title: A dynamic mass casualty incident at sea: lessons learned from the Mavi Marmara.
abstract: BACKGROUND
  Mass casualty incidents (MCIs) represent one of the most difficult prehospital challenges faced by medical personnel. When they occur at sea, this challenge may be further complicated by isolation, distance, vessel structure, number of passengers, and limited evacuation means.
  
  
  METHODS
  We describe our experience and lessons learned from a dynamic MCI in an austere environment at sea.
  
  
  RESULTS
  Following an armed attack on navy operators boarding the MV Mavi Marmara, a vessel heading for Gaza, the Israel Defense Forces' medical teams triaged and cared for 62 casualties, among them 9 soldiers; 9 additional casualties were declared dead at the scene. The injured, including 10 triaged as severely wounded, were all evacuated to Israeli hospitals within several hours of the start of the event. Despite the austere conditions and the severity of injuries, all of the injured passengers were able to return to their home countries, and all soldiers returned to duty. Multiple issues were identified as requiring changes or heightened awareness so as to be better prepared for future events of this special nature.
  
  
  CONCLUSIONS
  The primary lessons learned related to difficulties in functioning without effective communication, maintaining command and control, coordinating serial evacuation of casualties who were being triaged in parallel, planning for an event with lengthy evacuation times, resolving real-time ethical dilemmas, and preparing our providers mentally. As MCIs tend to be unexpected, preplanning, using preestablished manuals, and drilling for them may prove crucial in such extreme events. Importantly, the lessons learned from this event, with its unique synthesis of multiple contributing factors, remain relevant even in less austere settings.
authors.affiliation: Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel. idf_trauma@idf.gov.il
authors.forename: Elon
authors.initials: E
authors.lastname: Glassberg
authors.forename: Ari M
authors.initials: AM
authors.lastname: Lipsky
authors.forename: Amir
authors.initials: A
authors.lastname: Abramovich
authors.forename: Ilia
authors.initials: I
authors.lastname: Sergeev
authors.forename: Ohad
authors.initials: O
authors.lastname: Hochman
authors.forename: Nachman
authors.initials: N
authors.lastname: Ash
mesh_terms: D000328:Adult; D003142:Communication; D004282:Documentation; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D054527:Mass Casualty Incidents; D008889:Military Personnel / Q000706:statistics & numerical data; D009792:Oceans and Seas; D018635:Rescue Work; D013997:Time Factors; D014187:Transportation of Patients; D014218:Triage; D014947:Wounds and Injuries / Q000628:therapy