Advanced rescue techniques: lessons learned from the collapse of a building in Nairobi, Kenya.

This paper examines the collapse of a five-storey building in Nairobi, Kenya, on 23 January 2006. It draws on reports from local authorities and on debriefings by Israel's Home Front Command (HFC), including information on injury distribution, rescue techniques, and the mode of operation. Most of the 117 people found under the structure were evacuated on the first day to a public hospital, which was overwhelmed by the incident. HFC forces arrived 23 hours after the disaster. At that stage, two people were still buried under the building and special techniques (tunnelling and scalping) were required to secure their evacuation. The two people quickly recovered after a short stay in hospital. Local technology is the preferred option during such events because time is crucial. International cooperation is required when this technology is not available. All of the hospitals in the disaster area, including private facilities, should participate in treating casualties.

Standards in collaborative international disaster drills: a case study of two international search and rescue drills.

INTRODUCTION: During the last few decades, various global disasters have rendered nations helpless (such as Thailand's tsunami and earthquakes in Turkey, Pakistan, Iran, and India). A lack of knowledge and resources make it difficult to address such disasters. Preparedness for a national disaster is expensive, and in most cases, unachievable even for modern countries. International collaboration might be useful for coping with large-scale disasters. Preparedness for international collaboration includes drills. Two such drills held by the Israeli Home Front Command and other military and civilian bodies with the nations of Greece and Turkey are described in this article. METHODS: The data were gathered from formal debriefings of the Israeli teams collaborating in two separate drills with Greek and Turkish teams. RESULTS: Preparations began four months before the drills were conducted and included three meetings between Israeli and foreign officials. The Israeli and foreign officials agreed upon the drill layout, logistics, communications, residence, real-time medicine, hardware, and equipment. The drills took place in Greece and Turkey and lasted four days. The first day included meetings between the teams and logistics preparations. The second and third days were devoted to exercises. The drills included evacuating casualties from a demolition zone and treating typical injuries such as crush syndrome. Every day ended with a formal debriefing by the teams' commanders. The fourth day included a ceremony and transportation back home. Members in both teams felt the drills improved their skills and had an important impact on creating common language that would enhance cooperation during a real disaster. CONCLUSIONS: A key factor in the management of large-scale disasters is coordination between countries. International drills are important to create common language within similar regulations.

Primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals--lessons learned from a suicide bomber attack in downtown Tel-Aviv.

INTRODUCTION: Terrorist attacks have occurred in Tel-Aviv that have caused mass-casualties. The objective of this study was to draw lessons from the medical response to an event that occurred on 19 January 2006, near the central bus station, Tel-Aviv, Israel. The lessons pertain to the management of primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals and the operational mode of the participating hospitals during the event. METHODS: Data were collected in formal debriefings both during and after the event. Data were analyzed to learn about medical response components, interactions, and main outcomes. The event is described according to Disastrous Incidents Systematic AnalysiS Through-Components, Interactions and Results (DISAST-CIR) methodology. RESULTS: A total of 38 wounded were evacuated from the scene, including one severely injured, two moderately injured, and 35 mildly injured. The severe casualty was the first to be evacuated 14 minutes after the explosion. All of the casualties were evacuated from the scene within 29 minutes. Patients were distributed between three adjacent hospitals including one non-Level-1 Trauma Center that received mild casualties. Twenty were evacuated to the nearby, Level-1 Sourasky Medical Center, including the only severely injured patient. Nine mildly injured patients were evacuated to the Sheba Medical Center and nine to Wolfson Hospital, a non-Level-1 Trauma Center hospital. All the receiving hospitals were operated according to the mass-casualty incident doctrine. CONCLUSIONS: When a mass-casualty incident occurs in the vicinity of more than one hospital, primary triage, evacuation priority decision-making, and rapid distribution of casualties between all of the adjacent hospitals enables efficient and effective containment of the event.

Leadership as a component of crowd control in a hospital dealing with a mass-casualty incident: lessons learned from the October 2000 riots in Nazareth.

INTRODUCTION: Crowd control is essential to the handling of mass-casualty incidents (MCIs). This is the task of the police at the site of the incident. For a hospital, responsibility falls on its security forces, with the police assuming an auxiliary role. Crowd control is difficult, especially when the casualties are due to riots involving clashes between rioters and police. This study uses data regarding the October 2000 riots in Nazareth to draw lessons about the determinants of crowd control on the scene and in hospitals. METHODS: Data collected from formal debriefings were processed to identify the specifics of a MCI due to massive riots. The transport of patients to the hospital and the behavior of their families were considered. The actions taken by the Hospital Manager to control crowds on the hospital premises also were analyzed. RESULTS: During 10 days of riots (01-10 October 2000), 160 casualties, including 10 severely wounded, were evacuated to the Nazareth Italian Hospital. The Nazareth English Hospital received 132 injured patients, including one critically wounded, nine severely wounded, 26 moderately injured, and 96 mildly injured. All victims were evacuated from the scene by private vehicles and were accompanied by numerous family members. This obstructed access to hospitals and hampered the care of the casualties in the emergency department. The hospital staff was unable to perform triage at the emergency department's entrance and to assign the wounded to immediate treatment areas or waiting areas. All of the wounded were taken by their families directly into the "immediate care"location where a great effort was made to prioritize the severely injured. In order to control the events, the hospital's managers enlisted prominent individuals within the crowds to aid with control. At one point, the mayor was enlisted to successfully achieve crowd control. CONCLUSIONS: During riots, city, community, and even makeshift leaders within a crowd can play a pivotal role in helping hospital management control crowds. It may be advisable to train medical teams and hospital management to recognize potential leaders, and gain their cooperation in such an event. To optimize such cooperation, community leaders also should be acquainted with the roles of public health agencies and emergency services systems.

Significance of a Level-2, "selective, secondary evacuation" hospital during a peripheral town terrorist attack.

INTRODUCTION: Mass-casualty incidents (MCIs) can occur outside of major metropolitan areas. In such circumstances, the nearest hospital seldom is a Level-1 Trauma Center. Moreover, emergency medical services (EMS) capabilities in such areas tend to be limited, which may compromise prehospital care and evacuation speed. The objective of this study was to extract lessons learned from the medical response to a terrorist event that occurred in the marketplace of a small Israeli town on 26 October 2005. The lessons pertain to the management of primary and secondary evacuation and the operational practices by the only hospital in the town, which is designated as a Level-2 Trauma Center. METHODS: Data were collected during the event by Home Front Command Medical Department personnel. After the event, formal and informal debriefings were conducted with EMS personnel, the hospitals involved, and the Ministry of Health. The medical response components, interactions (mainly primary triage and secondary distribution), and the principal outcomes were analyzed. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology. RESULTS: The suicide bomber and four victims died at the scene, and two severely injured patients later died in the hospital. A total of 58 wounded persons were evacuated, including eight severely injured, two moderately injured, and 48 mildly injured. Forty-nine of the wounded arrived to the nearby Hillel Yafe Hospital, including all eight of the severely injured victims, the two moderately injured, and 39 of the mildly injured. Most of the mildly injured victims were evacuated in private cars by bystanders. Five other area hospitals were alerted, three of which primarily received the mildly injured victims. Two distant, Level-1 Trauma Centers also were alerted; each received one severely injured patient from Hillel Yafe Hospital during the secondary distribution process. Emergency medical services personnel were able to treat and evacuate all severely and moderately injured patients within 17 minutes of the explosion. A total of 12 of the 21 ambulances arriving on-scene within the first 20 minutes were staffed by EMS volunteers or off-duty workers. CONCLUSION: When a MCI occurs in a small town that is in the vicinity of a Level-2 Trauma Center, and located a > 40 minute drive from Level-1 Trauma Centers, the Level-2 Trauma Center is a critical component in medical management of the event. All severely and moderately injured patients initially should be evacuated to the Level-2 Trauma Center, and given advanced, hospital-based resuscitation. The patients needing care beyond the capabilities of this facility should be distributed secondarily to Level-1 Trauma Centers. To alleviate the burden placed on the local hospital, some of the mildly injured victims can be evacuated primarily to more distant hospitals. The ability to control the flow of mildly injured patients is limited by the large percentage of them arriving by private cars. The availability of EMS in small towns can be augmented significantly by enrolling off-duty EMS workers and volunteers to the rescue effort. Level-2 hospitals in small towns should be prepared and drilled to operate in a "selective evacuation" mode during MCIs.

Distribution of casualties in a mass-casualty incident with three local hospitals in the periphery of a densely populated area: lessons learned from the medical management of a terrorist attack.

INTRODUCTION: A mass-casualty incident (MCI) can occur in the periphery of a densely populated area, away from a metropolitan area. In such circumstances, the medical management of the casualties is expected to be difficult because the nearest hospital and the emergency medical services (EMS), only can offer limited resources. When coping with these types of events (i.e., limited medical capability in the nearby medical facilities), a quick response time and rational triage can have a great impact on the outcome of the victims. The objective of this study was to identify the lessons learned from the medical response to a terrorist attack that occurred on 05 December 2005, in Netanya, a small Israeli city. METHODS: Data were collected during and after the event from formal debriefings and from patient files. The data were processed using descriptive statistics and compared to those from previous events. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology. RESULTS: Four victims and the terrorist died as a result of this suicide bombing. A total of 131 patients were evacuated (by EMS or self-evacuation) to three nearby hospitals. Due to the proximity of the event to the ambulance dispatch station, the EMS response was quick. The first evacuation took place only three minutes after the explosion. Non-urgent patients were diverted to two close-circle hospitals, allowing the nearest hospital to treat urgent patients and to receive the majority of self-evacuated patients. The nearest hospital continued to receive patients for >6 hours after the explosion, 57 of them (78%) were self-evacuated. CONCLUSION: The distribution of casualties from the scene plays a vital role in the management of a MCI that occurs in the outskirts of a densely populated area. Non-urgent patients should be referred to a hospital close to the scene of the event, but not the closest hospital. The nearest hospital should be prepared to treat urgent casualties, as well as a large number of self-evacuated patients.

Military Medicine Publications: What has Happened in the Past Two Decades?

BACKGROUND: Military medical personnel, like all other physician specialists, face the challenge of keeping updated with developments in their field of expertise, in view of the great amount of new medical information published in the literature. The availability of the Internet has triggered tremendous changes in publication characteristics, and in some fields, the number of publications has increased substantially. The emergence of electronic open access journals and the improvement in Web search engines has triggered a significant change in the publication processes and in accessibility of information. OBJECTIVE: The objective of this study was to characterize the temporal trends in the number and types of publications in military medicine in the medical literature. METHODS: We searched all PubMed-registered publications from January 1, 1990 to December 31, 2010 using the keywords "military" or "army". We used the publication tag in PubMed to identify and examine major publication types. The trends were tested using the Mann-Kendall test for trend. RESULTS: Our search yielded 44,443 publications in military medicine during the evaluation period. Overall, the number of publications showed two distinct phases over time: (1) a moderate increase from 1990 to 2001 with a mean annual increase of 2.78% (r(2)=.79, P<.002), and (2) a steeper mean annual increase of 11.20% (r(2)=.96, P<.002) from 2002 to 2010. Most of the examined publication types showed a similar pattern. The proportion of high-quality-of-evidence publication types (randomized controlled trials, systematic reviews, and meta-analyses) increased from 2.91% to 8.43% of the overall military medicine publications with a mean annual incremental increase of 14.20%. These publication types demonstrated a similar dual phase pattern of increase (10.01%, r(2)=.80, P<.002 for 1990-2001 and 20.66%, r(2)=.88, P<.002 for 2002-2010). CONCLUSIONS: We conclude that over the past twenty years, scholarly work in the field of military medicine has shown a significant increase in volume, particularly among high quality publication types. However, practice guidelines remain rare, and meta-analyses are still limited in number.

Lessons learned from an obstetrics and gynecology field hospital response to natural disasters.

Field hospitals were deployed by the Israel Defense Forces as part of the international relief efforts after major seismic events, one in Haiti (2010) and one in Japan (2011). The teams treated a total of 44 pregnant and 24 nonpregnant women and performed 16 deliveries and three cesarean deliveries under extreme conditions. Half of all deliveries were complicated by preeclampsia and 31% were preterm (at 30-32 weeks of gestation). It is imperative that obstetrician-gynecologists be included among humanitarian aid delegations sent to sites of natural disasters. The complicated cases we encountered required highly skilled obstetricians and led to a shortage of specific medications for these women. Cases that would have been considered routine under normal conditions created unanticipated ethical and practical issues in the face of very limited resources. The aim of this commentary is to share the experiences and lessons learned by our field hospital obstetrics and gynecology teams after the major earthquakes in Haiti and Japan. We present what we consider to be the 10 most important lessons learned and propose that they serve as guidelines in preparing for essential needs in other natural disaster settings.

The significance of a small, level-3 'semi evacuation' hospital in a terrorist attack in a nearby town.

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene-66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a 'semi-evacuation hospital'. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs.