BURNING FLOWERS, BURNING DREAMS

CONSEQUENCES OF SUICIDE BOMBINGS 

ON CIVILIANS IN ISRAEL 2000-2005

Chapter 4 

"TERROR-TAUGHT INNOVATIONS" 

4.1 BEFORE AMBULANCES ARRIVE – WHAT HAS TO BE IN PLACE? | 4.2 USING THE "TRIAGE" SYSTEM | 4.3. THE PENETRATING TRAUMA OF METAL SCREWS AND NAILS | 4.4 THE ANATOMY OF TERROR – WHAT REALLY HAPPENS TO THE BODIES OF CIVILIANS BLASTED BY SUICIDE BOMBERS? | 4.5 12-18 HOURS AFTER AN ATTACK – DEBRIEFINGS | 4.6 MAINTAINING OVERALL CONTROL – ROLE OF THE SURGEON-IN-CHARGE | 4.7 INSIDE A MASS CASUALTY EVENT | 4.8 FRONT-LINE HEALTH STAFF - WHAT THEY DO AND WHAT THEY FEEL | 4.9 TERROR RELATED INJURIES IN CHILDREN ARE MORE SEVERE | 4.10 MEDICAL INNOVATIONS – BITTERLY LEARNT | 4.11 HEPATITIS CARRIERS AND RAT POISON – AS TERROR WEAPONS | 4.12 HOSPITAL VOLUNTEERS WHO DEMONSTRATE THE SANCTITY OF LIFE | 4.13 THE CHALLENGES OF LONGER-TERM REHABILITATION | 4.14 TERRORISTS HAVE ABUSED THE HEALTH SYSTEM | 4.15 ATTACKS ON ISRAELI AMBULANCES 

What is it like to be a wounded survivor of a suicide bombing attack? Around you may be dead bodies 
strewn across the sidewalk, cafe, shopping mall, and scores of wounded civilians, some without limbs, some with shrapnel in their necks, screws in their legs, metal balls embedded in their chests. The lightly wounded may reach hospital with help from passers-by in private cars . The more seriously wounded and unconscious often have to be extricated from twisted metal by first responders who carry them to waiting ambulances and rush them to hospital. 

This is a 'mass casualty ' situation, like after the double suicide bombing in Jerusalem's Ben Yehuda pedestrian mall at 11.30 pm on Saturday, 1 December 2001. Eleven civilians died and one hundred and eighty were wounded, many of them teenagers out for the evening. The Hadassah Ein Kerem hospital received sixty-two wounded people within a very short time. By 1.30 am the doctors, nurses, spokeswoman, emergency room reception staff, and dozens of other workers still had 10 hours of work 
before them. Hospitals have to be ready to receive a great influx of dying and wounded, and distraught 
relatives. This chapter looks at preparations and innovations which have been introduced in response to 
suicidal and other terror attacks against Israeli civilians. 


4.1 BEFORE AMBULANCES ARRIVE – WHAT HAS TO BE IN PLACE? 


How do hospital staff prepare for the influx of hundreds of casualties within a short space of time? In 2002 the Israeli national strategy for mass casualty events was described. In a scenario of mass casualties, medical resources are overwhelmed. The demand on hospitals dealing with trauma victims varies according to the number of casualties and the severity of their injuries. "The number of casualties is limited by the capacity of the target (e.g. bus or restaurant). Ordinary hospital resources are heavily burdened, yet the delivery of efficient medical treatment is possible by the recruitment of all available personnel and resources...The number of casualties generated by attacks in open spaces depends on the density of victims at the scene, the number of attackers and the explosive load."(Almogy,G. et al. 2004)

Premature detonation of an explosive device in open spaces results in fewer casualties, but when attacks involve crowded open spaces or semi-confined spaces, such as buses, initial reports of Emergency Medical Services may be confused and contradictory. Israel has adopted a standardized response to attacks in crowded places. This involves evacuation of the emergency room, a halt to scheduled operating room activity, and mobilization of personnel. 

"A mass casualty scenario (MCS) is usually short in duration and resolves itself. To minimize the risks to 
patients during the MCS, planning is essential. (A major hospital in northern Israel describes the) 
preparations needed at the hospital level for a local MCS involving numerous trauma victims arriving at the Emergency Department at short notice. (It combines both responsibilities of the military and civilians)... The Israeli Ministry of Health distributes the master MCS plan to each hospital where a local committee adapts it to the specific situation in a format of standing orders. After its approval by the Ministry of Health, an annual inspection is conducted to check the ability of the staff to manage a MCS. A full-scale drill is conducted every second year during which each site's readiness level and the continuity of the flow of care are tested." (Levi et al. 2002). 

In building the strategy for treating trauma victims during a MCS, a few assumptions were taken into 
account. The goal of treatment in a MCS is to deliver an acceptable quality of care while preserving as many lives as possible. In theory, the capacity of the hospital is its ability to manage a load of patients in the range of 20% of the hospital bed capacity. Planning and drilling are the ways to minimize deviations from the guidelines and to avoid management mistakes. Special attention should be paid to problems related to the initial phase of receiving the first message, functioning of outside communications, inside hospital communication, and staff recruitment. Also to free access to the hospital, opening a public information center, and dealing with the media and VIPs. A new method for creating the needed MCS plan is suggested based upon knowledge of management techniques that use multi-level documents which are spread via Intranet between the different key figures. Using this method it is possible to keep the strategy, source documentation and reasons for choosing it, as well as immediate release of checklists for each functions." 
(Levi. L et al. 2002). 


"The only chance for victims who develop severe respiratory distress (breathing problems) or severe 
hemorrhagic shock ( from severe blood loss) in the field is the availability of early advanced life support. 
Emergency medical services crews are therefore instructed to follow the 'scoop and run' approach in these 
circumstances. Needle thoracostomy (the relief of pressure in the chest by puncturing the chest wall), and 
tracheal intubation (inserting a tube through the mouth into the windpipe in order to perform artificial 
breathing) are the only procedures performed in the field. Victims with amputated body parts who are not 
showing signs of movement and those who are pulse-less with dilated pupils are considered dead. No further efforts are spent on these victims and attention is directed to evacuating the remaining victims." (Almogy.G et al. 2004) 

Regardless of distance emergency services crews are instructed to evacuate the most severely 
injured victims of bombings in Jerusalem to the Ein Kerem Campus of the Hadassah Hospital, the only level 1 trauma center in Jerusalem, with more experience in recognizing and treating complex injuries. The 
trauma room is specially equipped to treat four severely injured patients simultaneously" (Almogy.G et al. 
2004). 

When the Sbarro Pizzaria bombing took place in Jerusalem on August 9, 2001, 15 people died and 146 were wounded. Within six minutes of the blast 18 patients were brought to the emergency department. The Hadassah Ein Kerem hospital activated the detailed protocol, specially designed for such purposes. For example, all patients already in the emergency department were transferred to other floors and all non-urgent activity was halted. Operating room administration personnel were alerted. The protocol includes the telephoning of hospital staff to alert them to the attack. Often they are already alerted, having been told of the attack by relatives, friends, the media, the internet, or by simply hearing the blast. 

"Surgical personnel arrived (at the Emergency Department) and were organized into predetermined teams... each team was assigned a bed in the trauma room or 3-4 beds in the admitting area...the surgeon in charge received incoming emergency services crews and triaged the victims into either the trauma room or the admitting area according to the presence of immediate life-threatening injuries. He accompanied the most severely injured into the trauma rooms and orally communicated his findings to the treating teams...Teams of general surgeons examined all patients initially. Due to the high incidence of tympanic membrane trauma (injury to the inner ear which causes deafness) following a blast injury, all patients were examined by teams from ENT (ear nose and throat.)" (Almogy. G et al. 2004). During the initial 6-8 hours patients were repeatedly assessed, including review of laboratory and imaging findings (e.g. X-rays). In the Hadassah hospital a nurse coordinator is appointed to contact families of the casualties and inform them of their condition and progress. The nurse has access to the Emergency Department, trauma room, operating rooms and crisis center, and is updated by the surgeons. Once the situation stabilizes the surgeons join the coordinator and update the families. 



4.2 USING THE "TRIAGE" SYSTEM 


The manager of intensive care at a coastal hospital observed that the most common injuries seen following a suicide bombing were a combination of blast injuries with tearing of internal organs, burns and limb injuries, often with penetration of the body by metal balls and nails. The bomb blast causes the shock waves to travel through internal organs such as liver, lungs; spleen, kidneys. Damage may depend also on the distance from the center of blast and the angle of the blast wave. Luck and fate play a part. For example, a blast in an open space may be less damaging than that in a closed space where some shock waves can rebound. One 24-yearold survivor was paralyzed by a single nail which had penetrated his spinal cord. 

When a suicide bombing occurs many victims are brought to hospital by emergency personnel in 
ambulances, and by bystanders in their own cars. The 'Triage system' then swings into place as a trauma-
qualified surgeon, or most experienced trauma surgeon available, screens each incoming patient. What 
he/she look for are signs of severe respiratory distress and 'hemodynamic instability' (the inability of the 
heart and blood vessels to maintain normal blood flow and pressure), The severely injured are evaluated and treated in the trauma room setting. A short evacuation time and the often young age of victims may enable an aggressive approach in treating such cases. Attention is initially given to identifying those with shortness of breath, tachycardia (unusually rapid heart-beat) and confusion, those with multiple entry sites and extensive tissue damage, which are markers of more severe trauma. These patients require immediate transfer to a higher-level care environment or to the operating room. A 2005 article concluded that external signs of trauma should be used to triage salvageable and non-salvageable victims, taking into account amputations, burns and open fractures (Almogy et al., 2005). 


Some differences between Israel's systems and those of countries such as in central Europe, was noted in a German article in 2003. The accumulation of bombing attacks made it necessary in Israel to "change the 
views of the system of triage, which has essential differences from the central European system. Apart from changing pre-hospital and clinical management 'algorithms' (decision-making flow-charts) the surgeons specializing in treating casualties must be prepared for a new quality of injuries. 'Barotrauma' (trauma caused by the sudden intense pressure of an explosion) of the lungs and multiple, seemingly superficial injuries often only emerge later as life-threatening and lead to the overload of intensive care and surgical capacity of the hospital (Stein.M et al. 2003). 

Degree of wounding and what the 'triage' approach means

'Light' wounds present no threat to the patient and very invasive surgery is not necessary, but injuries can range from scratches to a severed limb, provided bleeding has stopped. 'Medium 'wounds may not present immediate danger to life, but direct, immediate attention is necessary including surgery. 'Serious' wounds may include injury to a vital organ such as the brain, heart or lungs and present a grave danger to the patient. 'Critical' wounds occur where the patient arrives at the hospital usually unconscious, requiring immediate intervention to support vital life systems such as breathing or blood circulation. 

The 'triage' approach involved the medical sorting of patients according to type and seriousness of injury, likelihood of survival, and establishment of priority for treatment/evacuation to assure medical care of the greatest benefit to the largest number. The three categories relate basically to: those minimally wounded who require limited treatment; those wounded who after emergency treatment incur little additional risk by delay or further treatment; and those who are so critically injured that only complicated and prolonged treatment will improve life expectancy. 

 


4.3. THE PENETRATING TRAUMA OF METAL SCREWS AND NAILS 


Suicide bombers often deliberately place screws, nails, and metal bolts within their explosive devices to 
increase secondary blast injuries. Most victims of penetrating trauma sustain injury to the head, chest, 
abdomen and limbs. Blunt trauma is usually a 'multi-site' injury, and its severity depends on the mechanism of injury. The injuries sustained by victims of suicide bombings attacks 2000-2005 share the worst of both worlds. The multitude of heavy particles causes damage to a large surface area of the victim, much like blunt trauma. Each particle (metal screw, metal ball, nail) causes extensive tissue damage at the site of entry, much like penetrating trauma. Survivors typically suffer a combination of wounds of varying severity and location, and the diagnostic work up is focused on determining the extent of damage caused by each missile. 

Each particle causes extensive tissue damage at the site of entry. 


FROM PIPE BOMBS TO SUICIDE BOMBS 

"From 1994 to 1997, 892 people were injured in Israel by bomb attacks. Of these 154 did not survive... 
During the past 8 years (before 2002) 91 patients were admitted to (the Hadassah Ein Kerem hospital) 
following such attacks. Of these 10 (11%) had vascular injuries. The bombs were of two types. Some had 
been placed in crowded areas to be detonated remotely. Occasionally the bombs were constructed inside a lead pipe, a so-called 'pipe-bomb' with fragments of the pipes producing very harmful shrapnel. The second category of bombs, often resulting in worse injuries, were those carried by suicide bombers. These bombs had several features in common: they exploded in close proximity to the victims; two-thirds exploded in closed or confined spaces; and, to increase injury, they contained, in addition to the explosive material, numerous metal fragments, often nails, screws or screw nuts. 

These attacks resulted in a mortality rate of 17%. In survivors, they produced a combination of injuries: blast injuries manifested by tympanic membrane perforation (perforation in the inner ear) in 25% of patients and with pulmonary (lungs) blast injury in 5% to 14% of patients. Occasional abdominal blast injuries resulted in rupture of the spleen or perforation of the bowel. Shrapnel injuries occurred in 20%-42% of the victims, with a higher incidence in closed spaces. They could be distributed over many body regions but usually entered from one direction. The shrapnel often carried sufficient energy to produce severe tissue damage. Burns occurred in 15% of survivors. They were more common and more severe in confined spaces and occurred mostly on exposed body surfaces facing the blast" (Wolf & Rifkind 2002). 


In 1998 it was reported that "the types of injuries sustained by victims and perpetrators include body 
disruption, explosive injuries, flying missile injuries and blast injuries. Blunt trauma is directly produced by the explosion and flying missile injuries account for 80.1 % of the wounds. The number of fatalities was more closely related to the type of attack rather than the amount and type of explosives used. Swift 
identification of all victims and perpetrators was obtained through collaboration between the different 
professional teams involved: forensic scientists, law enforcement agencies, and secret service investigators" (Hiss & Kahana I998). 

An article published in 2002 observed, "During the past eight years the staff at the Hadassah University 
hospital (in Jerusalem) treated more than five hundred patients who were injured by gunshots or explosives. During the past four years, the authors have treated 267 such patients, of whom 163 (61%) were victims of terrorist attacks. The authors have developed a multi-disciplinary approach for the treatment of such patients." 

To simplify, treatment included: 'arteriography' (tracing the flow of blood in the arteries using X-rays); a treatment plan devised among vascular, orthopedic and plastic surgeons to determine type of 'fixations of bones' (fixing fractured bones with metal plates or screws), incisions, soft tissue coverage and the timetable involved; isolation of injured blood vessels; then, when blood flow had been re-established, shattered bones were fixed, and blood vessels repaired. Where necessary, arteries were reconstructed, injured major veins repaired, and skin grafts provided. With treatment of shrapnel blast injuries, fragments (such as large screws and nails) are often large with an irregular shape and their path within the body is unpredictable. 

Often there are multiple injuries. "Soft tissue injury is a decisive factor in the ability to salvage injured limbs, particularly after blunt trauma. Most important, in massive soft tissue injury, in addition to the named veins, numerous venous collateral channels have been severed as well. Penetrating injury by definition carries infectious agents into the body and creates a port of entry (antibiotics are required as well as surgical irrigation and drainage of wounds). The rate of infection involving vascular reconstruction, in the authors' experience, is 4%; however, following a bomb injury that took place in a vegetable marketplace, the rate of fungal infection was significantly higher than in similar attacks at other 
locations (Wolf & Rivkind 2002). 


4.4 THE ANATOMY OF TERROR – WHAT REALLY HAPPENS TO THE BODIES OF CIVILIANS BLASTED BY SUICIDE BOMBERS? 


When news announcers report bomb survivors were 'mildly' wounded, it is not just scratches and bruises. "A 'mild' injury could require five operations. A mild injury could be the loss of a few fingers, or a permanently lame arm or leg. It could mean acute stress disorder, which leaves the person looking fine, no blood, no bruises, but he may be so emotionally damaged that he can never work again, and his family collapses...The operative definition of a 'mild' injury is one that does not threaten life or limb. Mild injuries could be to the palms of the hand or soles of feet, or an eye. A 'moderate' injury is not life-threatening, but could involve the loss of an organm say a leg or an eye. A common moderate injury is a bad stomach wound, but one that misses a major blood vessel so that bleeding is not heavy...

'Critical' injuries threaten life and involve major bleeding. They are usually severe chest wounds, or penetrating head traumas. If the cervical spine has been hit, the victim may be paralyzed for life. 

'Grave' injuries are to the heart, the main blood artery or the brain, and usually result in death. 'Very critical' is even more urgent than critical but not as bleak as grave... 

'Stable' means the patient's condition isn't getting worse – but it isn't getting better either: (Derfner 2001, quoting Dr Shmuel Shapira, Deputy Director of Hadassah Hospital, Jerusalem). 

Of the 62 injured people brought directly to the Hadassah hospital after the Ben Yehuda pedestrian mall attack in December 2001, one was in grave condition, two very critical, six were critical spending also many days in intensive care, and the other 53 were classified as mild. 

INJURIES COMBINE LETHAL EFFECTS OF PENETRATING TRAUMA, BLAST INJURY and BURNS. 

(The following paragraphs are credited to Almogy et al. 2004, but have been modified for a general 
audience.) 

Suicide bombers mingle into a crowd – at a bus stop, in a cafe, outside a disco – and detonate their bombs in close proximity to their victims. How a civilian is killed or wounded often depends on his/her proximity to the bomber, and where the bomb was detonated. Between November 2000 and May 2003, seventy-one suicide bombing attacks were carried out in Open spaces (OS) such as pedestrian malls, open markets and bus stops; (B) buses; (SCS) semi-confined spaces such as restaurants and cafes. The energy of the blast dissipates inversely with the distance to the second power, and injury is limited to victims in close proximity to the bomb. 

When a bomb is detonated inside a confined space such as a bus victims usually sustain severe primary blast lung injury and the fatality to casualty rate is high. Of 52 suicide bombing attacks between 
November 2000 and May 2003, in open spaces the ration of fatalities to casualties was 4.8, but of 13 bus 
bombings for the same period was 21.9, and of 6 suicide bombings for the same period the ratio was 17.0. Attacks inside semi-confined, crowded spaces are characterized by the large number of casualties and fatalities and by the severity and scope of penetrating injuries, such as metal screws and nails. 

The degree of soft tissue damage associated with these injuries is also difficult to quantify. Since the 
attackers usually approach the victims from behind, the majority of entry sites are located on the back 
portions of the victims. Positioning the patient in the supine position and performing routine abbreviated 
laparotomy (opening the abdominal cavity) may actually postpone treatment of these potentially more 
serious injuries (Almogy et al. 2004). 

Up to 10 to 15 entry sites, ranging in size from 2 to 6 cm in diameter and up to 5-8 cm deep, are packed by 2 to 3 teams in a swift manner with the patient lying in their left or right side. Rapid haemostasis (stopping of the bleeding) should be achieved within 2-3 minutes. Hypothermia (low body temperature) leading to blood cloting abnormalities in trauma patients may also be diminished by covering these wounds. The patient is then positioned in the supine position and the laparotomy (opening of the abdomen) and/or thoracotomy (opening of the chest) is initiated. This modification may attenuate the degree of soft tissue damage, lessen hypothermia (low body temperature), achieve better stopping of the bleeding, and improve survival. 

A 14-year-old girl sustained multiple shrapnel wounds to her lower extremities with extensive soft tissue damage, which included multiple open fractures of her legs, and obstruction of a major blood vessel to her legs. The fractures were nailed but she developed hypothermia and blood clotting abnormalities so her vascular injuries were not repaired and she was transferred to the intensive care unit. She continued to bleed profusely from multiple entry sites and received 57 units of red blood cells, 39 units of fresh frozen plasma to correct blood clotting abnormalities, 14 units of platelets and 19 units of cryoprecipitate (solid material left when fresh-frozen plasma is thawed at two degrees Celsius and four degrees Celsius. This product is rich in clotting factors.) Twenty- two hours after admission she received additional inputs which stopped the bleeding (Almogy G et al. 2004). 

The threat of suicide bombings has escalated worldwide. The ability of the suicide bomber to delver a 
relatively large explosive load accompanied by heavy shrapnel to the proximity of his or her victims has 
caused devastating effects. From experience 2000-2003 "evacuation is usually rapid due to the urban setting of these attacks. Numerous casualties are brought into the emergency department over a short period. The setting in which the device is detonated has implications on the type of injuries sustained by survivors. The injuries sustained by victims of suicide bombing attacks in semi-confined spaces are characterized by the degree and extent of widespread tissue damage and include multiple penetrating wounds of varying severity and location, blast injury and burns' (Almogy. G et al. 2004). 

Suicide bombing victims suffer multiple penetrating wounds, blast injuries and burns.

 "The approach to victims of suicide bombings is based on the guidelines for trauma management in general, but has to include, specifically, large number of victims, effects of penetrating trauma, blast injuries and burns, and the numerous penetrating wounds sustained by each victim. Attention is given to the moderately injured, as these patients may harbour immediate life-threatening injuries. The concept of damage control can be modified to include rapid packing of multiple soft-tissue entry sites. Optimal use of manpower and resources is achieved by recruiting all available personnel, adopting a pre-determined plan, and a centrally coordinated approach. Suicide bombing attacks seriously challenge the most experienced health facilities" (Almogy et al. 2004). 

"There are several factors to consider in understanding the bodily damage caused by the recent wave of 
suicide bombing attacks in Israel: a) the high-grade explosive material used by the attackers; b) the ability of the attackers to detonate the explosive device in proximity to the victims by concealing the explosive device and mingling within a crowd; c) the ability of the attacker to precisely time the explosion at his or her discretion; and d) the large load of heavy shrapnel that accompany the explosive material.

 All these factors are combined by the attackers to increase the number of casualties and the severity of their injuries. The injuries sustained by the victim depend on the proximity of the victim to the explosive device, the angle at which the victim stands in relation to the center of the explosion, and the height of the explosive device in relation to the victim. The circumstances associated with these attacks also influence management and decision- making. The uncertainty as to the arrival of additional victims, the mayhem associated with the arrival of anxious family members, the florid scenes associated with these injuries, the often young age of the victims, the possibility that family members of hospital personnel are among the victims, and the risk of second-hit explosions intensify the chaotic atmosphere that already exists in the emergency department. These factors underline the importance of forming a plan at the hospital level designed to deal with these circumstances" (Almogy et al. 2004). 

A July 2003 article described the pattern of injury of terror victims hospitalized at 9 acute-care hospitals in Israel during a 15 month period of terrorism. "During the study period 23,048 patients were recorded, 561 (2.4%) injured through terrorist attacks... Thirteen percent of terror victims compared with 3% with other traumatic injuries arrived by helicopter. Injury mechanism consisted mainly of explosions 48% of 269 injured, and gunshot injuries 47% of 266 injured. One third of this population experienced severe trauma. 


One hundred and forty-two patients (26%) needed to be admitted to intensive care. Inpatient mortality was 6% of 35 admitted. Fifty-five percent of injuries (of 306) included open wounds and 31% (of 172) involved internal injuries (and) 39% of 221, sustained fractures. Half of the patients had a procedure in the operating room (298) Duration of hospitalization was longer than two weeks for nearly 20% of the patients" (Peleg et al. 2003). 

BLAST INJURIES -WHAT THEY DO AND WHAT ELSE TO SEARCH FOR 

When three aircraft crashed into three buildings on September 11 2001, it reminded healthcare workers of 
the magnitude of injuries and death that can result from a blast mechanism. Internationally, explosive 
devices frequently are used in war or acts of terrorism. Much of the challenge facing the care providers is the potential for the sudden creation of large numbers of patients requiring extensive medical resources.

This scenario can overwhelm local EMS and hospital resources. In general, most blast injuries cared for by US emergency departments tend to be accidental, including firework mishaps, unintended occupational or 
industrial fuel eruptions, and unseen mine explosions. In many parts of the world, however, the reality 
persists of deadly, dormant, non-detonated, military incendiary devices such as landmines and hand 
grenades. Such devices cause significant numbers of civilian casualties years after local hostilities cease. 
During wartime, injuries arising from explosions frequently outnumber those from gunshots; many victims 
are innocent civilians. Explosive devices inflict bodily harm by a variety of mechanisms, with multiple 
provisos ultimately determining the number of victims injured and killed. 

A case in point is that detonation forces (even those deemed low by most standards) can trigger the collapse of a building, crushing and maiming victims inside and nearby. There is also concern about radiation, chemical or biological contamination of explosion victims. Careful observation for signs and symptoms of exposure to poisonous chemicals, screening for radiation contamination and decontamination of patients as needed, are important steps in the management of victims of non- accidental explosions. 

In the first attack on the World Trade Centre, terrorists attached cyanide to a bomb placed in the underground parking garage. Fortunately, in that incident the cyanide was destroyed by the combustion. Hospital staff need to search for evidence of radiation, chemical or biological contamination in persons with blast injuries, as well as EMS personnel checking for radiation at the scene of the explosion. (This paragraph is indebted to Lavonas 2004 and has been simplified for a general audience.) 

Understanding the basics about blast injuries 
Blast injuries are traditionally divided into four categories:

 
1. Primary blast injury caused solely by the direct effect of the blast overpressure on tissue. Air is 
easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled 
structures such as the lung, ear, and gastrointestinal tract. Sometimes air emboli (small bubbles of 
air) occlude blood vessels in the brain or spinal cord. 


2. Secondary blast injury caused by flying objects that strike people, such as shrapnel, screws, and 
nails. 


3. Tertiary blast injury caused by high energy explosions when people fly through the air and strike 
other objects, such as pieces of metal from buses, shards of broken glass, such as in the Oklahoma 
City bombing in the USA where thousands of heavy chunks from the broken glass facade were 
propelled through occupied areas of buildings with devastating results. 


4. Miscellaneous blast injury encompasses all other injuries caused by explosions. For example, the 
collision of two jet airplanes into the World Trade Centre created a relatively low-order pressure 
wave, but the resulting fire and building collapse killed thousands. 


Blast Injuries – What hospital personnel are looking for in patients after an explosion: 


The lungs are examined for evidence of pulmonary contusion (traumatic injury to the lung by pressure 
of a blunt object. There is no perforation of the lining of the lung but the damage is to the tissue of the 
lung resulting in crushing, bleeding and an inflammatory reaction) and pneumothorax (an abnormal 
collection of air outside the lining of the lung, between the lung and the chest wall, often a consequence of pressure injuries.) Perhaps the patient is 'wheezing' and has a pulmonary contusion. Or, the wheezing could be from inhalation of irritant gasses or dusts, pulmonary edema from myocardial contusion, and adult respiratory distress syndrome. Symptoms of pulmonary contusion may take 12-48 hours to develop. 


The ears are examined for signs of ruptured eardrum (tympanic membrane) which indicates additional serious injury. But, even intact eardrums do not imply the absence of serious injury. The delicate bones of the inner ear may also be fractured or dislocated in high energy explosions. About one third of patients with ruptured eardrums have permanent hearing loss. 


The abdomen is examined for injuries to both solid organs (e.g. liver or kidney) and hollow organs 
(like the bladder) in people injured by closed-space explosions and blast injuries occurring in water.

 
Source: Lavonas, "Blast Injuries" 30 December 2003, online at Medicine: Instant Access to the 
Minds of Medicine 



A study in the nineties had looked at the link between eardrum perforation and pulmonary blast injury in 647 survivors who arrived at hospitals after 11 terrorist bombings in Israel between 6 April 1994 and March 1996. It was found that 193 (29.8%) of them sustained primary blast injuries including 142 with isolated eardrum perforation and 51 with other forms of blast injuries (Leibovic, D. et al. 1999). 

DUAL EXPLOSIONS CAUSE VERY SERIOUS INJURY 

An explosion that occurs in an enclosed space, such as a bus, or in water tends to cause very serious injury. The intensity of an explosion pressure wave declines with the cubed root of the distance to the explosion. A person three metres (10 feet) from an explosion experiences 9 times more overpressure than a person six metres (20 ft) away. Proximity of the person to the explosion is an important factor in a primary blast injury. 


Blast waves are reflected by solid surfaces, so a person standing next to a wall may suffer increased primary blast injury. Another ominous consideration is the tactic of setting dual explosions. The initial explosion is intended to injure civilians and to attract law enforcement and rescue personnel, followed by a delayed explosion designed to injure rescuers. Hospital disaster plans should include tight security at all hospital entrances in the event of a terrorist explosion in the community. All hospital personnel should be alert for unattended packages. In addition to protecting hospital patients and staff, sealing entrances helps control the chaotic flow of patients and visitors (Lavonas 2003). 


4.5 12-18 HOURS AFTER AN ATTACK – DEBRIEFINGS 


The Surgeon in Charge (SIC), department chair, treating teams, nurses, nurse coordinators hospital 
administration, hospital spokesperson and EMS representatives all participate in the debriefing discussions. 


The event is reviewed and analyzed beginning with the correlation between initial Emergency Medical 
Services reports and the number and condition of casualties, the number and makeup of teams participating in the event, the number of patients requiring surgery and timing of their surgery, the requirement for additional intensive care unit beds, and the need to cancel non urgent procedures. Some of the recommendations that we have implemented include: recruitment of personnel via telephone lines and not pagers or cellular phones which crash due to overload, placement of a portable sonogram in the trauma room, transformation of recovery room beds into temporary intensive care unit beds, regulation of 
physician's leave, and creation of the roles of SIC and nurse coordinator. The days following an attack are 
not normal. After the Sbarro attack and as a result of the overload on the ICU two major surgical procedures were postponed (in one Jerusalem hospital)." (Almogy et al. 2004) 



4.6 MAINTAINING OVERALL CONTROL – ROLE OF THE SURGEON-IN-CHARGE 


In the hospital setting, "control and coordination are achieved by the 'accordion approach', where patient 
evaluation and management proceed through repeated cycles consisting of a dispersal and a convergence 
phase... Activity is coordinated and controlled by the surgeon-in-charge who is aware of the overall situation and has the oversight to prioritize evaluation and treatment Chaos is gradually managed once the number of patients requiring further work up is reduced. Patients undergoing surgery, often simultaneously by different teams, are reassessed by the surgeon-in-charge or in the operating room with the treating teams. The overall condition of the patient, the sequence of therapy, the need for further imaging studies, and the need for intensive care unit admission are discussed and finalized" (Almogy et al. 2004) 

"The basic rules and concepts of trauma management are applied... Their application may be modified in 
different situations. As in all trauma cases, airway control and acute breathing problems are prioritized. 
Victims with low blood pressure due to penetrating abdominal or chest trauma are taken to the operating 
theatre to receive 'laparotomy' (an operation opening the abdomen by an incision through the abdominal 
wall) and/or 'thoracotomy' (surgical opening of the chest cavity to inspect or operate on the heart, lungs or other structures within.)...Multiple shrapnel entry sites are common in survivors and it is impossible to 
determine which of the numerous entry sites is the cause of (the low blood pressure). Many hours and 
sometimes days are required for the situation to stabilize and eventually normalize. Treating teams are 
physically and emotionally exhausted from the continuous workload, especially when repeat attacks occur 
within days. There are regular assessments by the surgeon-in-charge and the treating teams to ensure all 
patients receive optimal care. A strong personal commitment by the treating teams and surgeon-in-charge is pivotal to success. This may have to last from several hours to days depending on the magnitude of the attack. During this period other professional and personal commitments are sacrificed" (Almogy et al. 2004). 

Emergency medicine specialist killed by suicide bomber in Jerusalem Cafe. 
In September 2003 Doctor David Appelbaum and Professor Jonathan Halevy, director of Shaare 
Zedek hospital in Jerusalem had both been in New York near Ground Zero discussing ways of 
responding to 'mass casualty events'. The next night Dr. Appelbaum was himself a victim of the 
suicide bombers. 


"Upon returning to Jerusalem, Dr. Appelbaum went to Cafe Hillel in the German Colony to spend some time with his daughter Nova before her wedding, which was scheduled for the next day. They were sipping coffee when a suicide bomber struck, killing them and five others. Halevy heard the explosion from his home only 150 metres away and immediately drove to the hospital. 'One thing that surprised me was that I didn't see Dr Appelbaum there because he always arrived a few minutes before me.. About 15-20 minutes later, his wife Debra came in with a few of their kids and asked if David had been brought in; by that time everyone knew he had been at Cafe Hillel'. 

About an hour later, a paramedic and a physician – both trained by Dr Appelbaum – identified his body at the scene. It took a few more hours to identify Nova, "it was the most horrible night of my life' said Halevy. 'We were taking care of the injured, and crying all through the night'. 


Dr Appelbaum had left Shaare Zedek hospital in 1988 a few months before Dr Halevy took over the 
hospital, to found 'Terem'. It was in that flourishing private care clinic that Appelbaum began a revolution of sorts in emergency medicine in Israel....Terem provided highly trained staff and advanced facilities at a fraction of the cost of a visit to a hospital emergency room. Appelbaum also ensured a patient-friendly atmosphere.... Appelbaum in July 2002 returned to Shaare Zedek hospital; within a year he developed a computerized system at low cost which is now being copied around the country... Halevy observed, 'I've been around quite a bit, in hospitals all over the world, and I can tell you, I have never in my life met another person with the combination of noble qualities and skills like Appelbaum had." 

Source: Ser, "Appelbaum Recalled As Mensch, ER Revolutionary" Jerusalem Post, 13 August 
2004. 



4.7 INSIDE A MASS CASUALTY EVENT 


In Jerusalem's Hadassah Ein Kerem hospital in 2001 staff painted a vivid picture of what it is like to be 
'inside' a mass casualty situation. A suicide bombing on 1 December 2001 in the downtown pedestrian mall of Ben Yehuda had killed 11 people and wounded 180. Hamas claimed responsibility for the attack. 

Some unconscious wounded children were listed as 'anonymous' as searching parents swung between hope and despair. 

Shoshi was a new reception clerk in the hospital emergency room. She was driving to work for her 
midnight shift when the terrorists struck. By the time she arrived, the emergency room was already 
going full speed with stretcher bearers carrying bloody patients through the doors, as police officers, 
doctors, nurses, and others rushed past. This was her first mass casualty event. Her job was to type 
information into the computer. Shoshi says, 'They tell you not to look at the patients being brought in 
on the stretchers, but you can't help looking. I want to forget it.' 

Soon the families and friends of the victims began filling up the waiting area. 'Oh, the waiting! One mother waited about 5 hours to find out if her son was dead or alive, or how he was. She really went hysterical. I worked like a robot without thinking. I saw people were watching TV – the news about the attack.' 'An unusually high number of foreign journalists from Norway, Japan, Germany and France wanted access to the victims and their families everybody wanted to photograph the wounded. The reporters get there before the ambulances.' 

For the first three hours, she kept them from entering the building, until ER had finished with all the patients and sent them to X-ray, surgery or other departments. As she moved through the wounded in the ER, she looked for those with the mildest injuries. 'You have to be delicate. I ask them how they are feeling, talk with them and their families, and only at the end ask them if they want to be interviewed. Five agreed. Journalists are always looking for a dramatic story, so I found one boy whose brother had been wounded badly in a bus bombing a few years ago. At least 7 or 8 people refused to talk to the media. I never press them. In a situation like that some people feel a need to talk, and others just want their privacy.' 


The head of the ER, Dr Kobi Assaf, reported, 'We had so many (health staff) and they were all in here, 
all the time. A lot of others called in to ask if they could help – professors, nurses, and students; I told 
them thanks, but we've got enough hands. We had a girl with what looked like a cut on her leg that 
wasn't bleeding much. Another time we might have told her to sit over there and wait until a doctor 
saw her. Then this girl's leg started to swell up, and her blood pressure dropped rapidly – she was 
bleeding internally. But she was surrounded by doctors and nurses, so they saw it and treated her 
immediately.

 
Social workers had probably the most harrowing job that night, sitting for hours with families looking 
for their children. The families didn't know if their kids were dead or alive - or, if alive, how badly 
they had been hurt. Some wounded children were listed as 'anonymous' because they had no 
identification and were unconscious. The parents described their children physically, including special features such as tattoos or rings. They were shown photographs of the anonymous, unconscious kids lying on hospital beds, to see if any were their son or daughter. In some cases, the boys and girls are recognizable. 

Again and again, the parents asked the social workers to check at the other hospitals if their children had turned up. 'One thing we never tell them,' said the director of Hadassah social services, 'is, Don't worry, everything will be all right. They swing between hope and despair and we try to hold them up. But it is clear to us that the longer they are here, the longer their children have not been found at one of the hospitals, the more it points to their being at Abu Kabir (the forensic institute). Because the victims are so young, I reacted in part as a mother. I was thinking, this could have been my child. It makes you feel so powerless. You think, we can't even protect our children anymore.' 

Shoshi, the new clerk, finished her night shift at eight the next morning. Driving home she turned on the radio and listened to the news. 'That's when the penny dropped. To tell you the truth, I didn't stop crying until I got home. I slept until one o'clock that afternoon. Then a friend telephoned and told me that 15 people had just been killed by a suicide bomber in Haifa.' 


Source: Derfner.L "The Home Front Line" Jerusalem Post Friday December 4, 2001

Elsewhere in Israel similar scenarios have been played out over and over again during the past four years. A front-line senior nursing supervisor recalled how she prepares her hospital to receive bomb casualties. 



4.8 FRONT-LINE HEALTH STAFF - WHAT THEY DO AND WHAT THEY FEEL 


"Staff Call Me the 'King of Terror' Because I Organize Everything" 
"We first know when a suicide bombing has taken place in various ways. Civilians may phone our 
Emergency Room (ER), or we may hear from Magen David Adom (Israeli equivalent of Red Cross). Or, the police may phone us. If I am at home and I hear there has been an attack I call the hospital to find out if it is correct, and the number of confirmed wounded. Then I call the hospital administrator, then the surgery room to tell them to prepare for surgery and giving of blood. I call extra doctors and nurses to mobilize them in minutes (everyone knows their roles), and security. 

I take one doctor to the front of the Emergency Room to assess the incoming casualties and organize orderlies to take them to the correct receiving places. Security has also to deal with a flood of people trying to enter the Emergency Room. I take one nurse and she sits near the telephone until a social worker arrives. We get desperate calls from relatives seeking family members to know if they are dead or alive. She is the first to talk to them. We allow one relative to stay with a patient, especially if it is a wounded child who needs their mother. 


We do not have much time to prepare for the casualties, maybe 15 to 30 minutes. I start to work 
automatically. My staff call me "the king of terror' because I organize everything. I have to contact the ER staff, get extra staff to the ER from elsewhere in the hospital, station a nurse at the entrance to the Emergency room to direct the wounded according to initial assessment as serious/less serious cases, and manage the influx of relatives. The first to arrive in ambulances are the most badly wounded. The staff do a primary assessment of whether the case is critically wounded (with head injuries, legs or arms blown off, extensive burns all over their bodies), or medium or less seriously wounded. Some of the wounded are bleeding heavily, and some may have crush injuries from metal bus destruction. The worst cases are sent directly to the Trauma Room. 

Then there is a 'second wave' of traumatized people entering the hospital. We take them to our large hospital bomb shelter, which has been specially prepared to receive them. They can see psychologists, psychiatrists, psychiatric nurses and a trauma specialist nurse. It takes about half an hour for our hospital management to arrive. At around this time I begin to have feelings, and afterwards it takes about a week to feel like myself again. We health staff have to do everything at the time without letting feelings emerge or stress. 

One time near my home there was a large-scale bus suicide bombing. I heard the blast. My son said it was a bomb. I didn't want to believe him, almost like a denial. Then I looked out of my window and saw the smoke. I really knew then it was a bombing. I went immediately to the hospital. We see seriously injured people all the time, from road traffic accidents, but not like the multiple casualties after a suicide bombing. It is harder to organize. A road traffic accident has other causes. We civilians cause them. In our hearts, we health staff are also afraid that a member of our own family may turn up in the ER. 


This has happened elsewhere in Israel. For the health staff one of the worst suicide bombings was the 
Passover Massacre in Netanya. The bleeding, wounded survivors brought into the hospital were still 
wearing their best clothes. It was hard seeing that. I remember another suicide bombing where a 
mother with her eleven-year-old son and 14-year-old daughter were admitted. The son had actually 
seen the bomber. He was very quiet. The mother was stressed and hysterical, and her daughter tried 
to calm her. We took the family to talk to a psychologist. After three weeks the son developed post 
traumatic stress symptoms. They had also been psychologically and emotionally wounded. 

We have volunteers who come to help us when the multiple casualties are brought in. Some are 
retired doctors, some yeshiva (religious college) students and some are student nurses. After a suicide 
bombing attack, our staff meet to analyze how effective our response has been. For example, we 
learned that we needed to open an early information center for desperate relatives who phone in 
during the first minutes after an attack. 

We also learned that we need to take psychologically traumatized people out of the emergency room to another place in the hospital. Our staff function well as a team. They have not received any special courses, except for psychiatric nurses. Sometimes we have in-house lectures they can attend, like from an Israeli Community Crisis Prevention specialist. 


Our staff can themselves get help from psychiatric hospital staff if they feel the need for trauma 
counselling. So far none of our staff have been killed by suicide bombers, but one nurse lost her brother's wife in a bombing at a bus station. The nurse came to the emergency room searching for her 
sister-in-law, who had already died – but we did not know who she was. The nurse suddenly saw her 
dead sister-in-law. 

Some of our hospital staff are Arabs. Some of them try not to talk about the suicide bombings. Some seem to understand the motivation of the bombers. Some seem to feel some sympathy for them, and you can feel it. They say "Israel doesn't do enough for Palestinians." One time we had the body parts of two suicide bombers who blew themselves up in a bus station, brought into the hospital in five to six sacks. This was the same time as their victims were being admitted. I didn't know how to fit all the bags in the fridge. After that time the hospital no longer accepted suicide bombers' bodies, but sent them directly to the forensic institute." 


Source: Interview with R, a front-line nursing supervisor; October 2003. 

A hospital further south on the coast has experienced similar mass casualty events. A senior Emergency 
Room nurse explains how she prepares the ER for in-coming terror attack victims. 

"Time Zero – My job is to think of Doomsday — and prepare for it."
A senior ER nurse explains, " Our town is so small (80,000 people) that when suicide bombers detonate their explosives the immense blast can be heard all over town. In less than two minutes our 450-bed hospital receives its first phone call. Maybe a private car will pull up outside the ER bearing the first-blood-stained patient. Then the ambulances start arriving. 

On 27 March 2002 when the Park Hotel Passover bombing took place, in which 30 people were killed and 140 wounded, 20 seriously, it took only 12 minutes for the first 22 victims to reach the hospital. I always have to imagine the worst-case scenario, and spread out my 'troops' (staff). We call the time 
we hear there has been a bombing "time zero". From that instant there is a slight lull until the influx 
of terror victims. 

If you want to save lives you need a common Protocol, because you have to work so fast that nothing should be based on memory. I make the first phone call, which simultaneously reaches three people. I have heard people talk about the important 'golden hour' they may have to prepare for reception of victims in ER. But, we don't have an hour – we only have a 'golden minute'. 


We begin emptying the ER. I call staff from all over the hospital, and even from their homes. If surgeons are operating they finish the operation, but non-emergency operations have to be rescheduled to later. Staff are already organized into teams, and they know what to do. Some open pre-prepared packs containing intravenous fluids. Some take blood pressure of incoming patients.


If you want to save lives you have to have a common protocol, which also extends beyond the hospital 
walls. In our system we have a common protocol used by the hospital, the Magen David Adom (MDA) 
and the Home Front. We coordinate with the Ministry of Health, the ER, the Home Front, and the MDA. We are in reality a community hospital, without a resident vascular surgeon, or neurological surgeon. We work together, each one knowing what needs to be done quickly. Health staff have to carry out their duties like robots, but inside they may be asking, 'What if my husband is the next one carried in?' Or, 'Where are my children – why haven't they called me on their cell-phones?' 


Some in-coming patients after a suicide bombing may be white in appearance, and apparently otherwise unharmed. But this can be like having calm on the outside, but a volcano inside. Blast victims may have hardly any blood pressure. Such injuries are caused by the blast bouncing off walls and the sides of buses. Blood vessels may have burst - but there may be few outward signs. Damage control surgery is carried out. Victims with other severe injuries may even fare better than blast victims. I remember a young man who lost a leg and an arm in a grenade attack and who bled profusely. But he is still alive today. It can be different for blast victims. 


We photograph all terror victims and give them an identity number. We have to do that because sometimes the face of a person is too disfigured to be recognizable. We may, in such cases also have 
to photograph their jewellery, or even their boots. We have an information centre set up for the public. 

One time five families all claimed one victim belonged to them. What to do? I told them all gently to go and bring a photo back of their missing loved one. We reduced the possibility of identification to two. Then one got a phone call – they had found their girl. This left one family. I asked for a family representative and talked to him to 5-10 minutes to prepare him to see his dead family member. I showed him a small part of what was left of her face. He recognized her. 


We also have to prepare for chemical terror attack. If this happens, 90% of the poison is on the clothes. We prepare for people to disrobe, to be washed and disinfected, and if they were unconscious we prepare to cut off their clothes. We can open 20 shower heads at one time, situated outside of the 
hospital. Victims cannot go directly into ER or they could contaminate and poison the staff, who could 
not then be able to attend to them. Poisons of this kind can affect the eyes, intestinal tract, and urinary 
tract. 


We have annual training for our staff. We carry out drills, walking people through the steps and making every minute count. Outside the hospital, painted on the ground, are three lines. The red line is what directs the entry of severely injured patients, blue is for children, yellow for those with medium injuries green for mild injuries and white for those with conventional plus unconventional injuries. 

In the emergency room all beds have first aid equipment ready to use. All patients routinely receive pain control measures, blood if required, tetanus immunization, anti hepatitis B vaccine, and warm intravenous fluids if they require them. After the Dolphinarium bombing where the suicide bomber was found to be a carrier of hepatitis B, this procedure has become standard. 


Responsible overall for the functioning of emergency services in hospitals is a special body in the 
Ministry of Health. They know, for example, how many hospital beds there are for patients with 
burns. Radio and TV stations report the bombings within minutes. We have pre-printed medicine 
dosages as 'stick-ons' to patient notes to save time. Our emergency room nurses have to understand 
the protocol, believe in themselves and have confidence to take responsibility. 

We have special laminated 'Protocol cards" which they carry, and which enables them to carry out special procedures, like giving intravenous fluids to patients over ten years of age, which is normally done by doctors. 


Our staff wear special vests with their professional identities printed in large letters. Then it is clear 
who is who, amid the crowds in the emergency room. Sometimes we stabilize patients then transfer 
them for definitive care. The essence of our system is to provide quality care to victims in minutes, or 
when they come later. After a shopping mall bombing we had 114 admissions – and our E.R. only has 
normally 27 beds. In the Park Hotel Passover bombing 22 severely injured people arrived in the 
emergency room within 12 minutes. Then the other survivors were brought in. That night 29 people 
died. One of our nurses died in a suicide bombing. Others have had near misses.

 
Our staff elect to serve in the emergency room. We don't have the luxury of operating our system like 
a daily routine. We have to respond instantly in order to get good results. We have to harmonize things. We need to ensure a good survival rate for the first incoming victims. Since the year 2000 we have received around 800 victims of suicide bombings, of which around 350 were children. After a bombing we de-brief with our staff. Sometimes the stress can make them short-tempered, or they call in sick, or have sleep disturbances. They need personalized de-briefings. 

Terrorism has in mind to inculcate fear and death, to neutralize life-savers. We try to put a smile on people's faces. Our staff are always striving for excellence. They say 'how can we do what we do even better?" Terror is not the private lot of Israel. Without a disaster medicine system in place other countries will find it harder to save lives. I hope people can learn from our system how to adapt it for their own needs. They need to do it today." We have had a 20-year period in which these things have had to be learned. We are 15 years ahead of many hospitals worldwide as far as rapid response in terror attack is concerned. 


Source: Interview with L, Senior Nurse in charge of Emergency Room, 15 January 2004.

 


THE CONTRIBUTION OF TRAUMA CENTRES TO SURVIVAL 

"The trauma chain of treatment comprises several phases. The first is the pre-hospital phase, where care is afforded by non-professional bystanders and by professional emergency medical service teams. The hospital phase includes the admitting area, the imaging and laboratory services, the operating rooms, the intensive care unit, and the department to which the patient is transferred. The final phase is discharge, which should include rehabilitation care... The trauma system in Israel has travelled a long road to create an appropriate structure and process, by establishing the criteria as well as adopting guidelines offered by the American College of Surgeons with minor necessary modifications... There are different accounts in the literature regarding the relationship between mortality and the existence of trauma centres, although most emphasize the contribution of trauma centres to survival" (Shapira 2002). 

Hospital-based trauma units have an inlet of injured patients from the community, and ideally require an outlet to the community and to some form of supportive rehabilitation system, either an inpatient or outpatient setting. Insurance coverage and reimbursement methods will influence both the length of stay in a tertiary centre and accessibility to rehabilitation and medical follow-up. 


4.9 TERROR RELATED INJURIES IN CHILDREN ARE MORE SEVERE 


An article in 2003 observed: "In the past two years hundreds of Israeli children have been wounded in terror attacks. There is a paucity of data on terror-related trauma in the pediatric population and its effects on the health care system... (A study was carried out) to review the accumulated Israeli experience with medical care to young victims of terrorism and to use the knowledge obtained to contribute to the preparedness of medical personnel for future events... Data on all patients who were hospitalized from 1 October, 2000 to 31 December 2001 for injuries sustained in a terrorist attack were obtained from the Israel National Trauma Registry. The parameters evaluated were patient age, sex, diagnosis, type, mechanism and severity of injury, inter-hospital transfer, stay in intensive care unit, duration of hospitalization, and need for rehabilitation. 


Findings were compared with the general pediatric population hospitalized for non- terror-related trauma 
within the same period... During the study period, 138 children were hospitalized for a terror-related injury and 8,363 for a non-terror-related injury. The study group was significantly older (mean age 12.3 years versus 6.9 years) and sustained proportionately more penetrating injuries... Differences were also noticed in the proportion of internal injuries... open wounds to the head, and critical injuries. The study group showed greater use of intensive care, (longer stay in hospital) and greater need for rehabilitative care... Terror-related injuries are more severe than non-terror-related injuries and increase the demand for acute care in children" (Aharonson-Daniel 2003). 


4.10 MEDICAL INNOVATIONS – BITTERLY LEARNT


The growing Israeli experience of treating victims of suicide bombings is already being shared internationally. 

Fighting amputation to keep the legs of one survivor but leaving metal balls near the spine of another

Fifteen-year-old Adi, was one of the almost 200 casualties brought by ambulance to Hadassah 
Hospital Ein Kerem in Jerusalem on 1 December 2001, after the double suicide bombing in the Ben 
Yehuda pedestrian mall. Both her legs were fractured in a number of places and pierced by shrapnel. 
When her mother located her in the emergency room she was out of life-threatening danger, but there 
was a likelihood that she might lose one or both of her legs. Her mother gave permission for the 
experimental use of an expensive drug that might save Adi's legs. For days the decision on whether to 
amputate hung in the balance. Eventually, as her mother sighed with relief the Head of Trauma told 
her that they would be able to save Adi's legs. 


Eight months later Adi was taking her first hesitant steps. She and her mother praised the doctors as 
veritable miracle workers – 'angels from heaven'. Adi had several follow-up operations. She tried to 
go back to school a couple of times a week for a few hours, but quickly exhausted herself. Eight 
months later she was still having a couple of hours of physical therapy daily. In many other hospitals 
in the world Adi would likely have had both legs amputated. She is one of the many beneficiaries of 
Israeli doctors' unhappily growing experience in treating victims of bombing attacks. In her case, the 
decision to forego amputation was taken after extensive consultations by Hadassah specialists in 
orthopedics, vascular surgery and neurosurgery. Professor Avi Rivkind explained that no single specific lesson or technique was critical to the decision. Rather, he says, 'we were able to draw from our well of experience and knowledge'. 


By contrast, for a 38-year-old mother of four, whose body was punctured by bolts and a ball-bearing 
in a bus bombing, there was a single lesson, bitterly learnt. The metal pieces were lodged both in her 
brain and spinal cord. Conventional medical practice would have been to remove them right away. 
However, experience convinced the neurosurgeon to hold back. A CT scan and angiogram 
(radiological scan of the blood vessels) showed that a ball bearing was dangerously close to, but had 
not punctured, her spinal cord and an important blood vessel nearby. And the ball bearing was not 
causing infection. Assessing that there was only a low probability that the ball bearing could move or 
otherwise cause more damage, and taking into account the risks of surgery, he decided to leave the 
piece of metal where it was, as well as two other pieces of metal in her brain. They took into account, 
based on experience, that attempting to remove them was the more dangerous course of action. Weeks 
later she could recall nothing of the attack, having suffered some memory loss, possibly from the overall trauma, possibly from the metal in her brain. She was unconscious for ten days after the attack. 


Another terror-taught innovation is that angiograms are routinely performed on terror victims, to detect aneurysms (when blood vessels expand due to weakened walls). This can happen where blood vessels are weakened by the bomb blast. Aneurysms in the brain are fatal in 50% of cases. Hadassah is disseminating its grimly learned knowledge to other doctors and surgeons nationally and worldwide, including via journal articles and conferences and to medical students. 'We doctors can do nothing to prevent these attacks' said Professor Rivkind, 'What we can do, what we are doing, is learning as much as we can about their effects to reduce the suffering of the victims.' 


Source: Abramoff, "Medical Lessons Bitterly Learned" The Jerusalem Report, 12 August 2002 

 

4.11 HEPATITIS CARRIERS AND RAT POISON – AS TERROR WEAPONS 


In the summer of 2001, the Health Ministry announced that all survivors of suicide bombing attacks in Israel were to be vaccinated against hepatitis. "This policy was set after the Ministry's infectious disease laboratory found that two suicide bombers were carriers of hepatitis B, and that a passer by who was wounded in the blast had been left with a fragment of the bomber's bone in his own body (the vaccination with hepatitis B was a precautionary measure).. .Any blood-borne disease with a carrier stage, such as hepatitis B and C, and HIV/AIDS could theoretically be passed on to anyone whose skin is penetrated by biological material from a suicide bomber. There is no protective vaccine against hepatitis C and HIV, but the hepatitis B vaccine is safe and effective...The incubation period for hepatitis B is about 6 weeks... Hepatitis B is endemic in the Middle East. About 10% of the Arab population in Israel and the Palestinian territories are carriers, compared with only 1-2% of the Jewish population...All health-related workers – including doctors, nurses, ambulance volunteers and burial staff – who deal with the dead and wounded after terrorist attacks are vaccinated against hepatitis" (Siegal-Itzkovich, 2001). 

Doctors had also been noticing that when they operated on people wounded in suicide bombing attacks, patients often continued to bleed even after being sutured. Eventually, a young medical resident figured out why. The terrorists had filled their bombs with nails, screws, glass shards and pieces of shrapnel, and these had been dipped in rat poison, which acted as an anticoagulant, stopping blood from clotting. Vitamin K was used to control bleeding in wounded terror victims where there was suspicion of rat poison being used by the bombers. A 2005 article on injuries from biological material of suicide bombers (like bone fragments) concluded that such materials may transmit severe, incurable infectious diseases (Eshkol & Katz 2005). 

Israel has always relied on voluntary work to achieve many social objectives. The need for volunteers during the Second Intifada saw an outpouring of volunteers in many fields, particularly in the field of health. 



4.12 HOSPITAL VOLUNTEERS WHO DEMONSTRATE THE SANCTITY OF LIFE 


In the coastal town of Netanya, students from a religious 'yeshiva' (rabbinical academy) have undergone 
training so that they can respond to nearby Laniado Hospital in emergency situations. They are on call 24 
hours a day, seven days a week. The ages of the 150 volunteers range from 18 to 50, and they are regularly drilled under the supervision of hospital staff and the Home Front Command of the Israeli Defence Forces. 


After an attack on 14 June 2002 in a Netanya market place, the hospital told them that with their assistance never before had the surgeries gone so smoothly. 

The doctors and nurses were able to put their entire effort into the surgical procedures, while the trained 
volunteers rushed the blood to the laboratories to be typed, tested for RH factor, labeled them, and raced the blood back to the operating theatres. "In the first 20 minutes after an attack, the volunteers, who have also been trained to assist in taking the injured from the ambulances, filling out forms for identification and classification of injury, and expediting transfer to the correct sections of the hospital for treatment, helped save lives. 

These yeshiva students were recognized by the Commander of the Home Front Command as being the most successful group of volunteers to do these jobs because they were responsive and exacting in 
their methods. Additional training was being considered in 2002. A Rabbi from the Talmudic Academy had 
studied life support in the USA and been a volunteer member of an ambulance corps. Another Rabbi in the 
group recruits students for special hospital assistance in the operating rooms, and those trained by Magen David Adom, to administer CPR in emergency situations, to visit the sick and support family members. He is also in charge of a blood drive, a loan organization for medical equipment and financial assistance for people who require expensive medications. He says "It is our duty to help one another. One of the most important principles of the Torah is the sanctity of life" (Hershnson.S 2002.) 



4.13 THE CHALLENGES OF LONGER-TERM REHABILITATION


"There are three goals in rehabilitation: healing, becoming able and rejoining the community. This includes both the injured person and the whole family". (Hobbs. L et.al. 2002) Some of the wounds, both physical and psychological, caused by the suicide bombers take a long time to heal. The Director of a Rehabilitation Unit in a Jerusalem hospital explains: 

Rehabilitation Takes Time, We Work With Tragedy
When a suicide bomber detonated at the Ben Yehuda pedestrian mall in Jerusalem a 24-year-old 
Israeli civilian received serious brain injuries. For one year, he was treated at the Rehabilitation Unit 
at the Hadassah Mount Scopus Hospital. By the second year, he was still not speaking, and totally 
dependent on his caregivers. By the third year, he had gradually begun to improve. Today, he is 
walking 10-20 metres with help.

 
Since September 2000 over 70 patients aged 14-62, who were survivors of suicide bombings mostly in 
Jerusalem, had been treated in the Rehabilitation Unit. By October 2004 there were 68 inpatients and 
72 outpatients attending for day-care. Among the earliest survivors of suicide bombings being treated 
was a woman from the Park Hotel Passover Massacre in the coastal town of Netanya in 2003 in 
which 30 civilians died and 140 were wounded. She received spinal cord injuries which rendered her 
paraplegic. So traumatized was she that she once attempted suicide. 


In October 2004 the Unit inpatients included 16 with brain injury, 5 with spinal cord injury, others 
with multiple trauma injuries, extensive burns, fractured limbs, and peripheral nerve injuries. One 
survivor from the suicide bombing in Jerusalem's Ben Yehuda Pedestrian Mall was a fourteen-year old 
boy who had been celebrating his birthday. He received rehabilitation care for one and a half 
years. Now he has started to study again. Another young survivor was a fourteen-year-old girl who 
had serious leg injuries. By 2004 she was walking on crutches. 

The majority of patients admitted from suicide bombing attacks had injuries to blood vessels, fractured bones, and shrapnel, nails and screws embedded in their brains. The average length of admission in the Rehabilitation unit was 2-3 months. The Unit has acquired a new 'robot'-assisted computerized device to rehabilitate patients and to help them walk again after incomplete spinal cord injuries, or strokes. Body support is put on the legs, and the system has a psychological effect similar to walking. The system was developed originally in Germany and Switzerland. 

The Unit is also using a 'virtual reality' computerized treatment for those with serious brain injuries. Patients are placed in different situations, such as making a trip to a supermarket alone. Some treatments are paid for by Terror Victim's Organizations and some by the national Social Security system. Some patients receive treatment 2-3 times a week from 8 am to 4 pm, assisted by physiotherapists, speech therapists, social workers, and computer operators. 


The Unit staff of 70 comprises 8 physicians, 25 nurses, 8 occupational therapists, 3 speech therapists, 
and 2 psychologists. In addition there are five volunteers, usually over 50 years of age, who work with 
staff in rehabilitating patients from 2-4 pm twice a week. For some volunteers it is part of their army 
service. Volunteers take patients for therapy, help feed them, and help to put them back into bed. 
Rehabilitation medicine is a five-year medical specialty. Nurses opt to choose rehabilitation as a 
specialty. There are Israeli Arabs on the hospital staff. Sometimes this is difficult for bombing 
survivors. They may initially be reluctant to have Arab staff treat them. Some Arab staff feel badly 
about these kinds of situations but usually 'understand' why they occur. Hospital staff organize 
dialogues between patients, their families and Arab staff. It is rare for a patient and their family to 
finally refuse to accept Arab staff treating them. 


Rehabilitation takes time, sometimes a long time. 'We work with tragedy,' said the Unit Director, 'not 
only for individuals but also for their families. Rehabilitation is often for a life-time.' One beautiful 
17-year-old Russian girl wounded in a bus bombing had shrapnel in her elbow, and serious injuries 
to her face and eyes. Two years later she had improved sufficiently to live independently with a friend 
in Jerusalem. Another girl, injured in the Hebrew University Cafeteria attack on 31 July 2002 that killed 
nine civilians and wounded eighty-five, requires professional care and has had to live in a special 
home since the attack. 


Sources: Interview with Director of Rehabilitation Unit Hadassah Hospital Mount Scopus 
Jerusalem 28 October 2004. 

 

The last section of this chapter looks briefly at ways in which the Israeli health system has been abused 
during the Intifada. 



4.14 TERRORISTS HAVE ABUSED THE HEALTH SYSTEM 


Israeli soldiers at roadblocks carry out security searches of Palestinian ambulances and vehicles carrying 
Palestinian patients, women in the process of giving birth and medical teams. Such searches may cause a 
delay in their transfer. Such thorough searches are the result of past cases of the misuse of ambulances to smuggle terrorists or weapons or the disguising of terrorists as patients. As a result of warnings that a terror attack at the entrance of an Israeli hospital is being planned and that it will be carried out by a Palestinian ambulance or a stolen Israeli ambulance, Israeli hospitals have had to increase their caution whenever any Palestinian ambulance or Israeli ambulance nears an Israeli emergency room. 

In 2005 a doctor in MDA ambulances reported that every Israeli ambulance is searched every time it enters an Israeli hospital. Stringent security measures must be conducted before an ambulance is permitted to approach the emergency room area and before its patients, escorts and medical team are permitted to enter the emergency room (World Health Organization, 2003). 


During the current Intifada, Israeli hospitals have continued to provide medical care to Palestinian patients without interruption. In the period between April 2001 and April 2002, some 11,000 patients from the West Bank and Gaza were treated in Israeli hospitals. Another 10,000 patients from Palestinian areas were treated in Israeli hospitals between April 2002 and April 2003; a quarter of these patients were referred for hospitalization and three quarters were referred for ambulatory services including hospitalization in day-care units, consultations at outpatient clinics, and sophisticated diagnostic and investigatory procedures and laboratory tests of a wide variety. The Palestinian Authority stopped payments to Israeli hospitals, leaving an accumulated debt of around USD 4 million. In spite of the large debt, Israeli hospitals continue to admit Palestinian patients and casualties for treatment without political considerations, delays or restrictions (World Health Organization 2003). 




4.15 ATTACKS ON ISRAELI AMBULANCES 


The MDA and Palestinian Red Crescent continue to cooperate in emergencies and in evacuating the 
wounded. Israeli trauma units and emergency medical departments continue to treat Palestinians. And this in spite of the fact that, very often, MDA ambulances arriving to treat the injured in areas of confrontation have been attacked. 

During the first year of the Intifada, 71 Israeli ambulances were damaged by terrorists or rioters. There have been several proven cases of misuse of Palestinian ambulances to transport ammunition or explosive belts, or to transfer terrorists. The Israeli Ministry of Health and relevant authorities allow the 
admission of medicines, medical equipment and ambulances as donations to the Palestinians from European and Arab countries and international organizations. 

In 2002 the Israel Medical Association stated that it "unequivocally denounces the employment of terrorism in general, and the use of human bombs, whose sole objective is the indiscriminate killing of innocent civilians and the spread of fear among the general public, in particular. (It) expresses deep sorrow at the loss of life and suffering caused to both peoples in the course of the present conflict and is concerned over the spread of the conflict to innocent civilians in large population centers... (It) condemns the immoral use of ambulances for purposes of terrorism and sabotage... Our soldiers will continue to face difficult dilemmas every time a Palestinian Red Crescent ambulance speeds towards them. Our physicians will continue to face the emotional difficulty of treating the mangled bodies of children caught in a suicide bombing while doing their utmost to ensure the quick and optimal access of Palestinian civilians to necessary care in Israel. We will all continue to dream of the day when an Israeli can go to the pizza store, and a Palestinian can reach his doctor without it being an international event. We will all continue to dream of peace" ( Blachar. Y 2002).

 
International evidence may continue to point to the crumbling and struggling nature of the Palestinian health infrastructure, but while suicide bombers continue to slaughter Israeli civilians, it seems ironic that their taxes should be involved in providing health care for those who send the bombers. 

Selected additional information for the 2009 edition. 

From October 2000- January 2004, 577 victims of suicide bombings were admitted to the Hadassah-Hebrew University Medical Center. "A single bomber carrying a handbag or belt containing multiple metal objects and explosives carried out most of the attacks. As a result, many of the victims suffered massive tissue destruction in addition to conventional blast injuries." (Ad-El D. D. et al. 2006). 

Of a total of 1,155 patients injured by explosions between 2000-2004, nearly 30% suffered severe to critical injuries. Triage has changed as metal parts contained in bombs penetrate the human body with great force and may result in tiny entry wounds easily concealed by hair, clothes etc. "Specific injuries will require tailored approaches, an open mind, and close collaboration and cooperation between trauma surgeons to share experience, opinions and ideas". (Aharonson-Daniel L. et al. , 2006). 

Most patients operated on within the first 2 hours require multidisclipinary surgical teams (Einav S. et al. 2006.) 

Terror attacks may produce several modes of severe penetrating injuries causing high-grade open fractures of long bones. (Weil Y.A et al. 2007). 

During a two year period in Israel which saw 41 mass-casualty events, 160 children were hospitalized with injuries mostly caused by blasts and penetration of foreign objects. Sixty-five percent of children had multiple injuries. Terrorism-related injuries in children are severe and increase the demand for acute care. (Waisman Y et al. 2003). 

The suicidal bus bombing of French nationals in Pakistan and subsequent hospital admissions highlighted 
treatment in the context of the limited medical resources of a developing nation. (Zafar H. et al. 2005).

Terrorist bombings inflict injury of a distinctly different pattern than other means of trauma. The simultaneous combination of different injury mechanisms in explosions results in a multidimensional injury pattern and a complicated clinical course. Hospital preparedness and medical team awareness of the unique nature of the injuries are mandatory for improving the outcomes of these patients. (Kluger Y et al., 2004). 

At 7:39 on 11 March 2004, 10 terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing 177 people instantly and injuring more than 2000. There were 14 subsequent in-hospital deaths, bringing the ultimate death toll to 191. Of 243 in-patients patients 52% suffered head trauma. (de Ceballos J.P et al. 2005).

 
Two mass-casualty terrorist attacks had occurred in Istanbul, Turkey in November 2003 when improvised 
explosive devices in trucks were detonated outside the Neve Shalom and Beth Israel synagogues killing 30 people and wounding around 300. Five days later similar trucks were detonated outside the Hong Kong Shanghai Banking Corporation headquarters and the British Consulate killing 33 and wounding around 750 others. 

Terrorist attacks in Southeast Asia were almost nonexistent until the 2002 Bali bomb blast. There were further attacks in Jakarta in 2003 and Bali in 2005. A burns disaster plan was recommended and use of a health care team concept " to ensure that the sudden onset of a crisis situation at an unexpected time does not overwhelm hospital manpower and resources". (Chim H et al. 2007).

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