title: Trauma care and case fatality during a period of frequent, violent terror attacks and thereafter.
abstract: BACKGROUND
  From September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized.
  
  
  METHODS
  We tracked case fatality rates (CFRs) initially during a period of terror attacks (1999-2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (n = 2,000 patients), and 51 level I U.S. trauma centers (n = 265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010.
  
  
  RESULTS
  Five-year HHSTU CFR (2.62 %) was less than half that in 51 U.S. centers (5.73 %). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISS > 25 accounted for 170 (89 %) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISS < 25. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9 % up to 2010.
  
  
  CONCLUSIONS
  Sustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.
authors.affiliation: Department of General Surgery and Shock Trauma Unit, Hebrew University Hadassah Medical Center (Ein Kerem), P.O.B. 12000, 91120 Jerusalem, Israel. avir@hadassah.org.il
authors.forename: Avraham I
authors.initials: AI
authors.lastname: Rivkind
authors.forename: Rony
authors.initials: R
authors.lastname: Blum
authors.forename: Irena
authors.initials: I
authors.lastname: Gershenstein
authors.forename: Yael
authors.initials: Y
authors.lastname: Stein
authors.forename: Shula
authors.initials: S
authors.lastname: Coleman
authors.forename: Yoav
authors.initials: Y
authors.lastname: Mintz
authors.forename: Gideon
authors.initials: G
authors.lastname: Zamir
authors.forename: Elihu D
authors.initials: ED
authors.lastname: Richter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D007557:Israel / Q000453:epidemiology; D008875:Middle Aged; D009026:Mortality; D012042:Registries; D023481:Terrorism / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy*; D055815:Young Adult