Yehezkel Levi

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.

Response of Thai hospitals to the tsunami disaster.

The disaster caused by the Tsunami of 26 December 2004 was one of the worst that medical systems have faced. The aim of this study was to learn about the medical response of the Thai hospitals to this disaster and to establish guidelines that will help hospitals prepare for future disasters. The Israeli Defense Forces (IDF) Home Front Command (HFC) Medical Department sent a research delegation to Thai hospitals to study: (1) pre-event hospital preparedness; (2) patient evacuation and triage; (3) personnel and equipment reinforcement; (4) modes used for alarm and recruitment of hospital personnel; (5) internal reorganization of hospitals; and (6) admission, discharge, and secondary transfer (forward management) of patients. Thai hospitals were prepared for and drilled for a general mass casualty incident (MCI) involving up to 50 casualties. However, a control system to measure the success of these drills was not identified, and Thai hospitals were not prepared to deal with the unique aspects of a tsunami or to receive thousands of victims. Modes of operation differed between provinces. In Phang Nga and Krabi, many patients were treated in the field. In Phuket, most patients were evacuated early to secondary (district) and tertiary (provincial) hospitals. Hospitals recalled staff rapidly and organized the emergency department for patient triage, treatment, and transfer if needed. Although preparedness was deficient, hospital systems performed well. Disaster management should focus on field-based first aid and triage, and rapid evacuation to secondary hospitals. Additionally, disaster management should reinforce and rely on the existing and well-trusted medical system.

Primary Triage, Evacuation Priorities, and Rapid Primary Distribution between Adjacent Hospitals—Lessons Learned from a Suicide Bomber Attack in Downtown Tel-Aviv

INTRODUCTION Terrorist attacks have occurred in Tel-Aviv that have caused mass-casualties. The objective of this study was to draw lessons from the medical response to an event that occurred on 19 January 2006, near the central bus station, Tel-Aviv, Israel. The lessons pertain to the management of primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals and the operational mode of the participating hospitals during the event. METHODS Data were collected in formal debriefings both during and after the event. Data were analyzed to learn about medical response components, interactions, and main outcomes. The event is described according to Disastrous Incidents Systematic AnalysiS Through-Components, Interactions and Results (DISAST-CIR) methodology. RESULTS A total of 38 wounded were evacuated from the scene, including one severely injured, two moderately injured, and 35 mildly injured. The severe casualty was the first to be evacuated 14 minutes after the explosion. All of the casualties were evacuated from the scene within 29 minutes. Patients were distributed between three adjacent hospitals including one non-Level-1 Trauma Center that received mild casualties. Twenty were evacuated to the nearby, Level-1 Sourasky Medical Center, including the only severely injured patient. Nine mildly injured patients were evacuated to the Sheba Medical Center and nine to Wolfson Hospital, a non-Level-1 Trauma Center hospital. All the receiving hospitals were operated according to the mass-casualty incident doctrine. CONCLUSIONS When a mass-casualty incident occurs in the vicinity of more than one hospital, primary triage, evacuation priority decision-making, and rapid distribution of casualties between all of the adjacent hospitals enables efficient and effective containment of the event.

Physician versus Paramedic in the Setting of Ground Forces Operations: Are They Interchangeable?

BACKGROUND The setting of military ground force operations can be demanding and requires a matched medical assistance plan. A major consideration is the type of medical caregiver that is assigned to the mission. We studied the similarities, differences, advantages, and disadvantages of physicians versus paramedics in this scenario. METHODS We interviewed 20 ground force physicians, highly experienced in this setting. We summarized their responses and formulated quantitative decision-making tables regarding two sorts of missions: a long-duration mission, far from friendly definitive care, and a short-duration mission, close to friendly hospitals. RESULTS The major areas in which physicians and paramedics differ, pertinent to a ground force operation are: formal education, on-job training, knowledge base, ability to treat a wide variety of medical conditions, ability to perform manual lifesaving procedures, social and moral impact, availability, physical fitness, combat skills, and cost. Of a maximum score of 100 points, for a long-term mission a physician scores 77.7 points while a paramedic scores 63.6 points. The scores for a short-term mission are 72.7 and 67.9, respectively. DISCUSSION Physicians and paramedics are distinct groups of medical caregivers and this is also true for the setting of ground force operations. They are not interchangeable. Our data show that a physician has a relative advantage over a paramedic, especially in long-term missions, far from friendly facilities. CONCLUSION A physician is the first choice for all kinds of military ground force missions while a paramedic can be a reasonable substitute for missions of short duration, close to definitive care.

Israeli Defense Forces Medical Corps humanitarian mission for Kosovo's refugees.

In April 1999, during the crisis in Kosovo, the Israeli government launched a medical, field hospital in order to provide humanitarian aid to the Albanian refugees that fled from their homes in Kosovo. This facility was set up by the Medical Corps of the Israeli Defense Forces, in a refugee camp located in Northern Macedonia. During the 16 days during which the hospital functioned, the medical staff treated 1,560 patients and hospitalized >100. The field hospital served as a referral center for all of the other primary clinics that were hastily erected in the camp and its surroundings. This communication elaborates on the various aspects of the humanitarian medical aid that were provided by this medical facility and the conclusions that learned from such a mission.

Establishing a high level of knowledge regarding bioterrorist threats in emergency department physicians: Methodology and the results of a national bio-preparedness project

INTRODUCTION Medical systems worldwide are facing the new threat of morbidity associated with the deliberate dispersal of microbiological agents by terrorists. Rapid diagnosis and containment of this type of unannounced attack is based on the knowledge and capabilities of medical staff. In 2004, the knowledge of emergency department physicians of anthrax was tested. The average test score was 58%. Consequently, a national project on bioterrorism preparedness was developed. The aim of this article is to present the project in which medical knowledge was enhanced regarding a variety of bioterrorist threats, including cutaneous and pulmonary anthrax, botulinum, and smallpox. METHODS In 2005, military physicians and experts on bioterrorism conducted special seminars and lectures for the staff of the hospital emergency department and internal medicine wards. Later, emergency department senior physicians were drilled using one of the scenarios. RESULTS Twenty-nine lectures and 29 drills were performed in 2005. The average drill score was 81.7%. The average score of physicians who attended the lecture was 86%, while those who did not attend the lectures averaged 78.3% (NS). CONCLUSIONS Emergency department physicians were found to be highly knowledgeable in nearly all medical and logistical aspects of the response to different bioterrorist threats. Intensive and versatile preparedness modalities, such as lectures, drills, and posters, given to a carefully selected group of clinicians, can increase their knowledge, and hopefully improve their response to a bioterrorist attack.

Screening for Common Respiratory Diseases among Israeli Adolescents

BACKGROUND Respiratory diseases are responsible for a significant proportion of serious morbidity among adolescents. There are few reports on the prevalence of common respiratory disorders in this population. The previous studies focused on specific diseases and screened relatively small samples. OBJECTIVE To define the prevalence of different common respiratory disorders among 17-year-old Israeli conscripts. DESIGN All 17-year-old Israeli nationals are obliged by law to appear at the Israel Defense Forces recruiting office for medical examination. Respiratory disease specialists evaluated and classified nominees with suspected respiratory disorders. RESULTS A high prevalence of respiratory morbidity was found among 94,805 17-year-old conscripts (61.5% male, 39.5% female). The most prevalent diagnosis was asthma (in 8% of male and 6.8% of female subjects). Fifty-five per cent of the asthma patients suffered from moderate to severe disease. The prevalence of chronic obstructive pulmonary disease was 0.03% for the male and 0.01% for the female subjects. A difference in morbidity patterns between male and female adolescents was noted, particularly in the prevalence of chest deformation and spontaneous pneumothorax. CONCLUSIONS The most prevalent respiratory disorder among 17-year-old Israeli conscripts was asthma. One-half of the asthma patients in this study suffered from moderate to severe disease. The prevalence of other respiratory disorders was much lower.

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.

Allergic contact dermatitis among maintenance and clerical workers in a military population

Contact dermatitis is one of the leading causes of occupational morbidity and absenteeism and has become an intolerable cause of missed workdays and health problems in the Israeli military. The aim of this study was to determine the rate of contact dermatitis in maintenance and clerical workers, the common allergens causing it, and the background of atopy in the subjects in order to design preventive measures. Medical records of all recruits to the Israel Defense Forces from 2000 to 2003 were reviewed for contact dermatitis. The 102 cases found were further assessed for job assignment, atopic background, and allergens. Of the 102 cases, 60 had irritant contact dermatitis and 42 had allergic contact dermatitis, of which 33 (78.6%) were maintenance workers, mainly mechanics. 13 soldiers in the maintenance job category (39%) and 2 soldiers in the clerical group (22.2%) had atopic background. There were 55 positive reactions in patch tests, 25 of them to oil and cooling fluids, with 14.5% attributed to methylchloroisothiazolinone/methylisothiazolinone) (Kathon CG). Atopy was found to be a risk factor for allergic contact dermatitis in our study and should be screened for in job assignment procedures in the military. Oil and greases contain significant allergens, especially their preservatives.