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This report is entirely in Swedish. Only summary in English

Terror bombings in Jerusalem, Ashkelon and Tel Aviv 1996 – KAMEDO-report 72

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.


Terror bombings aimed at killing and injuring civilians has become an instrument of terror used in a number of countries. The terror bombings are frequently carried out by suicide bombers who wear the bomb close to their bodies when it explodes, making it extremely difficult to detect in time.
The bomb attacks often target public places where large numbers of people are gathered with the aim of killing as many as possible, disseminating fear and terror among the population.
Since it’s inception, the state of Israel has suffered a large number of these terror bombings and has today built up a medical organisation that can quickly adapt to mass casualty situations. During the early half of 1996 the country was the target of four terror bombing attacks that occurred at different places within a short period of time. In all these situations an efficient pre-hospital and hospital organisation could operate independent of where the bombings occurred. An almost standardised scheme for managing these mass casualty situations was applied both at the pre-hospital as well as at the hospital level.
In order to study this efficient medical system, and also to evaluate the serious repercussions of terror bombings may have on the population, the authors had the privilege of visiting Israel. We were well received and had the opportunity of meeting personnel from several of the medical categories involved at all levels, as well as social workers, rabbi’s and others involved in the care of those suffering serious psychological and social problems in the aftermath of the attacks.
Some of the more important observations are highlighted below.

The prehospital organisation: the Adom Magen David

Although a majority of the ambulance personnel work in a voluntary capacity, the Adom Magen David is capable of mobilising, in a relatively short time, a large number of emergency crew and ambulances by using a collective beeper system.
Medical assistance at the scene of the accident should concentrate on assuring airways and breathing are unrestricted, and stopping external bleeding. Medical care at the site of the accident should be limited, in order to get the patient to hospital as quickly as possible. Special attention should be paid to the risk of tension pneumothorax which, if present, should be treated immediately by thoracocentesis.
Hospitals with an adequate trauma level and with a high level of preparedness, e.g. the Hadassah Ein Karem in Jerusalem, or the Ichilov in Tel Aviv, can receive a large number of patients from the same accident.

The hospital organisation

When the alarm of a major accident or a disaster reaches the hospital, it is important to have different levels of readiness. When a large number of medical personnel is needed urgently, a single alarm should be transmitted to all staff simultaneously.
Triage at the entrance to the emergency department should be performed by an experienced doctor, most often the senior surgeon. Medical care of the severely injured is best performed in areas where personnel normally work, such as the emergency department where the necessary equipment is easy to locate.
On arrival, the injured should initially only be given an identification number which will be used on all records, x-ray forms, etc. The patient’s real identify can be ascertained and used on medical records in the post-acute period.
The patients first treated and then transported from the emergency department should not return to the emergency room after x-ray, etc. Follow-up treatment should be carried out in other wards, in the x-ray department or in the operating theatre.
In the early phase of a mass casualty situation, only essential radiographs or other examinations should be performed. For the diagnosis of internal haemorrhages, ultrasonography is an important alternative to diagnostic peritoneal lavage.

Specific injury patterns of bomb explosions

Exploding bombs cause injuries by several mechanisms, mainly:
– the primary blast of air that directly or indirectly hits the body
– the propulsion of the human body itself against surrounding material
– the displacement of surrounding materials that may hit or penetrate the body
– the flash of hot gases that may cause burns and inhalation of noxious gases
Many of these mechanisms of injury are aggravated when the explosion takes place within confined spaces, which accounts for the more devastating effects on the victims seen in these situations.
Independent of whether the explosion takes place in the open air or in a confined space, blast injuries to the lungs, should always be assumed, in particular if the patient complains of ear symptoms. On arrival at the hospital, these patients should be routinely connected to pulse oximeters and undergo ear inspections. Patients with blast injuries to the lungs may initially present no signs of distress. However, they can rapidly develop a severe respiratory insufficiency. In certain cases, X-rays appear normal in the initial phase but shortly after change to indicate the so-called "white lung" (picture page 22).
Respiratory distress in patients may suddenly become aggravated and intubation should be performed liberally. The patients should then be sedated as coughing and other factors that increase intrathoracic pressure should be avoided in order to minimise the risk of pneumothorax or the occurence of air emboli.
Pneumothorax occurs frequently and may appear on both sides. Thoracic drains should be inserted liberally and in a sufficient number to achieve effective drainage. The chest drains prevent eventual tension pneumothorax if assisted ventilation is needed. The assisted ventilation should be performed with precaution to avoid over pressures.
When continuous air leakage into the chest drain is observed, surgical closure of the bronchopulmonary lesion should be considered in order to prevent chronic bronchopleural fistulas.
Penetrating injuries due to shrapnel or penetration of foreign material should in general be considered as high-energy injuries and treated by thorough debridement and delayed primary closure.

Psychological and social aspects

The psychological and social problems for the victims, their families, and society as a whole after this type of terror bombing are considerable, prolonged and difficult to evaluate adequately. During the early aftermath, the best support is most often rendered by those closest to the victim, e.g., the family, the religious community and other organisations. The health system should therefore co-operate with these organisations and only become involved when professional, psychological or psychiatric assistance is needed.
Religion has an important role in Jewish society, and probably becomes more prominent when people are confronted by sickness, death and grief. Rules, rites and rituals independent of religion or faith, serve to guide and comfort people through difficult periods, and needs to be accepted by society. It is of great importance that relatives be allowed the time and the opportunity to take farewell of their relatives in their own way.

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Susannah Sigurdsson
+46 (0)75 247 30 00