3rd Opinion: The bus bombing in Tel Aviv – revisited

The first message came from my assistant, “Didn’t you hear? There was a bus bombing a few hundred meters from the hospital, at the corner of Henrietta Szold and Shaul Hamelech.”

I had not yet heard anything. I was immediately flooded with memories. It had been 10 years since we had last experienced a terror attack in Tel Aviv.

As the main metropolitan hospital, the Tel Aviv Sourasky Medical Center treated more than 1,000 casualties from those attacks between 1994 and 2003.

There were attacks after which up to 150 casualties streamed into our Emergency Department within less than one hour, and we admitted them all for immediate medical and surgical care.

The protocol for coping with that scenario has been embedded into our medical center’s way of life ever since, and our mental and physical preparation has become a matter of routine.

The trauma and mass casualty apparatuses worked faultlessly on Wednesday. Within minutes, stretchers were positioned at the entrance to the emergency services to enable immediate unloading of patients from ambulances and allow the quick return of the ambulances to the scene.

Triage physicians and clerks were positioned at the entrance to assess the wounded victims’ conditions, and senior trauma surgeons took charge of the patients’ management.

The operating theater wing was instructed to put a hold on non-emergency surgeries until the necessity for emergency procedures was ascertained.

One of the problems we have learned to expect was dealing with blast injuries that are so characteristic of the bombing of a vehicle. Explosions within a close space frequently cause internal injuries that may not be visible externally.

This means that a wounded person can be correctly treated for minor external injuries only for his condition to suddenly deteriorate because of internal bleeding.

This time, the explosive material was relatively small and, despite the fact that it was mixed with metal components (screws and other small, sharp objects) to increase the extent of injury, the amount was too small to cause such a blast effect.

The emergency room was crowded with many superficially wounded people. Ten years ago, one of my concerns in our preparedness for mass casualty events that occurred after working hours was recruiting the critical number of physicians and nurses necessary to deal with a large number of casualties.

Terror attacks during working hours were a kind of managerial luxury in this setting, and this week’s bombing was such an event, both because of the relatively moderate severity of the injuries and because the necessary number of available physicians were at hand.

I watched the same senior trauma physicians from the surgical division who ran the emergency ward and trauma unit 10 years ago lead the admission of the 21 casualties who were brought in on Wednesday afternoon.

I watched the clinical care of the wounded patients in the trauma unit: The senior surgeons were accompanied by a group of young residents and students for whom this was the first exposure to a mass casualty event.

Given that residency programs last an average of five years and the nurses’ characteristic turnover, 10 years means a new generation for the life of a hospital.

I looked at the faces of the medical students and the interns and saw their shock and amazement as they confronted a terror-driven mass casualty scene for the first time in their lives.

I thought to myself, they are still so young — too young — to witness the results of this crazy, inhuman behavior. For that matter, treating victims of terrorist attacks who could so easily be family members and friends is never easy on the more hardened physicians either.

Within one hour, the casualties had been safely evacuated from the emergency services units, with the exception of two with mild injuries. The other wounded who needed surgery were already in the operating theater and those who needed medical treatment were already in the surgical and orthopedic wards.

As I mentioned to one of the reporters who interviewed me, this event wound up having little medical significance, but it carries grave implications politically.

It may testify to a shift from the indiscriminate terrorist missile attacks on civilians in the South of Israel to the “historic” targeting of buses on the streets of every city nationwide.

Finally, I was humbled by the outpouring of support and concern from emails that I received from our friends all over the world.

Dr. Gabi Barbash is the CEO of the Tel Aviv Sourasky Medical Center.