BURNING FLOWERS, BURNING DREAMS
CONSEQUENCES OF SUICIDE BOMBINGS
ON CIVILIANS IN ISRAEL 2000-2005
4.1 BEFORE AMBULANCES ARRIVE – WHAT HAS TO BE IN PLACE?
| 4.2 USING THE "TRIAGE" SYSTEM | 4.3. THE PENETRATING TRAUMA OF METAL SCREWS AND NAILS
| 4.4 THE ANATOMY OF TERROR – WHAT REALLY HAPPENS TO THE BODIES OF CIVILIANS BLASTED
BY SUICIDE BOMBERS? | 4.5 12-18 HOURS AFTER AN ATTACK – DEBRIEFINGS
| 4.6 MAINTAINING OVERALL CONTROL – ROLE OF THE SURGEON-IN-CHARGE
| 4.7 INSIDE A MASS CASUALTY EVENT | 4.8 FRONT-LINE HEALTH STAFF - WHAT THEY DO AND WHAT THEY FEEL
| 4.9 TERROR RELATED INJURIES IN CHILDREN ARE MORE SEVERE
| 4.10 MEDICAL INNOVATIONS – BITTERLY LEARNT | 4.11 HEPATITIS CARRIERS AND RAT POISON – AS TERROR WEAPONS
| 4.12 HOSPITAL VOLUNTEERS WHO DEMONSTRATE THE SANCTITY OF LIFE
| 4.13 THE CHALLENGES OF LONGER-TERM REHABILITATION | 4.14 TERRORISTS HAVE ABUSED THE HEALTH SYSTEM
| 4.15 ATTACKS ON ISRAELI AMBULANCES
This is a 'mass casualty ' situation, like after the double suicide bombing in Jerusalem's
Ben Yehuda pedestrian mall at 11.30 pm on Saturday, 1 December 2001. Eleven civilians died and one
hundred and eighty were wounded, many of them teenagers out for the evening. The Hadassah Ein Kerem
hospital received sixty-two wounded people within a very short time. By 1.30 am the doctors, nurses,
spokeswoman, emergency room reception staff, and dozens of other workers still had 10 hours of work
Premature detonation of an explosive device in open spaces results in fewer casualties, but when attacks involve crowded open spaces or semi-confined spaces, such as buses, initial reports of Emergency Medical Services may be confused and
contradictory. Israel has adopted a standardized response to attacks in crowded places. This involves
evacuation of the emergency room, a halt to scheduled operating room activity, and mobilization of
Regardless of distance emergency services crews are instructed to evacuate the most severely
These attacks resulted in a mortality rate of
17%. In survivors, they produced a combination of injuries: blast injuries manifested
by tympanic membrane perforation (perforation in the inner ear) in 25% of patients and with pulmonary (lungs) blast injury in 5% to
14% of patients. Occasional abdominal blast injuries resulted in rupture of the spleen or perforation of the
bowel. Shrapnel injuries occurred in 20%-42% of the victims, with a higher incidence in closed spaces. They
could be distributed over many body regions but usually entered from one direction. The shrapnel often
carried sufficient energy to produce severe tissue damage. Burns occurred in 15% of survivors. They were
more common and more severe in confined spaces and occurred mostly on exposed body surfaces facing the
blast" (Wolf & Rifkind 2002).
To simplify, treatment included: 'arteriography' (tracing the flow of blood in the arteries using X-rays); a treatment plan devised among vascular, orthopedic and plastic surgeons to determine type of 'fixations of bones' (fixing fractured bones with metal plates or screws), incisions, soft tissue coverage and the timetable involved; isolation of injured blood vessels; then, when blood flow had been re-established, shattered bones were fixed, and blood vessels repaired. Where necessary, arteries were reconstructed, injured major veins repaired, and skin grafts provided. With treatment of shrapnel blast injuries, fragments (such as large screws and nails) are often large with an irregular shape and their path within the body is unpredictable.
Often there are multiple injuries. "Soft tissue injury is a decisive factor in the ability to
salvage injured limbs, particularly after blunt trauma. Most important, in massive soft tissue injury, in
addition to the named veins, numerous venous collateral channels have been severed as well. Penetrating
injury by definition carries infectious agents into the body and creates a port of entry (antibiotics are
required as well as surgical irrigation and drainage of wounds). The rate of infection involving vascular
reconstruction, in the authors' experience, is 4%; however, following a bomb injury that took place in a
vegetable marketplace, the rate of fungal infection was significantly higher than in similar attacks at other
Suicide bombing victims suffer multiple penetrating wounds, blast injuries and burns.
"The approach to victims of suicide bombings is based on the guidelines for trauma management in general,
but has to include, specifically, large number of victims, effects of penetrating trauma, blast injuries and
burns, and the numerous penetrating wounds sustained by each victim. Attention is given to the moderately
injured, as these patients may harbour immediate life-threatening injuries. The concept of damage control
can be modified to include rapid packing of multiple soft-tissue entry sites. Optimal use of manpower and
resources is achieved by recruiting all available personnel, adopting a pre-determined plan, and a
centrally coordinated approach. Suicide bombing attacks seriously challenge the most experienced health facilities"
(Almogy et al. 2004).
"There are several factors to consider in understanding the bodily damage caused by the recent wave of
suicide bombing attacks in Israel: a) the high-grade explosive material used by the attackers; b) the ability of the attackers to detonate the explosive device in proximity to the victims by concealing the explosive device and mingling within a crowd; c) the ability of the attacker to precisely time the explosion at his or her discretion; and d) the large load of heavy shrapnel that accompany the explosive material.
All these factors are combined by the attackers to increase the number of casualties and the severity of their injuries. The
injuries sustained by the victim depend on the proximity of the victim to the explosive device, the angle at
which the victim stands in relation to the center of the explosion, and the height of the explosive device in
relation to the victim. The circumstances associated with these attacks also influence management and
decision- making. The uncertainty as to the arrival of additional victims, the mayhem associated with the
arrival of anxious family members, the florid scenes associated with these injuries, the often young age of
the victims, the possibility that family members of hospital personnel are among the victims, and the risk of
second-hit explosions intensify the chaotic atmosphere that already exists in the emergency department.
These factors underline the importance of forming a plan at the hospital level designed to deal with these
circumstances" (Almogy et al. 2004).
A July 2003 article described the pattern of injury of terror victims hospitalized at 9 acute-care hospitals in Israel during a 15 month period of terrorism. "During the study period 23,048 patients were recorded, 561 (2.4%) injured through terrorist attacks... Thirteen percent of terror victims compared with 3% with other traumatic injuries arrived by helicopter. Injury mechanism consisted mainly of explosions 48% of 269 injured, and gunshot injuries 47% of 266 injured. One third of this population experienced severe trauma.
One hundred and forty-two patients (26%) needed to be admitted to intensive care. Inpatient mortality was 6% of 35 admitted. Fifty-five percent of injuries (of 306) included open wounds and 31% (of 172) involved internal injuries (and) 39% of 221, sustained fractures. Half of the patients had a procedure in the operating room (298) Duration of hospitalization was longer than two weeks for nearly 20% of the patients" (Peleg et al. 2003).
BLAST INJURIES -WHAT THEY DO AND WHAT ELSE TO SEARCH FOR
When three aircraft crashed into three buildings on September 11 2001, it reminded healthcare workers of
the magnitude of injuries and death that can result from a blast mechanism. Internationally, explosive
devices frequently are used in war or acts of terrorism. Much of the challenge facing the care providers is the potential for the sudden creation of large numbers of patients requiring extensive medical resources.
This scenario can overwhelm local EMS and hospital resources. In general, most blast injuries cared for by US
emergency departments tend to be accidental, including firework mishaps, unintended occupational or
industrial fuel eruptions, and unseen mine explosions. In many parts of the world, however, the reality
persists of deadly, dormant, non-detonated, military incendiary devices such as landmines and hand
grenades. Such devices cause significant numbers of civilian casualties years after local hostilities cease.
During wartime, injuries arising from explosions frequently outnumber those from gunshots; many victims
are innocent civilians. Explosive devices inflict bodily harm by a variety of mechanisms, with multiple
provisos ultimately determining the number of victims injured and killed.
A case in point is that detonation forces (even those deemed low by most standards) can trigger the collapse of a building, crushing and maiming victims inside and nearby. There is also concern about radiation, chemical or biological contamination of explosion victims. Careful observation for signs and symptoms of exposure to poisonous chemicals, screening for radiation contamination and decontamination of patients as needed, are important steps in the management of victims of non- accidental explosions.
In the first attack on the World Trade
Centre, terrorists attached cyanide to a bomb placed in the underground parking garage. Fortunately, in that
incident the cyanide was destroyed by the combustion. Hospital staff need to search for evidence of
radiation, chemical or biological contamination in persons with blast injuries, as well as EMS personnel
checking for radiation at the scene of the explosion. (This paragraph is indebted to Lavonas 2004 and has
been simplified for a general audience.)
Understanding the basics about blast injuries
|Blast injuries are traditionally divided into four
A study in the nineties had looked at the link between eardrum perforation and pulmonary blast injury in 647 survivors who arrived at hospitals after 11 terrorist bombings in Israel between 6 April 1994 and March 1996. It was found that 193 (29.8%) of them sustained primary blast injuries including 142 with isolated eardrum perforation and 51 with other forms of blast injuries (Leibovic, D. et al. 1999).
DUAL EXPLOSIONS CAUSE VERY SERIOUS INJURY
An explosion that occurs in an enclosed space, such as a bus, or in water tends to cause very serious injury. The intensity of an explosion pressure wave declines with the cubed root of the distance to the explosion. A person three metres (10 feet) from an explosion experiences 9 times more overpressure than a person six metres (20 ft) away. Proximity of the person to the explosion is an important factor in a primary blast injury.
Blast waves are reflected by solid surfaces, so a person standing next to a wall may suffer increased primary blast injury. Another ominous consideration is the tactic of setting dual explosions. The initial explosion is intended to injure civilians and to attract law enforcement and rescue personnel, followed by a delayed explosion designed to injure rescuers. Hospital disaster plans should include tight security at all hospital entrances in the event of a terrorist explosion in the community. All hospital personnel should be alert for unattended packages. In addition to protecting hospital patients and staff, sealing entrances helps control the chaotic flow of patients and visitors (Lavonas 2003).
The Surgeon in Charge (SIC), department chair, treating teams, nurses, nurse coordinators hospital
administration, hospital spokesperson and EMS representatives all participate in the debriefing discussions.
The event is reviewed and analyzed beginning with the correlation between initial Emergency Medical
Services reports and the number and condition of casualties, the number and makeup of teams participating in the event, the number of patients requiring surgery and timing of their surgery, the requirement for additional intensive care unit beds, and the need to cancel non urgent procedures. Some of the recommendations that we have implemented include: recruitment of personnel via telephone lines and not pagers or cellular phones which crash due to overload, placement of a portable sonogram in the trauma room, transformation of recovery room beds into temporary intensive care unit beds, regulation of
physician's leave, and creation of the roles of SIC and nurse coordinator. The days following an attack are
not normal. After the Sbarro attack and as a result of the overload on the ICU two major surgical procedures were postponed (in one Jerusalem hospital)." (Almogy et al. 2004)
In the hospital setting, "control and coordination are achieved by the 'accordion approach', where patient
evaluation and management proceed through repeated cycles consisting of a dispersal and a convergence
phase... Activity is coordinated and controlled by the surgeon-in-charge who is aware of the overall situation and has the oversight to prioritize evaluation and treatment Chaos is gradually managed once the number of patients requiring further work up is reduced. Patients undergoing surgery, often simultaneously by different teams, are reassessed by the surgeon-in-charge or in the operating room with the treating teams. The overall condition of the patient, the sequence of therapy, the need for further imaging studies, and the need for intensive care unit admission are discussed and finalized" (Almogy et al. 2004)
"The basic rules and concepts of trauma management are applied... Their application may be modified in
different situations. As in all trauma cases, airway control and acute breathing problems are prioritized.
Victims with low blood pressure due to penetrating abdominal or chest trauma are taken to the operating
theatre to receive 'laparotomy' (an operation opening the abdomen by an incision through the abdominal
wall) and/or 'thoracotomy' (surgical opening of the chest cavity to inspect or operate on the heart, lungs or other structures within.)...Multiple shrapnel entry sites are common in survivors and it is impossible to
determine which of the numerous entry sites is the cause of (the low blood pressure). Many hours and
sometimes days are required for the situation to stabilize and eventually normalize. Treating teams are
physically and emotionally exhausted from the continuous workload, especially when repeat attacks occur
within days. There are regular assessments by the surgeon-in-charge and the treating teams to ensure all
patients receive optimal care. A strong personal commitment by the treating teams and surgeon-in-charge is pivotal to success. This may have to last from several hours to days depending on the magnitude of the attack. During this period other professional and personal commitments are sacrificed" (Almogy et al. 2004).
Emergency medicine specialist killed by suicide bomber in Jerusalem Cafe.
|In September 2003 Doctor David Appelbaum and Professor Jonathan Halevy, director of Shaare
Zedek hospital in Jerusalem had both been in New York near Ground Zero discussing ways of
responding to 'mass casualty events'. The next night Dr. Appelbaum was himself a victim of the
About an hour later, a paramedic and a physician – both trained by Dr Appelbaum – identified his body at the scene. It took a few more hours to identify Nova, "it was the most horrible night of my life' said Halevy. 'We were taking care of the injured, and crying all through the night'.
In Jerusalem's Hadassah Ein Kerem hospital in 2001 staff painted a vivid picture of what it is like to be
'inside' a mass casualty situation. A suicide bombing on 1 December 2001 in the downtown pedestrian mall of Ben Yehuda had killed 11 people and wounded 180. Hamas claimed responsibility for the attack.
Some unconscious wounded children were listed as 'anonymous' as searching parents swung between hope and despair.
Shoshi was a new reception clerk in the hospital emergency room. She was driving to work for her
Soon the families and friends of the victims began filling up the waiting area. 'Oh, the waiting! One mother waited about 5 hours to find out if her son was dead or alive, or how he was. She really went hysterical. I worked like a robot without thinking. I saw people were watching TV – the news about the attack.' 'An unusually high number of foreign journalists from Norway, Japan, Germany and France wanted access to the victims and their families everybody wanted to photograph the wounded. The reporters get there before the ambulances.'
For the first three hours, she kept them from entering the building, until ER had finished with all the patients and sent them to X-ray, surgery or other departments. As she moved through the wounded in the ER, she looked for those with the mildest injuries. 'You have to be delicate. I ask them how they are feeling, talk with them and their families, and only at the end ask them if they want to be interviewed. Five agreed. Journalists are always looking for a dramatic story, so I found one boy whose brother had been wounded badly in a bus bombing a few years ago. At least 7 or 8 people refused to talk to the media. I never press them. In a situation like that some people feel a need to talk, and others just want their privacy.'
Again and again, the parents asked the social workers to check at the other hospitals if their children had turned up. 'One thing we never tell them,' said the director of Hadassah social services, 'is, Don't worry, everything will be all right. They swing between hope and despair and we try to hold them up. But it is clear to us that the longer they are here, the longer their children have not been found at one of the hospitals, the more it points to their being at Abu Kabir (the forensic institute). Because the victims are so young, I reacted in part as a mother. I was thinking, this could have been my child. It makes you feel so powerless. You think, we can't even protect our children anymore.'
Shoshi, the new clerk, finished her night shift at eight the next morning. Driving home she turned on the radio and listened to the news. 'That's when the penny dropped. To tell you the truth, I didn't stop crying until I got home. I slept until one o'clock that afternoon. Then a friend telephoned and told me that 15 people had just been killed by a suicide bomber in Haifa.'
Elsewhere in Israel similar scenarios have been played out over and over again during the past four years. A front-line senior nursing supervisor recalled how she prepares her hospital to receive bomb casualties.
"Staff Call Me the 'King of Terror' Because I Organize Everything"
|"We first know when a suicide bombing has taken place in various ways. Civilians may phone our
Emergency Room (ER), or we may hear from Magen David Adom (Israeli equivalent of Red Cross). Or, the police may phone us. If I am at home and I hear there has been an attack I call the hospital to find out if it is correct, and the number of confirmed wounded. Then I call the hospital administrator, then the surgery room to tell them to prepare for surgery and giving of blood. I call extra doctors and nurses to mobilize them in minutes (everyone knows their roles), and security.
I take one doctor to the front of the Emergency Room to assess the incoming casualties and organize orderlies to take them to the correct receiving places. Security has also to deal with a flood of people trying to enter the Emergency Room. I take one nurse and she sits near the telephone until a social worker arrives. We get desperate calls from relatives seeking family members to know if they are dead or alive. She is the first to talk to them. We allow one relative to stay with a patient, especially if it is a wounded child who needs their mother.
Then there is a 'second wave' of traumatized people entering the hospital. We take them to our large hospital bomb shelter, which has been specially prepared to receive them. They can see psychologists, psychiatrists, psychiatric nurses and a trauma specialist nurse. It takes about half an hour for our hospital management to arrive. At around this time I begin to have feelings, and afterwards it takes about a week to feel like myself again. We health staff have to do everything at the time without letting feelings emerge or stress.
One time near my home there was a large-scale bus suicide bombing. I heard the blast. My son said it was a bomb. I didn't want to believe him, almost like a denial. Then I looked out of my window and saw the smoke. I really knew then it was a bombing. I went immediately to the hospital. We see seriously injured people all the time, from road traffic accidents, but not like the multiple casualties after a suicide bombing. It is harder to organize. A road traffic accident has other causes. We civilians cause them. In our hearts, we health staff are also afraid that a member of our own family may turn up in the ER.
We have volunteers who come to help us when the multiple casualties are brought in. Some are
We also learned that we need to take psychologically traumatized people out of the emergency room to another place in the hospital. Our staff function well as a team. They have not received any special courses, except for psychiatric nurses. Sometimes we have in-house lectures they can attend, like from an Israeli Community Crisis Prevention specialist.
Some of our hospital staff are Arabs. Some of them try not to talk about the suicide bombings. Some seem to understand the motivation of the bombers. Some seem to feel some sympathy for them, and you can feel it. They say "Israel doesn't do enough for Palestinians." One time we had the body parts of two suicide bombers who blew themselves up in a bus station, brought into the hospital in five to six sacks. This was the same time as their victims were being admitted. I didn't know how to fit all the bags in the fridge. After that time the hospital no longer accepted suicide bombers' bodies, but sent them directly to the forensic institute."
A hospital further south on the coast has experienced similar mass casualty events. A senior Emergency
Room nurse explains how she prepares the ER for in-coming terror attack victims.
"Time Zero – My job is to think of Doomsday — and prepare for it."
|A senior ER nurse explains, " Our town is so small (80,000 people) that when suicide bombers
detonate their explosives the immense blast can be heard all over town. In less than two minutes our
450-bed hospital receives its first phone call. Maybe a private car will pull up outside the ER bearing
the first-blood-stained patient. Then the ambulances start arriving.
On 27 March 2002 when the Park Hotel Passover bombing took place, in which 30 people were killed and 140 wounded, 20 seriously, it
took only 12 minutes for the first 22 victims to reach the hospital.
I always have to imagine the worst-case scenario, and spread out my 'troops' (staff). We call the time
If you want to save lives you need a common Protocol, because you have to work so fast that nothing should be based on memory. I make the first phone call, which simultaneously reaches three people. I have heard people talk about the important 'golden hour' they may have to prepare for reception of victims in ER. But, we don't have an hour – we only have a 'golden minute'.
One time five families all claimed one victim belonged to them. What to do? I told them all gently to go and bring a photo back of their missing loved one. We reduced the possibility of identification to two. Then one got a phone call – they had found their girl. This left one family. I asked for a family representative and talked to him to 5-10 minutes to prepare him to see his dead family member. I showed him a small part of what was left of her face. He recognized her.
In the emergency room all beds have first aid equipment ready to use. All patients routinely receive pain control measures, blood if required, tetanus immunization, anti hepatitis B vaccine, and warm intravenous fluids if they require them. After the Dolphinarium bombing where the suicide bomber was found to be a carrier of hepatitis B, this procedure has become standard.
We have special laminated 'Protocol cards" which they carry, and which enables them to carry out special procedures, like giving intravenous fluids to patients over ten years of age, which is normally done by doctors.
Terrorism has in mind to inculcate fear and death, to neutralize life-savers. We try to put a smile on people's faces. Our staff are always striving for excellence. They say 'how can we do what we do even better?" Terror is not the private lot of Israel. Without a disaster medicine system in place other countries will find it harder to save lives. I hope people can learn from our system how to adapt it for their own needs. They need to do it today." We have had a 20-year period in which these things have had to be learned. We are 15 years ahead of many hospitals worldwide as far as rapid response in terror attack is concerned.
THE CONTRIBUTION OF TRAUMA CENTRES TO SURVIVAL
"The trauma chain of treatment comprises several phases. The first is the pre-hospital phase, where care is afforded by non-professional bystanders and by professional emergency medical service teams. The hospital phase includes the admitting area, the imaging and laboratory services, the operating rooms, the intensive care unit, and the department to which the patient is transferred. The final phase is discharge, which should include rehabilitation care... The trauma system in Israel has travelled a long road to create an appropriate structure and process, by establishing the criteria as well as adopting guidelines offered by the American College of Surgeons with minor necessary modifications... There are different accounts in the literature regarding the relationship between mortality and the existence of trauma centres, although most emphasize the contribution of trauma centres to survival" (Shapira 2002).
Hospital-based trauma units have an inlet of
injured patients from the community, and ideally require an outlet to the community and to some form of
supportive rehabilitation system, either an inpatient or outpatient setting. Insurance coverage and
reimbursement methods will influence both the length of stay in a tertiary centre and accessibility to
rehabilitation and medical follow-up.
An article in 2003 observed: "In the past two years hundreds of Israeli children have been wounded in terror attacks. There is a paucity of data on terror-related trauma in the pediatric population and its effects on the health care system... (A study was carried out) to review the accumulated Israeli experience with medical care to young victims of terrorism and to use the knowledge obtained to contribute to the preparedness of medical personnel for future events... Data on all patients who were hospitalized from 1 October, 2000 to 31 December 2001 for injuries sustained in a terrorist attack were obtained from the Israel National Trauma Registry. The parameters evaluated were patient age, sex, diagnosis, type, mechanism and severity of injury, inter-hospital transfer, stay in intensive care unit, duration of hospitalization, and need for rehabilitation.
Findings were compared with the general pediatric population hospitalized for non- terror-related trauma
within the same period... During the study period, 138 children were hospitalized for a terror-related injury and 8,363 for a non-terror-related injury. The study group was significantly older (mean age 12.3 years versus 6.9 years) and sustained proportionately more penetrating injuries... Differences were also noticed in the proportion of internal injuries... open wounds to the head, and critical injuries. The study group showed greater use of intensive care, (longer stay in hospital) and greater need for rehabilitative care... Terror-related injuries are more severe than non-terror-related injuries and increase the demand for acute care in children" (Aharonson-Daniel 2003).
The growing Israeli experience of treating victims of suicide bombings is already being shared internationally.
Fighting amputation to keep the legs of one survivor but leaving metal balls near the spine of another
Fifteen-year-old Adi, was one of the almost 200 casualties brought by ambulance to Hadassah
In the summer of 2001, the Health Ministry announced that all survivors of suicide bombing attacks in Israel were to be vaccinated against hepatitis. "This policy was set after the Ministry's infectious disease laboratory found that two suicide bombers were carriers of hepatitis B, and that a passer by who was wounded in the blast had been left with a fragment of the bomber's bone in his own body (the vaccination with hepatitis B was a precautionary measure).. .Any blood-borne disease with a carrier stage, such as hepatitis B and C, and HIV/AIDS could theoretically be passed on to anyone whose skin is penetrated by biological material from a suicide bomber. There is no protective vaccine against hepatitis C and HIV, but the hepatitis B vaccine is safe and effective...The incubation period for hepatitis B is about 6 weeks... Hepatitis B is endemic in the Middle East. About 10% of the Arab population in Israel and the Palestinian territories are carriers, compared with only 1-2% of the Jewish population...All health-related workers – including doctors, nurses, ambulance volunteers and burial staff – who deal with the dead and wounded after terrorist attacks are vaccinated against hepatitis" (Siegal-Itzkovich, 2001).
Doctors had also been noticing that when they
operated on people wounded in suicide bombing attacks, patients often continued to bleed even after being
sutured. Eventually, a young medical resident figured out why. The terrorists had filled their bombs with
nails, screws, glass shards and pieces of shrapnel, and these had been dipped in rat poison, which acted as an
anticoagulant, stopping blood from clotting. Vitamin K was used to control bleeding in wounded terror
victims where there was suspicion of rat poison being used by the bombers. A 2005 article on injuries from
biological material of suicide bombers (like bone fragments) concluded that such materials may transmit
severe, incurable infectious diseases (Eshkol & Katz 2005).
Israel has always relied on voluntary work to achieve many social objectives. The need for volunteers during the Second Intifada saw an outpouring of volunteers in many fields, particularly in the field of health.
In the coastal town of Netanya, students from a religious 'yeshiva' (rabbinical academy) have undergone
training so that they can respond to nearby Laniado Hospital in emergency situations. They are on call 24
hours a day, seven days a week. The ages of the 150 volunteers range from 18 to 50, and they are regularly drilled under the supervision of hospital staff and the Home Front Command of the Israeli Defence Forces.
After an attack on 14 June 2002 in a Netanya market place, the hospital told them that with their assistance never before had the surgeries gone so smoothly.
The doctors and nurses were able to put their entire effort into the surgical procedures, while the trained
volunteers rushed the blood to the laboratories to be typed, tested for RH factor, labeled them, and raced the blood back to the operating theatres. "In the first 20 minutes after an attack, the volunteers, who have also been trained to assist in taking the injured from the ambulances, filling out forms for identification and classification of injury, and expediting transfer to the correct sections of the hospital for treatment, helped save lives.
These yeshiva students were recognized by the Commander of the Home Front Command as
being the most successful group of volunteers to do these jobs because they were responsive and exacting in
their methods. Additional training was being considered in 2002. A Rabbi from the Talmudic Academy had
studied life support in the USA and been a volunteer member of an ambulance corps. Another Rabbi in the
group recruits students for special hospital assistance in the operating rooms, and those trained by Magen David Adom, to administer CPR in emergency situations, to visit the sick and support family members. He is also in charge of a blood drive, a loan organization for medical equipment and financial assistance for people who require expensive medications. He says "It is our duty to help one another. One of the most important principles of the Torah is the sanctity of life" (Hershnson.S 2002.)
"There are three goals in rehabilitation: healing, becoming able and rejoining the community. This includes both the injured person and the whole family". (Hobbs. L et.al. 2002) Some of the wounds, both physical and psychological, caused by the suicide bombers take a long time to heal. The Director of a Rehabilitation Unit in a Jerusalem hospital explains:
Rehabilitation Takes Time, We Work With Tragedy
|When a suicide bomber detonated at the Ben Yehuda pedestrian mall in Jerusalem a 24-year-old
Israeli civilian received serious brain injuries. For one year, he was treated at the Rehabilitation Unit
at the Hadassah Mount Scopus Hospital. By the second year, he was still not speaking, and totally
dependent on his caregivers. By the third year, he had gradually begun to improve. Today, he is
walking 10-20 metres with help.
The majority of patients admitted from suicide bombing attacks had injuries to blood vessels, fractured bones, and shrapnel, nails and screws embedded in their brains. The average length of admission in the Rehabilitation unit was 2-3 months. The Unit has acquired a new 'robot'-assisted computerized device to rehabilitate patients and to help them walk again after incomplete spinal cord injuries, or strokes. Body support is put on the legs, and the system has a psychological effect similar to walking. The system was developed originally in Germany and Switzerland.
The Unit is also using a 'virtual reality' computerized treatment for those with serious brain injuries. Patients are placed in different situations, such as making a trip to a supermarket alone. Some treatments are paid for by Terror Victim's Organizations and some by the national Social Security system. Some patients receive treatment 2-3 times a week from 8 am to 4 pm, assisted by physiotherapists, speech therapists, social workers, and computer operators.
The last section of this chapter looks briefly at ways in which the Israeli health system has been abused
during the Intifada.
Israeli soldiers at roadblocks carry out security searches of Palestinian ambulances and vehicles carrying
Palestinian patients, women in the process of giving birth and medical teams. Such searches may cause a
delay in their transfer. Such thorough searches are the result of past cases of the misuse of ambulances to smuggle terrorists or weapons or the disguising of terrorists as patients. As a result of warnings that a terror attack at the entrance of an Israeli hospital is being planned and that it will be carried out by a Palestinian ambulance or a stolen Israeli ambulance, Israeli hospitals have had to increase their caution whenever any Palestinian ambulance or Israeli ambulance nears an Israeli emergency room.
In 2005 a doctor in MDA ambulances reported that every Israeli ambulance is searched every time it enters an Israeli hospital. Stringent security measures must be conducted before an ambulance is permitted to approach the emergency room area and before its patients, escorts and medical team are permitted to enter the emergency room (World Health Organization, 2003).
During the current Intifada, Israeli hospitals have continued to provide medical care to Palestinian patients without interruption. In the period between April 2001 and April 2002, some 11,000 patients from the West Bank and Gaza were treated in Israeli hospitals. Another 10,000 patients from Palestinian areas were treated in Israeli hospitals between April 2002 and April 2003; a quarter of these patients were referred for hospitalization and three quarters were referred for ambulatory services including hospitalization in day-care units, consultations at outpatient clinics, and sophisticated diagnostic and investigatory procedures and laboratory tests of a wide variety. The Palestinian Authority stopped payments to Israeli hospitals, leaving an accumulated debt of around USD 4 million. In spite of the large debt, Israeli hospitals continue to admit Palestinian patients and casualties for treatment without political considerations, delays or restrictions (World Health Organization 2003).
The MDA and Palestinian Red Crescent continue to cooperate in emergencies and in evacuating the
wounded. Israeli trauma units and emergency medical departments continue to treat Palestinians. And this in spite of the fact that, very often, MDA ambulances arriving to treat the injured in areas of confrontation have been attacked.
During the first year of the Intifada, 71 Israeli ambulances were damaged by terrorists or
rioters. There have been several proven cases of misuse of Palestinian ambulances to transport ammunition
or explosive belts, or to transfer terrorists. The Israeli Ministry of Health and relevant authorities allow the
admission of medicines, medical equipment and ambulances as donations to the Palestinians from European and Arab countries and international organizations.
In 2002 the Israel Medical Association stated that it "unequivocally denounces the employment of terrorism in general, and the use of human bombs, whose sole objective is the indiscriminate killing of innocent civilians and the spread of fear among the general public, in particular. (It) expresses deep sorrow at the loss of life and suffering caused to both peoples in the course of the present conflict and is concerned over the spread of the conflict to innocent civilians in large population centers... (It) condemns the immoral use of ambulances for purposes of terrorism and sabotage... Our soldiers will continue to face difficult dilemmas every time a Palestinian Red Crescent ambulance speeds towards them. Our physicians will continue to face the emotional difficulty of treating the mangled bodies of children caught in a suicide bombing while doing their utmost to ensure the quick and optimal access of Palestinian civilians to necessary care in Israel. We will all continue to dream of the day when an Israeli can go to the pizza store, and a Palestinian can reach his doctor without it being an international event. We will all continue to dream of peace" ( Blachar. Y 2002).
International evidence may continue to point to the crumbling and struggling nature of the Palestinian health infrastructure, but while suicide bombers continue to slaughter Israeli civilians, it seems ironic that their taxes should be involved in providing health care for those who send the bombers.
Selected additional information for the 2009 edition.
From October 2000- January 2004, 577 victims of suicide bombings were admitted to the Hadassah-Hebrew University Medical Center. "A single bomber carrying a handbag or belt containing multiple metal objects and explosives carried out most of the attacks. As a result, many of the victims suffered massive tissue destruction in addition to conventional blast injuries." (Ad-El D. D. et al. 2006).
Of a total of 1,155 patients injured by explosions between 2000-2004, nearly 30% suffered severe to critical injuries. Triage has changed as metal parts contained in bombs penetrate the human body with great force and may result in tiny entry wounds easily concealed by hair, clothes etc. "Specific injuries will require tailored approaches, an open mind, and close collaboration and cooperation between trauma surgeons to share experience, opinions and ideas". (Aharonson-Daniel L. et al. , 2006).
Most patients operated on within the first 2 hours require multidisclipinary surgical teams (Einav S. et al. 2006.)
Terror attacks may produce several modes of severe penetrating injuries causing high-grade open fractures of long bones. (Weil Y.A et al. 2007).
During a two year period in Israel which saw 41 mass-casualty events, 160 children were hospitalized with injuries mostly caused by blasts and
penetration of foreign objects. Sixty-five percent of children had multiple
injuries. Terrorism-related injuries in children are severe and increase the demand for acute care. (Waisman Y
et al. 2003).
The suicidal bus bombing of French nationals in Pakistan and subsequent hospital admissions highlighted
treatment in the context of the limited medical resources of a developing nation. (Zafar H. et al. 2005).
Terrorist bombings inflict injury of a distinctly different pattern than other means of trauma. The simultaneous combination of different injury mechanisms in explosions results in a multidimensional injury pattern and a complicated clinical course. Hospital preparedness and medical team awareness of the unique nature of the injuries are mandatory for improving the outcomes of these patients. (Kluger Y et al., 2004).
At 7:39 on 11 March 2004, 10 terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing 177 people instantly and injuring more than 2000. There were 14 subsequent in-hospital deaths, bringing the ultimate death toll to 191. Of 243 in-patients patients 52% suffered head trauma. (de Ceballos J.P et al. 2005).
Two mass-casualty terrorist attacks had occurred in Istanbul, Turkey in November 2003 when improvised
explosive devices in trucks were detonated outside the Neve Shalom and Beth Israel synagogues killing 30 people and wounding around 300. Five days later similar trucks were detonated outside the Hong Kong Shanghai Banking Corporation headquarters and the British Consulate killing 33 and wounding around 750 others.
Terrorist attacks in Southeast Asia were almost nonexistent until the 2002 Bali bomb blast. There were further attacks in Jakarta in
2003 and Bali in 2005. A burns disaster plan was recommended and use of a health care team concept " to ensure
that the sudden onset of a crisis situation at an unexpected time does not overwhelm hospital manpower and
resources". (Chim H et al. 2007).
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