Principles of Mass Casualty: Response to Terrorist Attacks

Principles of Mass Casualty: Response to Terrorist Attacks

Article Sep 30, 2007

     In January 2007, I participated in a mass casualty and terrorism workshop hosted by the Institute of Terrorism Research and Response (ITRR) in Israel. As part of the workshop, attendees met with internationally recognized terrorism response experts from several agencies including the Israeli Defense Force, Magen David Adom (MDA), Hadassah Medical Center, Barzilai Medical Center, and the Israel Trauma Center for Victims of Terror and War.

Principles of Mass Casualty Management
     Each expert we met emphasized that the parameters and principles they share are unique to the Israeli service model and experience. They have been developed to meet the resources available and the experience gained from regular application.

     The textbook definition of a mass casualty event is the same in Israel as it is in America: any situation where there is an imbalance of needs and resources, regardless of the number of patients. According to Shmuel Shapira, MD, MPH, deputy director general of the Hebrew University Hadassah School of Public Health in Jerusalem, this traditional definition of a mass casualty event is impractical for making decisions about patient triage and staffing at the hospital. Shapira explained to us that Hadassah has categorized the size of a mass casualty event based on the number of casualties his hospital receives, regardless of their injury severity.

  • Small: 10-24 patients
  • Medium: 25-59 patients
  • Large: 60+ patients

     Defining event size has given Israeli emergency responders and hospitals tangible preparedness targets for staff and equipment readiness. For example, mega-terror events are exceedingly rare, but would require an integrated national response. Medium mass casualty events were fairly regular at the height of the second intifada. Triage, transport and treatment protocols were developed for a maximally efficient response to allow a rapid return to normal operations to meet the day-to-day needs of Israel's citizens and visitors.

     As we discussed mass casualty management with numerous experts, the following concepts emerged:

  • Terrorism is a different kind of trauma
  • Uniform national training, equipment and response protocols are essential for a successful response
  • Rapid scene evacuation is imperative
  • Simple assessment and treatment of patients is a priority
  • Returning to normal as soon as possible is key.

Terrorism Is a Different Kind of Trauma
     The blunt, penetrating and blast injuries suffered by terrorism victims are a unique type of trauma. According to Shapira's research, the types and severity of injuries, need for emergent surgery and length of hospital stay are longer for victims of terrorism than of motor vehicle collisions. Victims of suicide bombers are likely to experience multiple penetrating wounds from small, high-velocity projectiles that may impact all major body systems and regions. The suicide bomber's vest or belt is often packed with screws, nails, bolts and bearings. On-scene EMS may not be able to locate small object entrance wounds that would help them understand the potential injuries to underlying organs and vasculature. Terrorist victims might also experience blunt trauma from being thrown by the blast wave or structural collapse.

     Shapira said that although 10% of terrorism patients undergo urgent surgery, nearly two-thirds are discharged within several hours of hospital presentation. He also said that most terrorism-related fatalities are immediate and happen at the scene of the incident. Thus it becomes important for EMS to focus resources on the critically injured patients, not on the already dead and expectant patients. As with any kind of trauma, treatment priorities for EMS remain the same: rapid identification and control of severe external hemorrhage, airway management, ventilatory assistance as needed and rapid transport to a trauma center capable of treating the patient's life-threatening injuries. To learn more about Shapira's research and the Terror Medicine International Center, visit

National Uniformity
     Magen David Adom, the Israeli ambulance service, has 1,400 paid employees and 8,500 volunteers for 350 ambulances in 100 stations. All MDA employees receive the same training from MDA training centers. A single set of protocols is used. Every ambulance is stocked with the same supplies in the same locations. The consistency of training and operations is a great benefit during a mass casualty incident when providers are working with colleagues they don't normally respond with in high-stress situations.

     Most MDA employees begin as volunteers at age 15. Volunteers must complete an 80-hour training course before being assigned as an assistant to a two-person, full-time ambulance crew. At age 21, a volunteer can apply for a spot in a 200-hour EMT-Basic with advanced skills course. Becoming an MDA paramedic requires three years of full-time EMT-Basic experience, acceptance through a highly competitive admission process, and 1,500 hours of training. Paramedic training is 14 weeks in the classroom, followed by 10 weeks of hospital rotations and 100 shifts in the field. After completing the rigorous training program, paramedics work with an MD in a mobile intensive care ambulance until approved for work with a paramedic partner.

     Instead of 9-1-1, there are separate numbers for fire, police or ambulance service. Callers dialing 1-0-1 are connected to a regional MDA dispatch center. Dispatchers receive 60 hours of additional training and are all cross-trained as EMTs or paramedics. Our tour included a few minutes in the busy Jerusalem dispatch center.

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     Chaim Rafalowski, Emergency Management Department manager at MDA in Tel Aviv and our MDA instructor, explained that many former MDA employees continue as volunteers. They work and live in their response areas and have pagers and jumpkits. Volunteers may respond directly to the scene. In the minutes after the coffeeshop suicide bomber attack described in the sidebar on page 94, a volunteer paramedic and EMT responded and were able to triage the critical patients before ambulances arrived.

Rapid Scene Evacuation
     Incident response is almost simultaneous to a mass casualty event. Uniformed soldiers and police officers are in constant view, and almost every citizen has served in the Israeli Defense Force; many stay on in a reserve capacity. Thus, most citizens have basic emergency response training. Also, because of the frequency of mass casualty terrorism incidents, citizens have learned what to do, such as being watchful for secondary devices or suspects, clearing access for emergency responders, and not transporting severely injured patients by private vehicle.

     According to Rafalowski, MDA has learned that simplifying processes and emergency communication increases efficiency. Upon notification of a terrorism incident, MDA dispatch "sends it all," including on-duty, off-duty and back-up crews. The first MDA unit on scene is instructed not to count patients but to simply report single patient, multiple patients or a lot of patients. That is enough information for dispatchers and supervisors to activate the initial response.

     The first EMT or paramedic on scene is expected to be EMS command until relieved. Rafalowski told us that chaos is to be expected, not managed. EMS command needs to focus on identification and rapid evacuation of critical patients. He reported that suicide terror events are just 0.4% of MDA calls, but 45% of fatalities. On average, the first MDA ambulance is on scene 4.6 minutes after an explosion. The first ALS patient is transported within 11.5 minutes of the event and, by 36 minutes after the explosion, all critical patients are en route to a hospital. Within an hour all patients are evacuated.

     Rafalowski also reported that the average terrorism incident during the second intifada involved 42 MDA ambulances with 116 personnel for 60 patients. About 20% of those patients are usually critical; more than 30% of patients, likely noncritical, self-evacuate. Because of the high rate of self-evacuation, MDA does not transport noncritical patients to the closest hospital, which is probably inundated with walking wounded before the first critical patient arrives. The hospital that receives the most critical patients does not receive noncritical patients.

Dealing With Terror on a Daily Basis
     As a crowd of commuters and schoolchildren pushed forward to board a bus on a street corner in Jerusalem, the bus driver and several passengers noticed anxiety on the face of a passenger who was surging through the crowd. In a flash, the driver closed the door as other passengers pushed the suicide bomber away. Their actions prevented a blast in the enclosed bus and probably saved dozens from injury and potential death. Just outside the bus, the blast from the bomber's jacket killed 11 people and injured many more.

     On the fourth day of our mass casualty and terror workshop in Israel, our guide, retired Colonel Raanan Tal from the Institute of Terrorism Research and Response (ITRR), took us to numerous mass casualty sites in and around Jerusalem. The narrative of each event was horrifically similar: a suicide bomber choosing a densely crowded public place to detonate a bomb and inflict the most casualties.

     There are seven million people living in Israel-Jews, Muslims and Christians. The 10,840-square-mile country-a bit larger than the state of Maryland-is situated on the eastern edge of the Mediterranean Sea. Until I saw it, I did not realize how densely the population is distributed, nor did I realize the close proximity of Palestinian-controlled areas of the West Bank territories and Gaza Strip to Israeli-controlled lands and communities. Centuries-old conflicts are still evident within Israel's borders. Since the early 2000s, escalating violence in Israel has resulted in more than 8,000 casualties and 1,110 fatalities. Many of those deaths and injuries were caused by suicide bombers.

     During our tour, Tal told us about a suicide bomber who waited outside a coffee shop for most of the day, then attacked when the security guard at the door left to use the bathroom. As he talked, I wondered how these levels of violence would affect life in my state of Wisconsin-65,000 square miles for 5.5 million people.

     Everyone we met in Israel had been personally affected by terrorism. They had either responded to incidents, known people who were killed or severely injured, or had been involved in incidents. Out of that direct and personal experience, Israel's emergency responders and hospitals have developed systems for preparing for, responding to and recovering from mass casualty events.

Simple Assessment and Treatments
     To achieve the rapid evacuation goals, MDA personnel only provide simple assessment and treatment on scene and en route to the hospital. The goal at the incident is to divide the critical from the non-critical. On-scene and transport treatment might be limited to controlling severe external bleeding, BLS airway management, assisting ventilations and spine precautions. En route, ALS providers might consider other interventions, such as IV access or intubation for critical patients, but not at the expense of rapid transport.

     Rafalowski advises disrobing all patients before transport. The worst-case scenario feared by many responders is finding among the living a second suicide bomber whose bomb has not detonated. MDA never transports or picks up any patient bags or belongings when responding to a terrorism incident.

     The focus on simple assessment and treatment continues at the receiving hospitals. Since hospitals have been suicide bomber targets, all arriving ambulances are searched at the entrance to hospital grounds and again at the emergency department entrance. The hospitals we visited had outdoor decon infrastructure that could be rapidly deployed to simultaneously decontaminate dozens of patients. After transport and decon, if needed, the patient is started on a one-way path to definitive assessment and care. The goal is for patients to not return to the emergency department, but always flow in one direction toward definitive care, diagnostics or discharge.

     At the Barzilai Medical Center, CEO/Medical Director Simon Scharf, MD, MPH, explained his facility's mass casualty response plan. The hospital has been the target of missiles launched from Gaza, car bombs and suicide bombers. After clearing the perimeter fence with secured gates, ambulance patients are routed to treatment areas; ambulatory patients follow painted lines on the pavement, floors and fold-down signs; and non-ambulatory patients are triaged in the emergency department before transfer to surgery or another facility.

     Hadassah Medical Center in Jerusalem has responded to 43 mass casualty events since September 2000. They have had no choice but to become well-trained and prepared for terrorism incidents. Out of 5,000 employees, two have been killed in terrorism incidents and 28 have lost primary family members. Hadassah spends more than a million dollars a year securing its campus and preparing and training for mass casualty events.

Institute of Terrorism Research and Response
     The Institute of Terrorism Research and Response's Israeli and American experts provide counterterrorism training seminars and security expertise in dealing with threats of international terrorism, and preparing for WMD attacks, suicide bombers and other forms of international terror. For more information, visit

Return to Normal
     The Israeli approach to mass casualty events is to rapidly return to normal. To achieve a maximum impact, most suicide bomb events occur in densely populated areas. Reopening busy streets and sidewalks within four to six hours of the incident seemed to be the goal most often discussed.

     In Israel, the police department is always in command of a mass casualty event. Usually, within minutes of a suicide bomb attack, responsibility is claimed by the terrorist organization and the bomber's name and village are publicized. Nevertheless, police gather intelligence, interrogate witnesses, collect evidence and detain suspects. Most suicide bombers have a handler or accomplice near the scene, possibly even videotaping the incident.

     Ideally, a police bomb disposal unit would arrive early and spend several hours locating and disposing of secondary devices. In reality, large numbers of citizens and emergency responders rush in to evacuate critically injured patients. In the time it would take for bomb technicians to guarantee scene safety, most critically injured patients would die from ABC life threats.

     After rapid evacuation of patients by EMS, a unique, all-volunteer agency, ZAKA (, serves the function of "honoring the dead." ZAKA volunteers respond to any fatal incident, terror and non-terror, to identify and recover victims' body tissue. ZAKA volunteers are first-aid trained and initially assist with lifesaving operations as requested by MDA EMS command. Once patient evacuation is completed, and with police authorization, ZAKA volunteers begin the painstaking process of removing all body tissue and fluids from the scene. As much as possible, all of each victim's body tissue is packaged together and transported to the forensics institute for analysis and preparation for burial. ZAKA works quickly to clear the area with respect for the victims and to achieve burial the same day as death.

     While most citizens realize that "life goes on," some are emotionally paralyzed with fear and worry. Dr. Rony Berger, director of community services for the Israel Trauma Center for Victims of War and Terror in Tel Aviv (, told us that the ratio of emotionally injured to physically injured is 10 to one. It is easy for EMS and the hospitals to identify and treat the physically injured at the incident. It is much harder to identify the witnesses of a suicide bombing who are not physically injured but are emotionally traumatized.

     American emergency responders would benefit greatly from participating in an ITRR mass casualty and terrorism workshop. The perspective I gained from looking back at American principles for mass casualty event management was invaluable to my knowledge of and preparation for mass casualty response.

     Finally, I was struck by the "life- must-go-on" attitude of everyone we met. Terrorism is a fact of life in Israel. People still ride the bus, go out in public and return to normal routines as quickly as possible. To allow this, they have developed a sophisticated, multifaceted prevention and response system.

Greg Friese, MS, NREMT-P, is president of Emergency Preparedness Systems LLC, which helps clients rapidly deploy emergency education. Greg and EPS associates have authored and edited dozens of online education programs. Friese is a paramedic, Wilderness Medical Associates lead instructor, conference speaker and EMS author. Contact him at

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