Principles of Mass Casualty: Response to Terrorist Attacks

American responders can learn from the Israeli experience: In January 2007, I participated in a mass casualty and terrorism workshop hosted by the Institute of Terrorism Research and Response (ITRR) in Israel.


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.

     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.