Prehospital Care Under Fire: Strategies for Evacuating Victims from the Mega Terrorist Attack in Israel on October 7, 2023.

On October 7, 2023, somewhere around 1,500-3,000 terrorists invaded southern Israel killing 1,200 people, injuring 1,455, and taking 239 as hostages resulting in the largest mass-casualty event (MCE) in the country's history. Most of the victims were civilians who suffered from complex injuries including high-velocity gunshot wounds, blast injuries from rocket-propelled grenades, and burns. Many would later require complex surgeries by all disciplines including general surgeons, vascular surgeons, orthopedists, neurosurgeons, cardiothoracic surgeons, otolaryngologists, oral maxillofacial surgeons, and plastic surgeons. Magen David Adom (MDA) is Israel's National Emergency Prehospital Medical Organization and a member of the International Red Cross. While there are also private and non-profit ambulance services in Israel, the Ministry of Health has mandated MDA with the charge of managing an MCE. For this event, MDA incorporated a five-part strategy in this mega MCE: (1) extricating victims from areas under fire by bulletproof ambulances, (2) establishing casualty treatment stations in safe areas, (3) ambulance transport from the casualty treatment stations to hospitals, (4) ambulance transport of casualties from safe areas to hospitals, and (5) helicopter transport of victims to hospitals. This is the first time that MDA has responded to a mega MCE of this magnitude and lessons are continually being learned.

Revolutionizing Bladder Health: Artificial-Intelligence-Powered Automatic Measurement of Bladder Volume Using Two-Dimensional Ultrasound.

INTRODUCTION: Measuring elevated post-void residual volume is important for diagnosing urinary outflow tract obstruction and cauda equina syndrome. Catheter placement is exact but painful, invasive, and may cause infection, whereas an ultrasound is accurate, painless, and safe. AIM: The purpose of this single-center study is to evaluate the accuracy of a module for artificial-intelligence (AI)-based fully automated bladder volume (BV) prospective measurement using two-dimensional ultrasound images, as compared with manual measurement by expert sonographers. METHODS: Pairs of transverse and longitudinal bladder images were obtained from patients evaluated in an urgent care clinic. The scans were prospectively analyzed by the automated module using the prolate ellipsoid method. The same examinations were manually measured by a blinded expert sonographer. The two methods were compared using the Pearson correlation, kappa coefficients, and the Bland-Altman method. RESULTS: A total of 111 pairs of transverse and longitudinal views were included. A very strong correlation was found between the manual BV measurements and the AI-based module with r = 0.97 [95% CI: 0.96-0.98]. The specificity and sensitivity for the diagnosis of an elevated post-void residual volume using a threshold ≥200 mL were 1.00 and 0.82, respectively. An almost-perfect agreement between manual and automated methods was obtained (kappa = 0.85). Perfect reproducibility was found for both inter- and intra-observer agreements. CONCLUSION: This AI-based module provides an accurate automated measurement of the BV based on ultrasound images. This novel method demonstrates a very strong correlation with the gold standard, making it a potentially valuable decision-support tool for non-experts in acute settings.

Integrating the six C's of disaster response: Lessons from the mega terrorist attack on October 7, 2023.

On October 7, 2023, over 2,500 Hamas terrorists infiltrated Israel from Gaza and killed over 1,400 people and injured 2,800, resulting in the largest terrorist attack in Israel's history. Several models describe the principles of managing a mass casualty event. One of them is an Australian construct known as the six C's. While command, control, and coordination are familiar concepts, the six C's emphasize the importance of communication and community (consequences and community connection). We describe how two emergency departments in Israel-Assuta Ashdod and the Hadassah Medical Center-Ein Kerem-responded to this disaster in the context of the six C's.

Artificial Intelligence-Based Left Ventricular Ejection Fraction by Medical Students for Mortality and Readmission Prediction.

INTRODUCTION: Point-of-care ultrasound has become a universal practice, employed by physicians across various disciplines, contributing to diagnostic processes and decision-making. AIM: To assess the association of reduced (<50%) left-ventricular ejection fraction (LVEF) based on prospective point-of-care ultrasound operated by medical students using an artificial intelligence (AI) tool and 1-year primary composite outcome, including mortality and readmission for cardiovascular-related causes. METHODS: Eight trained medical students used a hand-held ultrasound device (HUD) equipped with an AI-based tool for automatic evaluation of the LVEF of non-selected patients hospitalized in a cardiology department from March 2019 through March 2020. RESULTS: The study included 82 patients (72 males aged 58.5 ± 16.8 years), of whom 34 (41.5%) were diagnosed with AI-based reduced LVEF. The rates of the composite outcome were higher among patients with reduced systolic function compared to those with preserved LVEF (41.2% vs. 16.7%, p = 0.014). Adjusting for pertinent variables, reduced LVEF independently predicted the composite outcome (HR 2.717, 95% CI 1.083-6.817, p = 0.033). As compared to those with LVEF ≥ 50%, patients with reduced LVEF had a longer length of stay and higher rates of the secondary composite outcome, including in-hospital death, advanced ventilatory support, shock, and acute decompensated heart failure. CONCLUSION: AI-based assessment of reduced systolic function in the hands of medical students, independently predicted 1-year mortality and cardiovascular-related readmission and was associated with unfavorable in-hospital outcomes. AI utilization by novice users may be an important tool for risk stratification for hospitalized patients.

Characteristics and Motivational Factors of Whole Blood and Convalescent Plasma Donors during the SARS-CoV-2 Pandemic in Israel.

Demands for whole blood (WB) and COVID-19 convalescent plasma (CCP) donations during the SARS-CoV-2 (COVID-19) pandemic presented unprecedented challenges for blood services throughout the world. This study aims to understand the motivating factors that drive WB and CCP donations in the context of the pandemic. This cross-sectional study is based on data extracted from surveys of the two volunteer donor cohorts. The findings reveal that when compared to CCP donors, WB donors were more likely to view donation as a form of social engagement (97.7% vs. 87.1%, p < 0.01), advantageous in the workplace (46.4% vs. 28.6%, p < 0.01), advantageous in their social network (58.6% vs. 47.0%, p = 0.01), and view their donation in the context of positive self-satisfaction (99% vs. 95.1%, p = 0.01). The average age of CCP donors was 7.1 years younger than those who donated WB (p < 0.01). Motivational factors were also analyzed by sex and religiosity. In conclusion, whereas both donor groups showed a high motivation to partake in these life-saving commitments, WB donors were more likely to be motivated by factors that, when better-understood and implemented in policies concerning plasma donations, may help to increase these donations.

Secondary Ambulance Transfers During the Mass-Casualty Terrorist Attack in Israel on October 7, 2023.

On October 7, 2023, Israel experienced the worst terror attack in its history - 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel's National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals - the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.

Point-of-care ultrasound by emergency physicians for direct ureteral stone detection: a case series and review of the literature.

Symptomatic urolithiasis is a common cause of emergency department visits, with noncontrast computed tomography considered the imaging gold standard. According to the current guidelines, point-of-care ultrasound (POCUS) is limited to evaluating hydronephrosis as a secondary sign of acute ureteral stones. However, the use of POCUS to detect ureteral stones may lead to decreased radiation to the patient and a more rapid diagnosis. This case series describes 10 patients with suspected symptomatic urolithiasis who were diagnosed accurately by emergency physicians using POCUS to detect obstructive ureteral stones. In three of the cases, POCUS significantly changed the patient's management. This article also describes the proper techniques for the emergency physician to learn to master POCUS for ureteral stone detection.

Empowering Medical Students: Harnessing Artificial Intelligence for Precision Point-of-Care Echocardiography Assessment of Left Ventricular Ejection Fraction.

Introduction: Point-of-care ultrasound (POCUS) use is now universal among nonexperts. Artificial intelligence (AI) is currently employed by nonexperts in various imaging modalities to assist in diagnosis and decision making. Aim: To evaluate the diagnostic accuracy of POCUS, operated by medical students with the assistance of an AI-based tool for assessing the left ventricular ejection fraction (LVEF) of patients admitted to a cardiology department. Methods: Eight students underwent a 6-hour didactic and hands-on training session. Participants used a hand-held ultrasound device (HUD) equipped with an AI-based tool for the automatic evaluation of LVEF. The clips were assessed for LVEF by three methods: visually by the students, by students + the AI-based tool, and by the cardiologists. All LVEF measurements were compared to formal echocardiography completed within 24 hours and were evaluated for LVEF using the Simpson method and eyeballing assessment by expert echocardiographers. Results: The study included 88 patients (aged 58.3 ± 16.3 years). The AI-based tool measurement was unsuccessful in 6 cases. Comparing LVEF reported by students' visual evaluation and students + AI vs. cardiologists revealed a correlation of 0.51 and 0.83, respectively. Comparing these three evaluation methods with the echocardiographers revealed a moderate/substantial agreement for the students + AI and cardiologists but only a fair agreement for the students' visual evaluation. Conclusion: Medical students' utilization of an AI-based tool with a HUD for LVEF assessment achieved a level of accuracy similar to that of cardiologists. Furthermore, the use of AI by the students achieved moderate to substantial inter-rater reliability with expert echocardiographers' evaluation.

Artificial Intelligence-Powered Left Ventricular Ejection Fraction Analysis Using the LVivoEF Tool for COVID-19 Patients.

We sought to prospectively investigate the accuracy of an artificial intelligence (AI)-based tool for left ventricular ejection fraction (LVEF) assessment using a hand-held ultrasound device (HUD) in COVID-19 patients and to examine whether reduced LVEF predicts the composite endpoint of in-hospital death, advanced ventilatory support, shock, myocardial injury, and acute decompensated heart failure. COVID-19 patients were evaluated with a real-time LVEF assessment using an HUD equipped with an AI-based tool vs. assessment by a blinded fellowship-trained echocardiographer. Among 42 patients, those with LVEF < 50% were older with more comorbidities and unfavorable exam characteristics. An excellent correlation was demonstrated between the AI and the echocardiographer LVEF assessment (0.774, p < 0.001). Substantial agreement was demonstrated between the two assessments (kappa = 0.797, p < 0.001). The sensitivity, specificity, PPV, and NPV of the HUD for this threshold were 72.7% 100%, 100%, and 91.2%, respectively. AI-based LVEF < 50% was associated with worse composite endpoints; unadjusted OR = 11.11 (95% CI 2.25-54.94), p = 0.003; adjusted OR = 6.40 (95% CI 1.07-38.09, p = 0.041). An AI-based algorithm incorporated into an HUD can be utilized reliably as a decision support tool for automatic real-time LVEF assessment among COVID-19 patients and may identify patients at risk for unfavorable outcomes. Future larger cohorts should verify the association with outcomes.

Biomedicine and the treatment of difference in a Jerusalem emergency department.

Biomedicine has played a key role in the dissemination of modern social norms, such as the emphasis on individual autonomy and the distinction between science and religion. This study examines the way the mostly-Jewish members of the medical staff at an emergency department of a Jerusalem hospital perceive Jewish ultra-Orthodox and Arab patients' behaviors vis-à-vis the existing biomedical norms. We analyzed participants' perceptions in terms of the social constructs they reveal, their meanings, and their implications. Semi-structured in-depth interviews were conducted with 24 staff members and were analyzed using content analysis. The staff described challenges in treating Arab and ultra-Orthodox patients, which they related to both groups' embeddedness in traditional "cultures" and collective identities. According to the participants, in both cases, the patients' cultural affiliations constrained their sense of individual autonomy and rationality. However, in the comparative analysis, two differences emerged. First, while both groups were perceived to diverge from modern norms of individual autonomy, in the case of Arab patients, these characteristics were presented as disruptive and potentially threatening to the hospital staff. By contrast, in the case of ultra-Orthodox patients, adherence to traditional and collective values was more likely to be represented as a risk to the patient, rather than to the staff. Second, staff were more likely to provide accommodations for ultra-Orthodox patients than for Arab patients. These accommodations were often described in the frame of "cultural competency." We suggest that divergences in how staff understood and responded to perceived cultural differences of each group reflect unequal impacts of structural determinants of health, including of political conflict. We recommend moving beyond the conceptual framework of cultural competency to strengthen the staff's structural competency, cultural and structural humility, and critical consciousness.

The association between sonographic common bile duct dilatation and outcomes in emergency department patients with cholangitis.

BACKGROUND: The presentation of the patient with acute cholangitis (AC) ranges from mild illness to life-threatening shock. Therefore, prompt diagnosis and treatment are critical. Abdominal ultrasound (US) is the imaging of choice to locate bile duct dilatation. Other modalities include abdominal computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVES: To determine whether sonographic common bile duct dilatation in emergency department (ED) patients with AC predicts outcomes including sepsis, hospital length of stay (LOS), admission to the intensive care unit (ICU), time to ERCP, and mortality. METHODS: Electronic medical records of all patients hospitalized in a tertiary care medical center between July 2012-February 2021 with a discharge diagnosis of cholangitis were assessed. Patients were dichotomously classified as CBD dilated or CBD non-dilated based on ultrasound. Dilation was defined as CBD larger than 6 mm in patients younger than 60 or larger than 6 mm + 1 mm per decade in patients over 60. RESULTS: The study included 271 patients- 172 with CBD dilation versus 99 without. Mean LOS was 9.92 days for those with a dilated CBD versus 13.4 days without. The mean time to ERCP was 4.26 days for those with a dilated CBD versus 6.56 days without. Sepsis, mortality, and ICU admission were scarce and there was no statistically significant difference between the cohorts. CONCLUSION: Patients with a dilated CBD per the abdominal US performed during the patient's ED stay, underwent ERCP earlier, and were hospitalized fewer days than patients without CBD dilation.

Factors that affect pain management in adults diagnosed with acute appendicitis in the emergency department: A retrospective study.

BACKGROUND: Analgesic treatment, including with opioids, can safely be given to patients who are suspected of having appendicitis. The study examined factors which may influence the treatment of pain in appendicitis in the adult emergency department (ED). A secondary objective was to determine if analgesia affected clinical outcomes. METHODS: This single-center retrospective study examined medical records of all adult patients with a discharge diagnosis of appendicitis. Patients were categorized based on the type of analgesia received in the ED. Variables included the day of week and staffing shift of presentation, gender, age, and triage pain scale, as well as time to ED discharge, imaging, operation, and hospital discharge. Univariable and multivariable logistic regression models were performed to determine which factors influenced treatment and affected outcomes. RESULTS: Records of 1839 patients were categorized into three groups - 883 (48%) did not receive analgesia, 571 (31%) received only non-opioid medications, and 385 (21%) received at least one opioid. Patients with a higher triage pain level were significantly more likely to receive analgesia (4-6: OR = 1.85; 95% CI = 1.2-2.84, 7-9: OR = 3.36; 95% CI = 2.18-5.17, 10: OR = 10.78; 95% CI = 6.38-18.23) and at least one opioid (4-6: OR = 2.88; 95% CI = 1.13-7.34, 7-9: OR = 4.36; 95% CI = 1.73-11.01, 10: OR = 6.23; 95% CI = 2.42-16.09). Male gender was associated with a significantly lower likelihood of receiving analgesia (OR = 0.74; 95% CI = 0.61-0.9), but a significantly greater likelihood of receiving at least one opioid given that they received any pain medication (OR = 1.87; 95% CI = 1.41-2.48). Patients aged 25-64 years old were significantly more likely to receive at least one opioid if they received any pain medication (25-44: OR = 1.47; 95% CI = 1.08-2.02, 45-64: OR = 1.78; 95% CI = 1.15-2.76). Presentation to the ED on Sundays was associated with lower rates of opioid treatment (OR = 0.63; 95% CI = 0.42-0.94). Regarding clinical outcomes, patients who received analgesia waited longer for imaging (+0.58 h; 95% CI = 0.31-0.85), stayed longer in the ED (+2.2 h; 95% CI = 1.60-2.79), and had a slightly longer hospitalization (+0.62d; 95% CI = 0.34-0.90). CONCLUSIONS: Almost half of patients with appendicitis didn't receive analgesia, with most of those treated receiving only non-opioid analgesia. Older age and Sunday presentations were associated with less opioid treatment. Patients who received analgesia waited longer for imaging, stayed longer in the ED, and had a longer hospitalization.

Disaster Medicine Education for Israeli Medical Response Teams to the Ukrainian Refugee Crisis.

INTRODUCTION: Disaster Medicine (DM) requires skills, knowledge, and prior experience that are rarely put to test by health care providers. Pediatric DM presents unique challenges in terms of both knowledge and practice. METHODS: An anonymous survey consisting of demographic and five-point Likert scale questions was administered to physicians, nurses, and other medical personnel from Israel's major medical emergency teams who were deployed to respond to the refugee crisis in Ukraine. This included teams from the Hadassah and Tel Aviv Sourasky Medical Centers and the Israel Ministry of Health. RESULTS: Of the 171 members of the medical teams deployed on the Ukraine border, a total of 105 responses were obtained (61.4%) from 61 physicians, 50 nurses, and 12 other health care providers. The teams were composed of pediatricians (31.6%), internal medicine physicians (21.6%), Emergency Medicine and intensive care physicians (18.0%), and 31.0% other specialties.For 60% of the participants, this was their first deployment, and 78% had received no training in DM. Members rated the need for DM training at 4/5 (IQR 3-5). Forty-nine (49) members (46.6%) were not briefed on situational awareness and 97 members (89.5%) were not trained in the recognition of acute stress reactions. The responders also rated their concerns about providing medical aid to children at 2/5 (IQR 1-3). A medical clown was part of the teams 42.8% of the time; the presence of clowns was rated at a median of 4/5 (IQR 4-5). The team members underscored the need for more targeted training in DM at 5/5 (IQR 3-5). CONCLUSION: The findings highlight the need for the formulation of a disaster education model that includes pediatric DM.

Impact of repeated military conflicts on civilian patterns of emergency medical services utilization: A retrospective cohort study.

OBJECTIVE: To assess the impact of repeated rocket attacks on a civilian population during successive military conflicts on the patterns of emergency medical services (EMS) utilization. DESIGN: This retrospective cohort study (2008-2021) analyzed EMS data from one region of Israel characterized by intensive rocket attacks on a civilian population during four successive military conflicts. EMS activity for the periods prior to, during, and after the conflicts was compared. Data included call volume, type of calls ("medical illness," "motor vehicle collision (MVC)," and "other-injuries"), and level of response (advanced life support (ALS) or basic life support (BLS)). RESULTS: Compared to the Pre-Conflict period, there were statistically significant decreased volumes of calls during the 2008 (-20 percent), 2012 (-13 percent), and 2021 (-11 percent) military conflicts for "medical illness" and during the 2008 (-23 percent), 2012 (-30 percent), and 2021 (-31 percent) for "MVC." Decreases in calls for "medical illness" were accompanied by decreased ALS dispatches (-28, -33, and -18 percent for 2008, 2012, and 2021, respectively). The number of calls returned to preconflict values during the Post-Conflict periods. No change was evidenced in numbers of calls during the 2014 military conflict. CONCLUSION: Military conflicts involving a civilian population were usually found to be associated with lower numbers of calls for the categories of "medical illness" and "MVC." Less calls for "medical illness" were associated with fewer ALS dispatches. There was a rapid return of call volumes to preconflict levels shortly after a ceasefire was reached. The absence of change in calls during the 2014 conflict suggests involvement of habituation processes.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem.

BACKGROUND: A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance. METHODS: A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days. RESULTS: There were differences between Jewish and Arab patients' social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty. CONCLUSION: The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.