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.

Clinical Characteristics and Management of Snake Bite Injuries in the Jerusalem Area.

Venomous snake bites can constitute medical emergencies, and without immediate care may be life-threatening. This study describes the characteristics and management of patients suffering from snake bite injuries (SNIs) in the Jerusalem area. A retrospective analysis of all patients who were admitted to the Hadassah Medical Center emergency departments (EDs) due to SNIs between 1 January 2004 and 31 March 2018 was conducted. During this period, 104 patients were diagnosed with SNIs, of whom 32 (30.7%) were children. Overall, 74 (71.1%) patients were treated with antivenom, 43 (41.3%) were admitted to intensive care units, and 9 (8.6%) required treatment with vasopressors. No mortality was recorded. On ED admission, none of the adult patients presented with an altered mental state compared to 15.6% of the children (p < 0.00001). Cardiovascular symptoms were observed in 18.8% and 5.5% of the children and adults, respectively. Fang marks appeared in all of the children. These findings underscore the severity of SNIs and the differences in clinical presentation between children and adults in the Jerusalem region.

Does clinical decision support system promote expert consensus for appropriate imaging referrals? Chest-abdominal-pelvis CT as a case study.

OBJECTIVES: We assessed the appropriateness of chest-abdominal-pelvis (CAP) CT scan use in the Emergency Department (ED), based on expert physicians and the ESR iGuide, a clinical decision support system (CDSS). METHODS: A retrospective cross-study was conducted. We included 100 cases of CAP-CT scans ordered at the ED. Four experts rated the appropriateness of the cases on a 7-point scale, before and after using the decision support tool. RESULTS: Before using the ESR iGuide the overall mean rating of the experts was 5.2 ± 1.066, and it increased slightly after using the system (5.85 ± 0.911 (p < 0.01)). Using a threshold of 5 (on a 7-level scale), the experts considered only 63% of the tests appropriate before using the ESR iGuide. The number increased to 89% after consultation with the system. The degree of overall agreement among the experts was 0.388 before ESR iGuide consultation and 0.572 after consultation. According to the ESR iGuide, for 85% of the cases, CAP CT was not a recommended option (score 0). Abdominal-Pelvis CT was "usually appropriate" for 65 out of the 85 (76%) cases (score 7-9). 9% of the cases did not require CT as first exam modality. CONCLUSIONS: According to both the experts and the ESR iGuide, inappropriate testing was prevalent, in terms of both frequency of the scans and also inappropriately chosen body regions. These findings raise the need for unified workflows that might be achieved using a CDSS. Further studies are needed to investigate the CDSS contribution to the informed decision-making and increased uniformity among different expert physicians when ordering the appropriate test.

Clinical decision support system recommendations: how often do radiologists and clinicians accept them?

OBJECTIVE: To assess the acceptance and reliability of clinical decision support system (CDSS) imaging referral scores (ESR iGuide). METHODS: A pilot study was conducted in a tertiary hospital. Four different experts were invited to rate 40 simulated clinical cases on a 5-level scale, for the level of agreement with the ESR iGuide's recommended procedures. In cases of disagreement, physicians were asked to indicate the reason. Descriptive measures were calculated for the level of agreement. We also explored the degree of agreement between four different specialists, and examined the cases in which clinicians disagreed with ESR iGuide best practice recommendations. RESULTS: The mean rating of the four experts for the 40 clinical simulated cases was 4.17 ± 0.65, median 4.25 (on a scale of 1-5). All four raters totally agreed with the system recommendation in 75% of cases. No significant relationship was found between the degree of agreement and the number of indications and the patient's age or gender. In an optimistic scenario, using a binary agree/disagree variable, the Overall Percentage Agreement for the rating of the 40 simulated cases between the four experts was 77.28%. There were a total of 20 disagreements out of 160 cases with the ESR iGuide, of which 7 were among the two radiologists. CONCLUSIONS: CDSS can be an effective tool for guiding the selection of appropriate imaging examinations, thus cutting costs due to unnecessary imaging scans. Since this is a pilot study, further research on a larger scale, preferably at national level, is required. KEY POINTS: • The average of the mean rating of the four experts was 4.17 ± 0.65, median 4.25, on a scale of 1-5 where 5 represents total agreement with the CDSS tool. • In an optimistic scenario, using a binary agree/disagree variable, the Overall Percentage Agreement between the four experts was 77.28%. • Radiologists had fewer disagreements with the recommendations of the CDSS tool than other physicians, indicating a better fit of the support system to radiology experts' perspective.

Medical lessons from terror attacks in Israel.

Mass casualty events that result from conventional terrorist attacks have become more common in recent years. These events are characterized by major chaos and a large number of injured victims that overwhelm local resources and personnel. Mass casualty protocols and management are often based on theoretical models adapted from the military experience and literature. Over the last few years the medical system in Israel has had to deal with multiple mass casualty events resulting from terrorist events. This has led to the development of novel strategies that may run contrary to traditional teachings. The current report summarizes the experience and lessons learned by the Israeli Emergency Medical Services and its hospitals over the last few years. Although each hospital and Emergency Medical Service agency will need to tailor its management plan to its particular needs, it is our hope that the lessons learned in Israel will assist others in optimizing the care of mass casualty events.

A multicasualty event: out-of-hospital and in-hospital organizational aspects.

UNLABELLED: In a wedding celebration of 700 participants, the third floor of the hall in which the celebration was taking place suddenly collapsed. While the walls remained intact, all three floors of the building collapsed, causing Israel's largest disaster. OBJECTIVES: To study the management of a multicasualty event (MCE), in the out-of-hospital and in-hospital phases, including rescue, emergency medical services (EMS) deployment and evacuation of casualties, emergency department (ED) deployment, recalling staff, medical care, imaging procedures, hospitalization, secondary referral, and interhospital transfer of patients. METHODS: Data on all the victims who arrived at the four EDs in Jerusalem were collected through medical files, telephone interviews, and hospital computerized information. RESULTS: The disaster resulted in 23 fatalities and 315 injured people; 43% were hospitalized. During the first hour, 42% were evacuated and after seven hours the scene was empty. Ninety-seven basic life support ambulances, 18 mobile intensive care units, 600 emergency medical technicians, 40 paramedics, and 15 physicians took part in the out-of-hospital stage. At the hospitals, about 1,300 staff members arrived immediately, either on demand or voluntarily, a number that seems too large for this disaster. Computed tomography (CT) demand was over its capability. CONCLUSIONS: During this MCE, the authors observed "rotating" bottleneck phenomena within out-of-hospital and in-hospital systems. For maximal efficiency, hospitals need to fully coordinate the influx and transfer of patients with out-of-hospital rescue services as well as with other hospitals. Each hospital has to immediately deploy its operational center, which will manage and monitor the hospital's resources and facilitate coordination with the relevant institutions.