It was a terrifying sight.
 
I knew why I was there and what needed to be done and yet I found myself shocked, and advancing - but only in slow motion.
 
Utter devastation, and in such close proximity to the holiest place on earth.
 
In the background, the Western Wall (Kotel), eternal and proud.
 
In the foreground, the shell of a bombed out bus; black with soot, smoke billowing from where windows once were. Charred body parts lay strewn haphazardly across the plaza; dozens of victims lying in pools of blood, near death - or worse.
 
I blinked.
 
Thank G-d, it was only a practice drill for an MCI, Mass Casualty Incident – known in Israel as an “ARAN”.
 
In this instance, the simulation was of a terrorist attack; more specifically a suicide bomber that had detonated on a bus.
 
“Practice! Practice! Practice! -  Aran! Aran! Aran!” came the calm voice over the radios.
 
Too calm. But then again she was reading from her computer screen back in the control room. She had prepared for this all morning. Staff meetings, rehearsing protocols, division of roles; I too was there. But then we parted ways; she to her screen, and I to the pre-designated spot just outside the old city walls. We had waited in ambulances, engines idle, for what seemed like an eternity; ready to spring into action at the drop of a hat.
 
The police had initiated this practice drill in order to test their readiness in the case of an MCI occurring, as they put it, in a ‘challenging’ location.
 
Challenging, was somebody’s idea of a positive spin on an impossible situation. Traversing the old city would be immensely difficult for emergency personnel, due to the huge amount of pedestrian and vehicle traffic coupled with narrow roads and alleyways.
 
We drove down towards the Western Wall plaza with lights and sirens blaring, unsure of what exactly lay in store. This was after all, someone else’s performance. We were just EMS extras, doing our thing, so that others could practice doing theirs.
 
This was all new territory for me; my driver on the other hand was a well-seasoned medic, having responded to tens of terrorist attacks in his career. Unfortunately.
 
The MCI (aka Organized Chaos)
 
At a mass casualty incident, the first Medic who arrives on scene is known as the ‘Command #10’ and is effectively the officer in charge of the entire operation. His first duty is to quickly deputize two other personnel.  One is called ‘Medical #10’ and his job is to categorize and direct medical attention to the causalities. The other is known as ‘Parking #10’ whose task is to stop, direct and eventually send the ambulances to the various hospitals.
 
We were instructed by ‘Parking #10’ to park our ambulance just outside the main gate. (If) A bomb had detonated on a bus inside the compound; it would be too difficult to maneuver the ambulances amidst the chaos. We parked as instructed, grabbed our equipment and ran toward the scene of the bombing. We sprinted up the hill and met with ‘Medical #10’ who directed us to the casualty group we were responsible for. I wore a bulletproof helmet and jacket over my uniform because this was an ‘act of terrorism’; we had to be prepared for the possibility of further detonations. I was sweating profusely under my heavy equipment and the helmet’s strap was chafing me beneath my chin, but I persisted up the steep incline.
 
As I neared the chaos, I noticed a photographer out of the corner of my eye; the exercise was being recorded to be reviewed later by the powers that be.
 
The scene that lay before me was horrifying, even if it was staged. Those in charge had done a very convincing job with the Hollywood effect. The shell of the bus was literally smoking, making it difficult to see and breathe.
 
After the bomb squad had done their initial sweep, we were allowed on board and I noticed the source of my discomfort – a smoke machine under the driver’s seat. Blaring from the radio was dark creepy music, or perhaps chanting – a genre that can only be described as ‘terrorist style’.
 
The mood was set. The atmosphere was unnerving and chilling.
 
Moving down the aisle now. (Fake) glass everywhere, seats in disarray, injured (actors) screaming. There were bloodied Madame Tussauds limbs strewn about, various volunteers lying dead, and red paint galore.
 
Full marks for introducing the concept of terror in a very real way.
 
We set about sorting and helping the victims.
 
There were numerous injured, both walking and stationary, scattered about. Each had a paper around their neck informing us of their supposed wounds and vitals. Heart and pulse rate, blood pressure, and a short description of the injury were all listed. We were expected to read the description and then initiate triage.
 
Triage can be an extremely difficult, even gut wrenching, decision-making process. A medic’s initial duty is to separate the wounded into four different categories:
 
RED = Immediate: The casualty requires immediate medical attention and will not survive if not attended to soon.
 
YELLOW = Delayed: Injuries are potentially life-threatening, but can wait until the immediate casualties are stabilized and evacuated.
 
GREEN = Minimal: ‘Walking wounded’ - the casualty requires medical attention when all higher priority patients have been evacuated, and may not require stabilization or monitoring.
 
BLACK = Expectant: This category is for the deceased or those whose injuries make survival unlikely.
 
This last category is hard for responders to accept. We would normally rush to initiate CPR on any lifeless person. Here we are told to move on, to assist people that are still amongst the living. A fatality that needs CPR would be classified as ‘non-salvageable’ because their care would mean that at least one responder would have to treat them and not be able to assist other people that are still clinging to life.
 
This obviously poses some serious moral and ethical issues for emergency responders who respond to mass casualty incidents, as they must make a determination as to who does and does not receive initial treatment.
 
We divided the various groups, treated, stabilized, and readied them for transport;
 
48 Casualties in total - (11 Dead, 6 Critical, 14 Moderate, 17 Mild)
 
• 13:51 – Emergency Call
• 13:55 – First on scene
• 13:58 – 1 ALS, 7 BLS Ambulances
• 14:01 – MCRV, 2 ALS, 13 BLS
• 14:05 – First evacuation
• 14:17 – Last patient transported
 
As I put a severely injured child doll on my stretcher, I looked toward the heavens and prayed that I would never have to do this for real.

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