so important that pharmacists are trained properly in this area.” (Pharmacist 10, Female)

Subtheme 4(c): Inadequate experiential learning opportunities

Ultimately, the absence of disaster drills and inclusive training emerged as a significant obstacle to effective disaster management. Unfortunately, the TC has not implemented any disaster drills, nor have the pharmacists participated in comprehensive training or workshops aimed at enhancing their disaster management skills, including TRDs. Disaster drills and exercises play a crucial role not only in skill development but also in building confidence, which leads to improved efficiency and effectiveness during emergencies, particularly in terrorism-related incidents.

“At this hospital, I’ve never seen a single training session on disaster management. We’ve never been part of drills or mock exercises to sharpen our response. Day to day, we just do our routine work as usual, with no real preparation in place for disaster situations.” (Pharmacist 9, Male)

Summarizing, pharmacists’ preparedness was largely shaped by experiential exposure rather than formal training or policy guidance. While experiential learning enabled adaptive responses, it simultaneously exposed systemic gaps, including the absence of written protocols, standardized triage systems, and clearly defined professional roles. This reliance on experience underscores an institutional dependence on individual resilience in place of structured disaster preparedness.

Subtheme 4(d): Minimal pharmacist contribution to planning and management activities

The study respondents also identified an additional barrier. Like other areas in the province, pharmacists at the TC are primarily focused on supply chain and logistics despite their multifaceted roles. As a result, many of their other potential contributions may be overlooked, leading to an underdeveloped pharmacy response to disasters. This barrier could ultimately increase the risk and impact of terrorist activities.

“When it comes to terrorism-related disaster planning, pharmacists aren’t involved. It’s not because we lack capability, but because our role still isn’t clearly outlined in specialized services such as emergency response frameworks.” (Pharmacist 4, Female)

Theme 5: Suggestions and recommendations.

Pharmacists of our study unanimously emphasized the need for significant improvements in terrorism-related disaster management (Theme 5). Key recommendations included are as follows:

1. a). Upgrading and expanding the TC with respect to human resources, physical infrastructure, medical supplies, and logistics,
2. b). Establishing an independent procurement system for medicines and related items,
3. c). Developing standard operating procedures for TRDs, and
4. d). Strengthening and expanding the role of pharmacists in disaster preparedness and response.

Moreover, pharmacists recommended implementing advanced communication and coordination systems, organizing specialized training programs for pharmacists, conducting regular mock drills, and revising the pharmacy curriculum to better address TRDs in the future.