Intended for healthcare professionals


Lessons learnt from the front line in Israel

BMJ 2006; 333 doi: (Published 19 October 2006) Cite this as: BMJ 2006;333:862
  1. Shmuel C Shapira, Director, Hebrew University-Hadassah School of Public Health (sshapira{at}
  1. 1 Hadassah University Hospital and Hebrew University School of Medicine and Public Health, POB 12000 Jerusalem, Israel 91120

    EEDITOR—Over the past six years my pager has accompanied me everywhere. The bleep all too often signals another terror attack. Together with my team, I have managed 43 terror related mass casualty events and cared for over 3000 victims. Although the work is difficult, we try to make the most of our experience. Thus Israeli doctors have written guidelines on management of terror related emergencies, published lessons learnt,1 initiated research projects related to terror related injuries, carried out workshops, and given lectures all over the world.

    But terror is not merely of professional interest. Every time my pager announces a terrorist attack I wonder whether any of my family has been affected. I often have to work for many hours before I get a message confirming everyone is safe. In the emergency department it is not uncommon to find a captured terrorist in one bed and his victims in the three adjacent gurneys. Who is the team meant to attend to first? Of course, these decisions are dictated solely by the medical priorities, although we sometimes get complaints from the families.

    We hope that others will learn from our mistakes. These include, for example, depending solely on the mobile telephone system (which often collapses because of overload in an emergency), establishing a public information centre too close to the emergency department, and underestimating the severe mental and physical stress on all staff (we now offer psychological counselling and external stress relief activities).

    The most important lesson has been that the best investment is in good quality preparation for terrorist related emergencies. We have a detailed manual for each type of potential threat—conventional, chemical, biological, radiological, or cyber.2 3 Staff are instructed both in the care of various terror related injuries and in the administrative aspects of these emergencies. Relevant staff are given treatment cards and checklists for non-conventional injuries. Good team work and robust methods of communications, which are both crucial, are emphasised. Minimal structural modifications (such as establishing oxygen pipes in improvised admission areas) and maintaining adequate supplies are essential.4

    We constantly strive for quicker, more efficient ways to save life and limb. Both the operation and coordination of the emergency plans are regularly re-evaluated and tested by full scale drills with simulated casualties.5 Our hospital, as well as all others in Israel, goes through this process twice a year, under the supervision of the Department of Emergency Services of the Ministry of Health. Although in this kind of chaos practice never makes perfect, it does allow us to be as effective as circumstances allow.


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    • I thank Mark Clarfield for his helpful comments.

    • Competing interests None declared.


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