Medical consequences of suicide bombing mass casualty incidents: the impact of explosion setting on injury patterns.

BACKGROUND: The increase in the incidence of suicide bombings on urban civilian populations in the recent years necessitates a better understanding of the related epidemiology in order to improve the outcome of future casualties. OBJECTIVE: To characterise the epidemiology of mass casualty incidents following suicide explosions in relation to the surrounding settings. METHODS: This study presents an analysis of the immediate medical consequences of 12 consecutive multiple casualty incidents (MCI's). Both pre-hospital and in-hospital data was assessed for each event including EMS evacuation times, types of injuries, body regions involved, Emergency Department (ED) triage, ED interventions and surgical procedures performed. RESULTS: The average arrival time of the first ambulance to the scene was 6.8+/-2.3 min. The first "urgent" patient was evacuated in average of 7.6+/-5.3 min later, while the last "urgent" patient was evacuated 27.8+/-7.9 min after the explosion. Explosions that occurred in buses had the worst rates of overall mortality (21.2%). However, those who survived closed space explosions suffered from the highest number of severe and moderate (ISS>8) injuries (22.9%). Casualties in this group underwent the largest number of both Emergency Room and Surgical interventions. Of the three settings, open space explosions resulted in the largest numbers of casualties with the smallest percentage of severe injuries or death. CONCLUSIONS: MCIs resulting from suicide explosions can be classified according to the setting of the event since each group was found to have distinct epidemiological characteristics.

Israeli hospital preparedness for terrorism-related multiple casualty incidents: can the surge capacity and injury severity distribution be better predicted?

BACKGROUND: The incidence of large-scale urban attacks on civilian populations has significantly increased across the globe over the past decade. These incidents often result in Hospital Multiple Casualty Incidents (HMCI), which are very challenging to hospital teams. 15 years ago the Emergency and Disaster Medicine Division in the Israeli Ministry of Health defined a key of 20 percent of each hospital's bed capacity as its readiness for multiple casualties. Half of those casualties are expected to require immediate medical treatment. This study was performed to evaluate the efficacy of the current readiness guidelines based on the epidemiology of encountered HMCIs. METHODS: A retrospective study of HMCIs was recorded in the Israeli Defense Force (IDF) home front command and the Israeli National Trauma Registry (ITR) between November 2000 and June 2003. An HMCI is defined by the Emergency and Disaster Medicine Division in the Israeli Ministry of Health as >or=10 casualties or >or=4 suffering from injuries with an ISS>or=16 arriving to a single hospital. RESULTS: The study includes a total of 32 attacks, resulting in 62 HMCIs and 1292 casualties. The mean number of arriving casualties to a single hospital was 20.8+/-13.3 (range 4-56, median 16.5). In 95% of the HMCIs the casualty load was

A biomechanical comparison between the thoracolumbosacral surface contact area (SCA) of a standard backboard with other rigid immobilization surfaces.

INTRODUCTION: Backboards are routinely used to protect the spine of trauma patients during transportation. Nevertheless, little is known about the biomechanical properties of this type of immobilization. OBJECTIVES: To evaluate the mechanical support of the thoracolumbosacral spine provided by a standard backboard in comparison with various rigid immobilization surfaces, by examining their respective surface contact area (SCA). MATERIALS: SCAs comparisons of a standard aluminum backboard, a rigid military stretcher, an aluminum backboard covered by blanket, 3 and 5 cm thickness foam, and a cushioned stretcher were made using 12 volunteers. The evaluation was performed by a computer- mediated system that generated a diagram indicating pressure distribution and SCA score in each volunteer. These data were compared with a medical grade mattress, which served as the control group. RESULTS: The median backboard's SCA was 14.6 +/- 5.5 times smaller than the stretcher's SCA (range 4.6-28, average 15, p < 0.001). Its median SCA was essentially doubled by covering it by a standard military blanket and tripled when covered by 3 cm layer of foam. Using a 5-cm layer of foam increased the backboard's SCA by 11 times. Cushioning the stretcher beneath the lumbar spine and the hamstrings by folded blankets, significantly improved its median SCA (96 +/- 31.1, range 36-125, average 89.7). CONCLUSIONS: The backboard's SCA was significantly inferior to all the other surfaces. Although no dynamic evaluation was performed, these data imply that backboards need to be appropriately cushioned or alternate surfaces should be employed to improve the mechanical support during trauma patient transportation. Level of evidence, Level I.

DISAST-CIR: Disastrous incidents systematic analysis through components, interactions and results: application to a large-scale train accident.

Disasters or hazardous incidents, either natural or man-made, continue to increase in frequency and affect more and more citizens of the world community. Many of these are published in the medical literature, each being a "case report" of a single event. In clinical medicine, a common nomenclature and uniform reporting of data enables the collection of similar cases to series studies, with clinical conclusions being drawn. Such a platform is lacking in the field of disaster medicine, impairing the ability to learn from past experiences. In the Medical Department of the Israeli Home Front Command, we coordinate the operation of various medical units and forces in a wide array of events. By doing so, we collect and analyze the relevant data related to disaster management, various components of the medical response, interactions between different components, and the ensuing results. We developed a systematic method of analyzing and describing disaster management issues in various events-DISAST-CIR-Disastrous Incidents Systematic AnalysiS Through Components, Interactions, Results. In this article, we describe this method by presenting the components, interactions, and results of a large-scale train accident that resulted in 270 casualties, 35 of whom were evacuated by helicopters from the accident site. Casualties were distributed among 10 different hospitals. The death toll was 7 people, 5 of whom died at the scene and 2 who died in hospitals. We recommend this method as a standard for scientific reporting of hazardous incidents. Accumulation of data, reported in a similar standardized fashion, would enable comparison and reporting of series, improving our understanding regarding the optimal medical response to various events.

Locking plastic tie--a simple technique for securing a chest tube.

A quick and simple technique for securing a chest tube in the prehospital setting is described. The technique makes use of a plastic tie with a self-locking mechanism that is wrapped around the tube and sutured to the skin. The use of a plastic tie is recommended as a valuable component to chest tube kits for use in the prehospital setting.

Distribution of casualties in a mass-casualty incident with three local hospitals in the periphery of a densely populated area: lessons learned from the medical management of a terrorist attack.

INTRODUCTION: A mass-casualty incident (MCI) can occur in the periphery of a densely populated area, away from a metropolitan area. In such circumstances, the medical management of the casualties is expected to be difficult because the nearest hospital and the emergency medical services (EMS), only can offer limited resources. When coping with these types of events (i.e., limited medical capability in the nearby medical facilities), a quick response time and rational triage can have a great impact on the outcome of the victims. The objective of this study was to identify the lessons learned from the medical response to a terrorist attack that occurred on 05 December 2005, in Netanya, a small Israeli city. METHODS: Data were collected during and after the event from formal debriefings and from patient files. The data were processed using descriptive statistics and compared to those from previous events. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology. RESULTS: Four victims and the terrorist died as a result of this suicide bombing. A total of 131 patients were evacuated (by EMS or self-evacuation) to three nearby hospitals. Due to the proximity of the event to the ambulance dispatch station, the EMS response was quick. The first evacuation took place only three minutes after the explosion. Non-urgent patients were diverted to two close-circle hospitals, allowing the nearest hospital to treat urgent patients and to receive the majority of self-evacuated patients. The nearest hospital continued to receive patients for >6 hours after the explosion, 57 of them (78%) were self-evacuated. CONCLUSION: The distribution of casualties from the scene plays a vital role in the management of a MCI that occurs in the outskirts of a densely populated area. Non-urgent patients should be referred to a hospital close to the scene of the event, but not the closest hospital. The nearest hospital should be prepared to treat urgent casualties, as well as a large number of self-evacuated patients.

The combative multitrauma patient: a protocol for prehospital management.

OBJECTIVE: To describe the management of the combative trauma patient in the prehospital setting, and to suggest a protocol for management. METHODS: A retrospective, prehospital case series conducted in Israel among military medical teams over the course of nearly 2 years, between January 2000 and October 2002. We collected a case series of patients who became combative following traumatic injury. Following data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon encountering a combative trauma patient. RESULTS: Available data were found for 11 patients and these were included in the analysis. Most victims included in this study were injured under military or geographical circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38-225 min). Five patients received intravenous ketamine, in three of which it was coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugs, was effective in all five cases. In no case did a patient become more agitated after administration. No adverse effects were recorded by the prehospital caregivers. CONCLUSIONS: In this article, an algorithmic approach to the treatment of the patient's agitation is outlined, using ketamine as the principal sedating agent, either alone or combined with midazolam. The combination of both drugs is suggested for the effective sedation of adult prehospital combative patient population.

The significance of a small, level-3 'semi evacuation' hospital in a terrorist attack in a nearby town.

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene-66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a 'semi-evacuation hospital'. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs.

Prehospital care of orthopedic injuries.

Orthopedic injuries are predominant among combat casualties, and carry the potential for significant morbidity. An expert consensus process (Prehospital care of military orthopedic trauma: A consensus meeting, Israel Defense Forces Medical Corps, May 2003) was used to create guidelines for the treatment of these injuries by military prehospital providers. The consensus treatment guidelines developed by experienced orthopedic trauma personnel from leading trauma centers in Israel are presented in this paper. For victims with open fractures, the first priority is hemorrhage control. Splinting, irrigation, and wound care should be performed while waiting for transport, or, in any scenario, in the case of an isolated limb injury. The use of traction splints was advocated for both the rapid transport scenario (up to one hour from the time of injury to arrival at the hospital) and the delayed transport scenario. In the urban setting, traction splints may not be necessary. Any victim experiencing pelvic pain following a high-energy mechanism of injury should be presumed to have an unstable pelvic fracture, and a sheet should be tied around the pelvis. The panel agreed that field-reduction of dislocations should be avoided by the medical officer unless it is anticipated that the patient will need to go through a long evacuation chain and the medical officer is familiar with specific reduction techniques.

Mass casualty incident after the Taba terrorist attack: an organisational and medical challenge.

Two suicide bombings in and around Taba, Egypt, on 7 October 2004 created a complex medical and organisational situation. Since most victims were Israeli tourists, the National Emergency and Disaster Management Division handled their evacuation and treatment. This paper describes the event chronologically, as well as the organisational and management challenges confronted and applied solutions. Forty-nine emergency personnel and physicians were flown early to the disaster area to reinforce scarce local medical resources. Two hundred casualties were recorded: 32 dead and 168 injured. Eilat hospital was transformed into a triage facility. Thirty-two seriously injured patients were flown to two remote trauma centres in central Israel. Management of mass casualty incidents is difficult when local resources are inadequate. An effective response should include: rapid transportation of experienced trauma teams to the disaster zone; conversion of local medical amenities into a triage centre; and rapid evacuation of the seriously injured to higher level medical facilities.

A four-step approach for establishment of a national medical response to mega-terrorism.

A simplified, four-step approach was used to establish a medical management and response plan to mega-terrorism in Israel. The basic steps of this approach are: (1) analysis of a scenario based on past incidents; (2) description of relevant capabilities of the medical system; (3) analysis of gaps between the scenario and the expected response; and (4) development of an operational framework. Analyses of both the scenario and medical abilities led to the recommendation of an evidence-based contingency plan for mega-terrorism. An important lesson learned from the analyses is that a shortage in medical first responders would require the administration of advanced life support (ALS) by paramedics at the scene, along with simultaneous, rapid evacuation of urgent casualties to nearby hospitals by medics practicing basic life support (BLS). Ambulances and helicopters should triage casualties from inner to outer circle hospitals secondarily, preferentially Level-1 trauma centers. In conclusion, this four-step approach based on scenario analysis, mapping of medical capabilities, detection of bottlenecks, and establishment of a unique operational framework, can help other medical systems develop a response plan to mega-terrorist attacks.

Lessons learned from cross-border medical response to the terrorist bombings in Tabba and Ras-el-Satan, Egypt, on 07 October 2004.

INTRODUCTION: Large-scale, terrorist attacks can happen in peripheral areas, which are located close to a country's borders and far from its main medical facilities and involve multi-national casualties and responders. The objective of this study was to analyze the terrorist suicide bombings that occurred on 07 October 2004, near the Israeli-Egyptian border, as representative of such a complex scenario. METHODS: Data from formal debriefings after the event were processed in order to learn about victim outcomes, resource utilization, critical events, and time course of the emergency response. RESULTS: A total of 185 injured survivors were repatriated: four were severely wounded, 13 were moderately injured, and 168 were mildly injured. Thirty-eight people died. A forward medical team landed at the border town's airport, which provided reinforcement in the field and in the local hospital. Israeli and Egyptian search and rescue teams collaborated at the destruction site. One-hundred sixty-eight injured patients arrived at the small border hospital that rapidly organized itself for the mass-casualty incident, operating as an evacuation "staging hospital". Twenty-three casualties secondarily were distributed to two major trauma centers in the south and the center of Israel, respectively, either by ambulance or by helicopter. CONCLUSION: Large-scale, terrorist attacks at a peripheral border zone can be handled by international collaboration, reinforcement of medical teams at the site itself and at the peripheral neighboring hospital, rapid rearrangement of an "evacuation hospital", and efficient transport to trauma centers by ambulances, helicopters, and other aircraft.

Influence of personal armor on distribution of entry wounds: lessons learned from urban-setting warfare fatalities.

BACKGROUND: This study was undertaken to examine the distribution of entry wounds resulting from firearms and shrapnel in soldiers wearing military personal armor systems (MPAS) in low-intensity urban combat conditions. METHODS: Data were collected for a retrospective analysis on all combat fatalities sustained by the Israeli Defense Force (IDF) between March 30, 2002, and April 22, 2002, during Defensive Shield Operation in the West Bank. Twenty-six of the 30 fatalities were evaluated in the Israeli National Center of Forensic Medicine. RESULTS: A total of 149 entrance wounds were divided into shrapnel and bullet groups. The "face-neck" region had the highest density rate compared with other body regions in both shrapnel and bullet groups (2.97 and 2.41, respectively; p < 0.0001). In both groups, the overall prevalence of anterior injuries was significantly higher than posterior ones (78.9% vs. 21.1% in the shrapnel group and 68.5% vs. 31.5% in the bullet group, p < 0.001). However, anterior and posterior chest injuries had a reverse yet more even distribution (43.8% and 56.2% in the bullet group and 40% and 60% in the shrapnel group, respectively; p < 0.001). The difference in the average diameters of entry wounds in the covered versus uncovered regions (0.79 +/- 0.42 cm vs. 0.73 +/- 0.29 cm, respectively) was not statistically significant (p = 0.11). CONCLUSION: The use of MPAS turned the face-neck region into the most vulnerable body part, as shown by its prominent density rate, especially in the shrapnel group. MPAS designed for urban setting warfare should provide maximal shielding both to the anterior and posterior chest regions. The diameter of entrance wounds in the covered versus the uncovered areas was not statistically significant, suggesting that only a minor deformation of the bullet takes place while traversing the Kevlar vest.

Israeli Army casualties in the second Palestinian uprising.

This study analyzes the pattern of injuries and evacuation in this unique low-intensity conflict with many casualties and high availability of medical services and evacuation means. Injury data regarding Israel Defense Forces casualties during the first 19 weeks of the events were collected and analyzed. Ninety-six of the 356 Israel Defense Forces casualties during the first 4 months of the events were admitted or killed. Bullets (63.5%) were the most common cause of injury. Fragments and explosives accounted for 14.6% of injuries, stones and sling-thrown marbles accounted for 9.4% of injuries, and 12.5% of injuries were from miscellaneous causes. The most commonly injured body regions were the head, face, and neck (54.2%) and the limbs (50.0%). The trunk was injured in 25.0% of cases, and 4.2% of injuries were classified as external. Injury severity distribution was bimodal. The largest group represented patients with Injury Severity Scores (ISSs) between 1 and 14. The other large group was the 23 dead soldiers. The group of soldiers with ISSs between 16 and 75 included five patients only. Sixteen of the 23 dead soldiers were killed in action. Seven soldiers died of their wounds in the hospital, four of them within the first hour after admittance. A total of 83.8% of the casualties were evacuated by ambulances and the rest were evacuated by air. All casualties except one reached the hospital within 1.5 hour after the injury. Seventy-five percent of the injured were evacuated to trauma centers, and the rest were evacuated to other hospitals. The group of soldiers evacuated to trauma centers had a significantly (p = 0.021) higher mean ISS. The nature of this conflict resulted in a bimodal distribution of injuries. Most of the soldiers were either mildly injured or killed, whereas relatively few suffered severe injuries. The prehospital medical forces should be able to identify such patients and provide prompt treatment and evacuation. The abundance of head, face, neck, and limb injuries suggests that the current armor systems should be further investigated and improved.

Mass medical repatriation of injured civilians after terrorist attack in Mombassa, Kenya: medical needs, resources used, and lessons learned.

INTRODUCTION: On 28 November 2002, three suicide bombers crashed their car into a hotel in Mombassa, Kenya; 12 people were killed, including three Israelis, and 80 were wounded (22 of whom were Israeli). The Israeli Defense Force Airborne Medical Evacuation Flight Teams participated in a repatriation mission to bring the wounded home. OBJECTIVES: The objectives of this study are to outline the distinctive aspects of this mission, as well as to share the experiences and lessons learned. METHODS: Israeli Army debriefing reports were used to study the composition of the crew, medical equipment taken, injury distribution, mode of operation, and mission schedule. RESULTS: A total of six fixed-wing aircraft were used--two Boeing 707s and four Hercules C-130s--with a total of 54 medical team members on board. A total of 260 Israelis were repatriated, 22 of whom were wounded, and three were dead. Of the casualties, 14 were conveyed sitting, and eight supine. The time from the first landing in Kenya to the evacuation of the last supine patient was 5.5 hours. Nurses, as well as social workers, played a central role in the mission. A forward team, including five doctors, was used for the initial organization and for gathering information on the medical status of the casualties. CONCLUSIONS: There was redundancy in the medical crew and medical equipment sent. The need for improved infrastructure on the medical aircraft was stressed. Based on this experience, a new mode for operation for similar missions in the future was formulated.

Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care.

In this prospective study, we used two full-scale prehospital trauma scenarios (severe chest injury and severe head injury) and checklists of specific actions, reflecting essential actions for a safe treatment and successful outcome, were used to assess performance of postinternship physician graduates of the Advanced Trauma Life Support (ATLS) course. In the first 36 participants, simulated training followed basic training in airway and breathing management, whereas in the next 36 participants, 45 min of simulative training in airway management using the Air-Man simulator (Laerdal, Norway) were added before performing the study scenarios. The content of training was based on common mistakes performed by participants of the first group. After the change in training, the number of participants not performing cricoid pressure or not using medication during intubation decreased from 55% (20 of 36) to 8% (3 of 36) and from 42% (15 of 36) to 11% (4 of 36), respectively (P < 0.05). The number of participants not holding the tube properly before fixation decreased from 28% (10 of 36) to 0% (0 of 36) (P < 0.05). In the severe head trauma scenario, performed by 15 of 36 participants in each group, the incidence of mistakes in the management of secondary airway or breathing problems after initial intubation decreased from 60% (9 of 15) to 0% (0 of 15) (P < 0.05). The present study highlights problems in prehospital trauma management, as provided by the ATLS course. It seems that graduates may benefit from simulation-based airway and breathing training. However, clinical benefits from simulation-based training need to be evaluated.

Medical consequences of terrorist bombs containing spherical metal pellets: analysis of a suicide terrorism event.

OBJECTIVE: Various metal objects added to explosives increase and diversify the wounding from bombing; especially favoured are spherical missiles for their special injuring characteristics. Our objective was to study the medical consequences and ballistic effects on human tissue of spherical metal pellets used in terrorist bombings. METHODS: The clinical and forensic data of all bodily injured casualties of a suicide terrorist bombing in a crowded hotel dining room were analysed retrospectively. RESULTS: Of the 250 people at the scene, 164 were injured, with 91 (55.5%) suffering bodily injuries; 30 of them died. The immediately deceased had disseminated tissue damage and their bodies were saturated with steel spheres. Thirty-two immediate survivors sustained severe injuries (Injury Severity Score > or =16), and all suffered tissue penetration by the pellets. Twenty-three (32%) underwent surgery and 15 (21%) required intensive care. CONCLUSIONS: Metal pellets propelled by the explosion enhanced the secondary pattern of injury and injured even patients remote from the origin. Tissue destruction and specific organ injuries among survivors were limited. To evaluate and manage victims of terrorist bombings properly, medical teams should become familiar with these severe injuries.

Application of a cuirass and institution of biphasic extra-thoracic ventilation by gear-protected physicians.

OBJECTIVES: To evaluate the speed by which cuirass application, followed by biphasic extra-thoracic ventilation, can be instituted by full anti-chemical protective gear-wearing physicians. MATERIALS AND METHODS: Ten physicians of variable subspecialties applied a cuirass on an adult volunteer and instituted biphasic extra-thoracic ventilation, using the RTX respirator (Medivent, London, UK). Endotracheal (ET) intubation and manual ventilation of a mannequin and its ventilation was comparatively assessed. Performances were conducted in a prospective, crossover, randomized manner. Times to successful applications as well as failure rates were recorded. RESULTS: Cuirass application was performed more rapidly (102 +/- 9 s, 177 +/- 31 s, respectively, P <.01) and with a slightly lower failure rate than ET intubation. CONCLUSIONS: Physicians wearing full anti-chemical protective gear applied the cuirass and instituted biphasic extra-thoracic ventilation faster than ET intubation and manual positive pressure ventilation. Extra-thoracic ventilation should be further evaluated as an option for emergent respiratory support during toxic mass casualty events.