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Mass casualty incident management, triage, injury distribution of casualties and rate of arrival of casualties at the hospitals: lessons from a suicide bomber attack in downtown Tel Aviv
  1. Y Raiter1,
  2. A Farfel1,
  3. O Lehavi2,
  4. O B Goren2,
  5. A Shamiss3,
  6. Z Priel4,
  7. I Koren5,
  8. B Davidson6,
  9. D Schwartz7,8,
  10. A Goldberg8,
  11. Y Bar-Dayan1,8
  1. 1
    Home Front Command Medical Department, Israel
  2. 2
    Sorasky Medical Center, Tel Aviv, Israel
  3. 3
    Sheba General Medical Center, Israel
  4. 4
    Edith Wolfson Hospital, Holon, Israel
  5. 5
    Rabin Medical Center, Petah Tikva, Israel
  6. 6
    Asaf Ha’rofe Hospital, Ramla, Israel
  7. 7
    Israeli EMS, Magen David Adom, Medical Division, Israel
  8. 8
    Faculty of Health Sciences, Ben Gurion University, Beer-Sheva, Israel
  1. Dr Col Y Bar-Dayan, IDF Home Front Command, Department of Disaster and Emergency Medicine and Department of Healthcare Systems Management, Faculty of Health Sciences, Ben Gurion University, Beer-Sheva, 16 Dolev St Neve Savion, Or-Yehuda, Israel; bardayan{at}


Background: Terrorist attacks in Israel cause mass events with varying numbers of casualties. A study was undertaken to analyse the medical response to an event which occurred on 17 April 2006 near the central bus station, Tel Aviv, Israel. Lessons are drawn concerning the management of the event, primary triage, evacuation priorities and the rate and characteristics of casualty arrival at the nearby hospitals.

Methods: Data were collected both during and after the event in formal debriefings. Their analysis refers to medical response components, interactions and main outcomes. The event is described according to the DISAST-CIR methodology (Disastrous Incidents Systematic AnalysiS Through – Components, Interactions and Results).

Results: 91 casualties were reported in this event; 85 were evacuated from the scene including 3 already dead on arrival, 9 severely injured, 14 moderately injured and 59 mildly injured. Six were declared dead at the scene. Emergency medical service (EMS) vehicle accumulation was rapid. The casualties were distributed between five hospitals (three level 1 and two level 2 trauma centres). The first evacuated casualty arrived at the hospital within 20 min of the explosion and the last urgent victim was evacuated from the scene after 1 h 14 min. Evacuation occurred in two phases: the first, lasting 1 h 20 min, in which most of the patients with evident trauma were evacuated and the second, lasting 8 h 15 min, in which most patients presented with tinnitus and symptoms of somatisation. The most common injuries were upper and lower limb injuries, diagnosed in 37% of the total injuries, and stress-related disturbances (anxiety, tinnitus, somatisation) diagnosed in 41%.

Conclusion: Rapid accumulation of EMS vehicles, effective primary triage between urgent and non-urgent casualties and primary distribution between five hospitals enabled rapid conclusion of the event, both at the scene and at the receiving hospitals.

Statistics from

The frequency of mass casualty incidents due to terrorist attacks has increased in recent years in Israel and worldwide. These events can occur in central or peripheral towns, in urban or rural areas. Numerous events, mainly involving conventional bombs detonated in heavily populated areas, have occurred all over the world, such as happened in London1 and also in numerous events in Israel in the vicinity of level 1 to level 3 trauma centres.29

The management of such an event differs according to the location, the character of the event, the number and severity of the casualties, the rate of accumulation of evacuation vehicles , the experience and skills of the field first aid teams, the number and level of nearby hospitals and their capacities.10 Researching the unique characteristics of the management and outcomes of every one of these events has taught us different new lessons, and it is suggested that proper management of the event can be a key factor in reducing the mortality rate in a mass casualty incident.110 We believe that lessons learned from every such event must be prospectively described and analysed using the same methodology to allow generalisation from the accumulated experience and to draw conclusions from them. Such a methodology was recently described and used by our group in previous articles.39 11

On 19 January 2006 a suicide bomber detonated himself near a fast food stand in downtown Tel Aviv.12 On 17 April 2006 another suicide bomber detonated himself in exactly the same fast food stand. The site of the mass casualty incident is shown in fig 1. This paper describes the event of 17 April and draws lessons about its management, primary triage, evacuation priorities and the rate of arrival of casualties at nearby hospitals.

Figure 1 A terrorist bombing in Neve Shaanan, very close to the central station in Tel Aviv (marked with white star).


Pre-event organisation

The medical section of the Israeli Home Front Command comprises soldiers and officers, physicians, nurses and medical officers. The medical operational centre is a 24 h active “war room” manned with one officer and 2–3 experienced soldiers. The operational centre is able to communicate with relevant organisations or set-ups which either provide the centre with information or receive information and operational instructions from it. Such organisations or set-ups include all Israeli general hospitals, the national EMS centre and districts, other military or home front command rooms, the fire brigade, police headquarters, search and rescue units, military medical units including nuclear, biological and chemical units, the Israeli Air Force and the hazardous material information centre. The operation centre is also in touch with the Ministry of Health and the Ministry of the Environment.

The event

The relevant hospitals received early notification of a mass casualty incident both from the EMS and from the Home Front Command medical department by the EMS beepers and by a direct telephone call from the Home Front Command officers to the emergency department managers and to the hospital managers. The hospitals were instructed by the latter to activate their mass casualty incident protocols and the national online casualty surveillance computer software which is connected to all hospitals and all medical operation centres in Israel. Officers from the medical department of the Home Front Command were sent to the scene and to the various hospitals. These officers, physicians and nurses gather information and update the operational centre. They also try to draw a clear picture of the evolving incident and to pass on this crucial information directly to hospital managers and emergency responders.


Debriefings were carried out at the medical department, Israeli defense forces medical corps trauma branch, Israeli EMS and the participating hospitals according to a standardised protocol. Each organisation reported its own data, answering questions asked in the protocol. Post-mass casualty incident debriefings were closed to the media, allowing free communication between organisations.

DISAST-CIR methodology

Data were organised according to the Disastrous Incidents Systematic AnalysiS Through – Components, Interactions, and Results (DISAST-CIR) methodology.39 11 This methodology uses the information gathered by prospective systematic structured debriefings of all the organisations involved in the event and a prospective review of the computer system data and the patient medical charts from the EMS and the hospitals. The data gathered from the medical charts include the time of evacuation, time of arrival, mode of evacuation (basic life support ambulance, advanced life support ambulance or self-evacuation), symptoms and signs, physical examination, radiographic and laboratory findings, diagnosis, medications given and operations performed. The DISAST-CIR methodology presents the data in a uniformly structured set of figures and tables in order to enable the readers and emergency managers all over the world to make a comparison between different events.

The DISAST-CIR figures include a map of the scene, a chart flow of casualties in the national level and a chart flow of casualties within the hospitals. Another set of figures shows the time distribution of the arrival of casualties at the hospitals, the time distribution of the arrival of casualties at different hospitals according to their proximity to the scene of the event and the time distribution of the arrival of casualties at the hospitals according to their chief complaint. The point of time between the early phase of arrival and the second phase of arrival of casualties at the hospital is determined by finding the point where the rate of arrival of casualties at the hospitals becomes low compared with the high rate of arrival of casualties at the hospital which characterises the first minutes of a mass casualty incident. Patients are divided into four categories according to their chief complaint: (1) organic trauma; (2) tinnitus (which usually represents a minor blast injury); (3) anxiety (patients with stress symptoms such as palpitations, tachycardia, sweating, tremor, hyperventilation); and (4) somatisation (patients with headache, nausea, abdominal pain without evidence of organic trauma).

The DISAST-CIR tables include data on the components of the medical system operated in the event, the timetable of the event, primary distribution of casualties between the hospitals and the injury distribution of casualties.


The components of the medical response in this event included the Israeli EMS and hospitals, and the components of mass casualty incident management included the central operational centre of the police, the Home Front Command and the EMS, as shown in table 1.

Table 1 Components of the medical system operated at the event

Interactions between the components of the medical response system are shown in fig 2. The cellular telephone network at the site of the event was overloaded and information from the scene was transferred via radio communication devices to the command centres of the EMS and Home Front Command and from there by telephones, cellular phones, direct telephone operator systems and beepers to all the customers of information in all of the medical system components in Israel including the Ministry of Health managers, the Home Front Command managers, EMS managers, hospital managers and the Israeli Air Force rescue unit. The timetable is shown in table 2.

Figure 2 Interactions (according to DISAST-CIR methodology) between different responders: police command, EMS ambulances, primary triage or self-referral to close circle hospitals (mainly Sourasky Medical Center). Non-urgent evacuation is shown by grey arrows and evacuation of urgent casualties is shown by black arrows.
Table 2 Timetable of the event

Sourasky Medical Center, the closest to the central bus station (5 min drive), was notified of the event by the EMS beeper system immediately after its occurrence and was officially informed of the event (by the Home Front Command medical operation centre) 10 min after its occurrence (10 min before the arrival of the first casualty to the emergency department). Casualties did not arrive at the hospital on foot because of the distance between the site of the event and the closest hospital, and casualties evacuated by private cars started to arrive at the hospital more than 20 min after the event. The last casualties evacuated by ambulance from the scene arrived at the hospital 3 h after the explosion. Interactions inside Sourasky Medical Center are shown in fig 3.

Figure 3 Interactions (according to DISAST-CIR methodology) inside Sourasky Medical Center. The flow of mild casualties is shown by broken arrows, moderate casualties by grey arrows and severe and expectant casualties by black arrows.

Ninety-one casualties were injured in the incident. The first casualty arrived at the hospital within 20 min of the blast. Four casualties were self-evacuated to the hospitals after >4 h, one with tinnitus, one with headaches and two with symptoms of anxiety. The last casualty with symptoms of anxiety evacuated himself from his home to the hospital after 9 h 35 min. Figure 4 shows the time distribution of arrival of the casualties to the hospitals.

Figure 4 Distribution of arrival of casualties at the hospitals. EPA, early phase of arrival; SPA, second phase of arrival.

The EMS services evacuated 57 casualties out of the 91 taken to the hospitals after primary triage and life-saving procedures in the field. Six victims were declared dead by a physician at the scene. Twenty-eight mild casualties were evacuated by private car to the hospitals a few minutes to a few hours after the event. The distribution of casualties between the hospitals is shown in table 3.

Table 3 Primary distribution of casualties

There were 26 expectant (dead on arrival), severe and moderate casualties. All were evacuated by the EMS ambulances and distributed between three hospitals: the nearest (5 min drive) Sourasky level 1 trauma centre received 17, the nearby (10 min drive) Wolfson level 2 trauma centre received 8 and Sheba (20 min drive) level 1 trauma centre received 1. The mild casualties were distributed by EMS between five hospitals: Sourasky, Sheba and Rabin level 1 trauma centres and Wolfson and Asaf Ha’rofe level 2 general hospitals. The casualties arrived at the hospitals in two phases (fig 5). The three closest hospitals received most casualties in the early phase of arrival, while the two more distant ones received casualties together with the closest hospitals only in the second phase of arrival.

Figure 5 Distribution of casualties between the hospitals as a function of time. EPA, early phase of arrival; SPA, second phase of arrival.

Figure 6 shows the time distribution of arrival of casualties at the hospital divided into four categories based on chief complaint/diagnosis (trauma, somatisation, tinnitus and anxiety). Figure 7 shows the distribution of chief complaints/diagnosis of the casualties according to the phase of arrival at hospitals according to the hospital records. Most of the casualties evacuated to hospitals in the early phase suffered from obvious traumatic injuries, whereas most of the casualties evacuated to hospitals in the second phase suffered from tinnitus and somatisation.

Figure 6 Time distribution of arrival of casualties at hospital divided into four categories by the chief complaint. EPA, early phase of arrival; SPA, second phase of arrival.
Figure 7 Distribution between the chief complaints of the casualties according to the phase of arrival at the hospitals.

Hospitals rapidly prepared according to mass casualty incident protocols including reinforcement of the emergency department by medical personnel, triage at the entrance by an experienced traumatologist and distribution of the casualties between the mild, moderate and severe sites. The mass casualty incident flowchart used in the Sourasky medical centre during the event is shown in fig 3.

The injuries included blast injuries, penetrating injuries, soft tissue injuries, anxiety and somatisation. Their distribution is shown in table 4.

Table 4 Injury distribution of casualties


This attack took place at midday in the centre of Israel’s largest metropolitan area, which had a positive effect on EMS vehicle and personnel availability and on the number of nearby hospitals and personnel available in them, but a negative effect with regard to evacuation times secondary to traffic congestion.

A total of 91 casualties were reported in this event; 85 were evacuated from the scene including 3 expectant casualties, 9 severely injured, 14 moderately injured and 59 mildly injured. Six were pronounced dead at the scene. The casualties were distributed between five hospitals, three level 1 trauma centres and two level 2 trauma centres. The first evacuated casualty arrived at the hospital within 20 min of the explosion. The last urgent victim arrived at the hospital after 1 h 14 min.

Evacuation phases

Evacuation occurred in two phases. The duration of the first phase was 1 h 20 min, in which most of the patients with evident trauma were evacuated, while the second phase lasted 8 h 15 min, during which 41% of the patients evacuated to hospitals were suffering from stress-related disturbances (anxiety, tinnitus, somatisation) and 37% from upper and lower limb traumatic injuries.

One of the challenges in this event was to synchronise the EMS response and to distribute the casualties optimally among five hospitals after rapid triage. This challenge was met by effective interactions between the EMS operational centre and the EMS ambulances, police, Home Front Command operational centres and the receiving hospitals.

The EMS and the Home Front Command has several backup communication systems which enable us to overcome the difficulties in communication that usually happen during a mass casualty incident, and to build a clear and accurate picture of the event and enable the system managers to control the event. These communication systems include radio communication devices with the police and the EMS, television, internet system, line telephone, cellular telephones, direct telephone operator systems and beepers that operate simultaneously in order to give backup in case one or more of the communication systems dose not function correctly during an event.

Each mass casualty incident differs from others with regard to location, number and distribution of casualties, severity, type and the nature of injuries, size of available rescue teams, time and equipment needs, damage to roads, distance from hospital, hospital trauma level and other variables. One of the most important lessons learned from the management of mass casualty incidents is not to set fixed protocols but, rather, principles only. By applying principles adapted to the situation, managers will be able to perform better.10

Interestingly, in this case a similar event had occurred at exactly the same place 3 months earlier, with similarities with respect to the receiving hospitals and EMS forces involved. The major differences between the events were the amount of explosives and the greater number of people in close proximity to the explosion in the latter event, resulting in the large number of deceased and severely injured as well as an almost threefold higher total number of casualties. This led the command system to increase the number of receiving hospitals and prolonged treatment times both at the scene and at the hospitals, although the principles of event management remained similar.

At the previous event on 17 January 2006, a terrorist bomb injured 38 (1 severely injured, 2 moderately injured and 35 mildly injured). The casualties in the previous event were distributed between three hospitals, two level 1 trauma centres and one level 2 trauma centre. EMS capabilities in this area are professional and suitable for an event of this magnitude. Computer systems between hospitals provided crucial information regarding the capacities of the surgical and intensive care departments at the hospitals to receive casualties. The primary triage in the field, the evacuation priority decision-making and rapid distribution of casualties between hospitals enabled a rapid and effective management of the event.

The current larger scale incident was managed similarly. The dilemma of life support in the field or rapid evacuation to a nearby hospital is critical in the management of mass casualty incidents. Similarly, giving clear instructions to hospitals regarding the operational mode needed for the specific incident is mandatory. Proper triage, appropriate resuscitation and timely evacuation decrease morbidity and mortality in trauma patients and facilitate utilisation of the available resources appropriately ((M Pinkert et al, unpublished, 2007)

Our previous experience in terrorist bombing-induced mass casualty incidents has taught us that, as events can happen anywhere, all hospitals (not only trauma centres) should undergo courses in advanced trauma life support preparedness and mass casualty incident drills and be prepared for a high flow of casualties.11 This concept was proved again in this event where Wolfson Hospital, a level 2 trauma centre, was one of the main hospitals providing care for casualties from the event. It was shown that even a level 2 trauma centre close to a level 1 trauma centre must be prepared to care for casualties during a mass casualty incident.


As terrorist events and mass casualty incidents have become a worldwide problem, additional research needs to look at how transfer times, hospital surge capacity and the “density” of urgent casualties affect survival. When a mass casualty incident occurs in an urban area in the vicinity of more than one hospital, the preferred mode of action is based on rapid arrival of large numbers of EMS ambulances and personnel, primary triage, evacuation priorities and primary distribution of casualties between all nearby hospitals to contain the mass casualty incident rapidly and effectively.



  • Competing interests: None declared.

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