Civil unrest resulting in clashes between citizens and security forces has happened recurrently since the days of ancient Greece and Rome.1 Such clashes can result in significant injuries and even death for both security personnel and citizens.2^–5

Mass casualty incidents (MCI) can be caused by natural or man-made disasters. In Israel, the latter have been mostly caused by wars and terror attacks, in which the initiator usually aims to kill or maim as many enemies as possible. In riots and other situations of civil unrest, such as forced evacuation, special circumstances prevail. They usually involve clashes between uneven forces. On the one hand, state security forces are equipped with protective and anti-riot gear. On the other hand, civilians, sometimes including children and women, are usually equipped with improvised gear. The aim of both sides may be to inflict limited damage on their opponents in terms of the number of injured and the severity of their injuries. At times, security forces even use special weapons (such as rubber and plastic bullets, tear gas, water canons), designed to minimise injury severity, while still ensuring deterrence.6^–9 The literature provides little information on injury patterns in civil riots, in which rubber or plastic bullets were not used.10^–12

On 1 February 2006, under Israeli government instructions, the West Bank Amona outpost was forcibly evacuated. Some 5000 people (settlers and sympathisers), positioned themselves in the nine houses scheduled for evacuation or on their rooftops. They threw rocks, eggs and paint-filled balloons at the helmeted riot police, who approached, standing in the shovels of bulldozers, the rooftops, which were barricaded and ringed with barbed wire. The protesters used sticks to beat back troops climbing ladders. Eventually, the helmeted officers got up on the roofs, wrestled with demonstrators and took them down in the same bulldozer shovels.

The Amona outpost is located at 35–50 minute driving distance from the city of Jerusalem and its four general hospitals (three level-two centres and a level-one trauma centre). The closest hospital, Hadassah Mt Scopus, is at a 35-minute driving distance, whereas the Bikur Cholim and Shaarei Zedek hospitals are at a 45-minute driving distance and the city’s level-one trauma centre, Hadassah Ein Karem, at a 50-minute driving distance.

Our objectives in this study are to analyse the medical preparedness, injury patterns and subsequent evacuation and management of the injured. Given that such events have seldom been described in the medical literature, we have tried to make our description of their medical aspects as complete as we could, even though not all its aspects are equally pertinent to our analysis.

METHODS

Pre-event organisation

The medical department of the Israeli Home Front Command (HFC) deploys a medical operations centre staffed with an officer and two to three experienced soldiers. This centre can communicate with all relevant organisations, both acquiring and providing real-time information and instructions how to manage MCI and other emergencies. These organisations include all Israeli general hospitals, EMS national and district headquarters, other military or HFC units, the fire brigade, police headquarters, search and rescue units, military medical units including nuclear, biological and chemical units, the Israeli Air Force and the hazardous materials information centre. The operations centre also communicates directly with the Ministry of Health and the Ministry of the Environment.

The event

Hospitals received early notification from EMS and from the HFC medical department. The relevant hospitals were instructed by the latter to activate their MCI protocols. The direct connection between the HFC medical department and the Air Force command allows rapid reinforcement of medical evacuation helicopters for either primary evacuation to hospitals or secondary distribution. Our officers were dispatched to Amona and to the various hospitals. HFC officers, physicians and nurses, gathered information and updated the operations centre, hospitals, EMS and other relevant organisations.

Post-event

Debriefings were carried out at the HFC medical department and national EMS, according to a standardised protocol—with each organisation reporting its data and answering questions. Post-MCI debriefings are closed to the media, allowing free communication between the various organisations. The data presented here were organised according to the Disastrous Incidents Systematic AnalysiS Through—Components, Interactions, Results (DISAST–CIR) methodology.13

DISAST–CIR methodology

This methodology uses the information gathered by prospective systematic structured debriefings of all the organisations involved in the event and a prospective review of the computer system data and the patient medical charts from the EMS and the hospitals. The data gathered from those charts include the time of evacuation, time of arrival, mode of evacuation (basic life support ambulance, advanced life support ambulance or self-evacuation), symptoms and signs, physical examination, radiographic and laboratory findings, diagnosis, medications given and operations performed. The DISAST–CIR methodology presents the data in a uniformly structured set of figures and tables to enable emergency managers and other readers to compare events systematically. This methodology includes a graphical presentation of all involved medical units, facilities and evacuation venues, a detailed timetable of the events and patient flow, starting with the initial incident and ending with the last patient’s arrival at the point of definitive care, and a detailed table describing all involved prehospital care givers and evacuation vehicles.

Statistical analysis

Data were entered and descriptive statistics were calculated using a commercially available spreadsheet (MS Excel 2003); χ² analysis was performed using SPSS (version 12).

RESULTS

The clashes between security forces and settlers started at 04:30 hours and by 16:30 hours the evacuation had been completed. A total of 229 injured arrived or were evacuated to the hospitals, 174 were civilians and 55 security forces personnel (police and military). Additional victims were treated on site and did not seek hospital care. Victims were evacuated by Israeli defence force (IDF) aeromedical evacuation helicopters, Magen David Adom (MDA) (national EMS) ambulances or arrived by private vehicles at the six receiving hospitals. The four Jerusalem general hospitals included three level-two trauma hospitals (Hadassah Mt Scopus, Shaarei Zedek and Bikur Cholim) and a level-one trauma centre, Hadassah Ein Karem. The two additional receiving hospitals were level-one trauma centres in the larger Tel-Aviv metropolitan area. The cumulative flow of patients to the receiving hospitals is shown in fig 1.

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Figure 1 Accumulative casualty arrival at the various hospitals. BC, Bikur Cholim; EK, Hadassah Ein Karem; MS, Hadassah Mt Scopus, SZ, Shaarei Zedek.

EMS and IDF medical units on the scene

As clashes were expected between the 5000 settlers and approximately 4000 policemen backed up by soldiers, medical units both civilian MDA (national EMS) and military were positioned in the area. In addition, the IDF aeromedical evacuation unit was placed on high alert. The units are shown in table 1. A first aid station was also set up near the Amona outpost.

Aeromedical evacuation

There was a total of six aeromedical evacuation flights. The first evacuated the only severely injured victim of the Amona clashes, an unconscious police officer who had sustained a closed head injury, as a result of a direct hit by a cement block. Two additional moderately injured victims were evacuated on that flight. Five additional evacuation flights were performed, two of them to the nearby level-one trauma centre and three to more distant level-one trauma centres. A total of 16 injured were evacuated by air, transporting one severely injured, five moderately injured and 10 mildly injured.

Injury patterns

Most of the injuries to both security forces and settlers were caused by blunt objects. The most common injuries were to the head and face and to the extremities. Table 2 describes the injuries sustained by settlers and security forces and compares the injuries most commonly sustained by security forces with those most often sustained by the settlers.

Head injuries were more commonly sustained by settlers, 87 of 174 (50%), than by security forces, 12 of 55 (21.8%), χ²  =  14.358 (p<0.001). Extremity injuries, however, were more than twice as common among security personnel, 40 of 56 (72.7%), as among settlers, 54 of 174 (31%), χ²  =  28.273 (p<0.001).

Distribution between the receiving hospitals

As mentioned, the hospital closest to the incident is Hadassah Mt Scopus, a level-two trauma community hospital, which thus received the largest number of victims, many of whom arrived by private cars. Table 3 describes the hospital distribution and severity of injuries.

Hospital resource utilisation

The numerous injured, although mostly mild significantly affected the allocation of resources in all four general hospitals of the Jerusalem area. The procedures and resource use are shown in table 4.

DISCUSSION

MCI can be caused by a variety of natural and man-made disasters. MCI caused by civil unrest and clashes between the state’s security forces and its own citizens are potentially devastating. It is usually in the state’s interest, under such circumstances, to minimise casualties. Such incidents may have severe implications in the internal political and civic arenas. Any fatality or serious casualty can throw the country into turmoil. Appropriate medical planning and management of such events can minimise damage to humans and negative political consequences.

Medical units on the scene

In anticipation of the potential for numerous injuries, a large medical force was amassed before the event, including civilian EMS, army and air-evacuation medical units. Evacuation was planned by civilian and military ambulances as well as by medical helicopters for the more severely injured. In view of the large number of lightly injured, the possibility of using buses to transport large numbers of lightly injured was raised in some debriefings. Such an option would have been economical and would have freed up many ambulances.

Aeromedical evacuation

A total of 16 victims were evacuated by aeromedical evacuation, in a total of six flights performed by three helicopters. The first aeromedical evacuation transported the only severely injured patient of the event to the closest level-one trauma centre. The last three flights transported patients to more distant level-one trauma centres, easing some of the load off the four Jerusalem hospitals.

Injury patterns

Head and extremities were the two most common injury sites, respectively accounting for 41% and 39% of the total injuries. The prevalence of injury sites differed significantly between the two groups. Head injuries were present in 50.0% of the injured settlers and only 21.8% of the injured security personnel. This difference is probably due to the helmets worn by all security forces members, but not by the settlers. In addition, although most settlers were pedestrians, many of the security forces personnel were mounted on horses or bulldozer shovels, making injuries to the head and face less likely. Injuries to the extremities, however, were more common among the injured security forces, 72.7% versus 31.0% of injured settlers. It is likely that this difference is related both to the nature of the forced evacuation and to the need for security forces to use their arms in the process. Other injury sites were much less common in both groups and therefore hard to compare.

Hospital resource utilisation

On arrival at the hospitals only one of the many injured was categorised as severe and another one as moderately injured. Despite this seemingly mild course, the incident had a severe impact on the operation and ability to care for additional patients of all Jerusalem general hospitals (table 4). The city’s only level-one hospital, Hadassah Ein Karem, even requested at one point that additional wounded be diverted to other hospitals. Hadassah Mt Scopus, a 288-bed community hospital, being the closest hospital to the incident, was challenged by the 77 injured and the need to perform five computed tomography scans and x ray 30 patients, in addition to caring for its routine patient flow. The two other city hospitals, Shaarei Zedek and Bikur Cholim, were also strained by the casualty influx.

Limitations

We have described a single incident, and as the literature on similar cases of coping with civil unrest is limited, the relevance of our analysis can only be validated once additional data become available. In addition, some data collection was retrospective and therefore potentially subject to bias, which we attempted to minimise by collating and matching information from multiple sources.

CONCLUSIONS

Preparedness and the efficient management of civil unrest casualties is of crucial importance. Given the number of victims and the strain they created on prehospital resources and Jerusalem hospitals, this event can be classified as a MCI. Although injury severity was mild, the incident with the resulting wounded challenged EMS and all general hospitals in the Jerusalem area. On that day, their ability to care for casualties from a terror attack or some other disaster could have been hampered.

Injury patterns

The injuries of the security forces members differed from those of the settlers, with extremity injuries predominating among the former and head injuries among the latter.