Principles of Mass Casualty: Response to Terrorist Attacks

     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 www.terrormedicine.com.