Introduction: Over 2000 improvised rockets (called “Kassam” rockets) have been targeted at the south of Israel from the Gaza strip since 2001. Most of them have injured relatively few people. The first known case of a multicasualty incident (MCI) caused by the landing of a single, improvised rocket is described.
Methods: The event is described according to the disastrous incidents systematic analysis through components, interactions and results methodology (DISAST-CIR).
Results: The rocket hit a military training tent camp in the south of Israel at 01:18 hours. At that time, all soldiers were in bed and were not using any protective gear. A total of 76 soldiers was injured (three severe, eight moderate and 65 mild). The most prevalent types of injuries were upper extremity (33%) and lower extremity (30%) trauma, tinnitus (30%) and acute stress reactions (32%). A total of 67 casualties was evacuated to the nearest level two hospital, Barzilai, in a two-phase distribution characterised by different patterns of injury severity and type. All urgent casualties arrived at hospitals within 1 h 24 minutes, whereas most stress casualties arrived in the later phase. Seven casualties were secondarily transported to level one trauma centres. 42 of the casualties were hospitalised and 17 needed urgent surgery. None has died.
Conclusions: A single low-tech mortar with poor accuracy and small warhead (estimated weight of 10 kg only) can cause a large-scale MCI. As international terrorist organisations can easily gain access to improvised rockets, the latter may become a threat in many countries. Emergency systems should thus be prepared for that adverse possibility.
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Improvised rockets (called “Kassam” rockets) have been targeted at the south of Israel from the Gaza strip since 2001.1 They have evolved over the years. Although initially they had a maximum range of 3 km and a warhead of 0.5 kg, newer models have a range of 10 km, whereas the maximum weight of their warheads has increased to more than 10 kg. The rockets are inaccurate and therefore usually launched towards large towns or installations. Over 2000 rockets have been launched since 2001, most of them landing in uninhabited areas and thus injuring relatively few people. The single most damaging incident up to 2007 occurred in 2004, when a rocket hit a kindergarten in the city of Sderot, killing two and injuring an additional nine.1 We are unaware of any previous report in the literature of a multicasualty incident (MCI) caused by a single improvised rocket bombing.
In the second Lebanon war, ie, between 12 July and 14 August 2006, Hezbollah’s strategy included rocket bombing of civilian populations in the north of Israel with non-improvised rockets with warheads of up to 25 kg. A total of 4000 rockets directed at city centres wounded 4304 civilians. Forty-two died immediately at the scene, another 32 were severely injured, 68 were moderately injured and 1388 were mildly injured, whereas 2774 needed medical care because of acute stress reactions.2
In the past decade, Israel, as well as other countries, has experienced growing numbers of MCI, mainly as a result of terrorist suicide bombers.3–16 Some of these incidents have been systematically studied; using a standardised method of debriefing and analysis of these MCI, in a prospective methodology called disastrous incident systematic analysis through components, interactions and results (DISAST-CIR).5–9
On the night of 11 September 2007 at 01:18 hours, a “Kassam” rocket exploded in an army training camp, a few kilometers from the Gaza strip. It exploded near the trainees’ sleeping quarters. Most soldiers were asleep in tents at the time of the explosion. The Zikim base is located approximately a 15-minute drive from the closest hospital, Barzilai, a level two hospital in the city of Ashkelon. The closest level one trauma centre is in Beer-Sheva, a 35-minute drive from the base. The base itself is staffed with an army physician and medics and has a clinic with MCI medical gear and two ambulances.
This study aims to describe the unique characteristics of this rare incident, focusing on injury patterns, on its overall management, on its timetable, on the medical resources used, on prehospital care and evacuation, on primary and secondary triage, on the rate and injury characteristics of the arrival of casualties at the nearest hospital and on the latter’s mode of operation.
Information was gathered during and after the event by Home Front Command (HFC) officers, physicians and nurses. Debriefings were carried out at the HFC medical department, at all the hospitals involved in the event, at the Southern Command medical department, at the Israeli Defence Force (IDF) ground forces medical department, at the Israeli Air Force, at the IDF Surgeon General headquarters as well as at the national emergency medical services (EMS) and at the Ministry of Health, according to a standardised protocol—with each organisation reporting its data and answering questions. Post-MCI debriefings are closed to the media, allowing free communication between organisations. The data presented here were organised according to our DISAST-CIR methodology.5–9
This methodology uses the information gathered by systematic structured debriefings of all the organisations involved in the event and a review of the computer system data and the patient medical charts from the EMS and the hospitals. The data gathered from medical charts include time of evacuation and arrival, mode of evacuation (basic life support (BLS) ambulance, advanced life support (ALS) ambulance or non-designated vehicle evacuation), symptoms and signs, physical examination data, radiographic and laboratory findings, diagnosis, medications given and operations performed.
Injury severity was classified in retrospect, based on the injury severity score.17 A score of 0–8 is classified as mild, 9–14 as moderate and 16 and over as severe. The event was divided in retrospect into two phases related to the time of the explosion. The boundary between the early and the late phase of arrival of casualties at the hospital was the point when the rate of arrival of casualties at the hospital dropped considerably.
The DISAST-CIR methodology presents the data in a uniformly structured set of figures and tables, to allow emergency managers and other readers to compare events systematically. The DISAST-CIR figures include a chart flow of casualties at the national level and another chart flow of casualties in the hospitals. Another set of figures shows the time distribution of casualty arrivals at the hospitals by severity of the injury. The DISAST-CIR tables include data on the components of the medical system operated in the event, the latter’s timetable, the distribution of casualties between hospitals and the injury distribution of casualties.
Data were entered and descriptive statistics calculated using a commercially available spreadsheet (MS Excel 2003).
The components of the medical system operated at the event included military non-designated vehicles, military ambulances, civilian EMS ambulances, Israeli Air Force search and rescue unit medical helicopters, four level one trauma centres and one level two trauma centre, as shown in table 1. The cumulative numbers of caregivers and evacuation vehicles are shown in table 1. Fifteen medical command and operation centres participated in the event, as shown in table 1.
In the first hour after the explosion every one of the operational centres had a partial picture of the event and there was a difficulty in sharing the data gathered by each one of the operational centres between all the participants of the event in real time. Some of the data were collected by every medical operational centre directly from the operating forces. The mass media could not enter the military base and the information they reported was inaccurate and delayed compared with previous events in civilian settings. The problem of data sharing was solved only when all the operating organisations established a joined forces command post, located in Barzilai Hospital.
Overall flowchart of casualties in the event
Prehospital care and evacuation
The initial care at the scene was provided by the base’s physician and nine medics. Additional medical units arrived from a nearby army base. Some of the wounded were initially transferred to the base’s medical clinic, where they underwent a second sieve and sort triage. Initially, wounded soldiers were evacuated, after rapid sort triage, by non-designated army vehicles and by army ambulances. The first four soldiers to arrive at Barzilai Hospital were thus evacuated in a military jeep. In total, 35 soldiers were evacuated by army vehicles and 24 by non-designated vehicles (table 3).
Hospital arrival times
A total of 67 of the 76 wounded was initially evacuated to Barzilai Hospital. Two phases of patient evacuation (based on arrival times at the hospital) with different injury severity and patterns are shown in fig 2. The early phase, starting at the time of the event lasted 90 minutes, whereas the late phase started 90 minutes after the event. All moderately and severely injured soldiers arrived at the emergency department (ED) within 90 minutes, in contrast to less than 50% of the mildly injured.
Secondary patient transport
A total of 76 soldiers was injured; 67 were evacuated to Barzilai Hospital, two to Soroka Medical Centre and seven anxiety patients were treated at the military base clinic and were not evacuated from the base (table 4). A flow chart of casualties in Barzilai Hospital shows that it operated in semi-evacuation mode, ie, it reduced the load of moderately and severely stable casualties by secondary transfer to level one trauma centres (fig 3). Seven casualties were secondarily transported from Barzilai Hospital to three level one trauma centres (Sheba, Hadassah and Beilinson), by three evacuation helicopters. One patient, classified as severely injured (head injury), required urgent neurosurgical intervention; four others were eventually classified as moderately injured and two as mild (table 4).
Injuries were sustained from shrapnel and from the shockwave. There were also acute stress reactions. Of the 76 wounded, three were classified as severe, eight as moderate and 65 as mild. Table 5 lists the injury distribution of the casualties arriving in the early and late phase of the evacuation. The most prevalent types of injuries were upper extremity (33%) and lower extremity (30%) trauma, tinnitus (30%) and acute stress reaction (32%). A diagnosis of acute stress reaction or somatisation was present in 5% and 8% in the early phase group compared with 50% and 30% in the late group. Injuries to the extremities, chest, abdomen and head were more prevalent in the early arrival group.
The Zikim incident was unique in a number of ways. It is the first reported single low-tech rocket with poor accuracy and a low-weight warhead that caused a large-scale MCI. Since 2001, when “Kassam” rockets were first deployed, most rockets caused no significant damage or injuries. In incidents in which the rockets hit populated areas, the number of casualties was usually small, rarely exceeding 10. Possible reasons for the high number of casualties in the Zikim incident are that the rocket exploded where many soldiers were gathered in a small area and that tent walls offer little or no protection against shrapnel or shockwaves. A second unique characteristic was that the explosion occurred in an army training base, thus requiring coordination between civilian and military medical forces, as well as between a number of medical operational centres. A third unique characteristic is that this MCI occurred late at night, which limited the ability to assess the scene, lengthened response times and scaled down medical response (mainly EMS and hospital personnel).
The command and control of the event involved at least 15 different operational centres as seen in table 1, with different ranges of responsibilities and different medical forces under their command. Such a structure demands efficient information sharing in real time. Hospital notification was delayed (31 minutes) compared with MCI that have occurred in Israel in the past 3 years, when it took between one and 11 minutes from the explosion to alert the hospitals.6 8 9 13 14 Better coordination between participating operational centres could ensure better results.
Prehospital care and evacuation
Initial care and evacuation were carried out by the medical staff at the base and by other military units in close proximity to the base. The first ALS team arrived at the scene 3 minutes after the explosion and ALS triage was not delayed compared with most other events in which the first civilian ALS teams arrived within 1–6 minutes after the explosion.6–14 However, in the first 30 minutes there was a shortage of ambulances at the scene. This led the physician in charge to decide to evacuate the stable urgent casualties by non-designated military vehicles (jeeps and trucks) to the nearest hospital. The use of such vehicles to transport patients was justified in the first stages in view of the short evacuation distance and the initial ambulance shortage.
Civilian EMS activation occurred 12 minutes after the explosion, later than in other MCI, in which it occurred 1–3 minutes after the explosion.5–14 It took seven more minutes for the EMS central operational centre to understand the magnitude of the incident. That delay may have been caused by the late hour, the difficulty in assessing the scene of the explosion, the lack of communication between operational centres and the unexpected character of an MCI caused by a Kassam rocket.
The time it took to evacuate all urgent casualties from the scene was in the range seen in previous events in Israel (between 15 minutes and 2:05 h).5–14 Patient evacuation was successfully prioritised so that all patients with moderate or severe injuries reached the hospital within 90 minutes of the explosion (in the early phase), whereas late phase evacuees only had mild injuries and acute stress reactions. This two-phase distribution pattern has been described in other MCI of similar magnitude.6 12
Barzilai Hospital is a level two trauma centre, relatively accustomed to MCI drills and actual MCI. During the initial 55-minute period, 37 wounded soldiers arrived at this hospital, 11 of them moderately or severely injured and 17 requiring emergency surgery.
The fact that 67 of the 69 evacuated soldiers were initially evacuated to one peripheral hospital is unusual compared with other MCI and does not fit the primary distribution policy in Israel in the past decade.5–14 In most incidents of such a magnitude patients were distributed among several hospitals so as not to impose such a patient load on any single hospital. This unusual primary distribution pattern may have delayed care for some of the injured. Therefore, Barzilai Hospital adopted the “semi-evacuation hospital” mode as was done in similar MCI in the periphery of a densely populated area, such as the suicide bombers attacks in Netanya.7 9 The hospital completed the care for 60 of the total 67 casualties who arrived at the ED, including two out of the three severely injured patients, whereas seven casualties were secondarily distributed by helicopters led by physicians between three level one trauma centres in Israel.
Injury severity and injury types
The prevalence of the moderately and severely injured casualties in this event was 15%, higher than reported in the civilian population hit by rockets in the second Lebanon war, in which only 3% of the casualties were moderately and severely injured or deceased.3 This was surprising, especially as the warheads of the rockets used in the second Lebanon war weighed more than the Kassam warheads and were directed against densely populated areas in city centres. The greater incidence of moderate and severe casualties in the Zikim event was perhaps a result of the shelters or protected areas in which the civilian population stayed during the second Lebanon war, whereas in Zikim the soldiers were gathered in tents that gave them no protection against shrapnel and shockwave injuries.
The prevalence of moderately and severely injured or deceased in suicide bomber explosions between 2004 and 2007 was between 23% and 39% in six suicide bomber attacks, higher than in the Zikim event. This may be caused by different bomb build and the spread of the soldiers over a larger area than the crowds in open market places, malls or hotels in which suicide bombers detonated themselves.6–8 10–11 13 In three suicide bomber explosions the prevalence of moderately and severely injured casualties was between 3% and 10%, probably because the suicide bomber was discovered by the security forces before he could approach the crowd and detonated himself far away from it.9 12 15
Another interesting finding was that although the number of urgent casualties was 11, and at least five needed immediate life-saving procedures, none have subsequently died. That the event ended with no mortalities can be attributed to the distance between the site of explosion and the crowd, the area over which the soldiers were spread and the differences between the makeup of the Kassam rocket and that of the explosives used by suicide bombers. The low mortality as a result of rocket bombing (<1%) in the second Lebanon war3 supports the notion that a rocket explosion is less lethal than a suicide bomber explosion. This low mortality may also be partly due to the effective triage and rapid evacuation of the urgent casualties by non-designated, as well as designated vehicles to the nearest hospital. Our previous report also found that evacuating all the urgent casualties to the closest hospital ended with 0% in-hospital mortality, thanks to emergency life-saving procedures carried out in the hospital in the first few minutes after the event.10
The injury distribution in this incident was different from those described in suicide bomber explosions.6 9 12 Upper limb trauma was found in 33% of the casualties, whereas in suicide bomber events it ranged between 1% and 11%.6 9 12 Injuries to the abdomen, chest, back and head were almost twice as common in the Zikim incident as in the suicide bomber events studied using DISAST-CIR methodology.6 9 12 Perhaps because most of the soldiers were lying down sleeping at the time of the explosion, whereas in suicide bomber explosions people are usually standing, and their hands and upper parts of the body are relatively out of the range of shrapnel. The prevalence of tinnitus was 30%, which was similar to that found in suicide bomber explosions.6 9 12 Acute stress reactions were found in percentages similar to those of suicide bomber explosions6 9except one case in which the suicide bomber detonated himself more than 25 m from the crowd and almost all the casualties had symptoms of stress and anxiety.12
Unsophisticated, low-weight and low accuracy rockets can cause a significant MCI. Factors such as the density of population at the explosion site and the lack of environmental and personal protection were major contributors to the high number of casualties in the incident described. Injuries to the upper parts of the body were more prevalent than seen in suicide bomber MCI. Mortality was lower than expected in view of the number of urgent casualties. The use of non-designated vehicles to evacuate patients without immediate life-threatening conditions may be justified in the first stages, when available ambulances are in limited numbers and distance to the nearest hospital is short. A typical two-phase evacuation profile was seen, with a high proportion of mostly stressed patients arriving in the late phase. Knowledge and anticipation of this pattern can help EMS, ED and hospital managements to prepare for patient flow. A semi-evacuation mode of hospital work enabled urgent casualty load reduction and better attention to each patient in a level one trauma centre. As improvised rockets are easily available to international terror organisations, they may become a worldwide threat. Emergency systems should be prepared for this.
Competing interests: None.
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