Significance of a Level-2,“Selective, Secondary Evacuation” Hospital during a Peripheral Town Terrorist Attack

Abstract

Introduction:Mass-casualty incidents (MCIs) can occur outside of major metropolitan areas. In such circumstances, the nearest hospital seldom is a Level-1 Trauma Center. Moreover, emergency medical services (EMS) capabilities in such areas tend to be limited, which may compromise prehospital care and evacuation speed. The objective of this study was to extract lessons learned from the medical response to a terrorist event that occurred in the marketplace of a small Israeli town on 26 October 2005. The lessons pertain to the management of primary and secondary evacuation and the operational practices by the only hospital in the town, which is designated as a Level-2 Trauma Center.Methods:Data were collected during the event by Home Front Command Medical Department personnel. After the event, formal and informal debriefings were conducted with emergency medical services personnel, the hospitals involved, and the Ministry of Health.The medical response components, interactions (mainly primary triage and secondary distribution), and the principal outcomes were analyzed.The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology.Results:The suicide bomber and four victims died at the scene, and two severely injured patients later died in the hospital. A total of 58 wounded persons were evacuated, including eight severely injured, two moderately injured, and 48 mildly injured. Forty-nine of the wounded arrived to the nearby Hillel Yafe Hospital, including all eight of the severely injured victims, the two moderately injured, and 39 of the mildly injured. Most of the mildly injured victims were evacuated in private cars by bystanders.Five other area hospitals were alerted, three of which primarily received the mildly injured victims. Twodistant, Level-1 Trauma Centers also were alerted; each received one severely injured patient from Hillel Yafe Hospital during the secondary distribution process.Emergency medical services personnel were able to treat and evacuate all severely and moderately injured patients within 17 minutes of the explosion. A total of 12 of the 21 ambulances arriving on-scene within the first 20 minutes were staffed by emergency medical services volunteers or off-duty workers.Conclusion:When a mass-casualty incident occurs in a small town that is in the vicinity of a Level-2 Trauma Center, and located a >40 minute drive from Level-1 Trauma Centers, the Level-2 Trauma Center is a critical component in medical management of the event. All severely and moderately injured patients initially should be evacuated to the Level-2 Trauma Center, and given advanced, hospital-based resuscitation. The patients needing care beyond the capabilities of this facility should be distributed secondarily to Level-1 Trauma Centers.To alleviate the burden placed on the local hospital, some of the mildly injured victims can be evacuated primarily to more distant hospitals.The ability to control the flow of mildly injured patients is limitedby the large percentage of them arriving by private cars. The availability of emergency medical services in small towns can be augmented significantly by enrolling off-duty emergency medical services workers and volunteers to the rescue effort. Level-2 hospitals in small towns should be prepared and drilled to operate in a “selective evacuation” mode during mass-casualty incidents.

A single, improvised "Kassam" rocket explosion can cause a mass casualty incident: a potential threat for future international terrorism?

“…Such a structure demands efficient information sharing in real time. Hospital notification was delayed (31 minutes) compared with MCI that have occurred in Israel in the past 3 years, when it took between one and 11 minutes from the explosion to alert the hospitals 6 8 9 13 14. Better coordination between participating operational centres could ensure better results.…”

“…This may be caused by different bomb build and the spread of the soldiers over a larger area than the crowds in open market places, malls or hotels in which suicide bombers detonated themselves 6 – 8 10 – 11 13. In three suicide bomber explosions the prevalence of moderately and severely injured casualties was between 3% and 10%, probably because the suicide bomber was discovered by the security forces before he could approach the crowd and detonated himself far away from it 9 12 15…”

Systematic literature review of templates for reporting prehospital major incident medical management

“…One has not been used in other publications 32. DISAST-CIR24–30 35 is routinely used to report each mass casualty incident in the registry of the Israeli Defence Force Home Front and Ministry of Health. Guidelines for reporting health crises and critical health events37 have been used to report international disasters, but these publications were not available as official publications at the time of correspondence with the authors.…”

Indoor fire in a nursing home: evaluation of the medical response to a mass casualty incident based on a standardized protocol

“…A systematic review compared different available protocols of standardized reporting [14] and we chose this protocol because it was developed to report real incidents, has a practical approach, is freely available, has been published [1,15,16] and has been used previously [10,17,18]. Other protocols are more extensive but less practical, such as the Utstein template [19], the DISAST-CIR, a protocol used by the Israeli Defense Force Home Front and Ministry of Health [20][21][22][23][24][25][26][27][28] and two unused protocols [29,30]. None of these protocols have been tested on Internal and external validity [14].…”