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.
This is not only due to possible secondary devices, but because Jewish law requires collection of all body fragments for burial before they're lost or destroyed (challenging in some bomb attacks) and because Israel puts a premium on a fast return to normalcy--denying terrorists the victory of disruption. During the March Jerusalem bus stop bombing, the first patient was removed nine minutes after the first call for help. "It's a completely different approach than we teach here," says Wingrove, "where we wait to secure the scene before any EMS personnel go in."
"A lot of our response is about triage, setting up all this stuff, controlling the scene, getting transportation and all of these things there," adds DeTienne. "They really emphasize, not just with EMS but for all the responders, clearing the scene quickly and getting back to normal. That's part of the resiliency. Like the MDA folks said, ‘You killed some of us, but you didn't stop us.' That's the mind-set."
Suicide bombers represent a unique and lethal threat that really has not yet made its way to the U.S. In Israel their attacks are rare but deadly: Between September 29, 2000, and December 29, 2007, they accounted for just 155 of 30,595 tallied attacks--half of one percent--but 525 of those attacks' 1,065 resulting deaths, or 49%. The suicide bomber is in effect a human smart bomb that can choose the time and place of its own detonation.
From 2002–05, MDA averaged a 4.6-minute first-ambulance response to suicide bombings, and 11.5 minutes to first evacuation. Keeping things moving requires keeping things simple. Crews arrive at scenes and deliver primary reports, then establish medical command, conduct triage and immediate lifesaving procedures, and then load and get going as quickly as further resources permit. Regional dispatch, upon identifying a scenario, activates its relevant protocol/checklist, notifies hospitals and ensures appropriate distribution of casualties. As more responders arrive, an overall incident commander is named (police always in charge), EMS command shifts to higher-ranking personnel, and scenes can be divided into sectors.
Reinforcements at major-incident scenes come not only from first responders and volunteers, but from off-duty crews (some keep ambulances at their homes) and regional mutual aid. Bystanders are also frequently incorporated under the theory that it's better to utilize them than combat them.
Common injuries in suicide bombing events include blast and burn injuries and blunt and penetrating trauma. Initial triage is focused only on immediate life threats--"the reds and the rest." Lifesaving procedures performed on scene, needed by only 3%-5% of casualties, include airway control/intubation and hemorrhage control. Fluids and additional care are given en route.
Other measures help keep up the pace. No one marks sectors; instead they use landmarks to identify them. There's no scene decontamination; patients are deconned at the ED. After events, crews undergo medical and operational debriefings where they examine what went right, what went wrong, and what else they could do on such scenes. Critical incident stress debriefing is also offered.
The U.S. Perspective
Those versed in ICS and U.S. major incident scenes will find much of the Israeli response structure familiar. Details differ, though, starting with the emphasis on speed. "Most of our mass-casualty scenes are crime scenes and can last for hours," says Stein-Spencer. "We truly don't get back to normal as quickly as we should."
"For us it's a lot more circumstance-driven," adds Charles Stewart, first deputy fire commissioner for the Chicago Fire Department. "We also work to clear the scene and get in and get out as quickly as possible, but it depends on the circumstances. I think there's a message to it [with the Israelis]: ‘We're not being consumed by these attacks. We're getting back to normal as quickly as possible.'"
Many of the U.S. delegation expressed an interest in working to expedite their own systems' scene times.
"Here in Montana, with our extremes in weather, we really shouldn't be on scenes too long anyway, so why don't we just function that way all the time, whether it's a great day or bad?" asks DeTienne. "We may have two or three ambulances at a scene and be waiting for more that are 50 miles away, but how quickly can we take any severely injured and get them away from the scene to the hospital? Because that's where we're going to save them."
"Treating mass-casualty patients is the same pretty much everywhere," says McCaughan. "They're much more expeditious with the entire process because they have to be. But I think if we step back and consider recent events [i.e., the death of Osama bin Laden, his ongoing plans and the possibility of reprisals by his followers], maybe there's more of a need for us to think in a similar fashion."
Then there's the issue of hands on scene. A big lesson we took from 9/11 was personnel accountability--knowing exactly who's on the team and what they're doing. The Israeli approach is, if not the opposite, at least more flexible, encouraging the use of bystanders when help is needed.
"In a nation that's prepared, that's a wise move," says Wingrove. "Since they start emergency preparation with their citizens when they're young, it's a good fit for them. But I don't think we're at the same level of preparedness."
Doing decontaminations at hospitals is another difference. Israeli hospitals have the resources to do this and practice it scrupulously, which allows EMS teams to merely strip contaminated patients, give them basic cover, and take them away.
"That's a pretty neat concept," says Schmider. "We could certainly clear a scene more easily that way." And hospitals need the capability anyway, as contaminated patients could turn up in EDs without calling EMS. On the other hand, not deconning in the field could raise contamination concerns in transport vehicles.
"Those ambulances will have to be deconned afterward, and we may be subjecting paramedics and EMTs to contamination," notes Heilicser. "Our people have the ability to put on personal protective equipment, but they don't have the sophisticated stuff we saw on those Israeli ambulances."