Featured in Foreign Exchange, a supplement to EMS World Magazine, July 2011
One of the scariest aspects of Eric Rudolph's terrorism was his use of secondary bombs. The second explosive he planted outside an Atlanta gay bar in 1997 was found and detonated harmlessly by police responding to the first, but the one he left at a local abortion clinic a month earlier exploded, injuring responders and a reporter.
When you face lots of terrorism, EMS safety involves more than ambulance crashes and needlesticks. Secondary bombs are rare, but their possibility necessitates fast, efficient and well-coordinated incident scenes. That's what Magen David Adom prioritizes.
The Israeli national ambulance service operates more than 100 stations throughout the country, across 11 regions. In addition to providing prehospital care and instruction, it is the country's national blood service and an auxiliary arm of the Israel Defense Forces. With 1,545 employees and 11,450 volunteers, it answered an estimated 557,000 calls in 2010. The MDA fleet includes ALS and BLS/ILS ambulances, first-responder motorcycles, multicasualty response vehicles and an air-med unit.
Each of those 11 regions has a dispatch center, and there's a national dispatch center in suburban Tel Aviv. Access is through the emergency number 1-0-1. Police and fire are separate (dial 1-0-0 and 1-0-2, respectively) but communicate closely. If a regional dispatch center doesn't pick up a call after four rings, it goes to the national center, which answers and sends it back. The national center can also assume a regional center's duties, and in peak hours calls may be answered at either place. Normal staffing is two operators per region, with supervisors to monitor the big picture. They work to send ambulances within two minutes of calls. Funding comes from patients and their HMOs (their HMO pays if a patient is hospitalized, but patients are charged if they call and aren't, except in vehicle accidents), services at public events, and donations. The American Friends of Magen David Adom contributes more than $20 million a year.
One of the most remarkable aspects of MDA is its support from the citizens it serves in time and labor. The service has around seven times as many volunteers as paid employees, and its volunteers contribute more than a million man-hours a year on crews, at stations or wherever else needed.
Fifteen is the minimum age to volunteer and enroll in MDA's basic first aid course, and about half of volunteers are 15-18. Others participate after their mandatory national service, which begins upon high school graduation or their 18th birthday. Service lasts two years for women, three for men. Volunteers are particularly important as extra hands in responding to multicasualty incidents.
EMS in Israel faces the same threats as everyone else--beyond the routine stuff, there are MCIs large and larger, CBRNE threats, disasters and war--and is a major part of an integrated response to all of them. The potential players are many: hospitals, police and fire, the Ministry of Health and National Emergency Management Authority, environmental protection, local authorities and healthcare, and the IDF. That puts a premium on cooperation and means not only joint training and exercises, but integrated debriefings and lessons learned.
"EMS is truly an equal partner and leader in the healthcare system there," says Schmider, chair of NASEMSO's Domestic Preparedness Committee. "Here it sometimes seems EMS is the third wheel in the national system. I think they distinctly recognize the difference between EMS and police and fire, and the roles that each play."
On scenes, seconds count. The biggest difference between American and Israeli prehospital operations is the latter's emphasis on quick triage, clearing and resolution of even large and complex scenes. There's no staging, no lengthy assessment or decon processes--just a precisely choreographed "scoop and play" designed to get patients stabilized and gone.