Case study of the terrorist bombing in Tel Aviv market - putting all the eggs in one basket might save lives

Objectives: On 1 November 2004 a suicide bomber detonated himself in Tel Aviv, in a crowded open market space, resulting in 3 dead victims and 34 casualties. This event in a central urban area was handled quickly by experienced emergency medical service (EMS) teams. We analysed evacuation destinations of urgent casualties in order to learn whether severe casualties should all be evacuated to the closest trauma centre. Alternatively, they might be distributed to all nearby hospitals, both trauma and non-trauma centres. A third possibility is directing urgent casualties only to trauma centres, dividing them between the close trauma centre and a 'second cycle' distant level A trauma centre. Methods: Data were collected from formal debriefings carried out after the event in the Ministry of Health, in the Israeli Defense Forces Medical Corps (IDF MCs) and in the Home Front Command (HFC). Other debriefings, in which we took part, were those of the EMS and participating hospitals. We analysed these data to learn about the timetable of the event, the number of EMS ambulances and medical personnel involved in the event, the number of casualties evacuated to each hospital (both primary and secondary evacuation), and the major medical problems (resuscitations, operations) encountered by EMS and by the hospital personnel. Results: Casualties were rapidly treated and evacuated: within 25 minutes of the blast (19 minutes after the arrival of the first ambulance), all urgent casualties had been administered airway and haemorrhage control and evacuated from the site. Seven of eight urgent casualties were evacuated to the closest trauma centre. Reviewing the trauma centre ER work found no bottlenecks either outside or inside the ER. All seven 'immediate' victims were treated simultaneously at the emergency department (ED). Two casualties arrived at the ED while being ventilated manually with a bag-valve-mask device, and required urgent tracheal intubation. Two urgent laparotomies and two orthopaedic operations were performed. The only immediate victim who was referred to the smaller nearby hospital needed secondary evacuation to a neurosurgical centre. Conclusion: The decision to send almost all severely injured patients to the nearest level A trauma centre, using a 'save and run' mode of evacuation, was life-saving in this event. As this is a study of a single case, further analysis of multiple similar events is needed, to examine whether the PHTLS guidelines regarding pr