title: 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.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors: Home Front Command Medical Department, Israel.
authors: Yuval H
authors: YH
authors: Bloch
authors: Dagan
authors: D
authors: Schwartz
authors: Moshe
authors: M
authors: Pinkert
authors: Amir
authors: A
authors: Blumenfeld
authors: Shkolnick
authors: S
authors: Avinoam
authors: Giora
authors: G
authors: Hevion
authors: Meir
authors: M
authors: Oren
authors: Avishay
authors: A
authors: Goldberg
authors: Yehezkel
authors: Y
authors: Levi
authors: Yaron
authors: Y
authors: Bar-Dayan
mesh_terms: D000552:Ambulances / Q000600:supply & distribution; D001753:Blast Injuries / Q000175:diagnosis*; D004189:Disaster Planning / Q000379:methods / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data; D005107:Explosions; D006801:Humans; D007557:Israel; D018635:Rescue Work / Q000458:organization & administration; D019036:Suburban Health Services; D023481:Terrorism; D013997:Time Factors; D014218:Triage